Every finding on record at Oak Grove Center

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units ([NAME] Unit, [NAME] Unit and [NAME] Unit) for 2 of 2 facility tours.Findings:1. On 6/1/26 at 7:04 p.m., a surveyor observed in Resident room [ROOM NUMBER]'s shared bathroom, a bedpan on the floor next to the toilet which was unbagged and unlabeled. At this time, in an interview with a surveyor, the Market Clinical Lead confirmed the finding. On 6/1/26 at 7:35 p.m., a surveyor observed in Resident room [ROOM NUMBER]'s bathroom, a dirty and unlabeled bed pan on the back of the toilet which had dried urine in it. At this time, in an interview with a surveyor, LPN #1 observed and confirmed the finding. 2. On 6/4/26 from 9:00 a.m. to 9:20 a.m., a surveyor conducted an Environmental tour with the Senior Maintenance Director, the Environmental Services District Manager, the Administrator and the facility Maintenance Director in which the following findings were discussed and/or observed: [NAME] House:- Resident room [ROOM NUMBER] - There was an unbagged commode lid on the floor in the bathroom next to the toilet. - Resident room [ROOM NUMBER] - The floor was dirty around the base of the toilet. - Resident room [ROOM NUMBER] - The bathroom ceiling exhaust vent was dusty/dirty. The bathroom had one ceiling tile that had a brown stained on it. The floor was dirty around the base of the toilet. [NAME] House:- Resident room [ROOM NUMBER] - The floor was dirty around the base of the toilet. - Resident room [ROOM NUMBER] - The wall at the head of bed 1 had chipped/missing paint exposing sheetrock and creating an uncleanable surface. [NAME] House:- Resident room [ROOM NUMBER] - The shared bathroom had a urine hat on the back of the toilet that was not labeled. - Resident room [ROOM NUMBER] - The shared bathroom had an unlabeled urinal, an unlabeled spray, and an unlabeled cream on the back of the toilet. The paint on the bathroom walls were marked/marred.- Resident room [ROOM NUMBER] - The bathroom door and door frame had chipped/missing paint creating uncleanable surfaces. There were used gloves on the counter of the shared sink. - Resident room [ROOM NUMBER] - The shared bathroom had an unlabeled container of Desenex powder, an unlabeled tube of Aquaphor cream and an unlabeled small bottle of Remedy body lotion on a small, wheeled set of plastic draws.On 6/4/26 at 9:20 a.m., in an interview with a surveyor, the Senior Maintenance Director, the Environmental Services District Manager, the Administrator and the facility Maintenance Director confirmed the discussed and observed findings.

Based on Payroll Based Journal staffing (PBJ) report, record reviews 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 for weekends of the first quarter 2026 (October 1 - December 31, 2025). This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings:1.Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the first quarter of 2025 (October 1, 2025 - December 31, 2025).During a review of nursing staffing sheets for certain dates between 6/8/25 and 6/9/25, weekends from 10/1/25 through 12/31/25, and 5/10/26 through 5/29/26. on 6/4/26 at 10:00 a.m., the acting Scheduler confirmed the above findings. 2.Review of facility Fall log from 10/1/25 through 12/31/25 revealed there were 130 falls.Review of facility Fall log from 3/1/26 through 5/31/26 revealed there were 86 falls.Review of facility Fall log from 6/1/26 through 6/12/26 revealed there were 17 falls. During an interview on 6/1/26 at 7:30 p.m. Resident #4 stated his/her med are given late because they are so short staffed.During an interview on 6/1/26 at 6:51 p.m., Resident #29 stated weekends are the worst and staff say it's hard to get to everybody because there are only 2 people working the wing. If he/she asks for more than one thing, they'll do that one thing and they are out the door before he/she can get the second request out of his/her mouth.During an interview on 6/4/26 at 1:45 p.m., the above was discussed with the Director of Nursing.

Based on observations, record reviews, interviews, and facility policy, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and ensure that two people who are authorized to administer medications signed the Shift Count page of the Controlled Substances book [a logbook used to record and inventory controlled medications], indicating that they counted all controlled substances at the change of shift for multiple shifts, for 3 of 4 medication carts observed on 2 of 3 units ([NAME] Unit Cart A, [NAME] Unit Cart B, [NAME] Unit Cart).Findings:Facility policy NSG300 Controlled Drugs: Management of revised 1/31/25 states, All staff who administer medications will safeguard controlled substances. Ongoing inventory: A complete count of all Schedule II-IV controlled substances is required at the change of shifts. The count must be performed by two licensed nurses and/or authorized nursing personnel. Centers will use the Controlled Substance book. for the inventory of all controlled substances.1. On 6/3/26 at 8:30 a.m., during a medication storage observation on the [NAME] Unit, a surveyor reviewed the Controlled Substance book and Shift Counts located on the Cart A medication (med) cart, which indicated the facility counts at the change of each shift, approximately 3 times per day, and observed the following:- The person authorized to administer medications coming on duty failed to sign the Shift Count page of the Controlled Substance book that indicated the controlled substances count was done on 5/15/26 at 5:00 p.m. and 5/15/26 at 11:30 p.m. (pg. 277)- The person authorized to administer medications going off duty failed to sign the Shift Count page of the Controlled Substance book that indicated the controlled substances count was done on 5/15/26 at 5:45 p.m. and 5/16/26 at 10:30 p.m. (pg. 277)2. On 6/3/26 at 8:38 a.m., during a medication storage observation on the [NAME] Unit, a surveyor reviewed the Controlled Substance book and Shift Counts located on the Cart B med cart and observed the following:- The person authorized to administer medications going off duty failed to sign the Shift Count page of the Controlled Substance book that indicated the controlled substances count was done on 12/29/25 at 4:44 p.m. (pg. 271)- Incomplete entries on 1/10/26 (pg. 272) and 1/20/26 (pg. 273) that lack the date and/or time the count was completed.On 6/3/26 at 8:40 a.m., the surveyor discussed the above findings with the Director of Nursing.3. On 6/4/26 at 7:39 a.m., during a medication storage observation on the [NAME] Unit, a surveyor reviewed the Controlled Substance book and Shift Counts located on the [NAME] med cart and observed an entry dated 6/4/26 and timed for 2:00 p.m. (pg. 285) that indicated yes for Status of Count Exact Yes/No. During interview at this time, Certified Nursing Assistant-Medication Tech (CNA-M) #1 confirmed that the 2:00 p.m. count has not been completed yet and that she will not know the status of the count until it is completed this afternoon with the oncoming CNA-M and the nurse. On 6/4/26 at 8:47 a.m., the surveyor discussed the finding with the Director of Nursing and the Market Lead Clinical Specialist.

Based on record review, interview, and facility policy, the facility failed to obtain informed consent for the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #36).Finding:Facility policy, NSG206 Behaviors: Management of Symptoms, revised 9/15/25, states, .When medication is ordered for behavioral symptoms: Obtain consent.Resident #36 has diagnoses including dementia with behavioral disturbance, depression, and epilepsy.A review of Resident #36's clinical record revealed the following active physician orders:An order with a start date of 1/20/26 for Citalopram Hydrobromide Tablet 10 MG [milligrams] Give 1 tablet by mouth one time a day for depressionAn order with a start date of 2/11/26 for diazepam (15 MG Dose) Nasal Liquid. 1 spray in both nostrils every 6 hours as needed for.seizure activityReview of Resident #36' care plan states, Resident is at risk for complications related to the use of psychotropic drugs. Provide informed consent to resident or healthcare decision maker.Further review of Resident #36's clinical record lacked documentation that Resident #36 and/or his/her representative was informed in advance of the risks and benefits prior to initiating the above medications.On 6/4/26 at 2:40 p.m. during an interview, the Market Lead Clinical Specialist confirmed that she could not find evidence that the facility had obtained informed consent prior to initiating the above medications.

Based on interview and clinical record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all the resident's pre- and post-discharge medications for 1 of 2 residents reviewed for discharge to the community (Resident #98).Finding: On review of Resident #98's clinical record, a surveyor noted an admission date of 12/13/25. The record indicated that on 1/14/26, Resident #98's managed care insurance denied coverage after 1/21/26, and Resident #98 was discharged home on 1/22/26. The surveyor located an incomplete recapitulation of stay in the electronic record dated 1/22/26. The record lacked evidence that the provider had completed a final summary of Resident #98's status, or a summary of the resident's pre- and post-discharge medications in the hard or electronic clinical record. On 6/2/26 at 3:55 p.m., in an interview with a surveyor, the Market Lead Clinical Specialist confirmed that the provider had not completed a discharge summary prior to Resident #98's discharge.

Based on interviews, document review, the facility's Suicide Precautions policy and the facility's Person Centered Care Plan policy review, the facility failed to ensure that a resident who had signs of self-harm and suicidal ideation received the care and services necessary to reach and maintain the highest level of mental and psychosocial functioning for 1 of 1 residents reviewed for mood/behavior (Resident #92).Findings:Review of the facility's Suicide Precautions revised 3/20/26, notedProcedure:1. Evaluate patients with suicidal behavior or ideation.2. Notify physician/advanced practice provider (APP) if assessment indicates patient is at risk for suicide. Collaborate with care team to determine risk level for suicide.2.1 Discuss Suicide safety plan with patient slash family slash representative.2.1.1 warning signs and triggers.3.1 Obtain order for suicide preventions from the physician slash app. Implementation of suicide precautions should not be delayed while awaiting physicians order. 3.2 evaluate immediate safety needs3.10 document: 1. Risk for suicide. 2. Actual/potential suicidal behavior observed. 3. Expression of wish to die, using patients own words, if possible. 4. Notification of physician (APP) including time notified and time of response. 5. Notification of family representative. 6. Safety plan information shared by patients representative/family. 7. Time of initiation of suicide precautions. 8. Notification of consultants archivists including time notified and time of response. Review of the facility's Person Centered Care Plan policy, revision date 9/15/25 notedPolicy: The center must develop and implement a person centered care plan for each patient slash resident consistent with patient rights measurable objectives and time frames to meet a patient's medical, nursing and mental and psychosocial needs and all services that meet professional standards of quality.Care plan Includes the measurable objectives and timetables to meet the patient's medical, nursing, nutrition and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan will be prepared by the interdisciplinary team. 3. A comprehensive person centered care plan must be developed for each patient and must describe the following: 3.1 Services that are to be furnished.5.1 The care plan must be customized to each individual's patients preferences and needs. 6. Care plans will be: 6.2 reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident #92's clinical record revealed Care Plan Meeting note dated 4/30/26 stating Resident #92 made a comment that he/she might as well commit suicide. Review of Resident #92's clinical record lacked evidence that the resident was assessed for self-harm/suicide ideation, or that the provider was made aware of this statement. Further review of Resident #92's clinical record revealed Provider communication note dated 5/10/26 stating: [.Describe behavioral changes: increasing confusion threatening to commit suicide tonight.]. Review of Resident #92's care plan most recently updated 5/12/26 lacked evidence that goals and interventions were put into place for suicidal ideation. On 6/2/26 at 2:20 p.m., in an interview with a surveyor, the Market Clinical Lead stated she reviewed Resident 92's clinical record and there is no evidence that the doctor was notified, that the resident was assessed for self-harm/suicidal ideation and no evidence that the current care plan was updated to include triggers, goals and interventions for threat of self-harm/suicide. On 6/2/26 at 3:30 p.m., in an interview with a surveyor, the current Social Service Director stated that if a resident said they wanted to commit self-harm or suicide in front of him in a meeting that he would get a team together(nursing) and assess the resident, the DON and the Administrator would be involved and they would notify the doctor. Depending what the doctor stated, they may send the resident out to the emergency room for an evaluation. He then stated that he would document it in notes with follow-up as to what was done. On 6/3/26 at 3:55 p.m., in an interview with a surveyor, the Market Clinical Advisor, the Director of Nursing and the Market Clinical Lead confirmed that the resident's care plan had been reviewed by them and that there was no evidence that the current care plan was updated to include triggers, goals and interventions for threat of self-harm and suicide ideation.

Based on observations, record reviews, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for Activities of Daily Living (Resident #14).Findings:1. Resident #14 has diagnoses including dementia.On 6/2/26 at 8:52 a.m. during an interview, Resident #14's son stated that he has observed Resident #14 in the same soiled clothes, sometimes for days.On 6/3/26 at 11:17 a.m. a surveyor observed Resident #14 dressed in a light blue t-shirt with a logo and dark blue pants. The surveyor observed Resident #14 in this clothing multiple times throughout the day.On 6/4/26 at 8:25 a.m. during a repeat observation, Resident #14 was dressed in the same light blue t-shirt and dark blue pants as the previous day.A review of Resident #14's clinical record revealed an Interdisciplinary Team (IDT) meeting note dated 4/8/26 that states, .[son] expressed concerns with the resident having the same pair of clothes on for several days in a row A review of Resident #14's care plan states, .Provide resident/patient with partial assist of 1 for dressing.On 6/4/26 at 11:40 a.m. during an interview, Certified Nursing Assistant (CNA) #4 stated that Resident #14 does not dress himself/herself and cannot select his/her own clothing and that he/she would wear the same clothing every day if staff let him/her. CNA #4 then stated that she did not provide Resident #14 dressing assistance today, and that the off-going night shift CNA told her that Resident #14 was already dressed for the day when she arrived for her shift this morning.A review of Resident #14's task documentation for Task: GG-dressing.Did you obtain clothing from the closet or drawers for resident? indicated No on 6/3/26 at 4:55 p.m. and Not applicable on 6/4/25 at 1:08 a.m. (night shift) and lacked evidence that the night CNA provided Resident #14 dressing assistance this morning, as stated by CNA #4 .On 6/4/26 at 1:13 p.m., the surveyor and the Market Clinical Lead observed Resident #14 in the hallway wearing the blue outfit. The surveyor discussed the above concerns and reviewed Resident #14's dressing task documentation with the Market Clinical Lead.On 6/4/26 at 2:10 p.m. during a follow-up Interview, the Market Clinical Lead stated that after speaking with the night CNA, Resident #14 was provided dressing assistance and changed into sleepwear last night and that this morning, Resident #14 requested to wear same clothing as yesterday. The Market Clinical Lead then confirmed that Resident #14's task documentation does not accurately reflect the care provided.

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 hand hygiene and the use of appropriate Personal Protective Equipment (PPE) while providing care for a resident on Enhanced Barrier Precautions (EBP) for 1 of 4 days of survey (6/3/26).Finding:Facility policy IC308 Enhanced Barrier Precautions, revised 11/14/25 states, .EBP expands on the use of gown and gloves. focusing on use of gown and gloves only during high contact patient care activities that have been demonstrated to result in transfer of MDROs (Multi Drug Resistant Organisms) to hands and clothing of healthcare personnel, even if blood and body exposure is not anticipated.Facility policy IC203 Hand Hygiene, reviewed 3/20/26 states, .The use of gloves does not replace hand hygiene2. If a task requires gloves, perform hand hygiene before donning gloves and immediately after removing gloves. Perform hand hygiene. After patient care; After contact with the patient's environment .Resident #29 has diagnoses to include left hip and left foot wounds and chronic indwelling urinary catheter.A review of Resident #29's care plan states, .has actual skin breakdown.Left Hip, Left foot and monitor Left Heel. Enhanced Barrier Precautions for any high risk care. and Resident requires indwelling foley catheter. Infection precautions-enhanced barrier.On 6/3/26 at 11:20 a.m. a surveyor observed Certified Nursing Assistant (CNA) #2 and CNA #3 don (put on) PPE and enter Resident #29's room with a mechanical lift (a device used to transfer residents) and proceed to transfer Resident #29 from his/her bed to his/her wheelchair. At 11:25 a.m., CNA #3 doffed (took off) and discarded her PPE and exited the room. At this time, CNA #2 exited the room wearing her gown and gloves and wheeled the lift into the hall outside Resident #29's room, re-entered the room, and then started to resume care before stating aloud that she had to take this gown off. CNA #2 then doffed her gown and gloves and discarded them in the trash. Without wearing any PPE, CNA #2 then obtained Resident #29's abductor-type pillow and proceeded to position the pillow between Resident #29's legs, lifting each of Resident #29's legs to position and secure the pillow's straps. With her bare hands, CNA #2 then lifted Resident #29's feet, which were in heel protector boots, and positioned them on the wheelchair footrests. CNA #2 then assisted Resident #29 to brush his/her hair and apply a headband and then transported Resident #29 to the dining room. Without sanitizing her hands, CNA #2 returned to Resident #29's room and donned gloves, collected the trash bag from the trash can by the sink and placed it in the trash can by the door. CNA #2 proceeded to doff and discard her gloves. Without sanitizing her hands, CNA #2 then straightened Resident #29's bed blanket, removed and tied the trash bag, and exited the room. CNA #2 then walked the trash bag to the whirlpool room, lifted the trash can lid with her bare hands, discarded the trash bag, and replaced the lid. Without sanitizing her hands, CNA #2 then exited the whirlpool room. At this time, the surveyor intervened and discussed the above observation with CNA #2. CNA #2 stated that she usually sanitizes her hands and that she will do so now. On 6/3/26 at 11:49 a.m. during an interview on the nursing unit with the Director of Nursing (DON), the surveyor discussed the above observation.

Based on interviews and record reviews, the facility failed to ensure that the current resident representative was notified of a change in the resident's medication regimen for 1 of 3 residents having court appointed guardianship (Resident #1 [R1]).Finding: On 1/28/26 at 1:12 p.m., in a telephone interview, R1's Public Guardian Representative stated the facility's primary provider increased R1's dose of Lithium (a mood stabilizer and antimanic agent) without obtaining the Guardian's consent. On 1/29/26 at 9:45 a.m., in an interview with a surveyor, the facility's social worker described the process for notification of changes to court appointed guardians. The social worker stated for any change in condition or need to send a resident out, nursing is to call and get approval of the guardian, specifically for anything requiring a decision. On 1/29/26, a review of R1's clinical record noted a copy of a court's decision, dated 10/31/18, appointing the Department of Health and Human Services as a full public guardian and conservator for R1. A review of provider orders noted that on 9/30/25, the provider increased R1's Lithium from 300 mg. (milligrams) twice daily to 450 mg. twice daily for increased hallucinations and delusions. The record lacked evidence that this increase in dosing was discussed with or consent obtained from the guardian. R1's care plan, last revised 9/11/25, included the focus area, R1 has a court appointed conservator or guardian of person. Interventions included State guardian will be involved with decisions being made. In addition, another focus area stated R1 is at risk for complications related to the use of psychotherapeutic medication. Interventions included provide informed consent to R1 or healthcare decision maker. A review of email correspondence between the facility and R1's guardian revealed on 10/2/25, the guardian discussed the facility's failure to obtain consent for treatment and medication changes. The guardian noted a phone call with a voicemail or email notification of what is going to be done does not constitute consent. Further, the guardian stated I found out today that R1's Lithium was changed and I was not previously made aware of this, nor was I asked for consent on this and, R1 is unable to provide his/her own consent which is why the State of Maine is his/her guardian. On 2/24/26 at 3:30 p.m., in a telephone discussion with the facility's Administrator, the surveyor discussed the finding.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units ([NAME] Unit, [NAME] Unit and [NAME] Unit) and the laundry room for 1 of 1 facility tour. Findings: On 3/20/25 from 11:00 a.m. to 11:30 a.m., a surveyor conducted an Environmental Tour with the Senior Maintenance Director, Administrator and the Maintenance Directo in which the following findings were observed: [NAME] Unit - Resident room [ROOM NUMBER] - The bathroom had urine around the base of the toilet and had a very strong odor of urine. - Resident room [ROOM NUMBER] - The sink countertop had chipped/missing laminate on the front edge. The sink overflow drain hole was broken open and rusty. The right side drawers under the sink were off-track and wouldn't close. The entire bathroom floor was dirty and dirty around the base of the toilet. The walls behind the head of the beds had paint that was chipped/gouged and missing, creating uncleanable surfaces. - Resident room [ROOM NUMBER] - There was a bed pan on the floor behind the toilet and a urine hat on top of glove box and both were unlabeled and unbagged. [NAME] Unit - Resident room [ROOM NUMBER] - The room wall, by the thermostat, had chipped/missing paint and was gouged exposing sheetrock which created an uncleanable surface. [NAME] Unit - The dining room walls had chipped/missing paint and were marred with black marks. - Resident room [ROOM NUMBER] - The baseboard heater had chipped/missing paint. The floor was dirty around the base of the toilet. There was dust and debris in the bathroom light lens. - Resident room [ROOM NUMBER] - The baseboard heater had chipped/missing paint and was broken apart with metal hanging down. - Resident room [ROOM NUMBER] - There was dust and debris in the bathroom light lens. The room baseboard heater had chipped/missing paint creating an uncleanable surface. There was an unlabeled urinal on the floor by the toilet and an unlabeled urinal on the toilet tank in the shared bathroom. There was a dirty plunger on the floor next to the toilet. - Resident room [ROOM NUMBER] - The room entrance door frame had chipped/missing paint. The baseboard heater had chipped/missing paint. The walls around the room had chipped/missing paint and had black marks on them. This created uncleanable surfaces. Laundry - There were 3 laundry carts with wheels that had untreated wooden bases creating uncleanable surfaces. - There was a cracked/broken 4-foot ceiling light lens. - There were 2 ceiling lights that were missing their 4-foot ceiling light lenses. On 03/20/25 at 11:30 a.m., in an interview, the Senior Maintenance Director, the Administrator and the Maintenance Director confirmed the findings.

Based on record review, observations, interviews, and facility policy, the facility failed to implement a care plan for 3 of 4 sampled residents (Resident (R20, R21, and R66). Findings: Review of the Person-Centered Care Plan policy dated 10/24/22 states a comprehensive person-centered care plan must be developed for each patient and must describe the following: .any specialized services or specialized rehabilitative services the Center will provide as a result of PASRR recommendations Care plans will be: . Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals . 1. During an interview on 3/18/25 at 7:53 a.m., R20 stated his/her dental bridge fell out a while ago and is still waiting for it to be replaced. At this time R20 opened his/her mouth and a surveyor observed multiple missing teeth and what appeared to be a broken bridge on the inside of his/her mouth. R20 stated his/her gums were really sore. Review of R20's Physician progress note dated 2/12/25 states We saw [R20] for an emergency apt concerning [his/her] missing bridge. [R20] wanted bridge recemented inside [his/her] mouth. Had to explain, the patient had teeth removed and thus the bridge no longer fits and will never fit. Referred pt[patient] to dentist to start partial denture process. Review of R20's care plan updated 2/25/25 lacked evidence that a care plan was established for dental. During an interview on 3/20/25 at 3:24 p.m., the [NAME] Unit Manger (JUM) reviewed and confirmed R20's care plan did not include goals and interventions in the area of dental. During an interview on 3/20/25 at 3:30 p.m., the above was discussed with the Director of Nursing (DON). 2. Review of R21's care plan updated 1/7/24 states Self administration of medication, saline nasal spray, seasonal allergies. Patient will correctly and safely: self-administer medication. Ensure availability/adequate supply of medication(s) for self administration. To Ensure patients ongoing functional and cognitive skills permit continued safe medication self-administration. Observe for indications of the patient skipping doses or refusing to take medication. During an interview on 3/20/25 at 12:09 p.m., JUM reviewed and confirmed R21's clinical record did not contain evidence he/she was assessed for use of duo neb or inhaler per care plan intervention. 3. Review of R66 Provider orders active for March 2025 revealed he/she was taking a diuretic medication: Lasix for congestive heart failure (CHF), opioid medication: Tramadol for pain, and anticoagulant medication: Clopidogrel Bisulfate for blood clot prevention, and has 3 stage II wounds on the left lower extremity (left lower leg). Review of R66's care plan updated 2/11/25 lacked evidence that goals and interventions were put into place for the use of diuretics, opioid, or anticoagulant use, and stage II pressure sores on the left lower extremity. During an interview on 3/20/25 at 3:20 p.m., JUM reviewed and confirmed R66's care plan did not reflect above concerns, stating I will update the care plan. The above was discussed with DON 3/20/25 at 3:28 p.m.

Based on observations, record reviews, interviews and facility policy, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 4 of 5 residents reviewed for respiratory care (Resident [R] R13, R21, R46 and R65). Findings: Review of policy Nebulizer: Small Volume dated 11/1/23 states: .Upon completion of the treatment, .Rinse SVN, mouthpiece, and T piece with sterile water and dry. Place in treatment bag labeled with patient name and date . 1. On 3/19/25 at 8:41 a.m., observation of room [ROOM NUMBER], 3/19/25 at 7:30 a.m., and 11:39 a.m. revealed nebulizer located on top of Resident R13's side table with tubing attached with/to nebulizer pipe which is resting/stored on top of a stuffed animal without a barrier between the nebulizer pipe and the stuffed animal allowing potential cross contamination. On 3/19/25 at 11:30 a.m. observation and interview with Licensed Practical Nurse (LPN), she confirmed nebulizer tubing was not bagged, and stated she does not know why the nebulizer was in the room because R13 only needed it for an exacerbation and hadn't used it in over a week. Review of R13's orders active March 2025 revealed [he/she] last used the nebulizer on 3/13/25. On 3/19/25 at 11:47 a.m. the above was discussed with Director of Nursing. 2. On 3/18/25 at 8:24 a.m., and 3/19/25 at 7:38 a.m., observation of room [ROOM NUMBER]-1, a nebulizer was observed on R21's nightstand with tubing attached to pipe which is resting/stored on top of dresser without a barrier between the nebulizer pipe and the side table allowing potential cross contamination. During an interview on 3/19/25 at 7:34 a.m., the Licensed Practical Nurse (LPN) confirmed the above findings. 3. On 3/18/25 08:23 a.m., and 3/19/25 at 7:45 a.m., and on 3/20/25 at 11:45 a.m., observations of a Nebulizer on top of R46's tv stand tubing attached to mask dated 3/16 - stored in top draw and resting on personal items without a barrier between the nebulizer mask and personal items allowing potential for cross contamination. During an observation of R46 on 3/20/25 at 11:45 a.m. with [NAME] Unit Manager (JUM), she confirmed above findings. 51669 4. On 3/19/25 at 8:19 a.m., during an observation, Resident #65's unbagged continuous positive airway pressure (CPAP) mask was lying on the floor underneath his/her bed. On 3/19/25 at 8:30 a.m., during an interview, Registered Nurse (RN) #6 stated when CPAP masks are not in use, they are stored in a plastic drawstring bag or sometimes the original device packaging. On 3/19/25 at 8:40 a.m., during an observation with a surveyor the [NAME] Unit manager confirmed the finding for Resident #65.

Based on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 3 of 3 sampled resident reviewed with a current diagnosis of PTSD (Resident #(R)15, R27 and R35). Findings: 1. Resident (R) 35 was admitted in 2024 and has diagnoses to include post-traumatic stress disorder. Review of R35's care plan updated 1/22/25 lacked evidence that a trauma informed care plan was established to include triggers for this resident's PTSD diagnoses. Review of R35's admission Minimum Data Set (MDS) 3.0, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate R35 had an active diagnosis for Post Traumatic Stress Syndrome (PTSD). The surveyor was unable to find information in the clinical record that indicated what R35's PTSD was caused by or what events might cause re-traumatization. During an interview with 4 surveyors on 3/21/25 at 3:00 p.m., Market Clinical Advisor confirmed Resident #35 did not have a trauma informed care plan. 51669 2. Resident #15 was recently admitted and has diagnoses to include Post-Traumatic Stress Disorder. Review of Resident #15's Admission Minimum Data Set (MDS), Section I, 16100. Post Traumatic Stress Disorder (PTSD), indicated Resident #15 has an active diagnosis of PTSD. Review of Resident #15's care plan, revised 3/18/25, includes, Focus: PASSR Level II: diagnosed with PTSD . but lacked evidence that a trauma informed care plan was established to include Resident #15's trigger(s) for PTSD. During an interview on 3/21/25 at 3:10 p.m., the Market Clinical Advisor confirmed Resident #15 did not have a trauma informed care plan. 37440 3. Resident #27 was admitted to the facility on [DATE] to include a diagnosis of PTSD. On 3/21/25, a review of Resident #27 's clinical record, in the Minimum Data Set (MDS) 3.0, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate Resident #27 had an active diagnosis for PTSD. The surveyor was unable to find information in the clinical record that indicates what Resident #27 's PTSD was caused by, what trigger(s) might cause re-traumatization, and measures to avoid trigger(s) that might cause re-traumatization. On 3/21/25 at 3:15 p.m., in an interview, the Market Clinical Advisor confirmed that Resident 27's care plan lacked what indicated what Resident #27 's PTSD was caused by, what trigger(s) might cause re-traumatization, and measures to avoid trigger(s) that might cause re-traumatization.

Based on observations, interviews, and record reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside on 3 of 3 units. Findings: 1. On 3/18/25 at 8:45 a.m., in an interview with a surveyor, RN5 stated the facility had changed to primary nursing and had taken away the medication technician position approximately 1 month ago. This change has resulted in nurses having to administer their own medications and treatments, often up to an hour late. On this day, the nurse had a discharge scheduled at 9:00 a.m., as well as an IV antibiotic to administer. RN5 stated wound care would be provided late due to lack of staffing. 2. On 3/20/25 at 11:20 a.m., a surveyor requested to observe wound care for Resident #9. LPN2 stated he/she would not be able to get to the twice daily wound care until 1:30 - 2:00 p.m. due to the workload and tasks to be completed. LPN2 stated he/she usually tries to complete the wound care before lunch, but today, he/she is unable to complete the wound care on time as there are only 2 licensed nurses, and 2 CNA's (Certified Nursing Assistants) on the unit. There are 2 admissions, and 2 discharges scheduled today, and on LPN2's assignment, 1 extensive wet to dry dressing change, Resident #9's dressing change, Resident #50's dressing change, and a new resident requiring care for 2 draining fistulas. LPN2 stated he/she also was responsible for all medication administration, blood glucose testing and insulin administration. 51669 3. Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the first quarter of 2025 (October 1, 2024 - December 31, 2024). On 3/19/25 at 3:00 p.m., during an interview, Resident #10 stated the primary concern at Resident Council meetings is lengthy call bell response times and that when staff come in to answer a call bell, they do not ask the other resident in the room if they need anything. On 3/20/25 at 11:05 a.m., during an interview Registered Nurse (RN) #4 stated the unit manager does not work the floor on the [NAME] unit and only does direct care if staff really needs help. RN #4 then stated that under the new staffing model, the medication tech (MT) goes home at 2:00 p.m., and the nurse takes over and administers all medications and treatments between 2:00-6:00 p.m. and then, the MT comes back from either 5:00-9:00 p.m. or 6:00-10:00 p.m. RN #4 then stated that last night, a resident fell at 3:30 p.m., and she had barely finished admitting another resident, when a third resident fell , all while she should be giving medications because the MT left. On 3/24/25 between 9:43 -10:15 a.m., during an interview, a surveyor reviewed weekend staffing for October 1, 2024 through December 31, 2024 with the Staffing Coordinator, and the Director of Nursing (DON). The DON stated she was aware of the shortages in the first quarter and confirmed the facility did not have enough staff to meet resident needs on the weekends.

Based on record reviews, observations and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation by failing to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 1 of 3 units reviewed ([NAME]). Findings: A review of the facility's policy and procedure: Controlled Drugs: Management Of, State of Maine, last revised 7/1/24, page 6, Section 5. Ongoing Inventory of Controlled Substances (Shift Count): 5.1 stated, Follow the Index Page to perform a complete count of all Schedule II to IV controlled substances at the change of shifts or at any time in which narcotic keys are surrendered from one licensed nursing staff to another. 5.1.3. Both medication nursing staff members participating in the count must: 5.1.3.3. Sign the shift count page in the 'Controlled Substances Book' to acknowledge a correctly reconciled count. On 3/20/25 at approximately 12:30 p.m., during a medication storage observation of the [NAME] unit medication cart, a surveyor reviewed the Controlled Substance Books and Shift Counts which indicated the facility counts at the change of each shift, approximately 3 times a day. The person authorized to administer medications coming on duty or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was completed on multiple days. At this time, the findings were discussed and confirmed with (Registered Nurse) RN #3 and RN #4. On 3/20/25 at 12:50 p.m., in an interview with the Director of Nursing and the Market Clinical Advisor, the surveyor discussed that multiple days on the [NAME] unit were missing staff signatures for verification and completion of the controlled medication count on the following dates: 11/25/24, 11/26/24, 11/29/24, 2/3/25, 2/4/25, 2/24/25, 2/25/25 (a.m. and p.m.), 3/6/25 (a.m. and p.m.), 3/7/25 (a.m. and p.m.), 3/11/25, 3/12/25, 3/18/25, and 3/19/25.

Based on observations, interviews and record reviews, the facility failed to ensure medications and treatments were stored properly, including removal of expired medications from available supply, on 3 of 5 days of survey (3/18/25, 3/19/25, 3/20/25). Additionally, the facility failed to obtain physician orders for medications located at a resident's bedside, for 2 of 2 sampled resident (Resident #65 and #79). Findings: Review of policy Medication Self-Administration, revised 10/15/2024, states, Patients who wish to self-administer medications will be evaluated for safe and clinically appropriate capability .If it is determined that the patient is able to self-administer: A physician/advanced practice provider (APP) order is required .Self-administration and medication self-storage must be care planned .patient must be provided with a secure, locked area to maintain medications . Review of policy, Bedside Medication Storage, dated 1/2024, states, The interdisciplinary team (IDT) will review and approve resident competencies and understanding prior to permission of bedside storage of medications .A written order for the bedside storage of medications is present in the resident's medical record .Bedside storage of medications is indicated on the resident medication administration record (MAR) .the manner of storage prevents access by other residents. Lockable drawers or cabinets are required . The facility's policy, titled 4.1 Storage of Medication, dated 1/25, stated, Procedures 4. Medications should be stored so that various routes of administration are separated. Internally administered medications are stored separately from medications used externally, such as lotions, creams, ointments, and suppositories. Section 12 stated, Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in refrigerator or at room temperature. (Refer to specific product labeling for additional detail). Opened insulin pens should be stored at room temperature. Do not freeze insulin. If insulin has been frozen, do not use. Section 14 stated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. According to the Institute for Safe Medication Practices website, Safety Tips for Storing Insulin, states Write the date you open the insulin on the product. On the day you open the insulin vial, pen, or cartridge, or start keeping it outside the refrigerator, write the date on the label. This will help you remember when to stop using it. Insulin expires 28 days after it is opened. 1. On 3/18/25 at 7:50a.m., during an observation of Resident #65's room, a Fluticasone/Salmeterol 250mcg-50mcg inhalation device was located on Resident #65's over-the-bed table. Review of Resident #65's clinical record lacked evidence of an order to self-administer medications. Further review of the clinical record lacked evidence of an IDT assessment. On 3/18/25 at 2:39 p.m., during an interview, Registered Nurse (RN) #1 stated she left Resident #65's Advair inhaler at the bedside so he/she could take his/her dose after breakfast. At this time, RN #1 stated medications should not be left at the bedside, and that Resident #65 does not have an order to self-administer medications. During an interview on 3/18/25 at 2:45 p.m., the finding was reviewed with the [NAME] Unit Manager. 2. On 3/19/25 at 8:24 a.m., during an observation of Resident #79's room, a 1.5 fluid ounce bottle of Deep Sea Premium Saline 0.65% nasal moisture spray was located on the windowsill next to Resident #79's recliner. At this time, Resident #79 stated he/she was given the medication in the hospital and uses the medication a couple times a day. Review of Resident #79's active orders lacked evidence of a physician order for the saline nasal spray and lacked evidence of an order to self-administer medications. Further review of the clinical record lacked evidence of an IDT assessment. On 3/19/25 at 8:40 a.m., a surveyor and the [NAME] Unit Manager observed the nasal spray on Resident #79's windowsill. At this time, the Unit Manager stated residents who self-administer medications must have an assessment to determine if it is safe to self-administer, an order to self-administer, a physician order for the medication, and the medication must be stored in a lock box. On 3/19/25 at approximately 11:00 a.m., the above findings were discussed with the Market Clinical Advisor. 37015 3. On 3/18/25 at 9:45 a.m., during a medication storage observation of Medication Cart B on [NAME] Unit, the following topical medications were observed undated when opened and stored in a drawer with oral medications: Therahoney, Anasep wound gel, zinc oxide skin protectant cream, Diclofenac gel, Prevent silicone cream. Oral medications stored among the topical medications included: Lactulose oral solution and Guaifenesin liquid. Also observed with these medications was a bottle of antifungal powder prescribed to Resident #9. (Registered Nurse) RN #1 stated the medication had been discontinued a while ago. Another bottle of antifungal powder had the pharmacy label torn off and was open and available for use. A review of the provider orders for Resident #9 noted the order for antifungal powder had been discontinued on 3/5/25. 4. On 3/20/25 at 9:00 a.m., during a medication administration observation on the [NAME] Unit, a surveyor observed an Insulin Lispro Kwik-Pen prescribed to Resident #4, in use and undated when opened stored in Medication Cart B. The surveyor brought this to the attention of the RN who threw it away at this time. 5. On 3/20/25 at 12:00 p.m., during an observation of the nurse treatment cart on the [NAME] Unit, a surveyor observed the following 7 insulin pens that were all prescribed to current residents and were open and available for use: > 2 - Undated when opened Insulin glargine-yfgn (U100) > Insulin Lispro Kwikpen (U100) labeled as opened on 2/16/25 (expired) > Undated Insulin Lispro Kwikpen (U100) > Insulin Lispro Kwikpen (U100) labeled as opened on 1/27/25 (expired) > Undated Insulin Glargine Solostar pen > Undated Basaglar Kwikpen (U100) On 3/20/25 at 12:05 p.m., the surveyor brought the above insulin pens to the JUM ([NAME] Unit Nurse Manager). 6. On 3/20/25 at 12:10 p.m., during an observation of the [NAME] Unit Medication Room with RN #2, a surveyor observed the emergency stock of intravenous antibiotic medications, stored in 3 plastic boxes with compartments. The following were noted: > 2 vials of Zosyn (piperacillin 3 grams/tazobactam 0.375 grams) - expired 1/25 > 2 vials of Cefazolin 1 gram - expired 11/24 7. The small medication refrigerator located on the floor was observed to have a large ice buildup. A stack of insulin pens were observed stored next to the ice buildup. At this time, the surveyor brought the expired antibiotics to the JUM and notified him/her of the ice buildup in the medication refrigerator. 8. On 3/20/25 at approximately 12:30 p.m., during an observation of the treatment cart on [NAME] Unit with RN #3, a surveyor observed 3 vials of single dose Shingrix vaccine stored in a plastic bag with a sticker which stated Keep Refrigerated. RN #3 removed the vaccines from use at this time. On 3/20/25 at 12:50 p.m., the surveyor discussed the above findings with the Director of Nursing and the Market Clinical Advisor.

Based on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 3 dumpsters for 1 of 4 days(3/18/24) and 1 of 3 dumpsters for 3 of 4 days of survey. (3/18/25, 3/19/25, and 3/20/25) Findings: 1. On 3/18/25 at 6:30 a.m., a surveyor observed 1 dumpster with the right-side slide door open exposing trash. Additionally, there was trash/debris on the ground. Another dumpster had a right-side top cover that was broken and open exposing trash. 2. On 3/19/25 at 8:00 a.m., a surveyor observed a dumpster had a right-side top cover that was broken and open exposing trash. 3. On 3/20/25 at 8:00 a.m., a surveyor observed a dumpster had a right-side top cover that was broken and open exposing trash. On 3/19/25 at 7:45 a.m., during an interview, the [NAME] stated the dumpsters are always supposed to be closed, but one of them has had a broken flap for a couple of weeks and she's not sure what they are doing about it. On 3/20/25 at 1:00 p.m., in an interview, the Administrator confirmed the findings.

Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 5 of 7 sampled residents reviewed for respiratory (Resident #[R] R15, R20, R21, R41 and R44). Findings: 1. Review of R20's Preadmission Screening and Resident Review (PASRR) level II dated 2/25/25 revealed [he/she] has a Mental health disability and is qualified for Specialized services: You will need to be provided the following specialized services: Service or Support: Initial psychiatric evaluation to determine diagnosis and develop plan of care. Review of R20's clinical record lacked evidence this was done. Review of R20s clinical record revealed order with start date of 2/13/25 states. Is resident free from side effects of psychotherapeutic medications? (if no, document side effects in PN) every shift AND as needed. Review of R20's care plan updated 2/13/25 states is at risk for complications related to the use of psychotropic drugs Medication as ordered. Resident will have the smallest most effective dose without side effects for 90 days. Monitor for side effects and consult physician and/or pharmacist as needed Review of R20's medication orders lacked evidence that R20 had any psychotropic medication orders. During an interview on 3/20/25 at 3:3:24 p.m., the [NAME] Unit Manger (JUM) reviewed R20's active orders and confirmed there was no order placed for psyche services, and R20 was not taking any psychotropic medicines. 2. Review of R21's active provider orders for March 2025 revealed order with start date of 10/30/24 to Please give patient 4 duo nebs to room daily for his own QID use every day shift. And order with start date of 4/17/24 for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally two times a day for sob Ok to have inhaler by bedside. Review of R21's Self -Administration of Medications Evaluation dated 9/20/23 states: What type(s) of medications has the patient requested to self-administer? :Nasal Saline Further review of clinical record lacked evidence that a self-administration evaluation was completed for R21 for the use of duo nebs or inhaler. Review of R21's care plan updated 1/7/24 states Self-administration of medication, saline nasal spray, seasonal allergies. Patient will correctly and safely. Self-administer medication. Ensure availability/adequate supply of medication(s) for self-administration. Ensure patients ongoing functional and cognitive skills permit continued safe medication self-administration. Observe for indications of the patient skipping doses or refusing to take medication. Review of clinical record lacked evidence that R21 was assessed to self-administer duo nebs or inhaler. During an observation on 3/20/25 at 12:00 p.m., Resident R21 was observed in [his/her] room, and was holding a nebulizer pipe in [his/her] lap. At this time R21stated he/she keeps [his/her] duo nebs and inhaler in [his/her] desk and uses them when [he/she] needs to. At this time R21 opened his/her desk draw and pointed to [his/her] medications. R21 stated the last time [he/she] used the inhaler was this morning and just finished a nebulizer treatment. When asked how long [he/she] has kept the medications in [his/her] room R21 replied It's been a while. During an interview on 3/20/25 at 12:09 p.m., the [NAME] Unit Manger (JUM) reviewed R21's clinical record and confirmed it did not contain evidence he/she was assessed for use of duo neb or inhaler. The above was discussed with the Market Clinical Advisor (MCA) on 3/20/25 at approximately 1:00 p.m. 51669 Review of Falls Management policy, revised 3/15/24, states, . in the event a fall occurs, an assessment will be completed to determine possible injury . Document circumstances of the fall, post-fall assessment, and patient outcome . 3. Resident #44 has diagnoses to include repeated falls. Review of Resident #44's clinical record revealed he/she sustained a fall on 11/14/24, 11/22/24, and 3/8/25 and lacked evidence that a post-fall fall risk assessment was completed following the falls. During an interview on 3/20/25 at 11:05 a.m. Registered Nurse (RN) #4 stated after a resident falls, a post-fall risk assessment is completed. During an interview on 3/21/25 at 1:38 p.m., the finding was discussed with the Director of Nursing, the Administrator, and the Market Clinical Advisor. At this time, the Director of Nursing reviewed Resident #44's entire clinical record and confirmed that it lacked evidence of a post-fall fall risk assessment for the above falls. 4. Resident #15 diagnoses include anxiety, Bipolar disorder, and psychotic disturbance. Review of Resident #15's active physician orders revealed: -Order with a start date of 3/18/25 for Seroquel 100mg oral tablet, give 1 tablet by mouth one time a day for bipolar d/o [disorder] with agitation - Order with a start date of 2/1/25 for Quetiapine Fumarate Oral Tablet 300mg, give 1 tablet by mouth at bedtime for psychosis Review of Review of Resident #15's Care plan, updated on 2/25/25, revealed, Resident is at risk for complications related to the use of psychotropic meds .Monitor for side effects . Further review of the clinical record lacked evidence of monitoring for side effects for the above medications. 5. Resident #41 has diagnoses to include End Stage Renal Disease (ESRD) and is dependent on dialysis. Review of Resident #41's Care Plan, updated 2/26/25 includes, Central tunneled jugular dialysis catheter for ESRD and dialysis Review of Resident #41's active physician orders revealed: -Order with a start date of1 2/10/24 for, Transfer to hemodialysis unit .on MWF [Monday, Wednesday, Friday] for treatment -Order with a start date of 2/25/25, Do not shower while still on tunneled dialysis catheter in place. Record review revealed a nursing progress note, dated 3/15/25, states, Patient had shower today. Skin assessment done . Review of Resident #41's bathing task revealed he/she received a shower on 3/10/25 and resident refused a shower on 3/15/25. Review of the nursing documentation on the March 2025 Treatment Administration Record (TAR) indicates Resident #41 has not received a shower during the month of March. During an interview on 3/21/25 at 1:42 p.m., the above findings were confirmed with the Director of Nursing.

Based on record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification dated 2/1/24, were effective. The Federal citations F584, F625, F656, F689, F725, F842 and F880 were cited again during the annual Long Term Care Recertification Survey dated 3/24/25. Findings: During the Annual Long Term Care Survey Process for Federal Recertification dated 3/24/25, it was determined that F584, F625, F656, F689, F725, F842 and F880 would be recited for the same reasons: F584 for failure to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment; F625 failure to issue a written bed hold notice to include cost of care to the Resident and/or resident representative; F656 for failure to implement a comprehensive person-centered care plan; F689 for failure to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured; F725 for failure to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents; F842 for failure to ensure that clinical records were complete and contained accurate information and F880 for failure to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases. On 3/24/25 at 12:28 p.m., during an interview, the above findings were discussed with the Administrator.

Based on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative were provided with written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, was completed for 2 of 22 residents reviewed for advanced directives. (Residents #27, and #79) Findings: 1. Resident #27 was admitted to the facility in 10/2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. On 3/19/25 at 11:56 a.m., in an interview, the Market Clinical Advisor confirmed that medical records lacked evidence that the facility offered or reviewed with the residents and/or resident representatives or that the residents and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 51669 2. Resident #79 was admitted in February 2025. Social Services assessment, dated 2/14/25, states, .Resident Rights/Healthcare Decision Making/Advance Directives .Resident unable to hear or communicate with staff, trying to reach spouse Further review of the clinical record lacked evidence that the facility offered or reviewed with the resident and/or resident representative, or that the resident and/or resident representative were provided, written information concerning the right to formulate an advanced directive. On 3/18/25 at 9:02 a.m., during an interview, Resident #79 stated he/she is severely hard of hearing, even with hearing aids in, and cannot read well. On 3/19/25 at 11:32 a.m., during an interview, the finding was reviewed with the Market Clinical Advisor. On 3/19/25 at 12:47 p.m., during an interview, the Director of Social Services stated he might have spoken to Resident #79's spouse a couple weeks ago about formulating an advanced directive but did not document the conversation. Further review of Resident #79's clinical record lacked evidence of the conversation.

Based on observations and interviews, the facility failed to ensure a safe environment by allowing access to a potentially unsafe environment on 1 of 3 units observed for ([NAME] House). Findings: On 5/28/24 at 8:21 a.m., During an initial observation of [NAME] small dining room, 2 surveyors observed a large hole in the ceiling with an obvious leak. A yellow plastic wet floor sign was under the hole. A yellow mop bucket was approximately 4 feet away from the sign containing about 4 inches of dirty water. There were no barriers noted to prevent access to this area. Follow-up observations of [NAME] House small dining room on 5/28/24 between 9:45 a.m., and 3:45 p.m. revealed the following: -On 5/28/24 at 9:45 a.m., during a follow up facility, Ombudsman indicated the ceiling in [NAME] small dining room has been leaking for quite some time and she is not aware of the current plan for repair. At this time Resident #6 was observed self-ambulating in wheelchair and grabbing yellow mop bucket containing dirty water and Resident #7 was observed using walker wandering around in [NAME] small dining room, walking under the hole in the ceiling. Multiple staff walking under hole to refrigerator. -Observation 5/28/24 at 11:42 a.m., Resident #6 was observed self-ambulating in his/her wheelchair in [NAME] small dining room, under hole in ceiling. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) 5 of 15 indicating severe cognitive impairment. -Observation 5/28/24 at 11:45 a.m., Resident #7 was observed self-ambulating with walker in [NAME] Small dining room. Review of quarterly MDS revealed BIMS of 0 of 15 indicating he/she had severe cognitive impairment. -Observation on 5/28/24 at approximately 3:45 p.m., Resident #7 was again observed wandering in [NAME] small dining room under the hole in the ceiling, Multiple staff members were observed to be walking under it past the yellow hazard sign to go into refrigerator. During an interview on 5/28/24 at 8:17 a.m., Clinical Research Coordinator (MDS) indicated the leak has been there for quite a while and they are getting estimates to have it fixed. MDS further indicated they have not been allowing residents in the dining room for safety reasons. During an interview on 5/28/24 at 8:52 a.m., Maintenance Director indicated that the leak has been there since January 2-24 and the company is making him get 3 estimates, they currently have 2 and have been having a difficult time getting a third. Maintenance Director confirmed there were no barriers put into place to prevent access to this area. During an interview on 5/28/24 at 3:56 p.m., Registered Nurse (RN)2 was asked if there was a reason why the dining room was deemed not safe for residents to eat in it, but they continued be able to sit or walk under the hole/leak or why staff continued to use the refrigerator in that area. RN2 indicated that it had been that way for quite a while and confirmed that it was unsafe for residents and staff to go in that area. At this time RN2 and another staff member made an effort to block the area. During an interview on 2/28/24 at 3:50 p.m., Director of Nursing (DON) indicated that the hole/leak had been there for approximately 6 weeks, and they were in the process of getting bids to repair it. DON further indicated that they had discussed blocking the area off but thought that the residents with dementia wouldn't understand and would try to get through it, which could potentially cause an accident. 50218

Based on observations, interviews and review of the Logbook Documentation for 'Water Temps', the facility failed to ensure that hot water temperatures, accessible to residents, did not exceed 120 degrees Fahrenheit in 16 of 23 resident rooms tested . The failure of the facility to lower hot water temperatures when the log for 2/9/18, 2/16/18, 2/23/18, 3/2/18 and 3/9/18 indicated temperatures exceeding 120 degrees Fahrenheit on the Wyeth, Millay and Jewett Units, created the potential for resident's to be burned by the domestic hot water. This resulted in Immediate Jeapordy. Findings: On 3/12/18 from 3:54 p.m. to 4:10 p.m., surveyors measured and observed hot water temperatures in the following rooms: Hot water temperature of 122.8 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 123.1 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 121 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 122 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 120.9 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 121.8 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 121.8 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 121.3 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 121.7 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 121.5 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 120.8 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 120.7 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 123.3 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 120.5 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 122.4 degrees Fahrenheit in Resident room [ROOM NUMBER] Hot water temperature of 121.1 degrees Fahrenheit in Resident room [ROOM NUMBER] On 3/12/18 at 4:26 p.m., in an interview with the Director of Nursing, she indicated that she was not aware that the facility's hot water temperature was over 120 degrees Fahrenheit. On 3/12/18 from 4:26 p.m. to 4:29 p.m., the surveyor along with the Director of Nursing, measured and observed hot water temperature of 123.8 degrees Fahrenheit in room [ROOM NUMBER] and a hot water temperature of 124.2 degrees Fahrenheit in room [ROOM NUMBER]. In a review of the facility water temperature log dated 1/29/18, the log contained water temperatures below 120 degrees Fahrenheit. In review of the facility water temperature logs dated 2/9/18 to 3/9/18, the logs contained water temperatures exceeding 120 degrees Fahrenheit. On 3/12/18 at 5:08 p.m., in an interview with the facility Maintenance Supervisor, he indicated that he thought that the water temperatures could not be over the 120 point something range and that once it reached 121 then it was over the regulation temperature. He indicated that when the water temperature is close to 120 then he tries to lower the water and rechecks the temperature. The Maintenance Supervisor confirmed that he lacked documentation of his attempts to lower the temperature or rechecks of the temperature after a temperature adjustment. The facility Maintenance Supervisor indicated that he turned the water temperature down 12 degrees prior to this interview. On 3/12/18 from 5:15 p.m. to 5:23 p.m. a surveyor tested the water temperatures and they were found to below 120 degrees Fahrenheit.