Every finding on record at Orono Commons

Based on review of Payroll Based Journal Report, facility schedules with census, review of timecards, 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 1 of 4 quarters reviewed (2nd quarter). This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Review of Payroll Based Journal staffing report revealed the facility triggered for excessively low weekend staffing during the second quarter of 2026 (January 1 - March 31). On 7/1/26 at approximately 12:45 p.m., during an interview with the Administrator and a surveyor, the staffing schedules, census numbers, and time cards were reviewed for the second quarter of 2026. On Sunday, 3/1/26, the facility had a census of 80 residents, which required 16 direct care staff to be on duty and providing hands-on care during the entire day shift. A review of the daily census and staffing schedules indicated that there were 14 direct care staff on duty for the entire day shift. On Saturday, 3/14/26, the facility had a census of 78 residents, which required 16 direct care staff to be on duty and providing hands-on care during the entire day shift. A review of the daily census and staffing schedules indicated that there were 14 direct care staff on duty for the entire day shift. On Sunday, 3/15/26, the facility had a census of 76 residents, which required 16 direct care staff to be on duty and providing hands-on care during the entire day shift. A review of the daily census and staffing schedules indicated that there were 14 direct care staff on duty for the entire day shift. On Saturday, 3/28/26, the facility had a census of 73 residents, which required 15 direct care staff to be on duty and providing hands-on care during the entire day shift. A review of the daily census and staffing schedules indicated that there were 14 direct care staff on duty for the entire day shift. During this review, the surveyor confirmed the facility did not ensure enough staff were on duty to meet resident needs on the weekends.

Based on record reviews and interviews, the facility failed to follow provider orders and ensure a resident's medical choices in accordance with professional standards for a resident who experienced a medical emergency (Resident #69 [R69]). Additionally, the facility failed to complete neurological assessments after an unwitnessed falls for 1 of 4 residents reviewed for falls (Resident #10 [R10]).Findings:1. On [DATE] at 11:11 a.m., during an interview with a surveyor, R69 stated he/she has had watery stools for the past couple weeks.On [DATE], review of R69's clinical record indicated the following:-Review of the bowel elimination record (30-day look back from [DATE] through [DATE]) indicated R69 had loose or watery stools for a total of 19 out of 24 days:R69 had loose or watery stools on 13 out of 15 days in June ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]).R69 had loose or watery stools on 6 out of 8 days in July ([DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]). R69 was hospitalized from [DATE] through [DATE] (6 days total).-Review of R69's Order Summary included the following orders:Loperamide 2 milligrams (MG) Tablets, dated [DATE], with direction to Give 1 tablet by mouth every 6 hours as needed(prn) for loose stools. Pink Bismuth Suspension 262 MG/15 [milliliters (ML)], dated [DATE], with directions to Give 30 ml by mouth every 4 hours as needed(prn) for diarrhea.-Review of the Medication Administration Record (MAR) indicated:R69 did not receive Loperamide for loose stools in the month of July per order.R69 did not receive Loperamide for 10 out of 13 days that R69 had loose or watery stools in the month of June.R69 did not receive a dose of Pink Bismuth for diarrhea as ordered on the days R69 had loose or watery stools in the month of July.R69 did not receive Pink Bismuth for 12 out of 13 days that R69 had loose or watery stools in the month of JuneOn [DATE] at 8:04 a.m., during an interview with a surveyor and the Licensed Practical Nurse (LPN) R69's clinical record was reviewed. At this time, the surveyor confirmed that R69 was not provided with prn(as needed) loperamide or Pink Bismuth per provider orders, to treat his loose/watery stools.2. On [DATE] at 4:02 p.m., the State Department received a complaint alleging that staff were attempting to coerce R69 to sign a Do Not Resuscitate (DNR) while in an impaired mental state after a several minute long loss of unconsciousness.Review of R69's medical record revealed the following:-On [DATE], R69 had an order for FULL CODE (perform cardiopulmonary resuscitation[CPR]). R69 signed a Physicians Orders for Life Sustaining Treatment (POLST) form on [DATE] indicating he/she wants Full Treatment to include CPR, transfer to a hospital if indicated, and intensive care.-On [DATE], review of the transfer discharge notice and bed hold notice indicated R69 transferred to the emergency room by ambulance as the Resident needs cannot be met by the facility. These notices were not signed by R69.-R69's medical record contained, a POLST form indicating DNR, signed by the provider but not R69 and back dated to [DATE], and inaccurate / incomplete records regarding vital signs and transfer information (See F842).On [DATE], the EMS Patient Care Report (PCR) revealed the following:-At 11:31 a.m., EMS arrived at R69's bedside. Staff reported to EMS that R69's baseline was loud, interactive, and his/her own Power of Attorney. Following a syncopal episode [a temporary loss of consciousness and muscle control. It occurs when a sudden drop in blood pressure or heart rate briefly reduces blood flow to the brain], patient was somnolent (feeling sleepy, drowsy, or inclined to fall asleep) and more confused than normal, unable to reliably answer questions. Primary assessment reveals. patient is unable to remember [his/her] age, the year, or how many quarters make a dollar. Deemed unreliable by EMS assessment. staff asks patient if [he/she] would like to change [his/her] DNR status. When handing DNR to EMR to have patient sign, EMS declines as patient is deemed unreliable by EMS assessment and facility report.-At 11:43 a.m., R69's blood pressure was 75/53 mm Hg (millimeters of mercury), indicated R69 was hypotensive (abnormally low blood pressure, typically reading below 90/60 mm Hg, that can cause symptoms like dizziness and fainting when the brain doesn't receive enough blood. In severe cases, it can indicate life-threatening conditions like shock).-At 11:47 a.m., R69's blood pressure was 83/61 mm Hg.-At 11:55 a.m., R69's blood pressure was 80/56 mm Hg.-At 11:57 a.m., EMS departed the facility with R69.On [DATE], a surveyor reviewed the following written, witness statements:-The Director of Nursing (DON)'s witness statement, dated [DATE], stated that on [DATE] a Registered Nurse/Unit Manager (RN/UM) told her that R69 was unresponsive and may need CPR. On arrival to R69's room, the DON stated R69 looked pale and diaphoretic, but the DON did not remain in the room as there were several others attending R69 including the Advance Practice Registered Nurse (APRN). She saw a Licensed Practical Nurse (LPN) walking down the hallway after they called [Emergency Medical Services (EMS)], and heard the resident identify [his/her] name and date of birth . The last thing she heard was staff asking [R69] can you squeeze my fingers.-On [DATE] the APRN signed a late entry progress note for [DATE] at 11:36 a.m. that stated R69's chief complaint was Altered Mental Status (AMS, a broad range of changes in a patient's baseline cognition, awareness, or consciousness). The progress note indicated Code status: FULL CODE. The provider's physical exam stated, General: .sitting upright in [wheelchair (WC)], awake but does not respond to questions. Skin: diaphoretic. Neuro: . Pt awake, eyes open does track, but does not follow directions or answer questions. Psych: not responding to questions. 911 called, by time EMS arrived [patient (pt)] was conversing, but still slightly obtunded [a dulled or reduced level of alertness. An obtunded patient is drowsy and requires repeated verbal or gentle tactile stimulation to awaken. When awake, they may appear confused, have a slowed reaction time, and quickly drift back to sleep]. Writer left room when EMS arrived, per nursing [he/she] initially declined to [emergency room (ER)] transport. RN came to inform this writer, by time got back to room pt had agreed to go ER and EMS was in process of preparing to transport.-Certified Nursing Assistant (CNA2)'s witness statement, undated, stated, When EMS arrived, the patient was responsive. Initially, the patient refused evaluation and transport to the local hospital. As time progressed the patient agreed to be evaluated at the hospital and expressed willingness to sign DNR paperwork. [RN/UM], went to speak with the provider regarding the patient's DNR status. When [RN/UM] returned, the patient remained responsive, alert, and willing to sign the DNR paperwork. At that time one member of the EMS crew stated, .I will not let [R69] sign that.-The Registered Nurse/Unit Manager (RN/UM)'s witness statement, dated [DATE], stated, at [11:24 a.m.] I received a phone call from my charge nurse.[R69] is now clammy, not very responsive with eyes rolling in the back of [his/her] head. I told [the charge nurse] to call 911., RN/UM confirmed in her statement that she discussed changing R69's code status while EMS was at the bed side and brought R69 the DNR documentation to sign. On returning to the room, EMS intervention prevented R69 from signing the document due to R69's altered mental status.On [DATE] at 9:00 a.m., during an interview with a surveyor and the Clinical Market Director, R69's clinical record and the facility's internal investigation were reviewed. At this time, the surveyor confirmed with Clinical Market Director that the medical record contained inaccurate and incomplete documentation (See F842) and that the facility attempted to pressure R69 to change his/her code status when he/she was experiencing a medical emergency and unable to give informed consent.3. On [DATE], R10's clinical record was reviewed for falls. The clinical record indicated that R10 experienced an unwitnessed fall on [DATE], [DATE], [DATE], and [DATE]. The clinical record lacked evidence that Neurological Assessments were completed.On [DATE] at 9:56 a.m., during an interview with a surveyor and a Licensed Practical Nurse (LPN), R10's clinical record was reviewed. The LPN was unable to determine when the resident fell, the circumstances around the fall, or what time R10 transferred to the hospital (F842). The LPN stated that neurological assessments must be restarted with each unwitnessed fall. At this time, the surveyor confirmed with the LPN that neurological assessments were not completed after unwitnessed falls.On [DATE] at 10:23 a.m., during an interview with a surveyor, the Market Clinical Lead stated that the facility had identified that completion of neurological assessments was a problem and developed a Performance Improvement Project (PIP) but had not implemented the PIP prior to survey. At this time the surveyor confirmed this finding with the Market Clinical Lead.

Based on record reviews and interviews, the facility failed to ensure that residents residing in the facility were free from neglect when residents were denied incontinence care during mealtimes for 4 of 4 residents reviewed/interviewed.Findings:On 8/17/25, a family member completed an online complaint regarding the care of their father/mother. It was stated that R87 was left soiled (incontinent) for 4 hours and that staff had told R87 they would come back to help but did not return.On 7/12/26 at 12:35 p.m., during a tour of the Homestead unit, residents were observed sitting around the area staff called the breakfast bar. A resident was heard asking to use the bathroom, staff did not respond to him/her they stating they were not able to provide personal care during meal service. The resident asked 2 additional times to go to the bathroom, the surveyor asked if anyone was going to assist him/her. With surveyor intervention a CNA then said she can help him/her. On 7/14/26 at 7:30 a.m., during a review of a facility reported incident and the review of the facility's complete investigation for R87, the facility failed to provide incontinence care to R87 during a supper meal.A transcribed statement from R87 states that he/she was incontinent with bowel and staff were busy and short-staffed and was not provided with incontinence care.Written statements from the CNA,s who worked on that day documented that it was during a meal pass (supper meal service starts at 4:30 p.m.) and the CNA assigned to care for R87 mentioned that R87 needed to be changed. The CNA who was assigned to R87 was seen going to assist R87 at approximately 7:00 or 7:30 p.m., almost 3 hours after he/she requested incontinence care.The written statement from the CNA who was assigned to care for R87 wrote that at approximately 5:30 p.m. while giving R87 their supper tray R87 had stated they needed to be changed (provided incontinence care) and the CNA informed R87 that it would be a while before he could assist R87 because he was told he could not perform personal care during mealtimes.R87 waited for assistance while sitting in a brief with a bowel movement from 4:30 until 7:30 p.m., he/she was sitting for 2-3 hours in a soiled brief because they are not allowed to stop meal service for any personal careOn 7/14/26 at 9:00 a.m., during an interview with an anonymous staff, he/she stated if a resident needs help during mealtimes we are not allowed to stop meal service for any personal care. If they call and want more drinks, they have to wait until all trays are passed and the feeders are helped. On 7/14/26 at 11:05 a.m., during a Resident Council meeting with R47, R43 and R5 in attendance, they stated that they all like to stay dry and fresh and when they are incontinent and have to stay in it for 1 to 2 hours it's not comfortable and it's embarrassing. During meals they have been told they are not allowed to help us change or go to the bathroom until they are done passing meal trays. R5 then stated that he/she had to pee so badly the nurse came in but left to get the CNA, when the CNA came in R5 was so upset and the CNA told him/her she was passing trays first then she came to help him. On 7/14/26 at 12:50 p.m., during an interview with the Administrator and the Clinical Market Lead, they stated the incident occurred during meal service, and we have to serve hot meals, so we need them (staff) to pass trays first. At this time the surveyor confirmed that R87 and other residents are not assisted with incontinence care in a timely manner and that the facility's practice is not to provide personal care/hygiene/incontinence care during meal services.

Based on record reviews and interviews, the facility failed to ensure that clinical records contained accurate and complete information in the areas of neurological assessments, transfer forms, resident falls, vital signs, Physician's Orders for Life Sustaining Treatment (POLST) forms, documentation regarding provider ordered medications, documentation for treatments provided, documentation for meal intake, and Bed Hold Notice Forms for 5 of 22 sampled residents (Resident #10 [R10], R69, R4, R24, and R43). Findings: 1. The Falls Management Policy, last revised [DATE], states under the Post-Fall Management: 5.3 Any patient who sustains an injury to the head from a fall and/or has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check, per policy. Neurological Assessments (Neuros) on the Neurological Evaluation Flow Sheet evaluate: Level of Consciousness (Alert, Drowsy, Stuporous, or Comatose), Orientation (person, place, time), Follows Simple Commands (yes or no), Sensation / Response to Pain (normal, unusual, or no response), Pupils response to light, Motor function (able to move limbs equally), Vital Signs (Temperature, Pulse, Respirations, and Blood Pressure), and Change from Resident's Baseline (yes or no). These assessments are to be completed every 15 minutes for First 2 Hours after the initial evaluation, then every 30 minutes for 2 hours, then every hour for 4 hours, and then every 8 hours for at least 64 additional hours. On [DATE], review of R10's clinical record indicated the following: -On [DATE] at 1:00 a.m., a progress note stating, nurse reporting unwitnessed fall, no injury but [patient(pt) complaint of (c/o)] low [back] pain. Pt has full [range of motion (ROM)], no head strike. Second call: Nurse reporting unwitnessed fall this morning with internal rotation left leg with hip pain. Lumbar xray was previously ordered. This visit was conducted on [DATE] [at] 05:09 a.m. Second call visit was conducted on: 6/626 [at] 9:20 [a.m.]. The time of the progress note (1:00 a.m.) occurs prior to the time of the reported first call (5:09 a.m.) and the second call (9:20 a.m.). It was unclear if the second call was for a second fall or a follow up to the initial fall. -Review of R10's Neurological Evaluation Flow Sheet indicated that on [DATE] at 4:45 p.m., R10 had an unwitnessed fall. Neuros initiated at 4:45 a.m. were incomplete (pulse and respirations not documented). All neuro assessments required for the first 2 hours were missing documentation of pulse and respirations. Additionally, all 30-minute neuros were missing documentation of all vital signs. Neuros completed at 8:15 a.m., and 8:45 a.m., indicated that R10 had a change from baseline but the clinical record lacks evidence of what the change from baseline was. At 9:00 a.m. the flow sheet states, Sent to [emergency room (ER)] for eval. -Review of the [Skilled Nursing Facility (SNF)/Nursing Facility (NF)] Transfer Form for transfer on [DATE] indicates the transfer vitals were taken at 9:13 a.m. on [DATE], and that the date of R10's transfer to the ER was [DATE] 02:48 [a.m.]. The nurse-to-nurse report for the transfer occurred [DATE] 10:29 [a.m.]. -On [DATE] at 9:51 a.m., a Transfer Note states, Note: [R10] was transferred to Sent to: [hospital] Date:[DATE] 2:48 Sent From: [facility] for Transfer: Fall. The clinical record contained incomplete documentation regarding post fall assessments, and inaccurate documentation regarding when the resident was transferred to the hospital following the unwitnessed fall on [DATE]. -On [DATE] at 12:58 a.m., a Change in Condition Evaluation stated that R10 had a fall on [DATE], vital signs were obtained at 12:36 a.m. on [DATE] following the fall, and that R10 was experiencing back pain. The Change in Condition Evaluation states family / resident representative was notified on 06/0326 at 01:20 [a.m.] (7 days before the fall). -Review of the neurological evaluation flow sheet indicated that R10 had an unwitnessed fall on [DATE] at 12:30 a.m., and neuros initiated at that time. Neurological Evaluations following the initial assessment were incomplete for 7 out of 8 of the 15-minute reassessments (missing vital signs and change from baseline assessment documentation), all 4 of the 30-minute reassessments were missing vital signs and change from baseline documentation, all 4 of the hourly reassessments were missing vital signs and change from baseline documentation. -On [DATE] at 8:45 p.m., R10 had an unwitnessed fall. Review of the neurological evaluation flow sheet indicated that neuros were restarted at that time. Neurological Evaluations following the initial assessment were incomplete for 5 out of 8 of the 15-minute reassessments (missing Vital Signs), 2 out of 4 the 30-minute reassessments were incomplete (missing Vital Signs), 3 out of the 4 hourly reassessments were incomplete (missing Vital Signs), and 3 out of 8 of the 8-hour neuro reassessments were incomplete (missing Vital Signs). -On [DATE] at 8:45 p.m., R10 had an unwitnessed fall. Review of the neurological evaluation flow sheet indicated that neuros were initiated at that time. 2 out of the total 25 required neuro reassessments were incomplete. The initial assessment was inaccurately documented as a 15-minmute reassessment, and the 8-hour reassessment due on [DATE] at 4:15 p.m., was not completed. On [DATE], review of Fall Incidents on the facility Incident by Incident Type indicated R10 had a fall on [DATE] at 4:45 a.m., [DATE] at 8:45 p.m., and [DATE] at 3:30 p.m. The facility report did not capture the fall on [DATE]. On [DATE] at 9:56 a.m., during an interview with a surveyor and the Licensed Practical Nurse (LPN), R10's clinical record was reviewed. The LPN stated, this makes no sense. LPN was unable to determine when R10 fell on [DATE] or if there was more than one fall, the circumstances around the fall, or what time R10 transferred to the hospital on [DATE]. Additionally, the surveyor confirmed with the LPN that the neuros were not completed after unwitnessed falls and stated that neuros must restart with each unwitnessed fall. On [DATE] at 10:23 a.m., during an interview with a surveyor and the Market Clinical Lead, R10's clinical record was reviewed. At this time the surveyor confirmed the clinical record contained inaccurate and incomplete information regarding R10's unwitnessed falls, R10's transfer to the hospital, and follow up neurological assessments. The Market Clinical Lead stated they had identified that neuros were a problem and made a Performance Improvement Plan, but it has not been implemented yet. 2. On [DATE], review of R69's clinical record indicated the following: -On [DATE], R69 was transferred to the emergency room. The Bed Hold Notice dated [DATE] was incomplete (did not identify how long the bed would be held for) and was unsigned by the Resident/Resident Representative. -Review of the Transfer Form indicated that R69 transferred to the hospital on [DATE] at 11:50 a.m. for Altered Mental Status, the Transfer Form vital signs are documented as taken at 2:58 p.m. (3 hours after the resident left the facility). Additionally, the vital signs are inconsistent with vital signs obtained and documented by the Emergency Medical Services at the time of transfer. -Review of R69's Medication Administration Record and Treatment Administration Record indicated that R69 did not receive medications as ordered for loose / watery stools (See F684). There was no documentation in the clinical record for why the medications were not administered as ordered. -On [DATE], a surveyor observed in R69's paper chart, a POLST form signed by R69 on [DATE] indicating he/she wants Full Treatment to include cardiopulmonary resuscitation (CPR), transfer to a hospital if indicated, and intensive care. Additionally, R69's medical record contained an incomplete POLST form indicating do not resuscitate (DNR), signed by the provider but not R69 and dated [DATE] (See F684). On [DATE] at 9:00 a.m., during an interview with a surveyor and the Clinical Market Director, R69's clinical record was reviewed. At this time, the surveyor confirmed with Clinical Market Director that the medical record contained inaccurate and incomplete documentation. 3. On [DATE], R4's clinical record was reviewed. The Treatment Administration Record (TAR) for July lacked evidence of documentation for 9 treatments completed or attempted by Licensed staff for [DATE]rd day shift. On [DATE] at 7:40 a.m., during a review of the TAR with the Director of Nursing (DON), a surveyor confirmed this finding. 4. On [DATE], R43's clinical record was reviewed for a nutrition concern because R43 was experiencing some weight loss. The surveyor observed that meal intake documentation was missing for 12 out of 99 of June meals and 6 of 52 meals July thru the 14th. On [DATE] at 10:24 a.m., during an interview with the DON, a surveyor confirmed the missing intake documentation. 5. On [DATE], R24's clinical record was reviewed for a nutrition concern because R24 was experiencing some weight loss. The surveyor observed that meal intake documentation was missing for 8 out of 46 of June meals and 2 of 24 meals for July thru the 14th. On [DATE] at 10:24 a.m., during an interview with the DON, a surveyor confirmed the missing intake documentation.

Based on record review and interview, the facility failed to follow physician orders by not checking vital signs prior to administration of blood pressure medications or administered blood pressure medications when they were outside of physician ordered parameters for 4 of 4 blood pressure medications reviewed with parameters for Resident #1. Findings:On 1/13/26 at 11:50 a.m., the Administrator and surveyor reviewed R1's physician orders for blood pressure medications and the documentation in the vital signs record and Medication Administration Record (MAR) for December 2025 for R1. The following were confirmed during this review:1. A physician order, dated 12/10/25, for Carvedilol directed staff to hold this medication if systolic blood pressure (SBP) was less than 110 or if heart rate was less than 60. This medication was ordered to be given once between 7 a.m.- 12 p.m. and once between 4 p.m. - 10 p.m. It was noted that between 12/10/25 - 12/23/25, blood pressure and pulse were not documented on the MAR. -On 12/11/25, documentation in the vital signs record indicated that the SBP was 90 at 6:49 p.m. The MAR was documented to indicate the medication was given.-On 12/12/25, documentation in the vital signs record indicated that the SBP was 95 at 8:52 p.m. The MAR was documented to indicate the medication was given.-On 12/13/25, documentation in the vital record indicated that the SBP was 98 at 8:36 a.m. The MAR was documented to indicate the medication was given.-On 12/14/25, there was no documented SBP between 4 p.m. - 10 p.m., however the MAR was documented to indicate the medication was given. -On 12/15/25, there was no documented SBP between 7 a.m. - 12 p.m., however, the MAR was documented to indicate the medication was given. Documentation in the vital signs record indicated that the SBP was 109 at 6:41 p.m., however the MAR was documented to indicate the medication was given.-On 12/17/25, documentation in the vital signs record indicated that the SBP was 95 at 10:35 a.m., however the MAR was documented to indicate the medication was given. There was no documented SBP between 4 p.m. - 10 p.m., however the MAR was documented to indicate the medication was given. -On 12/18/25, there was no documented SBP between 4 p.m. - 10 p.m., however the MAR was documented to indicate the medication was given. -On 12/19/25, there was no documented SBP between 7 a.m. - 12 p.m., however the MAR was documented to indicate the medication was given. -On 12/20/25, documentation in the vital signs record indicated that the SBP was 105 at 9:08 a.m., however the MAR was documented to indicate the medication was given. Documentation in the vital signs record indicated that the SBP was 90 at 8 p.m., however the MAR was documented to indicate the medication was given. -On 12/21/25, there was no documented SBP between 7 a.m. - 12 p.m., however the MAR was documented to indicate the medication was given. Documentation in the vital signs record indicated that the SBP was 104 at 8:20 p.m., however the MAR was documented to indicate the medication was given. -On 12/22/25, documentation in the vital signs record indicated that the SBP was 103 at 9:34 a.m., however the MAR was documented to indicate the medication was given. There was no documented SBP between 4 p.m. - 10 p.m., however the MAR was documented to indicate the medication was given. -On 12/23/25, documentation in the vital signs record indicated that the SBP was 86 at 10:12 a.m., however the MAR was documented to indicate the medication was given. Documentation in the vital signs record indicated that the SBP was 85 at 7:15 p.m., however the MAR was documented to indicate the medication was given. 2. A physician order, dated 12/18/25, for Diltiazem directed staff to hold this medication if systolic blood pressure (SBP) was less than 110 or if heart rate was less than 60. This medication was ordered to be given once between 7 a.m.- 12 p.m. It was noted that between 12/18/25 - 12/23/25, blood pressure and pulse were not documented on the MAR. -On 12/19/25, there was no documented SBP between 7 a.m. - 12 p.m., however the MAR was documented to indicate the medication was given. -On 12/20/25, documentation in the vital signs record indicated that the SBP was 105 at 9:08 a.m., however the MAR was documented to indicate the medication was given. -On 12/21/25, there was no documented SBP between 7 a.m. - 12 p.m., however the MAR was documented to indicate the medication was given. -On 12/22/25, documentation in the vital signs record indicated that the SBP was 103 at 9:34 a.m., however the MAR was documented to indicate the medication was given. -On 12/23/25, documentation in the vital signs record indicated that the SBP was 86 at 10:12 a.m., however the MAR was documented to indicate the medication was given. 3. A physician order, dated 12/10/25, for Enalapril directed staff to hold this medication if systolic blood pressure (SBP) was less than 110 or if heart rate was less than 60. This medication was ordered to be given once between 4 p.m. - 7 p.m. It was noted that between 12/10/25 - 12/23/25, blood pressure and pulse were not documented on the MAR. On 12/11/25, documentation in the vital signs record indicated that the SBP was 90 at 6:49 p.m. The MAR was documented to indicate the medication was given.-On 12/12/25, documentation in the vital signs record indicated that the SBP was 95 at 8:52 p.m. (out of range of the time of 4 p.m. - 7 p.m.), however the MAR was documented to indicate the medication was given. -On 12/14/25, there was no documented SBP between 4 p.m. - 7 p.m., however the MAR was documented to indicate the medication was given. -On 12/15/25, documentation in the vital signs record indicated that the SBP was 109 at 6:41 p.m., however the MAR was documented to indicate the medication was given.-On 12/17/25, there was no documented SBP between 4 p.m. - 7 p.m., however the MAR was documented to indicate the medication was given. -On 12/18/25, there was no documented SBP between 4 p.m. - 7 p.m., however the MAR was documented to indicate the medication was given. -On 12/20/25, documentation in the vital signs record indicated that the SBP was 90 at 8 p.m., however the MAR was documented to indicate the medication was given. - On 12/21/25, documentation in the vital signs record indicated that the SBP was 104 at 8:20 p.m. (out of range of the time of 4 p.m. - 7 p.m.), however the MAR was documented to indicate the medication was given. -On 12/22/25, there was no documented SBP between 4 p.m. - 7 p.m., however the MAR was documented to indicate the medication was given. -On 12/23/25, documentation in the vital signs record indicated that the SBP was 85 at 7:15 p.m., however the MAR was documented to indicate the medication was given.On 12/23/25, documentation in the vital signs record indicated that the SBP was 85 at 7:15 p.m., however the MAR was documented to indicate the medication was given.4. A physician order, dated 12/18/25, for Spironolactone directed staff to hold this medication if systolic blood pressure (SBP) was less than 110 or if heart rate was less than 60. This medication was ordered to be given once between 7 a.m.- 12 p.m. It was noted that between 12/18/25 - 12/23/25, blood pressure and pulse were not documented on the MAR. -On 12/19/25, there was no documented SBP between 7 a.m. - 12 p.m., however the MAR was documented to indicate the medication was given. -On 12/20/25, documentation in the vital signs record indicated that the SBP was 105 at 9:08 a.m., however the MAR was documented to indicate the medication was given. -On 12/21/25, there was no documented SBP between 7 a.m. - 12 p.m., however the MAR was documented to indicate the medication was given. -On 12/22/25, documentation in the vital signs record indicated that the SBP was 103 at 9:34 a.m., however the MAR was documented to indicate the medication was given. -On 12/23/25, documentation in the vital signs record indicated that the SBP was 86 at 10:12 a.m., however the MAR was documented to indicate the medication was given.

Based on observations, facility policy review, interviews, and record review, the facility failed to follow it's own policy after a new pressure ulcer was observed, for 1 of 1 resident reviewed (Resident #1 [R1]). On 12/1/25, a pressure ulcer was observed on R1's right big toe but a treatment/monitoring was not started until 12/9/25, 8 days later. Finding: The facility's policy, Skin Integrity and Wound Management, revised 9/15/25, stated the nursing assistant will observe skin daily and report any changes or concerns to the nurse. The licensed nurse will: evaluate any reported or suspected skin changes or wounds; document newly identified skin/wound impairments as a change in condition; document skin/wound findings on the 24-hour report; perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition; and complete wound evaluation upon admission/readmission, new in-house acquired, weekly, with unanticipated decline in wounds, and at planned discharge. On 12/8/25 at 10:07 a.m., during an interview with a surveyor, a family member stated that a wound to the right big toe was observed during a recent visit. On 12/9/25 at 9:45 a.m., a surveyor and a family member observed a wound to the top of R1's right big toe. The family member stated that she showed a nurse this area this morning and it seems that they were unaware of the wound. A cloth heel protector was observed on R1's right foot; the wound did not look infected or have drainage. On 12/9/25, a surveyor reviewed R1's clinical record; skin documentation and/or foot evaluation was completed on 12/2/25 and 12/4/25 with no mention of any type of wound on the right big toe, and there was no current treatment to the right big toe area ordered or being monitored. On 12/9/25 at 10:35 a.m., the Administrator, Director of Nursing, and surveyor observed R1's wound to the right big toe. The Homestead Unit Manager and Charge Nurse both denied being aware of the wound as they passed by R1's room. On 12/9/25 at 11:03 a.m., during an interview with a surveyor, the Administrator stated that staff that took care of R1 observed the right toe area yesterday but thought it was already a known area to nursing since R1 had an area to the left toe that was being treated (laceration). She stated that education will be done with staff to always report, and this communication to nursing was missed. The Administrator stated that they are working on taking photos and documenting at this time for the right big toe wound. On 12/9/25, a treatment was added twice a day to cleanse the right big toe (Stage II pressure) with wound wash and apply skin prep and to document wound status daily. On 12/22/25 at 10:13 a.m., during an interview with a surveyor, Hospice Registered Nurse (RN) stated that she had spoken to a charge nurse but couldn't remember who about the presence of R1's new pressure injury to the right big toe prior to surveyor's visit on 12/9/25 and that the facility was already aware of the right big toe pressure wound on 12/1/25. On 12/22/25 at 2:39 p.m., during an interview with a surveyor, Registered Nurse #2 (RN2) stated that on 12/1/25, she was asked to take photos of R1's right big toe wound with the tablet. RN2 stated that she was the only one that can see the photo on the tablet by signing in to the tablet, it did not cross over into the clinical record. RN2 completed no additional information in R1's clinical record regarding this wound, therefore no treatment or monitoring was started. On 12/22/25 at 4:11 p.m., during an interview with a surveyor, the Administrator stated that the Director of Nursing reviewed the photo that RN2 took, and it was the new pressure injury on the right big toe. The surveyor confirmed that the process was not followed when a new pressure injury was identified on 12/1/25, when nursing was aware of the new pressure injury and only took a photo and the CNAs who provided daily care from 12/1/25, until the surveyors visit on 12/9/25, did not report this new open area to the charge nurses.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections in the area of Enhanced Barrier Precautions (EBP) and linen handling for 1 of 1 day of survey (12/9/25).Findings:1. The facility's policy, Enhanced Barrier Precautions, revised on 11/14/25, indicated that in addition to Standard Precautions, Enhanced Barrier Precautions (EBP) will be used (when Contact Precautions do not otherwise apply) for novel or targeted multi-drug resistant organisms (MDROs). EBP expands on the use of gown and gloves beyond anticipated blood and body fluid exposures, focusing on use of gown and gloves only during high contact patient care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body exposure is not anticipated.The facility's procedure, Enhanced Barrier Precautions, indicated to follow the Centers for Disease Control (CDC) guidance as indicated per the table in the document. Enhanced Barrier Precautions (EBP) are to be used for any patient with a chronic wound during high contact patient care activities that included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assist with toileting, and device care or use. Personal protective equipment (PPE) to be used included gown and gloves prior to high contact care activity. On 12/9/25, a review of Resident #1's (R1) clinical record was completed and indicated that the resident had current pressure injuries that were being treated. R1's care plan included a FOCUS of: Patient is at risk of chronic infections related to multiple wounds and chronic skin issues and included an intervention of Enhanced Barrier Precautions to be utilized when performing high contact activities that was added on 12/8/25. On 12/9/25 at 11:03 a.m., during an interview with a surveyor while standing in the hallway, outside of R1's closed door to their room, the Administrator stated that staff were working on taking photos and documenting R1's new pressure wound at this time. A sign was observed placed inside of a [NAME] on the door that indicated EBP was needed for someone in this room and the Administrator noted the PPE cart that had been moved down the hallway, probably by another resident that liked to push things. At this time, a Certified Nursing Assistant (CNA) exited the room and went to get some clean linens. The CNA then returned to R1's room, knocked on and opened the door; the Administrator directed the CNA to look at the sign on the door. Additional staff observed at R1's bedside were not wearing the required EBP PPE; after being directed to put on PPE by the Administrator, two CNAs walked down the hallway and put on gowns and brought an additional one back to the room for the other staff member who was not wearing one. 2. The facility's policy, Linen Handling, last reviewed 5/1/25, indicated that all used linen should be handled using standard precautions and treated as potentially contaminated. Used or soiled linen should be collected at bedside (or point of use) and placed in a bag or directly placed in a lined and covered receptacle at the location where removing linen. On 12/9/25 at 11:45 a.m., a surveyor observed a staff member carrying soiled, loose clothing with a strong smell of urine down the Riverview hallway and then returned to the room empty handed. On 12/9/25 at 11:53 a.m., the Director of Nursing (DON) and surveyor observed the unbagged, soiled clothing in a room where the dirty linen cart was kept; at 11:55 a.m., the DON asked Registered Nurse #1 (RN1) if she carried unbagged clothing to the dirty linen cart and RN1 stated that she didn't have any bags to but the dirty linen in.

Based on record review and interviews, the facility failed to ensure that a clinical record contained accurate and complete information for Resident #1 (R1) in the area of level of eating assistance provided for 14 of 24 meals documented between December 1 - 8, 2025. Finding:On 12/9/25, R1's clinical record was reviewed. The care plan included a FOCUS (dated 6/28/24) of: Resident requires/is dependent for Activities of Daily Living (ADL) and the INTERVENTION indicated that R1 was a total assist in the area of eating (last revised on 7/26/24).A surveyor reviewed the meal documentation for December 1st - 8th, 2025 and noted that 14 of the 24 meal opportunities reflected inaccurate or incomplete documentation based on the care plan focus/intervention as follows: (5) meals were blank, (2) meals were documented as supervision, (4) meals were documented as independent, (2) meals were documented as setup, and (1) meal was documented as substantial assist.On 12/9/25 at 1:50 p.m., during an interview with a surveyor, Certified Nursing Assistant stated that R1 was a total assist for eating.On 12/22/25 at 10:17 a.m., during an interview with a surveyor, the Administrator stated that staff know that R1 was a total assist but have documented incorrectly.

2. On 5/4/25 at 11:15 a.m. during an interview with R40, he/she stated their admission date was on 4/10/25 between 5:00 and 6:00 p.m., R40 stated that they were in pain and that no staff came in to see him/her. R40 stated that he/she had to leave their room to find staff late in the night per R40 and ask for pain medication. He/she found the charge nurse and reports that RN told them that there were no written scripts for the pain medications therefore would not be giving R40 any pain medications. During a clinical record review on 5/4/25 the clinical record revealed that R40 arrived at the facility at 5:22 pm. and reported a pain level of 8 out of 10. The clinical record revealed that the resident was admitted for skilled care after a total hip replacement and had orders for pain management using the following medications: Acetaminophen 325 Milligrams (mg) 2 tablets for mild pain every 4 hours as needed, Cyclobenzaprine 10 mg every 8 hours as needed for muscle spasms and Hydromorphone 2 mg 1-2 tablets by mouth every 6 hours as needed for pain with a maximum daily dose of 12 mg. During a review of R40's Medication Administration Record (MAR), there was no documentation to indicate R40 received any pain medication until 11:37 p.m. and at that time R40's pain was documented at a level of 10, with 10 being severe pain. Based on the physician orders and discharge orders the resident was eligible to receive a dose of Acetaminophen 325 mg 2 tablets as needed, the last dose received was on 4/10/25 at 8:49 a.m. and was eligible to receive Hydromorphone 2 mg 1-2 tablets with the last dose received on 4/10/25 at 8:49 a.m. while at the hospital prior to discharge. On 5/6/25 during an interview with the Administrator, she stated that the facility has an Ekit (emergency kit) titled: RX Now. The RX Now list of available medications was not readily available in the nurses station and was found in the Providers office in a folder. Review of the RX Now medication list (Genesis Master Ekit contents list) revealed that the facility's RX Now (machine used in the facility as their emergency medication supply) showed the ordered medications for R40's pain control were available for use. On 5/6/25 at 8:09 a.m. The surveyor confirmed with the Administrator that R40 was admitted at 5:22 p.m. and per documentation on the CNA admission checklist documents that R40's pain was 8/10 and that he/she should have been provided pain medications and that he/she was not provided with any pain medications until 11:37 p.m. almost 6 hours after reported pain at a level of 8 out of 10 when admitted . Based on record reviews and interviews, the facility failed to provide pain management in a timely manner for 2 of 2 residents reviewed for pain management (Resident #40 [R40] and R268). Due to this facility's failure, R268 experienced consistent, unrelieved pain resulting in the resident discharging Against Medical Advice (AMA) to seek pain control from an emergency room (ER). Findings: 1. On 5/6/25, a review of the clinical record for R268 revealed the following: -R268 was admitted on [DATE] for skilled therapy after a spinal surgery. -Review of the admission orders revealed an order for MS Contin Oral Tablet Extended Release 30 [milligrams (MG)] (Morphine Sulfate) Give 30mg by mouth every 8 hours for pain, and acetaminophen Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Mild Pain no more than 3 doses in 48 hours, notify physician/ advanced practice provider(APP). Do not exceed 3[grams(g)]/day. (standing order). -Review of the admission assessment, dated 11/19/24 and completed by the Registered Nurse (RN) at 7:06 p.m., indicated R268 had an elevated heart rate, reported a Pain score: 10 (on a scale of 1 to 10, with 1 meaning little to no pain and 10 is the worst pain imaginable), vocal complaints of pain and resident unable to tolerate being still due to pain. The admission assessment also indicated Mood is pleasant, no unwanted behaviors witnessed. The admission assessment provided no indication the facility provided R268 with any pain relieving treatment when R268 complained of severe pain. -Review of R268's Medication Administration Record (MAR) for 11/19/24 shows that R268 did not receive morphine or acetaminophen as ordered for pain (these are stock medications that were available but not given). -Review of nurse notes documented at 8:29 p.m. on 11/19/24, indicated that R268 was verbally angry about uncontrolled pain resulting in R268 signing out AMA to get pain control from the ER. The nursing notes provided no indication the facility provided R268 with any pain relieving treatment when R268 complained of severe pain on 11/19/24. The clinical record lacks evidence that R268 received pain medications as ordered (See F684) or any other interventions for severe pain. Review of the facility's Ekit (emergency kit) titled: RX Now revealed Morphine Sulfate [extended release (Er)] 15 mg tablets MS Contin available for use. On 5/06/25 at 2:20 p.m., during an interview with the Administrator, the Market Clinical Advisor, and the Director of Nursing, R268's clinical record was reviewed. The Administrator stated R268 arrived at 4:51 p.m., and left the building at 8:52 p.m., R268 had mistakenly been transported from the hospital to the pharmacy before arriving at the facility which contributed to the resident going so long without pain medication. The Administrator stated they did not have his medications available. The list of available medication in the facility's Ekit (emergency kit) titled: RX Now was reviewed. At this time a surveyor confirmed the morphine was available in the facility's Ekit but not provided to R268, and there was no evidence that pain relieving interventions (pharmaceutical and non-pharmaceutical) were implemented for R268. On 5/7/25 at 10:22 a.m., during an interview with a surveyor, a RN stated that the delay in pain medication on admission is a common problem. RN stated he was waiting for the prescriptions to be delivered from the pharmacy and did not know the medication was available in the Ekit stock. RN confirmed the provider was not notified of the uncontrolled pain or elevated heart rate, and was unable to identify non-pharmaceutical interventions implemented to treat R268's pain. At this time the surveyor confirmed with RN there was no evidence that pain relieving interventions (pharmaceutical and non-pharmaceutical) were implemented for R268's severe pain.

Based on Payroll Based Journal staffing (PBJ) report and interview, 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 2025 (October 1 - December 31, 2024). Finding: A payroll based journal (PBJ) report for the first quarter of 2025 indicated the facility triggered for low weekend staffing. On 5/6/25 at 1:50 p.m., during an interview with the surveyor, the Administrator confirmed that the facility triggered for low weekend staffing for the first quarter per the PBJ report. The Administrator confirmed this finding and no additional information was provided to indicate that the PBJ information was incorrect which identified low weekend staffing.

Based on clinical record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours, that included the instructions needed to provide minimum healthcare information necessary to properly care for 5 of 10 sampled residents (Resident #40 [R40], R166, R56, R50, and R60). Findings: 1. On 5/6/25 during a clinical record review for R40, admitted to the facility for skilled care. The clinical record shows that R40's baseline care plan was not implemented or developed to provide the instructions needed to provide minimum healthcare necessary to properly care for R40. On 5/6/25 at 11:30 a.m. during an interview with the Regional Marketing Advisor the surveyor confirmed that R40's baseline care plan was not developed until 4 days after admission. 2. On 5/6/25 during a clinical record review for R166, admitted to the facility for skilled care. The clinical record shows that R166's baseline care plan was not implemented or developed to provide the instructions needed to provide minimum healthcare necessary to properly care for R166. On 5/6/25 at 3:45 p.m. during an interview with the Administrator the surveyor confirmed that R166's baseline care plan was not developed until 4 days after admission. 3. On 5/4/25, R56's clinical record was reviewed and indicated that R56 was admitted to the facility the last week of February 2025. R56's baseline care plan, which included problems, goals, and interventions, was not started until 3/5/25, greater than 48 hours after admission. On 5/6/25 at 8:23 a.m., during an interview with Market Clinical Advisor, a surveyor confirmed this finding. 4. On 5/6/25, R50's clinical record was reviewed and indicated that R50 was admitted to the facility in February 2025. The clinical record lacked evidence that R50's baseline care plan, which included problems, goals, and interventions, was developed and implemented within 48 hours of admission. On 5/6/25 at 2:13 p.m., during an interview with a surveyor, the Administrator, the Director of Nursing, and the Market Clinical Advisor, R50's clinical record reviewed. At this time a surveyor confirmed R50's baseline care plan was not completed with 48 hours of admission. 5. On 5/6/25, R60's clinical record was reviewed and indicated that R60 was admitted to the facility in April 2025. The clinical record lacked evidence that R60's baseline care plan, which included problems, goals, and interventions, was developed and implemented within 48 hours of admission. On 5/6/25 at 2:13 p.m., during an interview with a surveyor, the Administrator, the Director of Nursing, and the Market Clinical Advisor, R60's clinical record reviewed. At this time a surveyor confirmed R60's baseline care plan was not completed with 48 hours of admission.

Based on clinical record reviews and interviews, the facility failed to follow physician orders for 4 of 20 residents reviewed. (Resident #40 [R40], R51, and R172). Findings: 1. On 5/6/25 at 8:00 a.m. during a clinical record review for R40 shows an order for Aspirin 81 milligrams (mg) by mouth twice a day for clot prevention. Review of R40's Medication Administration Record (MAR) shows that R40 did not receive his/her bedtime dose as ordered. (this is a stock medication that was available but not given) R40 also had an order for Quetiapine 25 mg at bedtime, review of his/her MAR shows that this medication was not given as ordered. The facility has an Ekit (emergency kit) called Rx now that has medications available for use. This list included the Quetiapine 25 mg dose for R40 On 5/6/25 at 10:15 a.m. during an interview with the Director of Nursing (DON), and the Marketing Advisor the surveyor confirmed that Aspirin is a house stock medication and was not given to R40 as ordered and that the RX Now system had the dose of Quetiapine that was ordered for R40, and that this medication was not given to R40 as ordered. 2. On 5/6/25 at 2:17 p.m., during a clinical record review for R172, shows orders for atorvastatin 80 mg at bedtime, Calcium Carbonate 500 mg twice a day, Docusate 100 mg twice a day, Levetiracetam 500 mg twice a day, metformin 500 mg twice a day, Senna 8.6 mg twice a day, and Warfarin 3 mg at 5:00 p.m. The following medications are stock medications and were available but were not given to R172 as ordered; Calcium Carbonate 500 mg, Docusate 100 mg, Senna 8.6 mg. The following medications were listed on the medications available list for the RX Now and were available and were not given to R172 as ordered, Atorvastatin 80 mg, Levetiracetam 500 mg, metformin 500 mg and Warfarin 1 mg Review of R172's MAR showed that the above medications were on hold until arrival from pharmacy. On 5/06/25 at 2:09 p.m. During an interview with the Office Manager, R172's MARs were reviewed. The surveyor confirmed that the above medications were not given when they were available as stock medications and in the RX Now system. On 5/6/25 at 2:15 p.m. the above findings were reviewed with the DON and the Marketing Advisor, the surveyor, confirmed that the medications were not given to R40 and R172 as ordered when they were available as stock medications and in the RX Now system. 3. 4. On 5/6/25, clinical record review for R268 shows an order for MS Contin Oral Tablet Extended Release 30 [milligrams (MG)] (Morphine Sulfate) Give 30mg by mouth every 8 hours for pain. Review of the admission assessment indicated R268 had an elevated heart rate and reported a pain level of 10 on a scale of 1 to 10 (1 being little to no pain and 10 is the worst pain imaginable). Review of R268's Medication Administration Record (MAR) shows that R268 did not receive morphine as ordered for pain (this is a stock medication that was available but not given). The facility has an Ekit (emergency kit) called RX Now that has medications available for use. The list of medications available in the Ekit include the Morphine ordered for R268. On 5/6/25 at 2:20 p.m. during an interview with the Director of Nursing (DON), the Marketing Advisor, and the Administrator, a surveyor confirmed that the Morphine ordered for R268 is a house stock medication and was not given to R268 as ordered for pain. 4. On 5/7/25 R51's clinical record review indicated a physician order for Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/[Milliliter (ML)] (Insulin Glargine) Inject 25 unit subcutaneously one time a day for diabetes Hold for [Blood Glucose (BG)] [less than(<)] 110. Review of the Medication Administration Record (MAR) and Treatment Authorization Record (TAR) revealed insulin was administered outside of parameters on 7 out of 30 days in the month of April (4/1/25, 4/3/25, 4/15/25, 4/16/25, 4/17/25, 4/22/25, and 4/25/25). On 5/7/25 at 9:33 a.m., during an interview with a surveyor, the Market Clinical Advisor confirmed with the surveyor that R51 received insulin on 4/1/25, 4/3/25, 4/15/25, 4/16/25, 4/17/25, 4/22/25, and 4/25/25 with a blood glucose result less than 110. At this time the surveyor confirmed that the physician's order to hold insulin for a blood glucose less than 110 was not followed.

2. On 5/4/25 at 12:00 p.m., a surveyor observed in the Homestead Unit Refrigerator the following: 3 cartons of thickened beverage with directions to discard 7 days after opening. The dates written on the cartons were older than 7 days from 5/4/25; 1 individual glass of poured juice with a date of 4/27 on the cover; 2 individual glasses of poured juice with a date of 4/28 on the cover; and 2 pitchers of juice with a date of 4/26/25. On 5/4/25 at 12:20 p.m., during an interview with a surveyor, [NAME] stated that the individual poured glasses of juice were good for 3 days. [NAME] also stated that the dates written on the cartons were the dates that the kitchen received the item and was not the date the product was opened. The surveyor confirmed that these were either not dated or were expired but were in the refrigerator, available for use. [NAME] removed the items. On 5/5/25 at 9:35 a.m., a surveyor observed an open carton of Thickened Orange Juice with no open date in the Homestead Unit Refrigerator. On 5/05/25 at 11:45 a.m., a surveyor observed a Mighty Shake that was thawed with no written date in the Riverview Unit Refrigerator. The directions on the carton are to use within 14 days of thawing. On 12:55 p.m., during an interview with the District Manager of Health Services Group, a surveyor reviewed yesterday's observations that the cartons of thickened beverages are not being dated when opened, and that the thickened beverages are only good for 7 days after opening. She stated that the practice is to date them when they are received by the kitchen. She also stated that the juices in cups are good for 3 days. The surveyor also reported that there was a Mighty Shake currently in the Riverview Unit Refrigerator that was thawed with no date with directions to discard 14 days after thawing. On 5/05/25 1:08 p.m., the surveyor observed the Mighty Shake was still in the Riverview Unit Refrigerator and confirmed with Certified Nursing Assistant that the mighty shake was thawed with no open date and he discarded the carton. Based on observations, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not restraining hair with a hair net for 1 of 4 days of survey (5/4/25), ensuring the dishes were sanitized with regular monitoring of the dishwasher for 2 of 4 days of survey (5/4/25 and 5/5/25), not ensuring that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 4 days of survey (5/4/25 and 5/5/25), not maintaining food temperatures to prevent food borne illness prior to serving residents for 1 of 4 days of survey (5/5/25), and not storing dishes in a sanitary manner for 2 of 4 days of survey (5/5/25 and 5/6/25), In addition, the facility failed to ensure that beverages were removed when outdated or failed to include an open date in 2 of 2 unit refrigerators (Homestead and Riverview). This has the potential to effect all residents in the facility. Findings: 1. On 5/4/25 at 10:20 a.m., during an initial tour of the kitchen a surveyor observed Dietary Aide #1 (DA1) working within the kitchen without a hair restraint. DA1 sent several trays of dishes through the low temperature dishwasher. A surveyor and DA1 observed the wash cycle temperature was 95 degrees Fahrenheit (F), and the rinse cycle temperature was observed to be 100 degrees F (the minimum wash temperature should be 120 degrees F). DA1 stated he is not trained on how to test or monitor the dishwasher; he was only trained on how to change out the chemicals when they run low. A surveyor and DA1 reviewed the dishwasher logs. The dishwasher monitoring log had not been completed to ensure sanitation of resident's dishes for 8 out of 10 meals cycles (breakfast 5/1/25, 5/2/25, 5/3/25, and 5/4/25; lunch 5/2/25 and 5/3/25; dinner 5/2/25and 5/3/25). These findings were observed and confirmed with DA1 at the time of the observations. On 5/425 at 10:45 a.m., during an initial tour of the kitchen, a surveyor observed and confirmed the following with Cook1 at the time of the observations: -the air gap under the ice machine was less than 1 inch, 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). - Cook1 was working in the kitchen, and a hair restraint was not used to restrain his facial hair. -The kitchen floor was observed to be soiled with accumulations of food debris not associated with the current meal preparation. Cook1 stated they monitor temperatures of food, refrigerators and freezers, and chemical levels of cleaning solutions but do not have a cleaning schedule currently established. -Observation of the dry food storage revealed a 4 pound can of Light Tuna in water chunks, salt added, dented in on the top seal, on the shelf and available for use. On 5/4/25 at 11:00 a.m., a surveyor observed in the walk-in refrigerator, bags of thawing cooked chicken stored on a large tray. The bags extended beyond the ends of the tray allowing the runoff from the bags to drip onto the tray below. On the tray below the thawing chicken were large round balls of dough with plastic wrap partially covering the dough. At this time a surveyor observed and confirmed with Cook2 that thawing chicken was stacked in a manner that allowed runoff to drip onto the dough below. On 5/4/25 at 11:05 a.m., a surveyor observed 2 Dietary Aides entered the kitchen wearing hats (baseball cap style); both aides had facial hair and large amounts of hair protruded out from under their hats unrestrained by a hair restraint. This observation was observed and confirmed by a surveyor with Dietary Aide #2 and Dietary Aide #3 at the time of the observation. A surveyor also confirmed this finding with [NAME] #1 at 11:08a. On 5/5/25 at 8:02 a.m., a surveyor observed and confirmed the following with the District Manager for Health Services Group (DM): -the air gap under the ice machine was less than 1 inch, 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). The DM was able to manipulate the pipe into the correct position and stated the support was missing a screw. -the dishwasher wash cycle was observed to be 85 degrees F, the rinse cycle was observed to be 90 degrees F. The interior water temperature was 90 degrees F. The water was lukewarm to touch. -the floor by dishwasher was observed to have standing water and exposed concrete creating an uncleanable surface. On 5/5/25 at 11:20 a.m., a surveyor observed wet stacking of serving pans next to the steam table, and serving spoons stored in uncovered bins next to the steam table. The bins containing the serving spoons were observed to have food debris accumulated within the bins. These findings were observed and confirmed with DM at the time of the observation. On 5/5/25 at 11:34 a.m., a surveyor observed [NAME] 2 check holding temperatures on the steam table. The chicken was 120 degrees F (Minimum safe holding temperature for hot foods is 135 degrees Fahrenheit), [NAME] 2 turned up the temperature on the first bay of the steam table. The diced potato was 128 degrees F, at that time the second bay of the steam table was observed to be off, [NAME] 2 turned on the second bay of the steam table. At this time a surveyor confirmed with [NAME] 2 that the chicken and potatoes were not maintained at a safe holding temperature. On 5/6/25 at 9:47 a.m., during an interview with the DM, a surveyor observed in the walk-in refrigerator, a 75 count box of Mighty Shakes, approximately 1/2 full of vanilla flavored shake containers. The box was dated 4/23. The DM stated 4/23 is the date the facility received the box, but DM is unable to determined when the box was placed in the refrigerator (Mighty Shakes are good for 7 days after thawing). A second box of Mighty [NAME] was observed unopened and undated, DM stated the second box was moved from the freezer to refrigerator this morning (5/6/25).

Based on record review and interview, the facility failed to ensure a resident's right to formulate an advanced directive regarding code status (cardiopulmonary resuscitation [CPR]) was accurate in the clinical record for (Resident #60 [R60]). Finding: On [DATE] at 1:38 p.m., R60's clinical record was reviewed. R60's electronic record indicated (Advanced Directives) DO NOT RESUSCITATE (DNR) (Do not perform CPR). R60's paper chart contained a Physicians Orders for Life Sustaining Treatment (POLST) form indicating Attempt Resuscitation/CPR. On [DATE] at 12:36 p.m., during an interview with a surveyor and an LPN, R60's electronic and paper charts were reviewed. LPN stated she was unsure which directive was correct. At this time the surveyor confirmed R60's advance directive regarding code status had conflicting information.

Based on the facility's policy, Reportable Incident Form review, and interview, the facility failed to notify the State Agencies (Division of Licensing and Certification [DLC]) and Adult Protective Services (APS) timely for an allegation of abuse for 1 of 3 facility reported incidents (9/16/24) reviewed during an annual survey. Finding: The facility's policy, Abuse Prohibition, last reviewed 10/24/22, directed staff to Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. On 9/16/24, the State Agency - Division of Licensing and Certification (DLC), received a fax from the facility that included a Reportable Incident Form that alleged a resident to resident incident occurred on 9/12/24. The report indicated that the physician and Resident Representatives were notified of the incident on 9/12/24. On 5/5/25 at 12:25 p.m., during an interview with a surveyor, the Administrator stated that she reached out to APS and they have no record of receiving the initial report and she does not have evidence that one was sent to DLC. The surveyor confirmed that the initial report was not sent to the State Agencies timely at this time.

Based on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 2 sampled residents reviewed for PASRR (Resident #18 [R18]). Finding: On 5/4/25, R18's clinical record was reviewed. R18's PASARR, completed on 2/15/22, did not require a level II determination. On 8/6/24, R18 was diagnosed with bipolar disorder, but the clinical record lacked evidence that the resident was referred to the State mental health authority for a new PASARR determination. On 5/7/25 at 8:35 a.m., during an interview with a surveyor, the Administrator stated a new PASARR was submitted for R18 on 5/6/25. At this time a surveyor confirmed the facility failed to refer R18 for a PASARR after a new diagnosis and/or experienced symptoms related to a mental disorder.

Based on record review and interviews, the facility failed to provide respiratory care as order by the Provider for 1of 3 residents that use oxygen. Resident #165 [R165]) Finding: On 5/6/25 during a clinical record review for R165, it was noted that R165 uses oxygen daily and has had an order change dated 5/1/25 for oxygen to be administered by nasal cannula (NC) at 2 liters/min every shift for maintaining peripheral oxygen saturation (SPO2) between 88-93% evaluate HR (heart rate), respiratory rate, pulse oximetry, skin color and breath sounds. R165's clinical record was reviewed and there is no evidence that this order was completed as ordered as there is no documentation showing that his/her respiratory rate, skin color and breath sounds were evaluated as ordered. On 5/06/25 at 2:46 p.m., during a clinical record review for R165 the surveyor confirmed with the Director of Nursing, the Administrator and the Clinical Market Advisor that there is no nursing documented evidence of R165's respiratory rate, skin color and breath sounds being evaluated every shift as ordered.

Based on interviews, observations, and two lunch meal test trays, the facility failed to serve hot foods at an appetizing and palpable temperature for 1 of 2 lunch trays tested on [DATE] and 5/6/25. Findings: On 5/4/25 between 10:15 a.m. and 11:30 a.m., during a facility initial tour, several residents stated to the surveyors that hot foods were served cold. On 05/5/25 at 12:45 p.m., two surveyors tested food temperatures on a lunch test tray at the end of lunch delivery service to the residents on the Riverview Unit. The following food temperatures were: Cubed chicken was 96.4 degrees Fahrenheit and had a taste sensation of cool to cold. Macaroni and cheese was 94.3 degrees Fahrenheit and had a taste sensation of cool to cold. Cubed potatoes were 96.6 degrees Fahrenheit and had a taste sensation of cool. On 5/6/25 at 1:10 p.m., after the second lunch meal tray was tested, in an interview with the surveyor, the District Manager of Health Services Group, confirmed that the hot foods temped on 5/5/25 were not served hot.

Based on record reviews and interviews the facility failed to respond to residents request for assistance in a manner that maintained or enhanced their dignity by not answering the call bells in a timely manner for 3 of 9 residents interviewed (Resident #18 [R18], R9, R4). In addition, the facility failed to provide morning bathing care for 1 of 1 sampled resident (R9) and facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff failed to serve all residents seated at the same table at the same time for meal observations on 1 of 2 units (Homestead). Findings: 1. On 5/19/24, R18's clinical record was reviewed. R18 was diagnosed with Cerebral Vascular Accident (CVA) with hemiplegia and hemiparesis, wheelchair dependent, and the care plan indicated R18 requires extensive assist with toileting. On 5/19/24 at 10:35 a.m., in an interview with the surveyor, R18 stated he/she rang the call bell at around 10:00 a.m. because they had to move their bowels and needed the bedpan right away. R18 stated a half an hour had past and no one has answered his/her call bell. R18 stated their anal area was on fire and it hurt. R18's call bell was observed being answered at 10:50 a.m., fifty minutes after R18 stated he/she turned the call bell on. 2. On 5/19/24, R9's clinical record was reviewed. R9 was diagnosed with diabetes, atrial fibrillation, depression, anxiety and R9's Activity of Daily Living Toileting Task indicated R9 requires extensive to total assist with toileting. On 5/19/24 at 10:45 a.m., in an interview with the surveyor, Resident R9 stated that a couple weeks ago, he/she rang his/her call bell and waited for approximately an hour before someone answered it. R9 stated he/she couldn't hold it and was incontinent of bowel. R9 stated there aren't enough staff to answer call bells. R9 stated he/she has had other incontinent accidents waiting for the call bell to be answered. R9 also stated that he/she has not had a morning bath and likes to have a bath before noon and be clean. On 5/19/24 at 1:15 p.m., in an interview with the surveyor, Certified Nurse Assistant #4 (CNA4) stated she has not given R9 a morning bath because she had so much to do and not enough staff to help. She stated she will do the bath after lunch. On 5/20/24 at 8:00 a.m., in an interview with the surveyor, R9 stated he/she did not get a bath on 5/19/24 until after 3:00 p.m. 35904 3. On 5/20/24 at 10:00 a.m., in an interview with a surveyor, R4 stated that a couple of weeks ago he/she rang his/her call bell and waited for approximately one to two hours before someone answered it, mostly at night. R4 stated it's pretty rough if you gotta pee, have to hold it, and stated this happens a lot. 33242 4. On 5/20/24 8:45 a.m., R168 was observed sitting at table with another resident that was being assisted with eating by staff. R168 did not have his/her food. The CNA assisting the other resident stated that she had been assisting that resident while R168 had been there for 5 to 10 minutes. When asked if R168 was waiting for breakfast the whole time, the CNA stated yes; another CNA stated they were looking for R168's tray. At 8:52 a.m., dietary brought R168's tray up from the kitchen and staff apologized that it was late. On 5/20/24 at 8:57 a.m., during an interview with a surveyor, Homestead Unit Manager (HUM) stated that R168 had been at the table the whole time the other resident was being assisted with eating. R168's tray did not come up on either cart so HUM had to call down to the kitchen to get a breakfast tray. 5. On 5/20/24 at 12:15 p.m., a surveyor observed multiple residents sitting around the bar area of the Homestead Unit eating lunch. A surveyor observed that 2 residents did not have their lunch trays. During an interview with a surveyor, CNA7 stated that they separate the tickets for the residents by where they usually eat and send them to the kitchen that way but they just don't always come up that way. She stated that R57 and R219 typically eat at the bar. All other residents seated at the bar area have their food except R57, and R219, the cart was not here with their trays. At 12:22, R57 received his/her tray and 12:26 p.m. , R219 received his/her tray.

Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain an environment free from offensive odors for 2 of 3 days of survey (5/19/24 through 5/21/24) and to maintain the building in good repair and in a sanitary condition for 1 of 1 environmental tour (5/21/24). Findings: On 5/19/24 at 10:30 a.m., a surveyor observed a strong, foul odor of urine in the corridor outside room [ROOM NUMBER]. On 5/19/24 at 10:45 a.m., in room [ROOM NUMBER]-1, in an interview with the surveyor, Resident #9 (R9) stated that almost every day a strong urine odor from the hall seeps into his/her room and is very unpleasant. On 5/19/24, between 10:30 a.m. and 1:15 p.m., a surveyor observed a lingering, strong, foul urine odor in the corridor outside room [ROOM NUMBER]. On 5/20/24 at 7:30 a.m., in the corridor outside room [ROOM NUMBER], the strong, foul odor of urine continued and was observed throughout the day until 2:00 p.m. when the observations were stopped. On 05/21/24, between 2:10 p.m. and 2:29 p.m., a surveyor completed an environmental tour with the Director of Nursing, the Administrator, and the Maintenance Supervisor. The following findings were confirmed at the time of observations: At 2:15 p.m. during the tour, in the hallway near Rooms 133, and room [ROOM NUMBER] the strong odor of urine was confirmed with the Director of Nursing, the Administrator, and the Maintenance Supervisor. room [ROOM NUMBER], the floor tile had a torn section that was patched and had unsealed seams creating an uncleanable surface. room [ROOM NUMBER], the threshold has tear in the flooring which is unsealed creating an uncleanable surface. room [ROOM NUMBER], threshold has unsealed flooring creating an uncleanable surface. A wheelchair (K2-lite) being used on the Homestead unit has a torn armrest on the left side. room [ROOM NUMBER], the bathroom was observed to have flooring that was heavily soiled and stained around toilet. room [ROOM NUMBER], the bathroom was observed to be dirty and not homelike. room [ROOM NUMBER], the wheelchair in the room was observed to have torn armrests on the left and right side creating an uncleanable surface and the floor was noted to be sticky when you walked on it causing your shoes to stick to the floor, in the bathroom the toilet paper holder was missing a piece and was not attached to the wall, the walls had peeling/chipped paint and the sink top was peeling, all creating uncleanable surfaces. room [ROOM NUMBER], the baseboard heater was observed with chipped paint and the recliner chair was dirty. room [ROOM NUMBER], the bathroom had chipped paint on the walls and the wheelchair in the room had torn armrests on the left and right side creating an uncleanable surface. room [ROOM NUMBER], the bathroom walls had chipped paint and the recliner chair in the room had torn armrests. R38's recliner chair had torn armrest on the right and left side creating an uncleanable surface. R52's recliner chair had a torn back handle creating an uncleanable surface. R11's wheelchair had a torn armrest on the right side creating an uncleanable surface. In the large dining room on the Homestead unit a table had peeled top creating an uncleanable surface.

Based on review of the facility's Internal Investigation, clinical record review, facility Medication Administration Policy and Procedure, and interviews the facility neglected to protect a resident from receiving another residents medications resulting in the resident being transported to an Acute Care Emergency Department for evaluation and monitoring of low blood pressure and sustaining an [CONDITION(S)]. In addition, the resident suffered from emotional distress/fear of having to return to the facility after hospitalization , fear of receiving someone else's medications again and anxiety from feeling the sensation of falling/body going for 1 of 1 resident reviewed (Resident #1). Finding: A review of the facility's internal investigation stated 4/2/2021 at approximately 9:30 a.m., Licensed Practical Nurse (LPN) administered Resident #2's morning medications to Resident #1. Resident #1 was assessed and the Physician and resident representative was notified. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was transported to the Acute Care Emergency Department on 4/2/2021 at approximately 12:06 p.m. for evaluation and treatment per resident representatives request. Resident #1 received 10 of Resident #2's medications. Two of the medications were for high blood pressure (Carvedilol and Amlodipine), one was an anticoagulant (Eliquis), one had blood thinning properties (Aspirin) and the other medications had less serious potential for side effects. Resident #1 was not allergic to any of the incorrect medications received. Documentation in Resident #1's clinical record stated resident was recently admitted to the facility with a fractured Humerus and an [CONDITION(S)]. Resident #1 also was diagnosed with high blood pressure and a few other illnesses. A review of blood pressure (B/P) documentation's stated that on 4/2/2021 at 8:46 a.m., Resident #1's B/P was 126/75. After receiving the wrong medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/2/2021 at 11:10 a.m., the B/P was 70/62 the blood pressure continued to be below the residents normal range of 120's/70's and at time of transport to the Emergency Department remained low at 95/59 (around noon). Documentation in the initial hospital discharge report, dated 3/27/2021, stated the primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On page two of the report it stated that a repeat Computerized Tomography Scan (CT) was needed on 4/18/2021 to evaluate the left subdural hematoma and left parenchymal (functional tissues) hemorrhage. On page 4 of the discharge report, the discharge instructions stated; Please do not give patient Aspirin, [MEDICATION(S)] as patient has had a recent fall resulting in brain bleed. Documentation in Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician wrote orders for a CT scan and follow up with the neurosurgery clinic. Documentation in the facility's Medication Administration Policy and Procedure for oral medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/12/2021 at 9:00 a.m., in an interview with the surveyor, Resident #1 stated, After receiving the wrong medications, I was sitting in my room and I could feel myself going. I was falling over or something. I can't explain it, but I was not feeling well. I'm afraid to go back to that place. I can't go back to that place, I was afraid that they would overdose me again. On 4/20/2021 at 11:15 a.m., in an interview with the surveyor, Certified Nursing Assistant-Medication Technician (C.N.A.-M) stated she was training the LPN on medication administration. C.N.A.-M stated she told the LPN several times the name and room number of the resident she was to give the medications too. C.N.A.-M stated next thing she knew the LPN came to her and stated she had given the medication to the wrong resident. LPN stated to C.N.A.-M she did not check the resident's identity before administrating the meds. C.N.A.-M confirmed to the surveyor that the LPN gave Resident #1 the wrong medications. On 4/20/2021 at 2:59 p.m., in an interview with the surveyor, LPN confirmed that on the morning of 4/2/2021, she gave Resident #2's medication to the wrong resident-Resident #1. LPN stated she did not follow the facility's medication identification policy and procedure and she did not check to see who Resident #1 was before giving the medications.

Based on observations, interviews and record review, the facility failed to adequately secure windows in the residents' environment for 1 of 3 residents reviewed with a history of elopement risk. This failure resulted in a resident eloping from a window onto a side deck and wander to the front of the building (Resident #1). Findings: On 3/22/18 at 5:00 p.m., The Division of Licensing and Certification received a facility Reportable Incident Form indicating that on 3/22/18 at 2:35 p.m. Resident #1 was seen standing outside at the front door trying to get into the facility. Facility investigations indicated one of the dining room windows had been removed and there were footprints in the snow on the deck outside the dining room. The facility Reportable Incident Form indicated the Maintenance director is currently securing the windows so they cannot be tilted out/removed by residents. During a review of the medical record, Resident #1 was admitted on [DATE] to the Memory unit and a wander guard placed on resident at this time. A progress note dated 3/19/18 at 12:28 p.m., indicated that Resident #1 had been very agitated and anxious this shift, searching for his/her family and trying to get out of the building. Resident #1 had opened several windows and one in room [ROOM NUMBER] (second story room). Resident #1 had opened the window and was able to tip the window inward. Resident #1 stated it fell all the way out and landed on his/her leg. The note reflects that the window never actually fell and was not low enough to actually have fallen on residents leg. A progress note dated, 3/22/18 at 11:44 a.m. indicated that Resident #1 was very anxious and had gotten dressed in his/her coat and gloves several times that day. Each time the resident stating, was looking to go home even if he/she had to walk. At this time, outdoor clothing was removed and placed in the nursing office. A progress note dated, 3/22/18 at 3:15 p.m. indicated that the nurse was alerted at 2:35 p.m. that Resident #1 was standing outside at the front door trying to get into the facility. Resident #1 had been seen by the Clinical Reimbursement Coordinator walking past the office window, and was found attempting to come in the front door but the door would not open immediately as resident had a wander guard on. Resident #1 was assisted by the Administrator back into the facility and back to the unit. Resident #1 reported a sore hand/palm showing slight bruising. Upon return to the unit the charge nurse noted one of the dining room windows had been removed and footprints in the snow were seen on the deck outside the dining room. Resident #1 then stated he/she was going to a family members house thought to lived nearby. On 3/26/18 at 3:10 p.m., during an interview with a surveyor, the Medical Director stated that she was not aware of the elopement out the window on the 3/22/18, however, was aware that resident had gotten his/her head/shoulders out of the window yesterday (3/25/18). This was confirmed when a surveyor reviewed the following progress note dated 3/25/18 at 4:09 p.m. indicating Resident #1 was found in dining room with the window and screen up with his/her head/neck out the window. Resident stating I just wanted to get out on the deck On 3/26/18 at 1:30 p.m. during an interview with a surveyor the charge nurse stated that on the day of admission for Resident #1, the family member had revealed that when the resident was at home he/she climbed out the window and fell and fractured his/her ankle. On 3/27/18 during an interview with the surveyor the Maintenance director stated the windows on the Homestead unit (memory unit) were secured to prevent them from tilting outward on 3/22/18, and that on 3/26/18 the wedges used to prevent the windows from opening up more than 6 inches were observed. A few wedges were observed not to be at the correct height to prevent the windows from opening more than the 6 inches and were corrected immediately. A surveyor confirmed these findings with the Director of Nursing on 3/26/18 at 4:50 p.m. and on 3/27/18 at 4:00 p.m.

Based on record review and interviews, the facility neglected to properly perform a biliary tube drainage treatment by leaving the valve called a stopcock in the closed position. This failure to reopen the stopcock caused bile fluid to back up into Resident #1's abdomen instead of flowing into a drainage bag. The build up of fluid in the abdomen caused Resident #1 pain, discomfort and mental status changes for 1 of 1 Sampled Resident with a biliary drain (Resident #1) and for 2 of 3 incidences in a 24 hour period. Findings: Resident #1 had a biliary drain which is a tube to drain bile from his/her liver. The tube protrudes from the resident's abdomen area and the tube is connected to a bile collection bag. Closer to the abdomen, the tube has an on/off valve called a stopcock. When open the bile is allowed to drain into the collection bag and when closed the bile cannot drain and will back up into the abdomen. According to the biliary drain education information, Copyright 1/27/2012, The Ohio State University Medical Center: a biliary drain may be placed because of leakage or a hole that forms in the bile duct. This leakage can cause severe pain and infection. According to documentation in Resident #1's clinical record under the physician order [REDACTED]. On 04/18/17 at 11:40 a.m., in an interview with the DNS, she stated that the following events occurred: On 03/27/17 at 8:30 p.m., Licensed Practical Nurse #1 (LPN#1) performed the biliary tube flush and emptied the drain bag. The next morning, on 03/28/17 at 6:30 a.m., Registered Nurse #1 (RN#1) went to perform the biliary drain treatment and discovered that LPN#1 left the stopcock closed and fluid was leaking out around the tube that was going into Resident #1's abdomen. There was zero drainage in the drainage bag. RN#1 told the DNS that the resident was in pain and discomfort. RN#1 administered Tylenol per physician orders [REDACTED]. RN#1 did not write a nurse's note regarding this incident and did not notify the physician. The DNS stated that Resident #1 did require the administration of the medication [MEDICATION NAME] (narcotic for pain) later that day. According to documentation on Resident #1's Medication Administration Record, [REDACTED] That same day, 03/28/17 at 2:00 p.m., RN#2 went to perform the biliary drain treatment and discovered that RN#1 left the stopcock in the closed position. There was 20 CC of fluid in the drainage bag. RN#2 told the DNS that the resident knew her name but was drowsy and did not open his/her eyes. RN#2 did not write a nurse's note regarding this incident and did not ensure that the physician was notified. The DNS stated that the Resident#1's physician was notified of the first incident on 03/29/17 at 2:30 p.m., more than 24 hours after the second incident was discovered. On 04/06/17, RN#2 sent a fax to Resident #1's physician that on 03/28/17 at 2:00 p.m. she had found the stopcock turned off and that the resident responded to his/her name but was drowsy and not opening his/her eyes. On 04/06/07, The DNS filled out a facility form called the Corrective Action Notice/Education. The DNS wrote that Resident #1's treatment was done incorrectly (referring to 03/28/17 at 6:30 a.m.) by RN#1 and the biliary drain was in the 'off ' position causing the resident pain/discomfort, possible change in mental status. The DNS also wrote that RN#1 did not write a note regarding this incident and did not notify the physician. RN#1 signed this form on 04/06/17. On 04/18/17 at 11:50 a.m., RN#2 stated in an interview with the surveyor, that she did not notify Resident #1's physician regarding her discovery of the stopcock being closed and that the resident had a change in mental status. On 04/18/17 at 12:27 p.m., LPN#1 stated in an interview with the surveyor, that she was very upset about the stopcock being closed and couldn't believe that she had done it.

Based on record review and interviews, the facility neglected to administer pain medications as ordered for 1 of 5 Sampled Residents (#1). This failure to administer pain medications as ordered resulted in the resident experiencing increased pain and discomfort at a level of 9 out of 10 of the pain scale. Finding: Resident #1's admission paperwork, dated 1/23/17, indicated that the resident was admitted to the facility at approximately 6:30 p.m. for skilled services. Resident #1's hospital Discharge Orders/Summary, dated 1/23/17, indicated that the resident had a left total knee replacement 6 days prior. The discharge summary indicated the resident had increased pain and swelling in the left knee and calf and the treatment plan was for resident to be sent to Orono Commons Rehab for pain control and Rehab services. Resident #1's discharge orders from the emergency department (ED), dated 1/23/17, included a list of medications Resident #1 was to receive and when they were last received by Resident #1. Orders included pain medications: [MEDICATION NAME] ([MEDICATION NAME]) ordered as 2 milligrams (mg) to 4 milligrams by mouth every 5 hours as needed last received at 4:30 p.m. on 1/23/17, and [MEDICATION NAME] (MS Contin) 15 mg every 12 hours by mouth and was due on 1/23/17 at 9:00 p.m. Resident #1's clinical record, electronic medication administration record (EMAR) and nurses notes lacked evidence that Resident #1 received the scheduled pain medication [MEDICATION NAME] at 9:00 p.m. as ordered. The facility's Omnicell (machine used in the facility as their emergency medication supply) transaction sheet with a date range of 1/23/17 to 1/24/17 indicates that [MEDICATION NAME] extended release 15 mg tablets (2) were removed from the Omnicell system at 1:28 a.m. on 1/24/17. During an interview on 2/21/17 at 4:35 p.m. with Resident #1, he/she stated that they did receive a pain medication at approximately 2:00 a.m. on 1/24/17, which was 5 hours after the scheduled time which caused Resident #1 to have increased pain and discomfort. Resident #1's clinical record, EMAR and nurses notes lacked evidence that Resident #1 received any as needed pain medications until 11:41 a.m. on 1/24/17 which resulted in Resident #1 requesting to be released against medical advice (AMA) due to the facility failing to treat his/her pain in a timely manner. These findings were confirmed on 2/23/17 with charge nurse Licensed Practical Nurse (LPN #1) at 9:58 a.m. and with the Director of Nursing at 2:20 p.m.

Based on record reviews and interviews, the facility failed to follow physician orders [REDACTED].#4, #1). Findings: 1 The facility's policy Standing Orders, last updated on 3/15/16, directs staff to only use standing orders as defined in the process below. For Electronic Order Management (EOM) systems, staff will enter the template into EOM. The Standing Orders Template included fever - [MEDICATION NAME] 650 milligrams (mg) or [MEDICATION NAME] by mouth (PO) or [DEVICE], or Suppository (Supp), per rectal (PR) every four hours as needed (PRN) for temperature above 100 degrees Fahrenheit and to notify the physician. Resident #4's clinical record was reviewed and documentation, on 12/12/16 at 5:31 p.m., revealed Resident #4 had a temperature of 101.2 degrees axilla. Resident #4's physician orders [REDACTED]. Resident #4's Electronic Medication Administration Record [REDACTED]. On 2/22/17 at 2:55 p.m., during an interview with a surveyor, the Director of Nursing (DON) confirmed there is no evidence that [MEDICATION NAME] had been given. 2. Resident #1's discharge orders from the emergency department (ED), dated 1/23/17, included a list of medications Resident #1 was to receive and when they were last received by Resident #1. The orders included pain medication: [MEDICATION NAME] ([MEDICATION NAME]) was ordered as 2 milligrams to 4 milligrams by mouth every 5 hours as needed last received at 4:30 p.m. on 1/23/17. In addition, [MEDICATION NAME] (MS Contin) 15 mg every 12 hours by mouth and was due on 1/23/17 at 9:00 p.m. Documentation on the initial Admission Nursing Assessment, completed by Licensed Practical Nurse (LPN) #1 on 1/23/17 at 8:10 p.m., indicated Resident #1 verbalized they were experiencing increased pain/discomfort in the left knee and his/her current pain level was not acceptable. The Electronic Medication Administration Record [REDACTED]. On 2/23/17 at 9:58 a.m., in an interview with the surveyor, LPN #1 confirmed that the pain medications were not given as ordered.

Based on record review, observations and interviews, the facility failed to provide necessary maintenance services to maintain all resident's beds in good repair. This failure resulted in 1 resident (#1) sustaining a laceration requiring hospitalization and surgery. Finding: A nurse's note, dated 9/9/2012 at 21:15, indicated that Resident #1 was bleeding profusely from his/her leg. The Resident was assessed and sent to the Emergency Department of a local hospital. This surveyor was told by the Maintenance Director that on the morning of 9/10/2012, staff determined that Resident #1 must have received the laceration from the transfer bar on their bed. The transfer bar is manufactured with plastic caps on the end of the metal bars to avoid human contact with the end of the metal bar. When Resident #1's bed was inspected, it was missing a couple of plastic caps. This surveyor was informed by the Administrator that she instructed the Maintenance Director to replace any missing caps on all beds. According to the list of replaced caps, the facility needed to replace 61 caps. This finding was discussed with the Administrator, on 10/22/12 at 2:30 p.m.