Every finding on record at Pinnacle Health & Rehab at N Berwick

Based on record review and interview, the facility failed to ensure a care plan was accurately revised to reflect a resident's current needs for 1 of 4 residents reviewed for dementia care (Resident #40).Findings:Review of the clinical record for R40 revealed diagnoses that included Vascular Dementia, Obsessive Compulsive Disorder, Major Depressive Disorder, and Anxiety Disorder.In review of nursing documentation, a progress note dated 1/27/26, stated R40 was observed outside shoveling snow in the walkway without a coat or gloves on. Another note, dated 10/10/25, stated Resident wanted a phone card for his/her phone service. When told he/she would have to wait for help from an office worker, he/she reported (they) would go him/herself. Resident left the courtyard/facility to attempt to help him/herself. A staff member redirected the resident and (the Director of Nursing) spoke with him/her. Further review of progress notes revealed R40 had a history of poor decision making and difficulty understanding the rationale for instructions related to safety.On 1/27/25 at 10:35 a.m., in an interview with a surveyor, the facility's social worker discussed R40's impulsive behaviors and difficulty making safe decisions, requiring staff to set boundaries with the resident.On 7/2/25, a Wandering Risk Assessment was completed which identified R40 being at high risk for wandering.The quarterly minimum data set assessment (MDS), dated [DATE], noted a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. The care plan, last revised on 1/13/26, identified interventions to address mood and behaviors, including wandering and a need to keep busy. However, no specific approaches, such as boundary setting, were included.On 1/27/25 at 11:45 a.m., in an interview with the Assistant Director of Nursing (ADON), a surveyor discussed the progress note which stated R40 was outside shoveling and had been identified at high risk for wandering. The ADON stated R40 has an agreement with staff that he/she only goes in the fenced-in area outside of the front door and is continually monitored by staff. He/she also goes around filling bird feeders every morning in the fenced-in area. The ADON stated staff have set boundaries with R40 which he/she agrees to follow. The surveyor discussed that the current care plan lacks interventions to address behavioral concerns, including boundary setting and approaches to ensure safety due to R40's identified risk for wandering. The ADON confirmed the findings at this time.

Based on observations and interviews, the facility failed to maintain a clean kitchen floor and ensure products in the walk-in refrigerator and freezer were labeled and/or dated and failed to remove expired foods available for use for 1 of 3 kitchen tours. Findings: A surveyor completed Initial Kitchen Tour on [DATE] from 9:30 a.m. to 10:15 a.m. with the Food Service Director in which the following findings were observed: - The floor in the kitchen had a significant amount of visible crumbs/dirt debris and was discolored/stained in many areas and worn in appearance. During an interview with the Food Service Director, it was revealed that the flooring throughout the kitchen was very porous and was difficult to clean. - The food slicer had dried food particles on the blade and blade protector. - The floor in the dry storage room had excessive dirt debris and food particles on the floor. The Walk-in refrigerator contained the following open/undated or expired foods: --one 6 lb. block of moldy Mill Dance brand [NAME] cheese -one 5 lb. of moldy Sysco Block and [NAME] Swiss cheese -The walk-in freezer contained the following open/undated or expired foods: -one large bag of garlic bread -one 2 lb bag of chicken tenders -one 2 lb bag of chicken breast -one loaf of french bread -siz loaves of cranberry bread -one bag of 8 waffle's -one plastic container of ground sausage and sausage links -sixteen Strawberry Turnovers -one Gluten Free Meatloaf -one Container of Seafood pie dated ,d+[DATE] use by ,d+[DATE] -one Container of Breakfast Casserole dated ,d+[DATE] -thirteen plain muffins -one plate with a Western Omelet, dated ,d+[DATE] -one large container of chocolate chip cookie dough, dated [DATE] On [DATE] at 11:00 a.m., a surveyor discussed the above with the Administrator. 48648

Based on record review and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection relating to Legionella and failed to implement the elements of the Legionella Water Management Program. This has the potential to effect all 59 residents. Finding: The facility's Legionella Water Management Program initiated on 10/18/19, states Specific measures used to control the introduction and/or spread of Legionella (e.g. temperature, disinfectants), The control limits or parameters that are acceptable and that are monitored, A diagram of where control measures are applied, A system to monitor control limits and the effectiveness of control measures and documentation of the program On 10/30/24 at 11:10 a.m., during an interview, the Administrator confirmed the facility is not following its own Legionella Water Management policy, by not having measures in place to control the introduction of, assess and monitor areas where Legionella and opportunist waterborne pathogen can grow and spread and a diagram where these measures are applied.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable manner pertaining to floors for 1 of 1 facility tour (10/30/24). Findings: A surveyor conducted a facility environment tour on 10/30/24 from 1:20 p.m. to 1:35 p.m. with the Maintenance Director in which the following findings were observed: The entrance from the hallway into the resident room floor had black tape on the floor going from each side of the door frame for Rooms 19, 20, 21, 22, 23, 25, 27, 28, 31, 32, and 34. The hallway floor located near B unit, near the nursing station, had black tape on the floor that went widthwise across the floor from hall to hall that was scuffed, torn, and worn, creating an uncleanable surface. The hallway floors on A unit, B unit, and C unit, with a concentration at the end of the hallway on D unit had gaps in the flooring, creating uncleanable surfaces. On 10/30/24 at 1:35 p.m., in an interview with the Maintenance Director, a surveyor confirmed the above findings.

Based on observations and interviews, the facility failed to provide oxygen therapy in a sanitary manner for 4 of 5 sampled residents using oxygen (#6, #9, #22, #29) Findings: 1. On 10/28/24 at 9:30 a.m., a surveyor observed Resident #29's oxygen concentrator and found the intake filter coated in dust and debris. 2. On 10/28/24 at 9:45 a.m., a surveyor observed Resident #9's oxygen concentrator and found the intake filter coated in dust and debris. In addition, Resident #9's oxygen tubing was being stored in an unsanitary manner coiled on top of the concentrator with the tubing touching the floor. 3. On 10/28/24 at 10:09 a.m., a surveyor observed Resident #22 wearing oxygen via nasal cannula attached to an oxygen concentrator. The concentrator filter located on the back of the machine was dusty. 4. On 10/29/24 at 10:08 a.m., a surveyor observed Resident #6 wearing oxygen via nasal cannula attached to an oxygen concentrator. The concentrator filter located on the back of the machine was dusty. On 10/30/24 at 1:15 p.m., in an interview with the Assistant Director of Nursing/Infection Preventionist. a surveyor confirmed that Resident #9 and Resident #29's oxygen concentrator filters are dusty. On 10/30/24 at 1:40 p.m. in an interview with the Licensed Practical Nurse (LPN) #2 , a surveyor confirmed that Resident #6 and Resident #22's oxygen concentrator filters are dusty. LPN #2 stated they should be cleaned and stated she would clean them today. 35904

Based on review of the facility's immunization policy, record review and interview, the facility failed to implement their pneumococcal immunization policy for 3 of 5 residents whose immunization records were reviewed (#4, #25, #48) Findings: The facility's Pneumococcal Vaccine policy and procedure revised on 2/1/2020 states, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series with in (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated and Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Resident #4 was admitted on [DATE], the clinical record contained a Resident Immunization Consent Form signed on 1/11/24, which gave consent for the administration of the Pneumonia vaccines per CDC recommendations. As of 10/29/24, Resident #4's medical record lacked evidence of the facility offering and/or administrating the current Pneumonia vaccine as per CDC recommendations. 2. Resident #25 was admitted on [DATE], the clinical record contained a Resident Immunization Consent Form signed on 4/27/23, which gave consent for the administration of the Pneumonia vaccines per CDC recommendations. As of 10/29/24, Resident #25's medical record lacked evidence of the facility offering and/or administrating the current Pneumonia vaccine as per CDC recommendations. 3. Resident #48 was admitted on [DATE], the clinical record contained a Resident Immunization Consent Form signed on 8/31/23, which gave consent for the administration of the Pneumonia vaccines per CDC recommendations. As of 10/29/24, Resident #48's medical record lacked evidence of the facility offering and/or administrating the current Pneumonia vaccine as per CDC recommendations. On 10/29/24 at 1:48 p.m., during an interview, a surveyor confirmed the findings with the Infection Preventionist/Assistant Director of Nursing.

Based on observations, interviews, and record reviews, the facility failed to ensure food is stored, served and prepared in a safe, sanitary manner as evidenced by improper food storage in the dry storage area, and failure of staff to utilize beard restraints on 1 of 2 days of kitchen observations (8/21/23). In addition, the facility failed to maintain evidence of: temperature monitoring of food temperatures for 6 meals served in June and July, 2023; monitoring for sanitizer solution levels in sanitizing buckets; and maintain proper temperature ranges for the dishwasher machine, and refrigerators in 2 of 2 nursing unit kitchenettes. This has the potential to affect all residents. Findings: On 8/21/23 at 9:30 a.m., a surveyor completed the initial tour of the kitchen with the Food Service Director (FSD) and observed: 1. Several undated and open bags of rice, tri-color rotini, dry beans, and panko in the dry storage area. The FSD removed the items from stock. 2. The FSD confirmed that the facility does not maintain records of results of sanitizer solution checks of the sanitizing buckets (to ensure correct levels in parts per million [ppm] for proper sanitizing). On 8/21/23 at approximately 11:30 a.m., a surveyor observed the noon meal service and noted the following: 3. Three male staff with beards and mustaches were without beard restraints. 4. One staff donned gloves, picked up a bag of hamburger buns, removed a bun and carried it in his/her open hand to the stove. The staff then placed a hamburger patty, which was cooking on the stove, onto the bun, which remained in his/her hand, and then placed the hamburger onto a plate. At the time of the observations, the surveyor brought the findings to the attention of the FSD, who confirmed beards should be covered and food should not be handled in such a manner. A review of the facility's, Policy/Procedure: Food Preparation and Serving, for the Dietary Department, last revised 3/18/22, stated 10. A hairnet or baseball cap is to be worn by all kitchen employees at all times when in the kitchen, all hair must be covered with no hair dangling (including bangs and facial hair). And, the facility's Procedure and Policy for Taking Food, Freezer, Refrigerator and Dish Machine Temperatures, Times for Meals and Left Over Foods, last revised 6/20/23, stated All food temperatures will be taken 10 minutes before serving and written down on temperature sheet. 11. Freezer 0 or lower. 12. Diet kitchen, bayview refrigerator 41 or lower. Dish machine temps taken by person that is washing dishes for each meal. If not at proper temps, reset booster, put dishes through again, if still not at temps, make note and notify Food Service Director (FSD) and call Ecolab to put in a call for service for the dish machine. Morning cook takes temps of the walk-in and freezer and puts out the sanitizer container for cleaning on cook's side and tray side. AM tray side that stocks the kitchen takes temps for the country kitchens. 5. On 8/22/23, a surveyor reviewed the kitchen temperature logs. The logs lacked evidence that temperatures for meals were tested prior to being served to residents at the following times: 6/5/23: supper 6/19/23: supper 6/21/23: lunch 6/22/23: breakfast and lunch 7/23/23: lunch 8/1/23: lunch 6. A review of temperature logs for refrigerators in the nursing unit kitchenettes noted the following: In May, 2023, there were 11 out of 31 days with out of range temperatures (5/5/23, 5/9/23, 5/11/23, 5/12/23, 5/14/23, 5/17/23, 5/23/26, 5/26/23, 5/27/23, 5/30/23, 5/31/23). In June, 2023, there were 7 out of 30 days with out of range temperatures (6/8/23, 6/11/23, 6/17/23, 6/20/23, 6/21/23, 6/22/23, 6/28/23). In July, 2023, there were 3 out of 31 days with out of range temperatures (7/4/23, 7/10/23, 7/24/23). 7. A review of temperature logs for the wash and rinse cycles of the dishwasher machine noted the following out of range temperatures (in degrees Fahrenheit [F]), or lack of evidence of temperature monitoring: 5/2/23 - No temperatures Recorded for Lunch and Dinner 5/7/23 - Supper Rinse Temperature = 179 F 5/8/23 - Lunch Wash Temperature = 140 F 5/22/23 - Breakfast Wash Temperatures = 140, 157 F; Rinse = 160 F 5/24/23 - Supper Rinse Temperature = 170 F 5/30/23 - No Supper Wash or Rinse Temperatures Recorded 5/31/23 - No Lunch & Supper Wash or Rinse Temperatures Recorded 6/12/23 - Breakfast Rinse Temperature = 175 F 6/19/23 - Lunch Rinse Temperature = 175 F 6/27/23 - Breakfast Rinse Temperature = 174 F 7/9/23 - No lunch Rinse Temperature Recorded 7/16/23 - Lunch Rinse Temperature = 175 F 7/17/23 - Lunch Rinse Temperature = 170 F 7/24/23 - Lunch Rinse Temperature = 175 F 8/8/23 - Breakfast Rinse Temperature = 170 F 8/19/23 - Breakfast Rinse Temperature = 175 F On 8/22/23 at 2:00p.m., in an interview with a surveyor, the FSD confirmed the logs lacked evidence of consistent temperature monitoring for meals and equipment, as required per facility policy, and stated that out of range refrigerator and dishwashing machine temperatures should have been rechecked and reported.

Based on observations and interviews, Pinnacle - North [NAME] failed to label and/or dispose of opened vials of Tuberculin purified protein derivative (Tubersol), available for resident and staff tuberculosis screenings, in 1 out of 2 medication storage refridgerators . Finding: Observed on 8/21/23 at 11:05 a.m. in the AB unit medication room refrigerator: - Tubersol vial with no open date - Tubersol vial opened date7/16/23 - Tubersol vial opened date 7/17/23 Package Insert located in the box for Tubersol states, A vial of Tubersol which has been entered in use for 30 days should be discarded and Do not use after expiration date. On 8/22/23 9:20 a.m. this surveyor confirmed with Registered Nurse #3 the above findings and she/he removed and disposed of them immediately.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, for 1 of 1 environmental tour. Findings: On 8/21/23 at 2:30 p.m., a surveyor observed 2 fracture bedpans and a pink wash basin on the floor next to the toilet in the shared bathroom for resident rooms [ROOM NUMBERS]. At this time, the B Unit charge nurse confirmed the finding and asked staff to remove the items. The charge nurse stated the items should not be stored like that. On 8/23/23 at 10:00 a.m., during an observational environment tour with the Administrator, the following were observed: Resident Rooms: room [ROOM NUMBER] - Observed plunger in resident bathroom next to the toilet. room [ROOM NUMBER] - Observed the laminate around sink and on front of sink is chipped and has a sharp edge. room [ROOM NUMBER] - Observed in bathroom - toilet base caulking is discolored. room [ROOM NUMBER] - Observed in bathroom - floor tile chipped behind toilet. room [ROOM NUMBER] - Observed in bathroom - loose & chipped laminate on bathroom sink. room [ROOM NUMBER] bathroom - caulking around toilet peeling away from base. Laundry Room: Observed a moderate to large amount of dust on all flat surfaces of dryers and shelves in room. All the above findings were confirmed with the Administrator aon 8/23/23 at 10:45 a.m.

Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 23 sampled residents (#158). Finding: 1. A review of the clinical record of Resident #158 noted an admitted [DATE]. The baseline care plan included the following focus area: (Resident #158) has an established advanced directive order in place. Resident is a Do Not Resuscitate, Do Not Intubate, Do Not Hospitalize (DNR/DNI/DNH). The most recent physician's progress note, dated 8/18/23, stated Code Status: DNR, DNI, DNH, [NAME] Hospice. A review of the physician's orders since admission could not locate a signed order addressing the resident's code status. On 8/23/23 at 10:30 a.m., in an interview with the Director of Nursing (DON), the Infection Preventionist, and the Assistant Director of Nursing, the surveyor discussed that Resident #158's clinical record noted he/she was a hospice patient, however the record lacked a physician's order specifying the resident's wish to be a DNR, DNI, DNH. The DON reviewed Resident #158's record and noted that the care plan addressed Resident #158's Advanced Directive, but confirmed the Physician Orders did not specify a code status.

Based on interview and record review, the facility failed to include the resident and/or resident's representative, in the development of the resident's care plan, for 1 of 23 residents whose care plans were reviewed. (Resident #30). Finding: 8/21/23 at 1:28 p.m., in an interview with Resident #30, a surveyor asked if the facility invited him/her, or the Power of Attorney (POA), to attend a meeting and participate in the development of the resident's care plan. Resident #30 stated They've never had one for me. If they had one, I would want to go. A review of Resident #30's clinical record noted the most recent Minimum Data Set (MDS) 3.0 Quarterly Assessment was dated 6/12/23. The surveyor noted several progress notes from members of the interdisciplinary team completed on 6/22/23. Resident #30's care plan was noted with a revision date of 6/22/23. The record lacked evidence that a care plan meeting had been held and that the resident and/or her representative had been invited to attend. On 8/23/23 at 9:30 a.m., in an interview with a surveyor, the facility's Director of Social Services stated the MDS Coordinator schedules care plan meetings and sends out invitations. The Director of Social Services stated the MDS Coordinator completes an attendance form at the time of the meeting and confirmed that a care plan meeting was held on 6/27/23, but was unable to say if the resident and/or the representative was invited or attended. On 8/23/23 at 10:10 a.m., in an interview with a surveyor, the facility's MDS Coordinator stated he/she develops the care plan schedule but does not attend care plan meetings. The MDS Coordinator stated he/she schedules the team meetings based on the MDS Assessment Reference Dates and then distributes the schedule to the Interdisciplinary Team. He/she stated the facility's secretary then sends out invitations to resident families for the care plan meetings. The MDS Coordinator stated a care planning meeting was held on 6/27/23 and was attended by the nurse, social worker, activities, and therapy staff. The MDS Coordinator stated Resident #30's POA did not attend the meeting and that copies of the care plan are not sent to the family or resident representative that he/she is aware of. The MDS Coordinator stated if a family member wanted to know the details of the care plan meeting, the social worker would call them and discuss over the phone. On 8/23/23 at 10:30 a.m., in an interview with the Director of Nursing (DON), Infection Preventionist, and Assistant Director of Nursing, the surveyor discussed Resident #30 had stated he/she had not been included in development of the care plan and would like to be included. The surveyor also discussed the record lacked evidence that Resident #30's POA had been invited to participate in the development of the care plan. The DON confirmed the findings.

Based on interview, and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the minimum health care information needed to properly provide care for a newly admitted resident. In addition, the facility failed to ensure the resident, and/or resident representative, was involved in the development of the resident's baseline care plan and was provided a summary of the care plan for 1 of 1 residents sampled for new admissions (#158). Finding: On 8/21/23 at 2:37 p.m., Resident #158 stated no one had met with him/her since admission to discuss care planning, and he/she had not been provided a copy of the initial care plan. A review of Resident #158's clinical record indicated he/she was admitted to the facility on [DATE]. The baseline care plan was initiated on 8/15/23 and was noted to lack any interventions to address the problem areas of Impaired Mobility, Activities of Daily Living Self-Care Performance, and Alteration in Thought Processes. The clinical record lacked evidence that the resident, and/or resident representative, were provided a summary of Resident #158's baseline care plan. On 8/23/23 at 10:30 a.m., in an interview with the Director of Nursing (DON), Infection Preventionist, and Assistant Director of Nursing, the surveyor discussed Resident #158 had stated he/she had not been included in development of the baseline care plan and had not received a copy. The surveyor also discussed the record lacked evidence that Resident #158's representative had been included in the development of the care plan and had been provided a copy. Additionally, the baseline care plan had not been completed 9 days after Resident #158's admission. The DON confirmed the findings.

Based on observations, interviews, and review of documentation, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, food was not stored in safe and sanitary manner, the facility failed to produce evidence that food temperatures were being taken during preparation and that the facility failed to produce evidence that temperatures were being taken during the running of the high temp dish washer. Findings: Facility procedure and policy titled Temperature Policy with a revised date of 3/18/22 states All food temperatures will be taken 10 minutes before serving and written down on a temperature sheet Facility procedure and policy titled Food Preparation and Serving with a revised dated of 3/18/22 states .and temperatures are in compliance for both hot (150-170 degrees Fahrenheit) and cold (38-41 degrees Fahrenheit) foods. On 1/3/2023, at 9:15 a.m., during the initial tour of the kitchen with the Cook and the Dietician and again at 10:00 a.m. with the Dietician, the surveyor could not locate documented temperatures of food prepared and served for the breakfast meal. During an interview with the Cook, she stated she did not take temperatures of food during breakfast preparation. Facility procedure an policy titled Sanitary Conditions: with a revised date of 3/18/22 states Food is stored six inches above the floor and is properly refrigerated if necessary Kitchen and dish room floor are swept an mopped at least daily Refrigerator and freezer temperatures are monitored and recorded daily left over food is wrapped, dated and identified before storing .Water temperatures at the dishwasher are maintained at 150 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the rinse cycle, these temperatures are monitored and recorded daily . On 1/3/2023, at 9:15 a.m., observed an open box of food found on the floor of the walk-in freezer, as well as two unopened boxes of food observed on freezer floor On 1/3/2023, at 9:15 a.m., observed a small amount of dirt/dust around the ceiling vents above the food preparation area in kitchen. On 1/3/2023, at 10:00 a.m., observed that there was a lack of evidence that temperatures were consistently being taken for the refrigerator in the kitchen, for the walk-in refrigerator, and for the walk-in freezer. On 1/3/2023, at 9:15 a.m., observed unlabeled and undated hard-boiled eggs in a plastic bag, a large unfrosted cake, and 2 trays of fruit in individual cups. On 1/3/2023, at 9:15 a.m., observed lack of evidence that temperatures were being taken when running the high temperature dish washer. On 1/3/2023, at 9:20 a.m. and 9:45 a.m., the surveyor discussed the above dietary issues with Administrator, and the Dietician.

Based on interviews, review of the daily staffing postings, and the nursing working schedule the facility failed to have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week for 7 of 92 days reviewed for Sufficient and Competent Nurse Staffing. Finding: A review of the daily staffing postings, and nursing working schedule, indicated that on Saturday - [DATE], Saturday - [DATE], Thursday - [DATE] - Thanksgiving, Saturday - [DATE], Saturday - [DATE], Sunday - [DATE], and Saturday - [DATE], 2/24/19, the facility did not have an RN on duty for at least 8 consecutive hours. On 1/3/2023 at 11:45 a.m., in an interview with the Director of Nursing, the findings were discussed. The surveyor confirmed the lack of sufficient RN coverage.

Based on observations and interviews, the facility failed to adequately provide maintenance services necessary to maintain the building in good repair and sanitary conditions on 3 of 3 units (Unit A, Unit B & Unit C) for 1 of 1 environmental tours. Findings: On 5/05/2021 from 10:00 a.m. to 11:00 a.m , two surveyors and the Licensed Social Worker conducted an environmental tour of the facility in which the following findings were confirmed: Unit A Resident Room 27: Floor mat with multiple cracks creating an uncleanable surface. Unit B Resident Room 19-2: The windowsill missing varnish creating an uncleanable surface. Resident #46's bilateral wheelchair arms with multiple cracks creating an uncleanable surface. Resident Room 21-1: Sink countertop with rough edges creating an uncleanable surface. The windowsill without varnish creating an uncleanable surface. Resident #33's wheelchair with moderately soiled pink tape on both arm rest areas creating an uncleanable surface. Resident Room 22: The windowsill missing varnish creating an uncleanable surface. Resident Room 23: The windowsill missing varnish creating an uncleanable surface. Resident Room 24: Edge of door and door jam heavily marred. The wall by the sink heavily gouged. Unit C Resident Room 01: Heater cover partially off creating sharp edges. Resident Room 02: The windowsill without varnish creating an uncleanable surface. Heater cover partially off creating sharp edges. Resident Room 04: The windowsill without varnish creating an uncleanable surface. Heater cover partially off creating sharp edges. Resident Room 07: Heater cover partially off creating sharp edges. The windowsill without varnish creating an uncleanable surface. Resident Room 08: Inside of the bathroom heavily gouged. The base of the toilet with brown caulking. Resident Room 09: Chipped pain on door below the sink, wood molding on closet door marred, heater cover partially off creating sharp edges. Resident Room 10: Molding around the closet marred. Windowsill without varnish creating an uncleanable surface. Heater cover partially off creating sharp edges. Resident Room 12: The windowsill without varnish creating an uncleanable surface. Heater cover partially off creating sharp edges. Resident Room 14: Bed-2 floor with moderate dirt and dust. Resident Room 15: Molding marred around the closet and bathroom door. The windowsill without varnish creating an uncleanable surface. Resident Room 17: The windowsill without varnish creating an uncleanable surface. The lower portion of the bathroom door is heavily splintered creating sharp edges. A small area of the tile in front of the sink is missing. The window drape is unattached. The fourth drawer and door under the sink with chipped paint.

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 2 kitchen tour observations. Findings: On 5/03/2021, 9:30 a.m. and 10:30 a.m. a tour of the kitchen was completed with the Food Service Director and the Administrator in which the following were observed: -The dishwash room was missing pieces of floor tile creating an uncleanable surface on the floor in front of the dishwashing sink. -A moderate amount of dirt and debris was observed under the sink and all along the baseboard. - Dishwasher unit and tray rollers were heavily soiled with food debris on the outside. -The food preparation area of the main part of the kitchen; had loose base board and molding in areas running behind the white container of oatmeal, steamer units, warmers, and refrigerators. - 2 steamers, refrigerator, and 2 warmers were heavily soiled and food debris , food debris was also noted on the outside on the euipment. -No documentation of a cleaning schedule or regular assignments for cleaning tasks: Director submitted 16 assorted pieces of paper with dates of: 6/16/2020, 12/1/2020, 1/21/2021, 3/11/2021, and April 9 (without a year noted). On 5/03/2021 at 9:30 a.m., and 10:30 a.m., two surveyors confirmed the kitchen was not maintained in a clean and sanitary manner with the Director of Food Services and the Administrator.

Based on observation and interviews, the facility failed to ensure a resident had leg/foot rests attached to their wheelchair to ensure proper postioning for 1 of 3 residents reviewed for positioning. (#21) Findings: 1. On 5/03/2021 at 10:37 a.m., Resident #21 was observed in a wheelchair with both feet dangling from the wheelchair, not touching the floor and no foot/leg rests in place. 2. On 5/05/2021 at 7:50 a.m., and again at 9:46 a.m., Resident #21 was observed in a wheelchair with both feet dangling from the wheelchair, unable to touch the floor and no foot/leg rests in place. On 5/05/2021 at 8:00 a.m., in an interview with the Registered Nurse, she confirmed Resident #21 is currently working with physical therapy but is unaware of the resident utilizing foot/leg rests for positioning stating, not that I've seen. On 5/05/2021 at 1:45 p.m., in an interview with the Physical Therapists (PT), the surveyor discussed the observations of Resident #21 in the wheelchair without the foot/legs rest. The PT confirmed Resident #21 should have foot/leg rest while up in the wheelchair stating, because they forgot to put the foot/leg rests on otherwise [Resident #21's] feet do not hit the ground and they were not on and I told them [Resident #21] needs [his/her] foot/leg rests. On 5/05/2021 at 1:52 p.m., in an interview with a Certified Nurses Aid (CNA) #1 she stated, Resident #21 usually has foot/leg rests on the wheelchair so [his/her] feet will not dangle. On 5/05/2021 at 1:57 p.m., in an interview with CNA #2, who provided the a.m. care for Resident #21, confirmed he/she should have foot/leg rests in place on the wheelchair. When asked why the leg/foot rests were not on she stated, I didn't want [him/her] to fall, [he/she] always puts [his/her] feet behind the leg/foot rests I'm afraid [he/she] is going to hurt [his/her] feet and therapy is working with [him/her]. On 5/05/2021 at 2:15 p.m., a surveyor confirmed Resident #21 did not have the leg/foot rests attached to his/her wheelchair, causing his/her legs to dangle without touching the floor, thus not providing proper positioning in an interview with the Director of Nursing.

Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications for 1 insulin vial available for use, in 1 of 2 treatment carts and failed to secure medication properly on 1 of 3 units, (Unit C). Findings: 1. On 5/03/2021 at 2:25p.m., observation of C unit treatment cart contained an open vial of [MEDICATION(S)] 70/30 not labeled with an open and/or discard date. Manufacturer specifications on the insulin vial instructs to Discard unused portion 31 days after first opening. On 5/3/2021 at 2:34p.m., observation was discussed with the Director of Nursing. 2. On 5/03/2021 at 2:01 p.m., observation of Unit C medication cart, left unlocked and unattended for approximately 2 minutes. At 2:03 p.m., observation was confirmed with the Certified Medication Technician as she returned to the cart.

Based on record review and interview, the facility failed to ensure that the Consultant Pharmacist, during monthly review of medication, identified and reported to the Attending Physician and the Director of Nursing that adequate monitoring for an antipsychotic medication ([MEDICATION(S)]) was completed, for 1 of 5 residents reviewed for unnecessary medications (#23). Finding: A review of Resident #23's clinical record revealed a diagnosis of Alzheimer's Disease and a history of psychotic behaviors controlled with [MEDICATION(S)]. The record lacked evidence of adequate monitoring for the presence of extrapyramidal symptoms (EPS) and Tardive Dyskinesia (TD), neurological side effects that can occur at any time from the first few days of treatment with an antipsychotic medication to years later. The clinical record revealed an AIMS test, (Abnormal Involuntary Movement Scale), which detects the occurrence and severity of EPS and TD symptoms over time in patients receiving antipsychotic medication, was completed on 8/28/2019. The pharmacist's medical record reviews (MRR) failed to evaluate and report on the potential adverse consequences of failure to adequately monitor for the emergence or presence of neurological side effects for a resident receiving an antipsychotic medication. On 5/06/2021 at 1:15 p.m., the Interim Director of Nursing (DON) stated all residents on antipsychotics should have an AIMS test completed every 6 months. The DON confirmed that Resident #23's last AIMS test was completed on 8/28/2019, and was not noted by the consultant pharmacist on monthly review.

Based on review of the facility's Nursing Facility Reportable Incident Form, written statements, the facility's Free from Abuse and Neglect policy, and interviews, the facility failed to ensure a resident was free from involuntary seclusion for 1 of 3 sampled residents (#1). Findings: The facility's Free from Abuse and Neglect policy, revised 10/2017, states it will protect each resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. And that the facility will not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. The section titled Procedure. 1. Abuse, neglect, mistreatment or exploitation of a resident may involve: c. a resident and a staff person or volunteer. Where any one of the following conditions exists: a. Willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident that results in physical harm/pain or mental/emotional anguish. 2. Any employee who witnesses or has reasonable cause to suspect abuse, neglect, mistreatment or exploitation is mandated by Maine State Law to report the incident immediately. The steps to be taken are as follows: a. The witness will report it immediately to his/her supervisor. In turn, the supervisor will report the incident to the Administrator AND Director of Nursing. On 11/29/20, CNA #1 was witnessed placing Resident #1, who was screaming and causing disruption, into a shower room and close the door. The resident remained alone and without access to a call bell or ability to open the door or leave the room for a minimum of 15 minutes. The resident was reported to have continued to scream to have the door opened. On 11/30/20, the witnesses reported the incident to the Director of Nursing Services (DNS). The DNS filed a Reportable Incident Form and initiated an investigation. CNA #1 confirmed in a written statement that he/she placed Resident #1 alone in the shower room for 15 minutes because he/she was screaming. CNA #1 was terminated on 12/1/20. Clinical record review revealed Resident #1 has [DIAGNOSES REDACTED].#1's Quarterly Minimum Data Set (MDS), dated [DATE], was coded for Section C, Cognitive Patterns, Brief Interview for Mental Status (BIMS) with a score of 3, indicating severe cognitive impairment. Section G, Functional Status, was coded to indicate Resident #1 requires extensive, 2-person assistance for bed mobility, transfers, personal hygiene, and total assistance of 1 person for locomotion, requiring use of a wheelchair. On 2/17/21 at 1:00 p.m., the DNS stated CNA #1 had been terminated for placing Resident #1 in the shower room because he/she was yelling. The DNS stated Resident #1 was unable to open the door and was yelling let me out. On 2/22/21, during a telephone interview at 9:15 a.m., CNA #2 stated on the evening of 11/30/20, he/she witnessed CNA #1 place Resident #1 in the shower room. CNA #2 stated Resident #1 was screaming and CNA #1 shut the door. CNA #2 stated Resident #1 remained in the shower room while the aides completed rounds which lasted 30-45 minutes. CNA #3 removed the resident from the shower room at approximately 10:45 p.m. CNA's #2 and #3 reported the incident to the DNS on 12/1/20. On 2/22/21 during a telephone interview at 12:05 p.m., the DNS confirmed that CNA staff did not report the incident when it occurred to the charge nurse, though they did remove Resident #1 from the shower room and reported the incident to the DNS on 12/1/20.

Based on a review of the Nursing Facility Reportable Incident Form submitted to the Division of Licensing and Certification on 08/11/2020, the facility's internal investigation, dated 08/10/2020, written statements by staff, facility policy, clinical record review, and interviews, the facility failed to provide the necessary assistive device with a transfer, resulting in a resident (#1) sustaining an avoidable injury, and experiencing increased pain/discomfort for 1 of 3 residents requiring mechanical lift transfers. Finding: A review of the Nursing Facility Reportable Incident form submitted to the Division of Licensing and Certification on 08/11/2020 revealed that Resident #1 sustained an injury of unknown origin when an x-ray revealed that Resident #1 sustained a fracture of her/his left arm. Further, the facility's follow-up report form dated 08/18/2020 revealed that on the evening of 08/07/2020 Certified Nursing Assistant's (CNA's) #1, #2 and #3 transferred the resident (#1) onto a shower chair without the assistance of a Hoyer (mechanical) lift. A review of the facility's internal investigation dated 08/10/2020 revealed the following: CNA #1 stated they would try to two assist Resident (#1) onto the shower chair as opposed to utilizing the mechanical lift. In addition, the 08/10/2020 internal investigation noted that CNA's #1 and #3 transferred resident (#1) and she/he began to fall to the floor. The internal investigation further notes that CNA #2 assisted CNA's #1 and #3 to transfer Resident #1 onto the shower chair by grabbing Resident #1's waist to assist getting Resident #1 off her/his knees while CNA's #1 and #3 had Resident #1 under her/his arms. A review of the facility's ongoing internal investigation notes dated 08/11/2020 revealed that Resident #1 experienced pain after the manual transfer. CNA #3 stated shouldn't we report this to the nurse? CNA #1 stated No her arms hurt all the time and we will get in trouble because we didn't use the Hoyer. A review of nursing documentation dated 08/08/2020 noted an x-ray result of two complete [MEDICATION NAME] (extending across) fractures involving the middle third of the humerus (arm) with mild medial angulation and displacement (broken in half). A review of the CNA's Care Card (Kardex) reveals Resident #1 to be non-ambulatory, wheelchair dependent and requires the use of a mechanical lift for transfers. A review of the documentation in Resident #1's care plan, page 4, with the focus on impaired mobility included the following intervention: Resident transfers with (2) assist using a mech (mechanical) lift . A review of a written statement signed by CNA #2 dated 08/10/2020 noted the following: CNA's #2 and #3 two assisted Resident #1 and Resident #1 knees almost hit the floor. I then grabbed her/him around her/his waist, and they had her/his arms and she/he got put into the shower chair. A review of a written statement signed by CNA #4 dated 08/10/2020 noted the following: The girls on second shift were getting Resident #1 onto the shower chair without using the Hoyer lift. In the process of doing so she/he fell on to the floor. They quickly got her/him back up onto the chair without getting the nurse. A review of the facility's policy Safe Lifting and Movement of Residents, revised July 2017, noted the following: In order to protect safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. On 8/20/20 at 11:00 a.m., the surveyor confirmed in an interview with the Director of Nursing, the facility's failure to provide the necessary assistive device (mechanical lift) with a transfer resulting in Resident #1 sustaining an avoidable injury and experiencing increased pain/discomfort. As a result of the facility's investigation, the following corrective action was initiated: -A mandatory education for all direct care staff in the use of Hoyer and Sit to Stand Lift in-service. -All hoyer transfers will be monitored with a nurse present until further notice. -Employee Disciplinary Action which resulted in CNA #1's termination of employment effective 08/13/2020, CNA #2's immediate resignation with effective date 08/13/2020. CNA #3 and CNA #4 received written counseling with effective date 08/10/2020.

Based on a review of the Nursing Facility Reportable Incident submitted to the Division of Licensing and Certification on 08/11/2020, the facility's internal investigation, dated 08/10/2020, written statements by staff, facility policy, clinical record review and interviews the facility failed to provide the necessary assistance with a transfer resulting in a resident (#1) sustaining an avoidable injury, and experiencing increased pain/discomfort for 1 of 3 residents requiring mechanical lift transfers. Finding: A review of the Nursing Facility Reportable Incident form submitted to the Division of Licensing and Certification on 08/11/2020 revealed that Resident #1 sustained an injury of unknown origin when an x-ray revealed that Resident #1 sustained a fracture of her/his left arm. Further, the facility's follow-up report form dated 08/18/2020 revealed that on the evening of 08/07/2020 Certified Nursing Assistant's (CNA's) #1, #2 and #3 transferred (Resident #1) onto a shower chair without the assistance of a Hoyer (mechanical) lift. A review of nursing documentation dated 08/08/2020 noted an x-ray result of two complete [MEDICATION NAME] (extending across) fractures involving the middle third of the humerus (arm) with mild medial angulation and displacement (broken in half). A review of the facility's internal investigation dated 08/10/2020 revealed the following: CNA #1 stated they would try to two (2) assist (Resident #1)onto the shower chair as opposed to utilizing the mechanical lift. In addition, the 08/10/2020 internal investigation noted that CNA's #1 and #3 transferred (Resident #1) and she/he began to fall to the floor. The internal investigation further notes that CNA #2 assisted CNA's #1 and #3 to transfer Resident #1 onto the shower chair by grabbing Resident #1's waist to assist getting Resident #1 off her/his knees while CNA's #1 and #3 had Resident #1 under her/his arms. A review of the facility's ongoing internal investigation notes dated 08/11/2020 revealed that Resident #1 experienced pain after the manual transfer. CNA #3 stated shouldn't we report this to the nurse? CNA #1 stated No her arms hurt all the time and we will get in trouble because we didn't use the Hoyer. A review of the facility's policy Safe Lifting and Movement of Residents, revised July 2017, noted the following: In order to protect safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. A review of the CNA's Care Card (Kardex) reveals Resident #1 to be non-ambulatory, wheelchair dependent and requires the use of a mechanical lift for transfers. A review of the documentation in Resident #1's care plan, page 4, with the focus on impaired mobility included the following intervention: Resident transfers with (2) assist using a mech (mechanical) lift . A review of a written statement signed by CNA #2 dated 08/10/2020 stated the following: CNA's #2 and #3 both assisted Resident #1 and Resident #1 knees almost hit the floor. I then grabbed her/him around her/his waist, and they had her/his arms and she/he got put into the shower chair. A review of a written statement signed by CNA #4 dated 08/10/2020 stated the following: The girls on second shift were getting (Resident #1) onto the shower chair without using the Hoyer lift. In the process of doing so (she/he) fell on to the floor. They quickly got (her/him) back up onto the chair without getting the nurse. On 8/20/20 at 11:00 a.m., the surveyor confirmed in an interview with the Director of Nursing, that the facility had neglected Resident #1 by failing to provide the necessary assitance with a transfer resulting in Resident #1 sustaining an avoidable injury, and experiencing increase pain/discomfort. As a result of the facility's investigation, the following corrective action was initiated: -A mandatory education for all direct care staff in the use of Hoyer and Sit to Stand Lift in-service. -All hoyer transfers will be monitored with a nurse present until further notice. -Employee Disciplinary Action which resulted in CNA #1's termination of employment effective 08/13/2020, CNA #2's immediate resignation with effective date 08/13/2020. CNA #3 and CNA #4 received written counseling with effective date 08/10/2020.