Every finding on record at Pinnacle Health & Rehab at South Portland

Based on observations and interviews, the facility failed to promote care to residents in a manner that maintains each resident's dignity for 1 of 2 meals (Bayview and 200 unit) and failed to maintain a homelike environment for 2 of 2 meals observed on 2 of 3 survey days.Findings:1. During a meal observation on the 200 unit on 9/15/25 between 12:24 and 12:43 p.m. the following was observed:Table 1 contained 2 residents. One resident received their meal tray at 12:24 p.m., the staff served multiple other tables before returning to table 1 to give the second resident their meal at 12:34 p.m.Table 2 contained 2 residents. One resident received their meal tray at 12:26 p.m. The staff served multiple other tables before serving the second resident their meal at 12:29 p.m.Table three contained three residents. One resident was served at 12:27 p.m., the second resident was served at 12:39 p.m. At this time staff sat down with the second resident and provided feeding assistance although there were still residents that had not been served yet. The third resident was served at 12:43 p.m.2. During the meal observation of 200 dining room on 9/15/25 from 12:24 to 12:40 p.m., all meal trays were placed in front of each resident. No residents were asked if they wanted to keep the food on the tray.3. During an observation of Bayview unit lunch meal on 9/16/25 at 12:45 p.m. a surveyor observed all 9 residents in the dining room were sitting at the table with lunch trays. During an interview Registered Nurse (RN) #1 stated that since it's a dementia unit it's easier for staff to have the food on the tray to help prevent them grab each other's food.During an interview on 9/16/25 at 12:46 p.m. Certified Nurses Aid (CNA) #2 stated, she's never been told that each resident needed to be served at the table before moving to another table and has always just grabbed a tray and put it in front of the resident. In addition, she stated, that she just places the tray on the table, doesn't normally ask the residents if they want the plates placed on the table and had never been told to ask a resident what their choice was.On 9/16/25 at 12:15 p.m., during an interview, the Assistant Director of Nursing stated that residents should be asked if they want their plates removed for the tray for the meal.On 9/16/25 at 2:31 p.m., during an interview, the above was confirmed with Administrator and Director of Nursing.

Based on observations and interviews, the facility failed to ensure a residents call bell was within reach for 4 of 25 sampled residents for 2 of 3 days of survey with multiple observations. (Resident #5, #54, #7, and #67).Findings: 1. On 9/16/25 at 9:10 a.m., a surveyor observed Resident #5 seated in his/her Broda chair in his/her room, with the call bell tucked underneath the pillow on his/her bed, out of reach. At this time, Resident #5 stated he/ she was trying to get into bed and that he/she usually has to holler to get help. At 9:11 a.m., a surveyor pressed the call bell, and Certified Nursing Assistant #2 entered the room and stated that Resident #5 usually likes to go back to bed after breakfast and that the call light should not be under his/her pillow and should be within reach. On 9/16/25 at 9:27 a.m., the above finding was discussed with the Director of Nursing. 2. On 9/15/25 at 9:49 a.m., observation of Resident #54's call bell was hanging over the recliner chair at the head of the bed. At the foot of the bed, Resident #54 was in the wheelchair with the tray table in front of him/her. In a brief interview, the Surveyor asked if he/she could access the call bell. He/she wasn't sure and hasn't tried but did not know how to move the table that was in front of him/her. On 9/15/25 at 3:26 p.m., an additional observation, Resident #54 was lying in a low bed with the call bell still draped over the recliner chair out of reach of the resident Review of Resident #54's current care plan states, [Resident #54] is high risk for falls relating to confusion, gait/balance problems, incontinence, unaware of safety needs with nursing intervention of Be sure the residents call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 3. On 9/15/25 at 9:59 a.m., observation of Resident #7 lying in bed with the call bell attached the blankets, hanging off the side of the bed above the floor, not within reach. In a brief interview, Resident #7 did not know where the call bell was located. Review of Resident #7's current care plan states, Resident #7 has ADL self-care performance deficit r/t UTI, fall with minor head injury, . Macular Degeneration with nursing interventions of [Resident #7] has poor vision and poor hearing requiring tactile and physical cues and high risk of falls relating to gait/balance problems, vison/hearing problems with nursing interventions of needs a safe environment with . a working and reachable call light. 4. On 9/15/25 at 3:26 p.m., observation of Resident #67 lying in a low bed with the call bell clipped to the call bell wall jack at the foot of the bed, not within reach of the resident. On 9/16/25 at 7:48 a.m., an additional observation of Resident #67 lying in a low bed with the call bell still clipped to the call bell wall jack at the foot of the bed, not within reach. On 9/16/25 at approx. 10:15 a.m., the above was discussed with the Director of Nursing who confirmed the residents should have access to their call bells at all times.

Based on record reviews, and interviews, the facility failed to provide evidence to show Advance Directives were offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an Advance Directive, for 8 of 25 residents reviewed for advanced directives (Residents #4, #8, #29, #57, #68, #52, #34, #50).Findings: 1. Resident #4 was admitted to the facility in June 2022. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 2. Resident #8 was admitted to the facility in October 2023. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 3. Resident #29 was admitted to the facility in August 2025. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 4. Resident #57 was admitted to the facility in August 2025. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. On 9/16/25 at 2:55 p.m., during an interview, the Licensed Practical Nurse #2 confirmed above. 5. Resident #68 was admitted to the facility in October 2023. A review of the residents electronic medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive with the resident and/or resident representative. On 9/16/25 at 2:06 p.m., the above was discussed with the Director of Nursing. 6. Resident #52 was admitted to the facility in July 2024. A review of the resident's electronic medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive with the resident and/or resident representative. On 9/16/25 at 3:00 p.m., the above was confirmed by the unit manager, Registered Nurse (RN) #4. 7. Resident #34 was admitted to the facility in August 2025. A review of the resident's electronic medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 8. Resident #50 was admitted to the facility in July 2024. A review of the resident's electronic medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. On 9/16/25 at 2:29 p.m., during an interview, RN#4 confirmed that a yearly discussion regarding advanced directives is something we just need to do.

Based on observations and interviews, the facility failed to adequately provide maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 3 Units (100's and 200's).Findings: 1. During an initial observation of room [ROOM NUMBER] on 9/15/25 at 9:22 a.m., the footboard on B bed was observed to have missing/peeling areas of luminant, making it an uncleanable surface. On 9/16/25 at 12:51 p.m., during an observation of room [ROOM NUMBER] with Licensed Practical Nurse (LPN) #2 in the presence of Resident #57, LPN#2 observed the footboard and stated that she's never noticed it before, but it definitely needed to be fixed. At this time, Resident #57 stated I don't know how, since it's been like that for at least two years. On 9/16/25 at 2:31 p.m., during and interview, the above was confirmed with Administrator and Director of Nursing. 2. On 9/15/25 at 10:06 a.m., observation of 105 and 107's shared bathroom had 2 stained ceiling tiles near and around the light fixture with one of the tiles with a blueish gray spotty growth. On 9/16/25 at 7:47 a.m., during an interview, both the surveyor and the Maintenance Director observed the stained ceiling tiles and discussed the blueish gray spotty growth. The maintenance director stated there was a water leak that was recently fixed and he will replace the tiles immediately.

Based on record review and interview the facility failed to hold an Interdisciplinary Team Meeting (IDT) within 7 days of a completed Minimum Data Set (MDS) for 6 of 6 Residents reviewed for Minimum Data Set (MDS) (Resident's #4, #8, #13, #57, #5 and #16).Findings: 1. Review of Resident #4's clinical record revealed the following: -Annual MDS with completion date 6/23/25. Further review of Resident #4's clinical record revealed the IDT meeting was held on 7/7/25 (14 days after completed MDS). -Quarterly MDS with completion date 3/24/25. Further review of Resident #4's clinical record revealed the IDT meeting was held on 4/14/25 (21 days after completed MDS). -Quarterly MDS with completion date 12/20/24. Further review of Resident #4's clinical record revealed the IDT meeting was held on 1/9/25 (20 days after completed MDS). 2.Review of Resident #8's clinical record revealed the following: -Quarterly MDS with completion date 7/31/25. Further review of Resident #8's clinical record revealed the IDT meeting was held on 8/14/25 (14 days after the completed MDS). -Quarterly MDS with completion date 4/29/25. Further review of Resident #8's clinical record revealed the IDT meeting was held on 5/12/25 (13 days after the completed MDS). -Quarterly MDS with completion date 1/27/25. Further review of Resident #8's clinical record revealed the IDT meeting was held on 2/13/25 (17 days after completed MDS). 3. Review of Resident #13's clinical record revealed the following: -Quarterly MDS with completion date 6/30/25. Further review of Resident #13's clinical record revealed the IDT meeting was held on 7/17/25 (17 days after MDS completion). -Significant change MDS with completion date of 3/31/25. Further review of Resident #13's clinical record lacked evidence of an IDT meeting was held after this MDS. -Quarterly MDS with completion date 12/31/24. Further review of Resident #13's clinical record revealed the IDT meeting was held on 1/16/25 (16 days after MDS completion). 4. Review of Resident #57's clinical record revealed Quarterly MDS with completion date of 11/29/24. Further review of Resident #57's clinical record revealed the IDT meeting was held on 11/21/24 (8 days prior to completed MDS). 5. A review of Resident #5's clinical record revealed an MDS Quarterly Assessment was completed on 8/7/25. Further review of Resident #5's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. 6. A review of Resident #16's clinical record revealed the following: -An MDS admission Assessment was completed on 11/12/24. Further review of Resident #16's clinical record revealed an IDT meeting was held on 11/25/24 (13 days after completed MDS) and lacked evidence that an IDT meeting was held within 7 days following the assessment. -An MDS Quarterly Assessment was completed on 5/15/25, and an IDT meeting was held on 6/5/25 (21 days after completed MDS). -An MDS Quarterly Assessment was completed on 8/15/25, and an IDT meeting was held on 8/28/25 (13 days after completed MDS). On 9/16/25 at 2:29 p.m., during an interview with 2 surveyors, the above findings were discussed with the Administrator and the Director of Nursing.

Based on observations, record reviews, interviews and the facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 3 residents reviewed for respiratory care (Resident's #31, #19 and #57).Findings: Review of facility policy Oxygen Therapy, revised 12/6/22 states, .Change mask and/or cannula weekly and as needed . 1. On 9/15/25 at 9:25 a.m., observation of Resident #31 utilizing an oxygen nasal cannula tubing with a date of 9/5/25. Review of the electronic medical record lacked evidence of an order and/or the nasal cannula being changed weekly. On 9/16/25 at 10:00 a.m., during an interview, the Director of Nursing (DON) confirmed the above and stated all oxygen tubing is changed weekly by nursing and there should be an order in the resident's chart. 2. On 9/15/25 at 8:50 a.m. a surveyor observed Resident #19 utilizing an oxygen nasal cannula tubing with a date of 8/25/25. Review of the Treatment Administration Record (TAR) revealed, Oxygen maintenance weekly per protocol. Clean concentrator filter weekly. Replace nasal cannula weekly and PRN [as needed] . every Mon [Monday]. Further review of the TAR indicated the nasal cannula was replaced on 9/1/25 and 9/8/25. On 9/16/25 at 9:27 a.m., during an interview with the DON, a surveyor discussed the above finding, including that the label on Resident #19's nasal cannula indicated it had last been changed 8/25/25, despite documentation on the TAR indicating the cannula had been changed on 9/1/25 and 9/8/25. 3. On 9/15/25 at 9:23 a.m., and on 9/16/25 at 9:30 a.m., observations of Resident #57 to have a Continuous Positive Airway Pressure machine on top of the bedside table with the tubing/mask connected and not bagged. On 9/16/25 at 12:51 p.m., during a follow up observation with Licensed Practical Nurse #2 the above was confirmed.

Based on record review and interviews, the facility failed to monitor and document targeted behaviors and side effects of psychotropic medication to support the use of psychotropic medications for 3 of 5 residents reviewed for unnecessary medications (Resident #4, #6, and #31).Findings: 1. Resident #4 was admitted with diagnoses to include anxiety and psychosis and has diagnoses to include dementia, anxiety and a psychotic disorder. Review of Resident #4's pertinent medication orders revealed he/she was taking antipsychotic medication Risperdal Oral Tablet 0.25 MG (Risperidone) Give 0.25 mg by mouth two times a day, and antianxiety medication Lexapro Oral Tablet 10 MG (Escitalopram Oxalate) Give 10 mg by mouth in the morning. Further review of Resident #4's clinical record lacked evidence he/she was being monitored for side effects and behaviors for these medications. On 9/16/25 at 11:35 a.m. during a review of Resident #4's clinical record with Licensed Practical Nurse (LPN) #2, she confirmed Resident #4 is taking antipsychotic medication Risperdal and antianxiety medication Lexapro, and there are no orders for monitoring behaviors/side effects. On 9/16/25 at 2:31 p.m., during an interview, the above was confirmed with Administrator and Director of Nursing. 2. Review of Resident #6's medical record stated he/she has a diagnosis of anxiety, major depressive disorder, dementia with behavioral disturbance and psychosis. The current active physician orders for September 2025 reveal the following orders of: Seroquel (antipsychotic) 12.5 milligram (mg) daily, Lorazepam (antianxiety) 0.5 mg three times daily and every 4 hours as needed for agitation x 90 days and Zoloft (antidepressant) 75mg daily. Further review of Resident #6's clinical record lacked evidence and documentation of targeted behaviors and monitoring for side effects of these medications. 3. Review of Resident #31's medical record stated he/she has a diagnosis of bipolar disorder and dementia with behavioral disturbance. The current active physician orders for September 2025 reveal the following orders of: Seroquel (antipsychotic) 300 mg at bedtime, Divalproex Sodium 1500 mg at bedtime and Lorazepam (antianxiety) 1.5 mg at bedtime. Further review of Resident #31's clinical record lacked evidence and documentation of targeted behaviors and monitoring for side effects of these medications. On 9/16/25 at 3:00 p.m., the above was discussed with the Licensed Practical Nurse #2

Based on observations, record review and interviews, the facility failed to ensure expired medications were removed from the supply available for use and failed to ensure that medications were stored properly as per manufacturers' recommendations for 2 of 3 medication rooms reviewed for medication storage (100 unit and 300 unit).Findings:1. On 9/15/25 at 1:05 p.m., observation of the 100 unit medication room with the Licensed practical Nurse #1 the following was observed: 2 unopened bottles of liquid acetaminophen with expiration date of 8/2025 and an unopened bottle of Iron 325mg tablets with expiration date of 8/2025.2. On 9/15/25 at 1:38 p.m., observation of the 300 unit medication room with the Registered Nurse #1 the following was observed: an unopened bottle of Vitamin D 25 micrograms with expiration date of 8/2025. The refrigerator contained an opened vial of Tuberculin Purified Protein with manufactures directions to Store at 35 degrees to 46 degrees (F) Fahrenheit. Review of the refrigerator temperature logs from 8/25 through 9/15/25 revealed the lack of temperature monitoring for 18 of 62 opportunities for the month of August and 10 of 29 opportunities for the month of September.On 9/15/25 at 3:14 p.m., during an interview, the above was discussed with the Director of Nursing who confirmed the medication refrigerators should have the temperature monitored twice daily.

Based on facility policy, observation, interviews and record review the facility failed to ensure a smoking assessment of resident capabilities and deficits to determine resident safety was completed for 1 of 1 resident reviewed for smoking (Resident #48).Finding:Review of facility policy, Resident Smoking/Vaping Policy, revised 9/5/19 states, .designated as a non-smoking facility. Residents and/or staff are prohibited from smoking tobacco or any other substance in any enclosed area of the building. The residents.are prohibited from smoking/vaping both inside and outside the facility. Potential admissions. are informed prior to admission that is a non-smoking facility. On 9/15/25 at 8:34 a.m., during an interview, Licensed Practical Nurse (LPN) #2 stated that Resident #48 goes outside to smoke and that he/she has a cell phone and a call pendant and hands a corresponding pager off to the nurse because Resident #48 goes off facility property unsupervised to smoke.On 9/15/25 at 9:12 a.m. during an interview, Resident #48 stated he/she goes outside to smoke but is not permitted to smoke on facility property and that a staff member does not accompany him/her. Resident #48 then removed a pager and a lanyard from his/her bag and stated that he/she wears the lanyard and leaves the pager with the nurse when he/she goes out to smoke.A review of Resident #48's clinical record revealed the following progress notes:A Nursing progress note, dated 7/17/25 states, Res [resident] told nurse [he/she] was allowed to go outside. nurse.was unsure if this was ok.went outside to check on [him/her] went around building and down the street we could not see [him/her]. When we came back in and asked CNA [Certified Nursing Assistant] if [he/she] was allowed to leave facility CNA said [he/she] goes across the street to smoke, [he/she] returned shortly after that.A Care Plan Team Nursing Note dated, 7/23/25 states, .We had some Confusion with self outings and limitations regarding electric wheelchair. We have worked out an acceptable solution for now. Expresses need to get out and be alone sometimes to think, smoke or cry Further review of Resident #48's clinical record lacked evidence of a smoking assessment.On 9/16/25 at 9:27 a.m., during an interview, the Director of Nursing (DON) stated the facility is a no-smoking facility for residents and that Resident #48 goes outside but is not permitted to smoke on facility premises.On 9/16/25 at 2:29 p.m. during an interview with 2 surveyors, the above finding was discussed with the Administrator and DON, including the lack of a smoking assessment of resident capabilities and deficits to determine whether or not supervision is required.

Based on record review and interview, the facility failed to identify a resident's past history of trauma to determine what trigger(s) might cause re-traumatization and failed to revise the care plan to include trauma informed care for 1 of 1 residents reviewed for trauma. (#38) A review of the clinical record noted Resident #38 was admitted in May 2025. Medical diagnoses included vascular dementia. A brief trauma questionnaire, completed on 6/9/25, indicated Resident #38 had a history of significant trauma. The questionnaire stated family had identified showers provided by men were a trigger, and that showers should be provided by women only. The record lacked evidence that the results of the brief trauma questionnaire had been communicated to Resident #38's provider. The most recent MDS (Minimum Data Set) 3.0 Quarterly Assessment, dated 8/19/25, noted a BIMS (Brief Interview of Mental Status) score of 7, indicating severe cognitive impairment. The care plan, last revised 9/9/25, did not include the resident's history of trauma or interventions to prevent re-traumatization during care, such as having only female staff provide showers. On 9/16/25 at 4:45 pm, in an interview with the Director of Nursing, a surveyor discussed the results of the brief trauma questionnaire and that staff had not acted upon the findings to ensure Resident #38 received trauma informed care.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 1 of 1 walk in refrigerators on 1 of 3 survey days.Findings:During an observation of the walk in refrigerator on 9/15/25 at 8:20a.m., with Certified Dietary Manager (CDM), a surveyor observed a double fan on the right side over the shelving units containing food to have obvious built up/debris. CDM states that she will clean it. During an interview on 9/16/2025 at 2:31p.m., the above was confirmed with Administrator and Director of Nursing.

Based on record review and interviews, the facility failed to ensure records were complete and contained accurate information for 1 of 1 resident reviewed for pacemaker (Resident [R]13).FindingsResident [R]13 was admitted in 2022 and was admitted for end of life (Hospice) with diagnoses to include heart dysrhythmia with presence of a pacemaker.Review of R13's care plan updated 7/17/25 states [R13] has a pacemaker r/t Dysrhythmias .Observe for/document/report PRN any s/sx of altered cardiac output or pacemaker malfunction: dizziness, syncope, difficulty breathing (Dyspnea), pulse rate lower than programmed rate, lower than baseline B/P. Review of R13's active orders lacked evidence that orders were obtained for the pacemaker.During an interview on 9/16/25 at 11:36 a.m. Licensed Practical Nurse (LPN)2 provided document dated 4/29/22 which states Reason for exam Dx: Pacemaker .Implanted date 4/9/22 .Encounter Summary: Scheduled device follow up Plan for routine follow up Review of R13's clinical record with UM lacked evidence that this was done. UM confirmed there were no orders or follow up appointments made because she was on hospice on admission.During an interview on 9/16/25 at 10:31 a.m., Medical Doctor (MD) stated that it is his expectation that someone with a cardiac pacemaker would have orders to include pacemaker checks, and appointments. At this time MD reviewed R13's clinical record and confirmed there are no orders for this pacemaker.

Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the Complaint Survey Process dated 7/30/24, was effective. The federal citation F880 was cited again during the re-visit to the Complaint Survey, dated 9/25/24. Finding: At the Complaint Survey Process, the following deficiency was cited, F880. During the follow up survey on 9/25/24, it was determined the F880 would be recited for the same issue: failure to maintain and implement an infection control program to help prevent the development and transmission of disease and infection. On 9/25/24 at approx. 1:30 p.m., during and interview, the above was confirmed with the Administrator and Director of Nursing.

Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the Complaint Survey Process dated 7/30/24, was effective. The federal citation F880 was cited again during the re-visit to the Complaint Survey, dated 9/25/24. Finding: At the Complaint Survey Process, the following deficiency was cited, F880. During the follow up survey on 9/25/24, it was determined the F880 would be recited for the same issue: failure to maintain and implement an infection control program to help prevent the development and transmission of disease and infection. On 9/25/24 at approx. 1:30 p.m., during and interview, the above was confirmed with the Administrator and Director of Nursing.

Based on observation, facility policy review, and interviews, a staff member (LPN#1) failed to follow the facility's Infection and Prevention Policy and Update of 7/18/24. to prevent the introduction and spread of Coronavirus Infectious Disease 2019 (COVID-19) in the facility. Findings: On 7/30/24 at 7:45a.m., a surveyor entered the facility and observed signs stating that there were 5 (five) cases of COVID-19 in the facility and they were located on Unit 300. For staff to enter that unit a N-95 mask is required, and for care of a resident that is COVID-19 positive, full Personal Protective Equipment (PPE) is required including N-95, eye protection, gown, and gloves. On 7/30/24 at 8:05a.m. a surveyor observed LPN#1 enter room [ROOM NUMBER] to give a resident medication, LPN#1 was wearing only an N-95 mask, no other PPE was donned as per the facility policy. There was a sign on the door warning of respiratory precautions and a 3-drawer cabinet just to the right of the door filled with PPE. When LPN#1 she exited the room, she confirmed in an interview with the surveyor that the resident in the room was COVID-19 positive, and further stated that because she was only in the room briefly, she thought it was okay to only wear the N-95 mask, versus wearing the full PPE. On 7/30/24 at 8:15a.m. in an interview with the Director of Nursing, (DON) and the Infection Preventionist, the surveyor confirmed that all staff entering a room with a COVID-19 positive resident will wear Full PPE - N95, face shield, gown, and gloves.

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 on 3 of 3 Units (100s Unit, 200s Unit and 300s Unit), the laundry room and the front lobby sitting area for 1 of 1 Environmental Tour. Findings: On 12/8/22 from 8:45 a.m. to 9:15 a.m., an Environmental Tour was conducted with the Environmental Services Director in which the following findings were observed: > The front lobby sitting area had nine tan cloth chairs that were soiled with dried liquid residue on the backs, arms and seats. 100 Unit: > The hallway floor-carpet hard numerous large brownish stains and was heavily soiled. > Resident room [ROOM NUMBER] - The wall behind the head of bed A was gouged/cracked creating an uncleanable surface. The privacy curtain had missing hooks and was hanging in disrepair. > Resident room [ROOM NUMBER] - Bed A privacy curtain had missing hooks and was hanging in disrepair. > Resident room [ROOM NUMBER] - Bed A privacy curtain had missing hooks and was hanging in disrepair. > The hallway wall mounted fan, by resident room [ROOM NUMBER], was dusty/dirty. > The Arjo Patient Lift had gauze and cloth wrapped around the sling arm creating an uncleanable surface. 200 unit > The hallway floor-carpet hard numerous large brownish stains and was heavily soiled. > Resident room [ROOM NUMBER] - The ceiling above bed A had two large brown stains on it. The left armrest of the wheelchair was cracked/ripped. > Resident room [ROOM NUMBER] - Bed A floor mat was ripped and had frayed edges. The wall fan was heavily soiled with dust/dirt. The bathroom exhaust fan was dusty/dirty. The floor around the base of the toilet was dirty. > Resident room [ROOM NUMBER] - The bathroom exhaust fan was dusty/dirty. > The hallway wall mounted fan, by resident room [ROOM NUMBER], was dusty/dirty. > The hallway wall mounted fan, at end of the hall by the laundry room door, was dusty/dirty. The cloth chair, under this fan in hallway was soiled with dried liquid residue. > The sit-to-stand lift had ripped/missing non-skid tape on the foot area and chipped/missing paint on base legs. 300 Unit > The hallway floor-carpet hard numerous large brownish stains and was heavily soiled. >Broda chair #3, in the hallway by resident room [ROOM NUMBER], had ripped material on the right side. > The tilt back blue Geri-chair, in the hallway by resident room [ROOM NUMBER], had a ripped/ton left armrest > Resident #11's wheelchair had rips/tears in both the left and right armrests. > Resident #40's wheelchair had duct tape on the right hand grip and on the back creating uncleanable surfaces. > Resident room [ROOM NUMBER] - The ceiling tile, above the sink area, had a large brown stain. > Resident room [ROOM NUMBER] - Bed A privacy curtain had missing hooks and was hanging in disrepair. > The hallway wall mounted fan, by resident room [ROOM NUMBER], was dusty/dirty. > Resident #23's wheelchair had rips/tears in both the left and right armrests. > Resident #62's wheelchair had rips/tears on the right arm rest with foam exposed. Additionally, the wheelchair had dried food and liquid residue all over it. > Resident #43's wheelchair had rips/tears on the left arm rest. Additionally, the wheelchair had dried food and liquid residue on the frame. > Resident #24's wheelchair had dried food and liquid residue on the frame. > The Dining room wall had a large area, approximately 3 feet by 3 feet of patched wall with joint compound, which was un-sanded and unpainted. Laundry: > The ceiling vent, above the dryers, was heavily soiled with dust/dirt. On 12/8/22 at 9:15 a.m., in an interview, the Environmental Services Director confirmed the findings.

Based on interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 2 of 25 sampled residents (#7, #60). Findings: 1. During review of Resident 7's medical record, the surveyor noted a IDT Social Services Progress note dated 9/19/22 which stated, [Resident #7] was not invited r/t her dx. On 12/8/22 at 9:58 a.m., during an interview, the Licensed Social Worker (LSW) stated Resident #7 was not invited the IDT meeting due to the resident's cognitive status stating, I did not extend an invitation to him/her. The surveyor asked if all residents with cognitive deficits were not invited to their IDT meeting. she stated, it really depends, we look at the level of cognitive loss or understanding she then stated, she recently had a discussion with Resident #7 regarding his/her money and where Resident #7 wanted it to be distributed. At this time, the surveyor asked, why the resident can make decisions about where his/her money is distributed but did not have the cognitive capability to making decisions about his/ her plan of care. The LSW agreed confirming the above. 37440 2. During review of Resident #60's medical record, the surveyor noted a IDT Social Services Progress note dated 11/21/22 which stated, Email wasn't sent to Father & Step-Mom/Co-guardians or [NAME] r/t Covid +. No one attended on behalf of (Resident #60). Team didn't meet with (Resident #60) r/t him being quarantined (Covid+). Further review of Resident #60's clinical record noted Resident #60 tested positive for Covid on 11/10/22 and precautions were removed on 11/21/22. On 12/8/22 at 10:38 a.m., during an interview, the Licensed Social Worker (LSW) confirmed that no one was invited and no one was given the opportunity to attend using precautions or via video conference.

Based on observations, and interview, the facility failed to maintain adequate pharmaceutical services to ensure that outdated medications, and medication no longer in use be removed from availability as discovered in 2 of 3 medication carts and 1 of 3 medication storage rooms. Findings: 1. On [DATE], at 7:30 a.m. a surveyor observed in medication cart B for Unit 200, 1 bottle of Vitamin C with an expired date of ,d+[DATE]. At this time, this was confirmed with the Licensed Practical Nurse. 2. On [DATE], at 8:00 a.m. a surveyor observed in the medication cart on Unit 300, a box of liquid Morphine Sulfate with strips of paper tape across the open box with writing that said, Do not use. This bottle corresponds to page 37 in the narcotic book. The page in the indicates that there should be around 7.5 ml there and with observation it appears to be less than 5ml. The last date of use of the narcotic was [DATE] and should have been removed from the medication cart and taken to the Director of Nursing to be locked and stored until the medication could be destroyed. At this time, this was confirmed by Registered Nurse #1. 3. On [DATE], at 8:10 a.m. on Unit 100, a surveyor discovered a unopened box of Liquid Lorazepam with the expiration date of [DATE] in the locked refrigerator available for use. At this time, this was confirmed with the Nurse Manager. On [DATE], at approximately 3:00 p.m., the above were confirmed with the Director of Nursing.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for wall mounted fans, a window fan, the hood system, ceiling lights, ceiling tiles and the dry storage room. Additionally, the facility also failed to ensure products in the walk-in refrigerator and walk-in freezer were labeled and dated. Further, the facility failed to label whipped topping with a thaw date. Findings: On 12/5/22 from 9:10 a.m. to 9:40 a.m., a kitchen tour was conducted with the Certified Dietary Manager in which the following findings were observed: > The wall mounted fan, by a food storage shelf, was dusty/dirty. > Two wall mounted fans, in the dish room, were dusty/dirty and were blowing on clean dishes. > The window fan, in the dish room, was dusty/dirty and was blowing on a clean dish area. > The hood system filter was heavily soiled with dust/dirt. > Two ceiling lights had dust/dirt and debris in and on the lenses. > One ceiling light, in the dish room, had dust/dirt and debris in and on the lens. Additionally, the lens was cracked. > Four ceiling tiles, to the right of the hood system, were soiled with large brown stains. > The dry storage room had one ceiling light with a cracked lens and one ceiling light with a lens that had dust/dirt and debris in it. > The walk-in freezer had one previously opened package of small brown food chunks, five pie shells, one previously opened package of sliced pepperoni and one package of meat balls that was full of ice crystals, that were not labeled and dated. > The walk-in refrigerator had five packages of thawed whipped topping that did not have a thaw date on them. The package noted that the product was good for two weeks after thaw date. On 12/5/22 at 9:40 a.m., the Certified Dietary Manager confirmed the findings. On 12/5/22 at 10:00 a.m., the findings were discussed with the Administrator.

Based on observations, record review and interview, the facility failed to develop/implement a care plan in the area of respiratory and failed to implement the intervention for the care area of physical mobility for 2 of 25 sampled residents. (#7, #39) Findings: Facilities policy: Oxygen therapy, reviewed on 12/6/22 states, Oxygen administration requires a physician order. In an emergency, a nurse may administer O2 and obtain an order within 24 hours and Change mask and or cannula as needed if it becomes soiled. Update care plan in resident profile as needed. 1. On 12/5/22 at 10:01 a.m., observation of Resident #7 to have Oxygen (O2) on at 3.5 liters per minute via nasal cannula, the tubing did not have a date in place and the nasal cannula had darkened yellowish prongs. At this time in an interview with the resident, he/she stated the oxygen is used all the time and he/she is not sure if the tubing is changed frequently stating, I wondered about that, I thought they are supposed to. Review of the medical record revealed nursing documentation confirming Resident #7 had been using oxygen since October 2022. Further review, the medical record lacked evidence that a care plan was developed/implemented for the resident's respiratory needs and monitoring. On 12/6/22 at 12:38 p.m., during an interview, the Director of Nursing confirmed the above findings. 2. Resident #39's care plan initiated on 6/2/22, states the resident has a limited physical mobility with interventions for Teds [thromboembolic deterrant] hose as indicated - on in AM / off HS. A physician order dated 10/27/22 instructs nursing to apply Teds on in the am off QHS, in the morning for edema. On 12/5/22 at 10:19 a.m., observation of Resident #39 in bed with both lower extremities elevated on a pillow, both ankles were observed to be edematous, and he/she did not have Teds in place. On 12/6/22 at 8:13 a.m., observation of resident #39 standing at the sink, wearing slippers, he/she did not have Teds in place. On 12/6/22 at 11:46 a.m., additional observation of Resident #39 in the recliner with both lower extremities elevated, no Teds in place. The resident removed his/her slippers revealing an imprint of the slippers due to the edema. At this time, during a resident reprehensive interview it was reported that Teds were supposed to be ordered, but I haven't seen them on [him/her]. I looked for them. In the morning they should be put on. Haven't seen them and It would be something that would have to be washed, but I haven't seen any. The resident representative stated he/she visits Resident #39 two to three times weekly. On 12/6/22 at 12:09 p.m., during an interview with the Certified Nurse Assistant (CNA), she confirmed Resident #39 is to have Teds on daily and whoever is assigned to the resident is supposed to put them on. At this time both the surveyor and the CNA observed resident #39 without Teds on. The CNA seared the resident's room and could not find any pairs of Teds. On 12/6/22 at 12:38 p.m. the above findings were discussed with the Director of Nursing.

Based on record review and interviews, staff neglected 1 of 3 sampled residents (#1), by not providing care for an entire shift. The failure to provide care resulted in the resident being found at the change of shift saturated in urine, with dependent [MEDICAL CONDITION] of the left side of face and lower left arm and an abrasion on the left eyelid that had not been previously present. In addition, Resident #1 developed impaired skin integrity of the buttocks due to the lack of incontinent care. Findings: A "Nurse's Note", dated 1/21/13, in the clinical record of Resident #1 indicated that staff, at the beginning of the 7 a.m. - 3 p.m. shift, found Resident #1 lying on his/her left side positioned with a pillow. The left side of the resident's face and the left arm had dependent [MEDICAL CONDITION] and there was fresh and old blood noted on the pillow from an abrasion on the left eyelid. Resident #1 had been incontinent of urine and was described as "wet through brief, bed pad, and positioning pillow". The comprehensive care plan, in effect at the time, under the problem area of "Self-Care Deficit" indicated that Resident #1 required total care. A facility "Incident Report", dated 1/21/13, indicated that at 7:30 a.m. Resident #1 was found to have been incontinent of urine with the brief and bed pad saturated to the point that urine was overflowing onto the mattress. The incident report also indicated that it appeared the resident had been positioned on the 3-11 shift and not provided care or repositioning throughout the 11-7 shift. A 1/21/13 note, written by the Assistant Director of Nursing (ADON), to the Administrator, Director of Nursing and the two charge nurses on duty the night of the incident, indicated that it appeared in an attempt to move him/herself Resident #1 sustained an abrasion to the left eyelid. The note also indicated that "no resident should go a full shift without care particularly a resident who requires assist with turning and positioning. This is neglect." A 2/1/13 "Nurse's Note" in the clinical record of Resident #1 indicated that the resident's buttocks were peeling related to the incontinence on 1/21/13. A 2/7/13 "Nurse's Note' (17 days after the incident) indicated that the skin on the resident's buttocks was responding to treatment. On 8/12/13 at 3:15 p.m., in an interview with the surveyor, the ADON stated that on the morning of 1/21/13 a day shift Certified Nursing Assistant (CNA) came to her to report finding Resident #1 soaked with urine. The ADON stated she observed the resident to be soaked and suspected that the resident had not been touched since the 3-11 shift the previous day. In an interview with the surveyor, on 8/14/13 at 8:17 a.m. the Registered Nurse (RN), on duty the night of the incident, stated that the shift started out with four CNAs but then someone had to leave so were left with three CNAs. She stated that the assignment was switched to a three person assignment and that a CNA was assigned to care for Resident #1. The RN stated that she would have gone by the resident's room throughout the night but, does not recall noticing a problem. The failure of the CNA staff to provide care and the failure of the RN to supervise the delivery of care to the residents resulted in Resident #1 being found at the change of shift, on 1/21/13, saturated in urine, with dependent [MEDICAL CONDITION] of the left side of face and lower left arm and an abrasion on the left eyelid that had not been previously present. In addition, Resident #1 developed impaired skin integrity of the buttocks due to the lack of incontinent care.