Every finding on record at Sandy River Center

Based on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice by failing to follow a physician's orders for daily weights for 1 of 3 residents reviewed during a complaint investigation (Resident #1).Finding:Resident #1 was recently admitted with diagnoses to include congestive heart failure (CHF).Review of Resident #1's physician orders revealed an order for Daily Weight: Notify the provider if: resident has a weight gain > 2 lbs in 1 day, or 5 lb in a week.for CHF Review of Resident #1's October Treatment Administration Record lacked evidence of daily weights being done for 10/18/25, 10/19/25, 10/20/25, and 10/21/25. Further review of the weight summary in the clinical record lacked evidence that daily weights were started until 10/21/25. On 11/25/25 at 12:21 p.m. the above finding was discussed during an interview with the Market Clinical Lead. At this time, the Market Clinical Lead reviewed Resident #1's clinical record and confirmed that daily weights were not done for the above dates.

Based on record review, interviews, and facility policy, the facility failed to maintain adequate pharmaceutical services to ensure the receipt and administration of physician ordered medication was available to meet the needs of 1 of 3 residents requiring anti-seizure medication reviewed during a complaint investigation (Resident #1).Findings:1. Resident #1 was recently admitted with diagnoses to include epilepsy.On 11/10/25 the Division of Licensing and Certification received a complaint indicating Resident #1 . did not receive [his/her] prescribed medications including [his/her] seizure medication. supposed to take [his/her] seizure medications twice a day.A review of Resident #1's clinical record revealed a physician order for Phenobarbital Tablet 64.8MG, Give 1 tablet by mouth two times a day for seizures. A review of Resident #1's October 2025 Medication Administration Record (MAR) indicated the phenobarbital was scheduled to be given at 8:00 a.m. and 8:00 p.m. each day. Further review of the MAR revealed Resident #1 did not receive the 8:00 p.m. dose of the medication on 10/16/25 and did not receive the 8:00 a.m. dose or 8:00 p.m. dose on 10/17/25, resulting in three consecutive missed doses.A review of the October MAR nursing progress notes for the missed phenobarbital doses revealed the following:-A progress note dated 10/17/25 at 12:05 a.m. states, .New admission, awaiting for pharmacy delivery-A progress note dated 10/17/25 at 10:50 a.m. states, .Not available. checked pixies [Pyxis- an automated medication storage and dispensing machine] not available. Informed provider. waiting for delivery from pharmacy.A provider progress note dated 10/17/25 states, AFTER HOURS TELEHEALTH CONSULT . The individual has a known seizure disorder and is currently prescribed phenobarbital. The pharmacy contacted the facility after 6:00 PM requesting a prescription as no current script was available for dispensing. necessitating this urgent prescription request to ensure continuity of seizure management. Treatment Plan: Phenobarbital 64.8 milligrams twice daily prescription provided for immediate dispensing.On 11/25/25 at 9:07 a.m. during an interview with 2 surveyors, the Director of Nursing (DON) reviewed Resident #1's clinical record and confirmed he/she did not receive his/her prescribed phenobarbital doses on 10/16/25 and 10/17/25.On 11/25/25 at 11:42 a.m. during an interview with 2 surveyors, the above concerns were discussed with the Market Clinical Lead, and she stated it is her expectation that the pharmacy would have delivered Resident #1's phenobarbital by 10/17/25. At this time, a surveyor reviewed the Sugarloaf Unit controlled substance book with the Market Clinical Lead, which indicated the facility did not receive the phenobarbital delivery from the pharmacy until 3:00 a.m. on 10/18/25.2. Facility policy Ordering and Receiving Controlled Medications, revised January 2023 states, .Refill Requests for CIII-CV.requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand.The facility may be asked to contact the prescriber for a new prescription upon request for a medication with no remaining fills available.A review of Resident #1's November MAR revealed Resident #1 did not receive his/her scheduled 8:00 p.m. phenobarbital [a Schedule IV controlled substance] dose on 11/2/25 and did not receive the scheduled 8:00 a.m. dose on 11/3/25 until 2:26 p.m.A review of the November MAR nursing progress notes for the missed phenobarbital doses revealed the following:-A progress note dated 11/2/25 states, . informed online provider. pharmacy will send the medication tomorrow-A progress note dated 11/3/25 states, .medication not available nurse awareA review of the Sugarloaf Unit controlled substance book indicated that after the 8:00 a.m. dose on 11/2/25, the facility had no remaining doses of Resident #1's phenobarbital on hand. Further review of the controlled substance book revealed the facility did not receive a refill of Resident #1's phenobarbital until 11/3/25 at 2:08 p.m., resulting in the missed 8:00 p.m. dose on 11/2/25 and the late dose on 11/3/25. On 11/25/25 at 12:46 p.m. during an interview with 2 surveyors, the above findings were discussed with the Market Clinical Lead and the DON. At this time, the Market Clinical lead stated the nurse should have notified the provider by 10/31/25 that a script was needed in order to refill Resident #1's phenobarbital before the medication ran out.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 6 of 6 Units (Mt. [NAME], Mt. Blue, Sugarloaf, Porter, Rangeley and [NAME]), the laundry room and a common area for 3 of 4 days of survey.(9/15/25, 9/16/25 and 9/18/25).Findings: 1. On 9/15/25 at 6:20 p.m., two surveyors observed small fruit type flies around and on the table in the main office conference room. 2. On 9/15/25 at 8:00 p.m., a surveyor observed the following findings on the Rangeley Unit: - The linen closet had linen and dirt/debris on the floor. - The shower room had black buildup on the grout in the lower right corner of the room. - The dining room floor was heavily soiled with dirt throughout the floor and around the edges and the residents' room door frames. - The privacy curtains were missing hooks, hanging down and in disrepair for resident rooms 502, 503 and 506. 3. On 9/15/25 at 8:15 p.m., a surveyor observed the following findings on the [NAME] Unit: - The dining room floor was heavily soiled with dirt throughout the floor and around the edges and the residents' room door frames. - The unit entrance double doors had chipped/missing paint. - The shower room had black buildup on the grout in the lower left corner of the room. - The laundry room had linens on the floor. There was an approximately one foot by one foot square section of sheetrock cut out of the wall exposing insulation. 4. The common area flooring, in front of the [NAME] Unit entrance doors, had an approximately two inch by 4 inch section of linoleum missing creating an uncleanable surface. 5. On 9/16/25 from at 8:07 a.m. to 9:26 a.m., a surveyor observed the following findings during a facility tour: Porter Unit -Resident room [ROOM NUMBER] – There were numerous house flies flying around the room. The baseboard heater cover and window sill had chipped/missing paint creating uncleanable surfaces. The fall mat, stored by the window had ripped/torn edges exposing foam creating an uncleanable surface. - Resident room [ROOM NUMBER] – The baseboard heater cover, behind head of bed, was broken apart and had fallen down and had chipped/missing paint creating an uncleanable surface. - Resident room [ROOM NUMBER] – The entire bathroom was heavily soiled with dirt and was dirty around base of toilet. There were two cracked/broken floor tiles in front of the toilet. Rangeley Unit: - Resident room [ROOM NUMBER] – The bathroom floor was dirty around the base of the toilet. - Resident room [ROOM NUMBER] – There was a window shade on the floor by a window. Both wardrobe draws, on the right side, were off track and broken. The bathroom floor was dirty around the base of the toilet and there were two bedpans on the floor. - Resident room [ROOM NUMBER] – There were two cracked/broken floor tiles just inside the room entrance door. On 9/16/25 at 9:28 a.m., in an interview with a surveyor, the District Manager for Healthcare Services confirmed the findings. 6. On 9/16/25 at 1:07 p.m. in an environment tour and interview with a surveyor, Director of Operations, and District Manager for Health Care Services the following was confirmed: In room [ROOM NUMBER] the baseboard heater was rusted, had chipped paint, and the end cap of the baseboard heater at the head of the bed was falling off. In room [ROOM NUMBER] the baseboard heater was rusted, and had chipped paint. In room [ROOM NUMBER] the floor was visibly soiled, and when walking next to bed 1, there was a sticky substance on floor, the wall at the head of bed 1 was patched, peeling, and not painted, and the top of the nightstand was dusty. On 9/18/25 from 8 a.m. through 8:20 a.m., an environmental tour was completed. On the Mt. Blue Unit, the grooves of the shower room threshold is caked with dirt. On the Sugarloaf Unit in room [ROOM NUMBER], and 304, behind the toilet, the wall above the cove base has missing sheetrock and crumbling putty patches creating uncleanable surfaces. The above findings were confirmed with the Administrator, on 9/18/25 at 10:45 a.m. On 9/18/25 between 9:02 a.m. thru 9:10 a.m., an environmental tour was completed with the Administrator, Manager of Housekeeping and Laundry, and a surveyor with the following confirmed at time of observation: Mount Blue Unit In room [ROOM NUMBER]-204 bathroom, the floor tiles had gaps around the toilet that were filled with dirt. In room [ROOM NUMBER]-1, the portable fan was dusty. In room [ROOM NUMBER]-1, the fan was dusty, the air conditioner filter was dusty, and the wall behind the bed was gouged. In addition, the light switch to the bathroom did not work. Mount [NAME] Unit In room [ROOM NUMBER], the air conditioner filter was dusty and there were holes in the drywall that were patched but not painted by the entrance door. In room [ROOM NUMBER]-1, the air conditioner filter was dusty. In room [ROOM NUMBER] bathroom, the cove base by the toilet was not attached to the wall

Based on record reviews and interviews, the facility failed to ensure that care plans were updated to reflect the residents current needs for 2 of 39 resident care plans reviewed (Resident #44 [R44] and R11).Findings: 1. On 9/18/25, a review of R44's clinical record was completed. Documentation in R44's nurse note dated 6/20/25 indicated the resident is edentulous and is at risk for choking and has swallowing issues. R44's Physician orders dated 8/19/25, indicated the resident is to be fully upright for meals and to encourage R44 to remain upright for 45 minutes after meals. In addition if R44 wants to eat foods not on his food list, educate him on the possibilities of aspiration, choking and death. A review of R44's care plan was completed. The risk of aspiration and choking was not addressed. Interventions as indicated in the Physicians order for the resident to sit upright for meals and for 45 minutes after meals and education were not addressed on R44's care plan. The surveyor confirmed this finding on 9/18/25 at 10:00 a.m., in an interview with the Director of Nursing. 2. On 9/17/25, R11's clinical record was reviewed and indicated that 7/3/25, R11 started working with physical therapy (PT). The surveyor reviewed the care plan but could not find a care area/intervention regarding R11 currently receiving PT services. On 9/18/25 at 9/18/25 at 8:35 a.m., during an interview with a surveyor, the Director of Rehab stated that R11 entered the case load on 7/3/25 when a change in weight bearing status occurred and is currently working with PT at this time. On 9/18/25 10:20 a.m. during an interview with a surveyor, the Upper Level Unit Manager and surveyor reviewed R11's care plan but were unable to find in the care plan that R11 was currently receiving PT services and had been for over 2 months.

Based on observations, interviews, and review of the facility's Warewashing policy/procedure and the facility's Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a food disposal, a mouse trap, the floor, the stove hood, house flies, ceiling air vents, ceiling tiles and the ceiling metal grid; failed to ensure foods were dated, labeled and/or secured in a walk-in refrigerators and a walk-in freezer; and failed to ensure that the dish machine was monitored for proper wash and rinse temperatures to ensure clean and sanitized utensils and dishes, for 2 of 4 days of survey (9/15/25 and 9/17/25). In addition, the facility failed to ensure that expired food was removed and food dishes were covered in unit refrigerators, for 1 of 4 days of survey (9/15/25). Findings: The facility's Warewashing” policy/procedure dated 2/2023 noted: Policy: All dishware, serviceware, and utensils will be cleaned and sanitized after each use. Procedure: 2. All dishware machine water temperatures will be maintained in accordance with the manufacturer's recommendations for high temperature or low temperature machines. 3. temperature and or sanitizer concentration logs will be completed, as appropriate. 1. On 9/15/25 at 6:10 p.m., a surveyor entered the kitchen and spoke with a cook and a dietary aide who both stated that the dish machine was a high temperature dish machine that washed at a minimum of 150 degrees Fahrenheit (F.) and rinsed at a minimum of 180 degrees F. 2. On 9/15/25 from 6:15 p.m. to 6:50 p.m., a surveyor conducted a kitchen tour with the Traveling Executive Chef for Healthcare Services in which the following findings were observed: - There was dried liquid residue on the food disposal. - There was a rusty mouse trap on the floor under the dish machine. - There was food, trash and equipment(lids/utensils) on the floor under and around the equipment and the shelving. - There was dried liquid residue on the outside of the stove hood. - There were a large amount of house flies observed to be flying around the kitchen and landing on vents, lights and tables. The outside kitchen door next to the freezer door was propped open and had no screen door allowing pests to enter the kitchen. - There were two ceiling air vents, eight ceiling tiles around the vents and the ceiling grid that was dusty/dirty over food preparation areas. - The walk-in Freezer had one package of fish patties that were not labeled. There was one case of previously open sausage patties that was not secured and open to the air. There was a case of beef sandwich slices that had a large chunk of ice built up on the box. There was an excessive ice buildup on the bottom of the condenser unit causing water mist to spray out onto the floor making it slippery. - The walk-in refrigerator had one package of meatballs that was not dated and labeled. There were two, 16-ounce packages of whipped topping that did not have a thaw date and the manufacturer's instructions noted that the product was only good for 14 days after being thawed. - The emergency food storage room, located on the [NAME] Unit, had two ceiling tiles that had large brown stains on them. On 9/15/25 at 6:50 p.m., in an interview with a surveyor, the Traveling Executive Chef for Healthcare Services confirmed the findings. 3. On 9/17/25 at 9:45 a.m., a surveyor reviewed the kitchen documentation and found the dish machine temp logs for June, July, August and September were missing some dates and the rinse temps sometimes were documented below 180 degrees F. The facility Dish Machine Logs for June, July, August and September 2025 were missing temps taken or documented below 150 degrees Fahrenheit (F.) for washing and 180 degrees Fahrenheit (F.) for rinsing to make sure the dishes were clean and sanitized. June: Breakfast (wash temperature low) - 7th; (rinse temperature low)-7th, 8th, 14th, 16th, 17th, and 22nd-25th. Lunch(wash temperature low)- 19th, 23rd, 24th, 29th and 30th.; (rinse temperature low)-19th, 23rd, 24th, 29th and 30th. July: Breakfast (rinse temperature low)-1st, 4th, 6th-9th, 20th, 22nd and 26th. Lunch (rinse temperature low)- 7th-11th, 15th, and 29th-31st. Dinner (wash temperature missing)-28th.; (rinse temperature low/missing)-10th, 28th. September: Breakfast (rinse temperature low)-1st, 4th, 12th, and 13th. Lunch (wash temperature missing)- 15th.; (rinse temperature low/missing)- 9th, 11th, 12th, 11th, and 15th. Dinner (wash temperature missing)- 14th and 16th.; (rinse temperature low/missing)- 14th and 16th. On 9/17/25 at 9:45 a.m., in an interview with a surveyor, the Traveling Executive Chef confirmed the findings. On 9/17/25 at 10:00 a.m., in an interview with 4 surveyors present, the Administrator confirmed the findings from the kitchen. 4. On 9/15/25 at 8:35 p.m., a surveyor observed an opened gallon of milk with an expiration date of 9/3/25 in the Sugarloaf Mountain refrigerator. The surveyor confirmed this finding with Certified Nursing Assistant #2 (CNA2). On 9/15/25 at 8:41 p.m., two surveyors observed Beef snack sticks with an expiration date of 8/14/25 and a container of cantaloupe with was soft and watery, with a date of 9/4/25 on the lid in the Mount Blue refrigerator. The surveyor confirmed this finding with Licensed Practical Nurse #1 (LPN1). On 9/15/26 at 8:44 a.m., two surveyors observed a meal tray from tonight's supper with two bowls not covered in the Mount [NAME] refrigerator. The surveyor confirmed finding this with CNA3 at this time.

Based on observation, interview, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 1 of 4 days of survey (9/15/25).Findings:On 9/15/25 at 8:15 p.m., a surveyor observed the laundry room door not to be fully closed and latched. There was a sign on the door that noted Please Make Sure The Door Is Shut When You Leave. Thank You!!. Upon entering the room, the surveyor observed no one to be in the room and the following chemicals sitting in the open.One - 20-ounce container of Simple [NAME] foaming Coil CleanerOne - 32-ounce bottle of Bio Enzymatic Odor EliminatorOne - 32-ounce bottle of Rapid Multi-surface Disinfectant CleanerTwo - 1 pound 13-ounce containers of Germicidal Disposable wipesTwo - 1 pound 10-ounce containers of Bleach Germicidal wipesThe Safety Data Sheet for Clorox Healthcare Bleach Germicidal Wipes noted the following: 4. First Aid Measures: Inhalation: If breathed in, move person into fresh air. Skin contact: If on skin, rinse well with water. Eye contact: IF IN EYES: Hold eye open and rinse slowly and gently with water for 15-20 minutes. Remove contact lenses if present, after the first five minutes, then, continue rinsing eye. Call a poison control center or doctor for treatment advice. Ingestion: If swallowed, call a Poison Control Center or doctor immediately. DO NOT induce vomiting.The Safety Data Sheet for Super Sani-Cloth Germicidal Wipes noted the following: 4. First Aid Measures: Inhalation: Remove to fresh air. IF exposed or concerned: Get medical advice/attention. Skin contact: Wash off immediately with soap and plenty of water while removing all contaminated clothes and shoes. Eye contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Keep eye wide open while rinsing. Do not rub affected area. Remove contact lenses, if present, after the 1st 5 minutes, then continue rinsing eye. Get medical attention if irritation develops and persists. Ingestion: Do not induce vomiting unless directed to do so by a medical professional. Clean mouth with water and drink plenty of water afterwards. Never give anything by mouth if victim is unconscious or is convulsing. Call a physician.The Safety Data Sheet for Simple [NAME] Foaming Coil Cleaner noted the following: 4. First Aid Measures: Inhalation: If adverse effect occurs, move to fresh air. Skin contact: If adverse effect occurs, rinse skin with water. Eye contact: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. If irritation persists, get medical advice. Ingestion: May cause upset stomach. Drink plenty of water to dilute.The Safety Data Sheet for Rapid Multi Surface Disinfectant Cleaner noted the following: 4. First Aid Measures: Inhalation: Remove to fresh air. Treat symptomatically. Get medical attention. Skin contact: Wash off immediately with plenty of water for at least 15 minutes. Wash clothing before reuse. Thoroughly clean shoes before reuse. Get medical attention immediately. Eye contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Get medical attention immediately. Ingestion: Rinse mouth with water. Do NOT induce vomiting. Never give anything by mouth to an unconscious person. Get medical attention immediately.The Safety Data Sheet for Bio-Enzymatic Odor Eliminator noted the following: 4. First Aid Measures: Skin contact: Rinse with plenty of water. Eye contact: Rinse with plenty of water. Ingestion: Get medical attention if symptoms occur.On 9/15/25 at 8:25 p.m., in an interview with a surveyor, Administrator confirmed the finding. The Administrator stated that the lower level has confused residents that ambulate and also confused residents that move around the facility in their wheelchairs and with the laundry room door not secured, they would have access to these chemicals.

Based on observation, record reviews, and interview, the facility failed to follow a physician order for the use of continuous oxygen for 1 of 2 residents (Resident #30 [R30]) reviewed for oxygen use. Finding:On 9/16/25 at 8:17 a.m., a surveyor observed R30 sitting at the dining room table having already eaten breakfast; present in the dining room were 2 staff members. The surveyor observed a bunch of oxygen tubing coiled up, sitting on the table next to R30 but the tubing was not attached to an oxygen source. The surveyor asked R30 if he/she was supposed to wear oxygen all the time and R30 stated, yes. A review of R30's physician order, dated 8/8/25, indicated that R30 was to received oxygen at 2 liters per minute via nasal cannula continuously. At this time, a surveyor confirmed this finding with Registered Nurse #1 (RN1) who then went to find portable oxygen for R30.

Based on performance evaluation reviews and interview, the facility failed to complete 2 annual performance evaluations that were due to be completed at least every 12 months, for 1 of 3 sampled employees employed greater than 1 year (Certified Nursing Assistant #1 [CNA1]).Finding:CNA1 was hired on 2/21/23. The surveyor requested to review the annual performance evaluations that were due 2/24 and 2/25. On 9/18/2025 at 1:38 p.m., during an interview with a surveyor, the Administrator stated she was unable to find any performance evaluations for CNA1.

Based on observations and interviews, the facility failed to post the nurse staffing information in an area visible to residents for 3 of 4 days of survey (9/15, 9/16, and 9/17/25).Finding:On 9/15/25 at 8:20 p.m., s surveyor observed the staff listing with census in the foyer between the entrance and exit doors. The doors are locked to exit the building to the foyer area. Residents cannot see this without assistance. On 9/15/25 at 8:23 p.m., during an interview with a surveyor, Licensed Practical Nurse #2 (LPN2) stated the only posted nurse staffing information she is aware of is upstairs. Residents would have to use the elevator which needs a passcode to operate. On 9/16/25 at 2:10 p.m. and 9/17/25 at 4:00 p.m., the surveyor observed the staff listing with census in the foyer area, not viewable to residents unless they are able to leave the building. On 9/17/25 at 4:05 p.m., during an interview with a surveyor, the Administrator stated that the Daily Nurse Staffing Form was only posted in the foyer, between the entrance and exit doors. She stated that there was no posting downstairs and confirmed that residents cannot use the elevator without entering a passcode. In addition, the door to exit the building is locked after hours and you need a code to exit the building to the foyer area. The surveyor confirmed that the nurse staffing information was not posted in an area visible to residents at this time.

Based on the facility reported incident, record reviews and interviews, the facility failed to provide the appropriate textured meal to Resident #1 who was identified with swallowing issues and required a dysphagia advanced texture for all meals. This failure to provide the correct texture at the supper meal on 7/24/25 resulted in the resident choking, needing transfer to the hospital and subsequently passing away for 1 of 12 residents reviewed that were requiring dysphagia advanced texture meals. This failure determined an immediate jeopardy situation existed. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements.On 7/28/25, the Division of Licensing and Certification (DLC) received a Facility Reportable Incident Form stating, on 7/24/25 during dinner Resident #1 was found unresponsive, lips blue, broccoli appeared to be in the resident's mouth. The Registered Nurse (RN)#1 finger swiped the residents mouth and pulled out a piece of broccoli. The resident remained limp in the chair and was transferred to the floor, when he/she started gagging and was rolled to the side and vomited. Oxygen was then placed on the resident who was now breathing. Emergency Medical Services arrived, suctioned the resident and transferred him/her to the hospital. On 7/25/25 the facility was notified that Resident #1 was admitted to the Intensive Care Unit, later passing away. The residents' diet order specified advanced dysphagia, allowing soft vegetables cut into appropriate sizes.Resident #1 was admitted to the facility on [DATE] with a history of Cerebrovascular Accident (damage to the brain from interruption of its blood supply) resulting in dysphagia (difficulty swallowing) requiring a specialized diet of dysphagia advanced texture. A Physician diet order, dated 7/21/25 for a Regular/liberalized diet, Dysphagia advanced texture, Standard Thin Liquids consistency. The care plan dated 7/22/25, stated the resident required set up for eating.A nursing note, dated 7/24/25, RN went down to the unit, patient was sitting in wheelchair, not responding to stimuli, lips blue, broccoli appeared to be in [his/her] mouth, this RN finger swiped patients mouth, pulled out a piece of broccoli, patient was limp in chair. Patient was transferred to floor with assistance from CNA's (Certified Nurse Assistant). Patient started gagging, patient was rolled onto [his/her] side, [he/she] vomited. Oxygen was placed on patient, ambulance arrived, Patient was breathing, EMT (Emergency Medical Technician) suctioned patient and transported to ER (emergency room). Patient was responsive when transported.Review of the facilities 2019 Dysphagia Advanced diet states Under Foods Allowed - Vegetables should be soft, well cooked and chopped if needed, under Food to Avoid - Raw vegetables, cooked rubbery or nontender cooked vegetables. Under section Diet Guides states for dysphagia advanced diet broccoli is acceptable as Broccoli Florets, Chop On 7/30/25 at 8:15 a.m., during an interview, the Regional Director of Operations for dietary stated, with a dysphagia advanced diet the vegetables should be able to mash with a fork and pea size pieces. Broccoli florets are supposed to be soft, mashable and chopped. She confirmed she was made aware of the choking incident which happened on 7/24/25 and immediately started to re-educate staff on dysphagia diets. On 7/30/25 at 11:19 a.m., during a telephone interview RN #1 stated, I ran down, I hollered to {another nurse] to grab code status, because I couldn't remember [his/her] code status. The CNA was supporting [resident] in the chair, because [he/she] was unconscious, I scooched down, I looked at [Resident] #1. I was going to do a sternal rub and I saw something sticking out of [Resident #1] mouth. I took out a piece of broccoli that was about 3.5 inches. When I did that, [his/her] airway was open. [He/She] was still unresponsive, we lowered [him/her] to the floor, [he/she] started breathing, gagging. We rolled [Resident #1] to the side and [he/she] vomited. Once [he/she] was done with vomiting I placed oxygen on [him/her], then the EMT showed up. [He/she] was trying to respond to us . [He/she] was responding to the EMT as well. EMT tried to suction and there was nothing. It was the broccoli that was the issue. The surveyor asked if the piece of broccoli she removed from the resident mouth was appropriate for a dysphagia advanced diet. The RN #1 stated, No, it was a big piece On 7/30/25 at 11:48 a.m., during a telephone interview, CNA # 1 stated Resident #1 was doing well with eating, we she was told to supervise and check in. Resident #1 was sitting at the dinner table with another resident who asked to use the bathroom. CNA #1 left the unit to ask another CNA#2 for help with the sit-to-stand transfer. No more than 1 to 2 minutes later they noticed Resident #1 looking pale and not responding. They yelled for the nurse who was down within 30 seconds. When they tilted the residents head up, the nurse pulled broccoli out of [his/her] mouth. he/she was transferred to the ground and then started vomiting. When I picked up all the dishes from my hall. We have a strainer which we scrape the plates off to catch the food. The nurse stopped me, reached into the bucket and grabbed the broccoli and it wasn't fully cooked. The nurse felt the broccoli that was pulled out of [his/her] mouth and that was hard as well. The surveyor asked if the CNA could describe the piece of broccoli that was removed from the resident's mouth. CNA#1 stated, the top was crushed like [he/she] tried to chew it, the stock had teeth marks where [he/she] tried to chew on it and The length was probably between 1/2 to 1 inch and the diameter of the stock was probably the size of a nickel. On 7/30/25 at 12:35 p.m., the surveyor observed a bag of frozen Broccoli Florets which were approx. 2-3 inches long with a stalk and crown. At this time the Dietary Regional Director of Operations stated this is how they are supplied, and they are cooked and chopped before being served for a dysphagia advanced diet, in addition, she is trying to get broccoli crowns in place of the florets. On 7/30/25 at 2:29 p.m., during an interview, CNA #2 stated she was asked to help with a transfer that's when she noticed Resident #1 was about to fall out of the chair and had a pale almost jaundice color face. CNA#1 asked CNA#2 to get a nurse. CNA#2 ran to alert the nurse and was asked to get supplies, oxygen. When CNA#2 returned they had Resident #1 on his/her side and food started coming out of his/her mouth, like solid broccoli, then the EMT got here. CNA#2 stated she was aware resident #1 had dysphagia and we didn't know the broccoli wasn't soft enough and the kitchen didn't tell us. The surveyor asked how she knew the broccoli wasn't soft enough. CNA #2 stated, I was told the next day the broccoli wasn't soft enough. The surveyor asked if she could describe the solid broccoli that resident #1 vomited out. She stated, I would say a small singular piece it was the bottom stem of it. About the size of my index finger maybe about 1 inch 1/2 inch. On 7/30/25 at 2:37 p.m., during an interview, Licensed Practical Nurse (LPN) #1 stated she was passing medication in the hall when CNA#2 got her attention stating Resident #1 didn't look right. They had just finished serving dining. I called out [Resident #1's] name, gave [him/her] a little shake, gave a sternal rub, it didn't do anything. I hollered down the hallway, we had an unresponsive resident. RN #1 was already on her way down. We bent down and noticed a particle of food peeking out, RN#1 did the sweep and removed the object, and [Resident #1] took a breath, like agonal breathing. We lowered him/her to the floor and rolled him/her to his/her right side and he/she vomited, he/she was breathing like gasps. The surveyor asked if she could describe what was in the resident's mouth. LPN #1 stated, Broccoli, it was a mushed up green food item, rather large, it was the shape of [his/her] mouth so probably 2 inches, mushed flatten wad of broccoli. At this time LPN #1 stated the kitchen typically serves the meat cut up but not always the vegetables. We are now cutting them up if needed. Review of the EMS Patient Care Report dated 7/24/25 states, Upon arrival on the scene I am met by a worker at the front door and she states its a possible choking. The patient is located on the floor. the patient on a non-rebreather mask . The patient has a radial pulse and [he/she] is breathing. The patient is vomiting liquid and solid matter. laying in a recovery position. The patients nurse states that when they found [him/her] [he/she] was blue and she cleared [his/her] airway with a finger swipe and removed several large chucks of the patients dinner. I immediately begin to suction the patients vomit. I clear the airway and the patient is alert but not responding to commands. The patient begins to vomit a second time and I clear the airway with suction . The patient has strong radial pulses and [he/she] is breathing on [his/her] own. Review of the Hospital Emergency department notes for 7/24/25 stated under Reason for admission: Resident #1 began to choke during [his/her] meal and had a syncopal episode. [He/she] was in respiratory distress and became cyanotic. [He/she] was transferred via EMS to the ER. Initially, [he/she] was confused but saturating well but then began to rapidly decline, became hypoxic and intubated at families request.CT scan showed evidence of aspiration. after prolonged family discussion, resident #1 was extubated and allowed to die peacefully. The hospital discharge diagnosis was acute respiratory failure with hypoxia, sepsis with acute hypoxic respiratory failure and aspiration pneumonia. On 7/30/25 at approx. 4:55 p.m., the above was discussed with the Market Clinical Advisor and the Administrator. Please see F-0000 initial comments related to Immediate Jeopardy and measures the facility implemented.

Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADLs). Findings: During an interview on 8/5/24 10:33 a.m., Resident #181 indicated 2 Certified Nursing Assistant (CNA)'s on duty to cover entire floor - days and evening, and they are not offering a basin of water or assist to brush teeth. Resident #181 further indicated he/she asked a CNA for help the other day and she said, that figures because she was too busy. During an interview on 8/5/24 at 11:11 a.m., Resident #185 indicated that last week he/she called his/her girlfriend/boyfriend because he/she had used the call bell at 4 pm to be changed, as he/she had been incontinent of bowel. His/her girlfriend/boyfriend arrived at 6 p.m., and notified staff Resident #185 needed to be changed and a staff member stated they were busy with dinner, and he/she was finally changed around 6:30 p.m. Resident #185 further indicated he/she rang the call bell about 3:00 a.m. last Wednesday (7/31/24) to be changed and staff came an hour later. During a resident council meeting on 8/7/24 at 11:00 a.m., Resident #50 indicated that the staff take a very long time to answer call bells and it's been brought up in resident council many times. Review of April, May, June and July 2024 Resident Council meeting minutes revealed the call bells are not being answered in a timely manner and residents feel that staff are not always busy. During an interview on 8/7/24 at 1:55 p.m., Resident Representative indicated that his/her husband/wife never gets shaved unless he/she comes in to do it, and his/her teeth aren't getting brushed. Resident Representative states that he/she is being told that there aren't enough staff, or they're too busy. Weekend staffing is very poor and there are a lot of 2 person assists, and often the CNA has to go to another unit to get help and the floor is left unattended until they get back. During an interview on 8/8/24 at 10:23 a.m., CNA3 indicated that staffing is really bad and it's very difficult to get personal care done as it should and it's really hard to be the only CNA on a unit when you have a lot of residents with dementia and there are quite a few residents that are a 2 person assist. CNA3 further indicated that there were 3 falls during the same shift last week that could have been prevented, call bells are taking a long time to answer, and residents are going a long time between incontinent care episodes because there is so much to be done. The nurses try to help when they can, but they have their own responsibilities. During an interview on 8/8/24 at 10:45 a.m., Registered Nurse (RN) indicated that staffing has been an ongoing problem at the facility and there have been a lot of preventable falls. RN further indicated there are a lot of 2 person assists so a CNA needs someone to help them, and medication technicians and nurses try to help, but today there is one med tech to pass meds on three units so there's no way they can help at all. Review of 3 month fall report revealed there were 18 falls on the day shift, 43 falls during the evening shift and 21 falls during the night shift. During an interview on 8/7/24 at 1:48 p.m., Director of Nursing confirmed there have been some falls on the days they were short staffed, and the facility does not staff to acuity level, but the facility tries really hard to staff at least to state minimums.

Based on record review and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 7 of 15 residents reviewed for advanced directives (Resident's #7, #33, #51, 65, #16, #34, #69). Findings: 1. Resident #7 was admitted to the facility on [DATE]. A review of Resident #7's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Resident #33 was admitted to the facility on [DATE]. Review of Resident #33's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and or formulate an advance directive. 3. Resident #51 was admitted to the facility on [DATE]. Review of Resident #51's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and or formulate an advance directive. 4. Resident #65 was admitted to the facility on [DATE]. A review of Resident #65's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 8/6/24 at 10:17 a.m., Market Clinical Advisor confirmed Residents #7, #33, #51, and #65's clinical records did not include evidence that the residents and/or representatives were asked, or offered and refused, assistance filling out an advanced directive. 33639 5. Resident #16 was admitted to the facility on [DATE]. A review of Resident #16's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 6. Resident #34 was admitted to the facility on [DATE]. A review of Resident #34's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 7. Resident #69 was admitted to the facility on [DATE]. A review of Resident #69's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 8/7/24 at 11:51 a.m., Market Clinical Advisor confirmed Residents #16, #34, and #69's clinical records did not include evidence that the residents and/or representatives were asked or offered and refused assistance filling out an advanced directive. 37440

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 interior for the 6 of 6 units (Mt. [NAME], Mt. Blue, Sugarloaf, [NAME], Rangeley and Porter), the upper level common area, the lower level common area, a patio and the laundry for 1 of 1 facility tours (8/8/24). Findings: On 8/8/24 from 7:50 a.m. to 8:30 a.m., during a tour of the facility with the Maintenance Director, the Regional Health Care Services Housekeeping Supervisor and the Administrator, the following findings were observed: 1. Upper Level Common Area > The public bathroom near the main office had a dirty floor and dirty caulking around the base of toilet. Mt. [NAME] Unit: > Resident room [ROOM NUMBER] - The floor was soiled with dust/dirty inside of the room entrance door and around the entire edge of the room. The caulking was dirty around the base of the toilet. > Resident room [ROOM NUMBER] - The floor was soiled with dust/dirty inside of the room entrance door and around the entire edge of the room. > Resident room [ROOM NUMBER] - The floor was soiled with dust/dirty inside of the room entrance door and around the entire edge of the room. The caulking was dirty around the base of the toilet. > Resident room [ROOM NUMBER] - The floor was soiled with dust/dirty inside of the room entrance door and around the entire edge of the room. > The kitchenette upper cabinet doors had chipped/missing paint on the corners of the doors. Mt. Blue Unit: > The entire dining room floor and the edges were heavily soiled with dirt suspended in the wax. > Resident room [ROOM NUMBER] - The room entrance door frame had chipped/missing paint creating an uncleanable surface. > Resident room [ROOM NUMBER] - The room entrance door and bathroom door frames had chipped/missing paint creating uncleanable surfaces. The bathroom ceiling light had debris in it. > Resident room [ROOM NUMBER] - The room entrance door and bathroom door frames had chipped/missing paint creating an uncleanable surface. The walls by the sink were gouged and marked. The baseboard heater cover on right side of room was broken apart and the entire baseboard heater had chipped/missing paint creating uncleanable surfaces. The box fan on the left side of the room was heavily soiled with dust. The black, circular standing floor fan on the right side of the room was heavily soiled with dust. The ceiling tile, next to the air vent on the right side of room had a large brown stain on it. The air vent was heavily soiled with dust. The caulking and floor around base of toilet were dirty. The bathroom ceiling light has debris in it. > Resident room [ROOM NUMBER] - There was a broken/missing floor tile as you enter the room. There was a dusty white floor fan by the sink. There were multiple ceiling tiles stained with brown stains. The bathroom door frame and room entrance door frame had chipped/missing paint. The walls by the sink were marked/marred and gouged. The caulking and floor were dirty around the base of the toilet. The bathroom ceiling light was full of dust/debris. The box fan by the window was heavily soiled with dust. > Resident room [ROOM NUMBER] - The wall by the window on the right side of the room had holes in it. The fan in the window is heavily soiled with dust. The bathroom door frame and room entrance door frame had chipped/missing paint. The caulking was dirty around the base of the toilet. The bathroom privacy curtain was missing hooks, hanging down and in disrepair. There was a wash basin on the bathroom floor. Sugarloaf Unit: > There were 2 ceiling tiles in the hallway by resident room [ROOM NUMBER] that had large brown stains on them. > Resident room [ROOM NUMBER]- The caulking was dirty around the base of the toilet. > Resident room [ROOM NUMBER] - The caulking was dirty around the base of the toilet. There were 3 wash basins on the bathroom floor. > There air conditioning unit in the dining room had a dirty/dusty filter. > Resident room [ROOM NUMBER] - The caulking was dirty around the base of the toilet. The bathroom ceiling light was full of dust/debris. > Resident room [ROOM NUMBER] - The towel bar was missing on the bathroom door. The caulking was dirty around the base of the toilet. There was a wash basin on the bathroom floor. Porter Unit: >The kitchenette upper and lower cabinets had chipped/missing paint on the doors creating uncleanable surfaces. The wall near the cupboard had chipped/missing paint. The dining room floor was dusty/dirty in the corners. > Resident room [ROOM NUMBER] - The room entrance door frame had chipped/missing paint. Rangeley Unit: > Shower Room - There was a commode bucket on the floor. > Resident room [ROOM NUMBER]- The room entrance door had loose/chipped/missing laminate creating an uncleanable surface. > Resident room [ROOM NUMBER] - The walls by the beds had chipped/missing paint and exposed sheetrock creating uncleanable surfaces. [NAME] Unit: > Resident room [ROOM NUMBER] - The bathroom wall by the toilet had chipped/missing paint with exposed sheetrock creating an uncleanable surface. Lower Level Common Area > There were 3 ceiling tiles, by the elevator, that had large brown stains on them. Laundry Room > There was a heavy build-up of lint behind and on the dryers and washers. On 8/8/24 at 8:30 a.m., in an interview, the Maintenance Director, the Regional Health Care Services Housekeeping Supervisor, and the Administrator confirmed the findings. 2. On 8/8/24 at 11:45 a.m., a surveyor observed the patio fence door, between the Rangeley Unit and the [NAME] Unit, to be broken and missing 2 door panels. There was a green chair blocking the fence opening. On 8/8/24 at 11:50 a.m., in an interview, the Administrator confirmed the finding.

Based on record reviews and interview, the facility failed to ensure that 3 of 3 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review Level II (PASRR) evaluation and determination (Residents #48, #66 and #68). Findings: 1. Resident #48 was admitted to the facility on [DATE] with diagnosis of Bipolar Disorder. Resident #48's clinical record contained a PASRR Level I determination letter dated 6/24/24 that stated further PASRR evaluation was not required due to Resident #48 met the criteria for a short-term convalescence admission. Resident #48 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after Resident #48's stay changed from short-term to long-term. 2. Resident #66 was admitted to the facility on [DATE] with diagnosis of Anxiety. Resident #66's clinical record contained a PASRR Level I determination letter dated 2/23/24 that stated further PASRR evaluation was not required due to Resident #66 met the criteria for a short-term convalescence admission. Resident #66 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after Resident #66's stay changed from short-term to long-term. 3. Resident #68 was admitted to the facility on [DATE] with diagnosis of Bipolar Disorder. Resident #68's clinical record contained a PASRR Level I determination letter dated 4/18/24 that stated further PASRR evaluation was not required due to Resident #68 met the criteria for a short-term convalescence admission. Resident #68 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after Resident #68's stay changed from short-term to long-term. On 8/7/24 at 11:20 a.m., in an interview, the Market Clinical Advisor, confirmed the findings. 37440

Based on record reviews and interviews the facility failed to update and/or implement goals and interventions for 2 of 23 care plans reviewed for respiratory care, and 1 of 1 careplans reviewed for Post-Traumatic Stress Disorder (PTSD). (Resident's #28, #69, #26). Findings: 1. Resident #28 was admitted on [DATE] and has diagnoses to include obstructive sleep apnea, morbid obesity and chronic obstructive pulmonary disease (COPD). Review of Resident #28's care plan updated 5/6/24 states [Chronic Obstructive Pulmonary Disease (COPD)-Clinical Management Chronic Bronchitis; The patient will experience improved exercise tolerance as evidenced by a decrease in episodes of dyspnea on exertion. CPAP as ordered: set at 18, per resident . Review of Resident #28's clinical record revealed progress note dated 7/14/24 stating CPAP is broken. Resident requested if possible [he/she] can have oxygen for tonight. Notified on call provider .about the request of the patient. hooked oxygen 2 LPM as ordered. During an interview on 8/5/24 at 10:50 a.m., Resident#28 indicated his/her CPAP machine broke more than a month ago and they have not replaced it yet. During an interview on 8/6/24 at 12:48 p.m., Unit Manger and a surveyor reviewed Resident #28's care plan confirming his/her care plan had not been updated to reflect his/her current respiratory status. 33639 2. Resident #69 was admitted on [DATE] with a diagnosis of COPD and Congestive Heart Failure (CHF). A review of Resident #69's July 2024 Medication Administration Records (MAR) indicates that the resident received Oxygen at 2 liters per nasal cannula continuously from 5/1/24 - 7/29/24. A review of Resident #69's care plan did not include a focus, goals or interventions in the area of oxygen therapy. On 8/7/24 at 1:46 p.m., a surveyor confirmed the above finding during an interview with the Market Clinical Advisor. 50218 3. Resident #26 was admitted on [DATE] with diagnoses to include post-traumatic stress disorder, depression, and anxiety. Review of Care Plan for Resident #26, updated 6/5/24, states DX: PTSD from time served as a [NAME] . Resident/Patient will identify stressors and report to staff. Encourage Resident/Patient to identify personal trauma and triggers and take steps to eliminate/minimize.'' Review of Resident #26s entire clinical record lacked evidence that he/she was asked about PSTD triggers or how to eliminate/minimize them. During a review of Resident#26's care plan on 8/08/24 at 11:36 a.m., the Director of Nursing confirmed the above findings.

Based on interviews and record review, the facility failed to ensure residents' care plans were reviewed and revised by the interdisciplinary team (IDT) within 7 days after each comprehensive assessment for 4 of 4 residents reviewed for IDT meetings (Resident's #7, #32, #33 and #65). In addition, the facility failed to ensure a a resident's care plan was revised to address nutrition and weight loss (#42). Findings: 1.Review of Resident #7's clinical record revealed quarterly Minimum Data Set (MDS) dated [DATE]. Further review of Resident #7's clinical record revealed an Interdisciplinary Team Meeting (IDT) was held on 7/19/24 (30 days after MDS date). 2.Review of Resident #32's clinical record revealed quarterly MDS dated [DATE]. Further review of Resident #32's clinical record revealed an IDT meeting was held on 5/1/24 (19 days before the MDS date). 3. Review of Resident #33's clinical record revealed quarterly MDS dated [DATE]. Further review of Resident #33's clinical record revealed an IDT meeting was held on 5/1/24 (27 days before MDS date). 4. Review of Resident #65's clinical record revealed quarterly MDS dated [DATE]. Further review of Resident #65's clinical record revealed an IDT meeting was held on 5/1/24 (27 days before the MDS date). During an interview on 8/7/24 at 3:12 p.m., Director of Nursing confirmed IDTs were not held within 7 days after MDS dates, but in the future, it would be happening. During an interview on 8/8/24 at 9:28 a.m., Unit Manger indicated they haven't had a Social Woker since 7/5/24 and she was assisting with holding the IDT meetings and didn't understand that they were supposed to be held withing 7 days after the MDS date. 37015 5. A review of Resident #42's clinical record revealed an admitted [DATE]. Physician orders upon admission included a dysphagia, advanced texture diet, and weigh every day shift every Monday for baseline for 4 weeks, AND every day shift every 1 month starting on the 24th. An admission MDS assessment was completed on 5/29/24. Review of the MDS noted no issues identified with swallowing or weight changes, and revealed the resident received a mechanically altered diet. The baseline care plan was initiated on 5/2/24, and the IDT meeting was held on 5/28/24. A review of the care plan, noted under Activities of Daily Living (ADLs), included regular diet, dysphagia advanced. On 7/3/24, the Registered Dietitian noted a weight loss of 10.3 lbs. since admission and recommended the resident receive a house supplement twice daily. The last recorded weight was on 7/3/24. On 8/7/24 at 2:45 p.m., in an interview with the Registered Dietitian and the Market Clinical Advisor, the surveyor noted Resident #42's care plan had not been revised to address weight loss or include appropriate nutritional interventions. In addition, the record lacked evidence of a follow-up monthly weight being obtained on 7/24/24. The surveyor asked how staff would monitor to see if interventions for weight loss had been effective. The RD stated he/she would follow up. The Market Clinical Advisor confirmed the care plan had not been revised to address nutrition.

Based on observations, record reviews and interviews, the facility failed provide respiratory care consistent with professional standards of practice by failing to ensure that respiratory equipment was replaced for 1 of 1 resident (Resident #28) and failed to change oxygen tubing for 1 of 2 residents reviewed (Resident #69). Findings: 1. Resident #28 was admitted on [DATE] and has diagnoses to include severe morbid obesity, chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea, requiring a CPAP machine (a machine that uses mild air pressure to keep breathing airways open while you sleep). Review of Resident #28's clinical record reviewed Hospital Discharge Summary dated 2/12/24 states Special Instructions: Make sure you use your CPAP for any sleep, including daytime napping . Review of Resident #28's active orders dated August 2024 revealed the following: 1.Order with start date of 10/26/24 states CPAP [a machine that uses mild air pressure to keep breathing airways open while you sleep] mask on at HS. Fill reservoir to line with distilled water. Do not overfill. at bedtime for sleep apnea. Review of Resident #28's Treatment Administration Record (TAR) from 7/13/24 through 8/6/24 revealed this was not completed: broken (24 days). Order with start date of 10/9/24 states CPAP mask to be removed in a.m. Clean mask and reservoir with warm soapy water, rinse and air dry. Every night shift for sleep apnea CPAP mask to be removed in a.m. clean mask and reservoir with warm soapy water, rinse and air dry. every night shift for sleep apnea. Review of Resident #28's Treatment Administration Record (TAR) from 7/13/24 through 8/6/24 revealed this was not completed: broken (24 days). Review of Resident #28's care plan updated 5/6/24 states Chronic Obstructive Pulmonary Disease(COPD)-Clinical Management Chronic Bronchitis; The patient will experience improved exercise tolerance as evidenced by a decrease in episodes of dyspnea on exertion. CPAP as ordered . Review of Resident #28's clinical record revealed the following progress notes: -7/13/24 Water reservoir is leaking. This writer attempted to contact CPAP supplier without success. Further review of Resident #28's clinical record lacked evidence that facility made any further attempts to contact CPAP supplier. -7/14/24 Telehealth Notification Note The Cpap is not working and is leaking water; the patient is requesting supplemental oxygen tonight. Plan: supplement 0xygen 2-3 L, nurse to follow up Cpap machine in AM. Further review of Resident #28's clinical record lacked evidence this was done. -7/15/24 17:54:27 Night nurse passed onto writer that cpap wasn't working and [ sister/brother] was called and was going to get it fixed due to being pt's own machine. Writer called, [sister/brother], and [he/she] stated [he/she] knew nothing about this and doesn't know how to reach out to company to get fixed. Note put in MD's folder on above, ?ordering new machine. -7/16/24 Pt called company on CPAP machine. Pt stated they needed a new script for machine and supplies. Note put in MD's folder with above request. Review of Resident #28's clinical record revealed Provider Communication dated 7/15/24 states CPAP not working, this is Pt's [patients] personal machine .order new one? Review of provider response dated 7/16/24 states Please contact [Respiratory Company] May need a new sleep study. Review of facility fax states: Referral for new c-pap dated 7/25. No follow up documentation is noted in the resident chart. During an initial interview on 8/5/24 at 10:50 a.m., Resident #28 indicated [his/her] CPAP broke more than a month ago and hasn't been replaced. During a follow-up interview on 8/6/24 at 1:09 p.m., Resident #28 confirmed he/she did not receive CPAP last night and believed he/she was still waiting for a sleep study to happen. During an interview on 8/6/24 at 12:48 p.m., Director of Nursing and Unit Manager confirmed the facility has not followed-up with the respiratory company regarding replacement of CPAP or sleep study. At this time Unit Manager indicated that she grabbed order today and sent it to [respiratory company], but the unit secretary (UH) had been working on the sleep study referral. During an interview on 8/8/24 at 12:47 p.m., UH indicated that she is the only one that sends out referrals and also works as a Certified Nursing Assistant (CNA) on the floor as well as the UH position. UH further indicated that when a referral is done, they usually bring it right up to her or put it in her box and in this case, and it was probably bought up on that day, but she had been working the floor, so she didn't get back to her UH position until 7/25/24 and has not followed up on the referral. During an interview on 8/6/24 at 12:50 p.m., Unit Manager confirmed that Resident #28 has been without a CPAP machine since 7/15/24, and no one has followed up with the respiratory company. 33639 2. Review of the Procedure: Oxygen: Nasal Cannula Revision dated 8/7/23., #22. Replace disposable set-up every seven days. Date and store cannula in treatment bag when not in use. On 8/5/24 at 10:05 a.m., the surveyor and Licensed Practical Nurse #2 (LPN) observed Resident #69's oxygen nasal cannula tubing wrapped up and stored with the cylinder on the back of the wheelchair. The date on the oxygen tubing indicated the tubing had been changed on 6/18/24. On 8/5/24 at 10:10 a.m., during an interview with a surveyor, LPN #2 stated oxygen tubing gets changed weekly. Review of Resident #69's active orders for August 2024 revealed an order with a start date of 6/3/24 change the oxygen tubing weekly, label each component with the date and initials. The Treatment Administration Record (TAR) indicates that the oxygen tubing was changed on 6/24/24, 7/1/24, 7/15/24, 7/22/24 & 7/29/24. On 8/7/24 at 1:46 p.m., a surveyor confirmed the finding above of inaccurate documentation with the Market Clinical Advisor who stated she would inform the staff to change the tubing again.

Based on observations and interviews, the facility failed to ensure that medications were stored properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications, on 1 of 4 days of survey. In addition, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication storage rooms and 1 of 3 medication carts reviewed. Findings: 1. On 8/5/24 at 9:01 a.m. two surveyors observed an unlocked and unattended medication cart in the hallway of the Sugarloaf unit for approximately 2 minutes. During this time, one resident was observed in the hallway. Upon return to the medication cart at 9:03 a.m., the Unit Manager confirmed she had left the medication cart unlocked and unattended. 2. On 8/6/24 at 12:15 p.m., during review of the lower level Medication Storage room with LPN #1, a surveyor observed 1 open/undated 8 ounce bottle of Geri Care Senna liquid with an expiration date of 4/24, and 1 unopened 8 ounce bottle of Geri Care Senna liquid with an expiration date of 4/24. 3. On 8/6/24 at 12:20 p.m. during a review of the Rangeley Lake unit medication cart with LPN #1, a surveyor observed 1 open bottle of Geri Care Asprin 81 mg (milligram) Enteric coated with an open date of 7/1/24 and an expiration date of 6/24. 4. On 8/6/24 at 12:34 p.m., a surveyor observed the medication room refrigerator with LPN #2 and noted a dormitory style refrigerator with a freezer. Inside the refrigerator were 5 pneumococcal vaccines and 5 Purified Protein Derivative (PPD) which is used to test for tuberculosis for staff and residents. The United States Centers for Disease Control and Prevention's website, Vaccine Storage and Handling Toolkit, dated 3/24, states Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units often have a single exterior door and an evaporator plate/cooling coil, usually located in an icemaker/freezer compartment. These units pose a significant risk of freezing vaccines, even when used for temporary storage. On 8/6/24 at 12:43 p.m., a surveyor interviewed the Clinical Market Advisor and confirmed that a dorm style refrigerator with a freezer was being used to store vaccinations.

Based on observations and interviews, the facility failed to offer nourishing snacks to residents who want to eat at non-traditional times or outside of scheduled meal service times on 6 of 6 units (Mt. [NAME], Mt. Blue, Sugarloaf, [NAME], Rangeley and Porter), for 2 of 4 days of survey. Findings: On 8/5/24 at 10:37 a.m., in an interview, Resident #181 stated They don't have a snack cart and we don't get offered snacks. I was told there's a bag in the cupboard if you want something. No yogurt or puddings. No hydration cups. On 8/5/24 at 11:08 a.m., a surveyor checked and confirmed the Sugarloaf Unit cupboard contained only white bread and Ensure. No sandwich fillings, peanut butter, etc. On 8/5/24 at 12:36 p.m., a surveyor checked the Mt. Blue cupboards and refrigerator and found there was only a few small cracker packages, 2 small snack oatmeal pies, 1 very small container of tuna salad in the fridge and 1 loaf of bread. On 8/6/24 at 9:15 a.m., Resident #73 said to a surveyor that he/she is never offered snacks because they never have any snacks on the units. He/she said there is never anything in the refrigerator or cupboards. He/she said that he/she could have toast and that was it. On 8/6/24 at 9:30 a.m., a surveyor and the Food Service Director observed the Mt. Blue snack cupboards. The Food Service Director confirmed there was only a few small cracker packages, 2 small snack oatmeal pies, 1 very small container of tuna salad and 1 loaf of bread and agreed there was not enough snacks or a variety of snacks for the number of residents on the unit. The surveyor discussed with the FSD that it had been like this on 8/5/24 and 8/6/24. The FSD stated that the 2 staff that normally stock the snacks in the kitchenettes have had time off from work. On 8/6/24 at 9:45 a.m., in an interview, CNA #2 stated that before this week that there were hardly ever any snacks and drinks or a variety of snacks and drinks stocked on the units. She stated that maybe there would be a few small packages of crackers(2 in a package) and a loaf of bread. There was never coffee or tea left for the residents after any meals. If the residents wanted something other than toast, she would have to call the kitchen and then have to wait hours to get anything. On 8/6/24 at 10:00a.m., in an interview, CNA #3 stated that before this week that there was no variety of snacks and drinks. There were minimal snacks and drinks. She said that there might be a loaf of bread for toast but not much else. A few crackers and a couple small packages of oatmeal pies but that is it. There would be no sandwich making supplies or coffee and tea for the residents. She said if they called the kitchen for something for a resident, they had to wait over an hour to get anything. On 08/06/24 at 2:00 p.m., a surveyor and the Food Service Director District Manager looked at Sugarloaf Unit cupboards and refrigerator. The Food Service Director District Manager stated that when he arrived at the facility, he had checked all the units and they were not properly stocked with enough snacks or a variety of snacks for the residents on the units. He stated that as of right now, all units had been stocked now with snacks according to the newly created Snack Par List given to surveyor. He stated that kitchenettes will be stocked 3 times a day(10 am, 2 pm and 5pm) from now on. No policy or procedure could be provided to the surveyor for stocking snacks in the kitchenettes.

Based on observations, interviews, the facility's Refrigerated/Frozen Storage policy revision date 6/15/18, the facility's Environment: policy HCSG 028 revised 9/2017, the facility's Warewashing policy HCSG 022 revised 2/2023, the facility's Food Storage: Cold Storage revised 2/2023, the facility's Food Storage: Dry Goods revised 9/2017, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, ceiling tiles, ceiling lights, he hood system, the food slicer, the food mixer, and cement blocks. Additionally, the facility failed to ensure that foods in the dry storage room, the reach-in refrigerator and the walk-in refrigerator were labeled and/or dated. Further, the facility failed to ensure refrigerator temperatures were monitored for an area refrigerator. Findings: A surveyor completed Initial Kitchen Tour on 8/5/24 from 9:15 a.m. to 10:00 a.m. with the Food Service Director in which the following findings were observed: 1. > There were 3 ceiling vents, 2 ceiling lights and the 4 surrounding ceiling tiles, in the dish room, that were heavily soiled with dust/dirt. > There was 1 ceiling air, vent just inside the kitchen entrance door, that was heavily soiled with dust/dirt. > All ceiling tiles throughout the entire kitchen were marked/marred and/or dirty. > The hood system had chipped/missing paint creating an uncleanable surface. > The food slicer had dried food particles on the blade and blade protector. > The food mixer had dried food particles on the base and bowl riser arm and base. > There were 4 untreated cement blocks under the legs of the ice machine. > The dry storage room had 2 small bags of chips and 1 bag of clear small containers of peanut butter that were unlabeled and undated. > The reach-in refrigerator had one, 2-quart pitcher of red liquid that was unlabeled and undated. > The walk-in refrigerator had 2 large clear square containers of an unidentified creamy food, 1 large bowl of an unidentified creamy food and 1 bag of sliced potatoes that were unlabeled and undated. > The walk-in freezer had 1 previously opened bag of chicken patties that was unlabeled and undated. > The Activity room refrigerator contained 2 opened and undated whipped cream canisters. Additionally, the Refrigerator/Freezer Temperature Log for August 2024 was missing documented temperatures for the 2nd through the 5th. The facility's Refrigerated/Frozen Storage noted: 1. Refrigeration: 1.4 All foods are labeled with the name of product and the date received and used by date once opened. 1.5 prepared foods are labeled and dated with the name of the product, date open, and use by date. 1.10 Food and nutrition services employees observe and record equipment temperatures. The facility's Food Storage: Cold Storage noted: Procedures . All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's Food Storage: Dry Goods noted: Procedures 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. The facility's Environment: policy HCSG 028 revised 9/2017 noted: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. 3. All food contact services will be cleaned and sanitized after each use. The facility's Warewashing policy HCSG 022 revised 2/2023, noted: Procedures 1. The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine and proper handling of sanitized dishware. 2. All dish machine water temperatures will be maintained in accordance with manufacturer's recommendations for high temperature and low temperature machines. 3. Temperature and or sanitizer concentration logs will be completed, as appropriate On 8/5/24 at 10:00 a.m., in an interview, the Food Service Director confirmed the findings. 2. On 8/6/24 at 8:00 a.m., a surveyor observed the cook with facial hair not wearing facial hair protection. At this time, in an interview, the cook confirmed he was not wearing facial hair protection. On 8/6/24 at 8:03 a.m., in an interview, a surveyor discussed the finding with the Administrator

Based on the facility reported incident dated 4/12/22, review of the facility's investigation report dated 4/18/22, facility policy, record review, and interviews, the facility failed to protect a resident from potentially emotional and physically harm and causing the resident discomfort for 1 of 3 sampled for abuse (Resident #1). A reasonable prudent person could have psychosocial harm. Findings: On 4/12/22 at 6:57 p.m., the Division of Licensing and Certification received a facility reported incident. The report stated that on 4/12/22, the facility received notice that a current employee had shared a video of a resident receiving care. The facility started an immediate investigation. Documentation in the facility's Reportable Incident Form stated the video shows the resident lying face down on the floor with just a brief on and the Certified Nurse Aide (CNA) making the bed. The CNA then picked the resident's legs up and tossed them into bed. Then she did the same with the resident's torso. Facility Investigation Summary dated 4/18/22, stated on 4/12/22, at approximately 5:00 p.m., CNA #1 met with the Center Executive Director (CED) and the Center Nursing Executive (CNE) at the facility. CNA #1 denied ever having made a video of herself in a resident room. CNA #1 was told by the CED that the facility had received the video recording and that it had been posted in a Messenger (Social Media Platform) . CNA #1 denied the allegation and then declined to view the video with the CED and CNE. CNA #1 admitted to lifting the resident without a second staff member and not using the required lift. When asked, CNA #1 stated that she knows the facility has a no lift policy. CNA #1 asked to write a statement and when written, denied ever taking a video of a resident, or a video in the nursing home or posting a video on Messenger. On 4/13/22, at approximately 12:00 p.m., CNA #1 met with the Clinical Lead, the CED, and the CNE at the facility for a second interview. CNA #1 was asked about abuse/neglect and voiced knowledge and understanding of what abuse/neglect is. She also stated she had received education of abuse/neglect at the facility and had never purposely abused anyone. When asked about the facility's policy regarding taking photos/videos of residents and posting on social media, she stated that you can't do it. When asked if she posted the video in a Facebook chat group, she stated she didn't have a chat group. But, maybe on a Messenger chat. She stated that knew now that she posted on a Messenger chat and it was two other people and possibly a third that she sent the video to. She stated that she didn't know when she posted it and she no longer has the video. When asked about the resident on the floor, CNA #1 stated that she had found him/her there on rounds and she reported it to LPN #1 and LPN #1 never came to assess the resident so, CNA #1 put the resident in bed by herself. CNA # 1 asked to rewrite her statement and did so. Her statement continued to deny posting the video to social media but did admit to putting the resident to be by herself and concluded by saying she would never intentionally harm a resident. During a medical record review, documentation in Resident #1's annual Minimum Data Set (MDS), dated [DATE], stated that Resident #1 was care planned for dementia/cognitive loss. Resident #1's clinical record shows he/she was extensive assist for bed mobility and transfers. On 4/20/22 at 10:10 a.m., the surveyor observed the video. The video showed the CNA setting up her phone to record and giving a thumbs up. In the background the resident was observed lying face down on the floor, parallel to the bed wearing only a brief. The CNA lowered the bed and placed a sheet and a draw sheet on the bed. The CNA then lifted Resident 1's legs up onto end of bed, then lifted Resident 1's torso onto bed. The resident was placed on the bed lying face down and was heard saying ow. The CNA went to video, appears to mouth what the [OBSCENITY] , and then turned off the video. A surveyor was unable to interview Resident #1 at the time of the investigation as he/she had passed away. On 4/20/22 at 10:30 a.m., during a phone interview with CNA #1, the surveyor asked about the incident, of the resident on the floor in room [ROOM NUMBER]-2. CNA #1 stated, I had started to do rounds when I found the resident, only with a brief on, lying face down on the floor next to his/her bed. I tried to sit the resident up, but I couldn't. I was so frustrated because no one came to assess the resident or help me. When asked by the surveyor if she knew of a video of her doing care for a resident, CNA #1 stated, Yes, I know there is. It is me in the video and I recorded myself doing care for the resident on my phone. I was mad and very frustrated at waiting for help. I shared it on social media with two or three of my closest friends in a chat. At this time, CNA #1 confirmed she took a video of Resident #1 while she was doing care for him/her. Review of the facility's Personal Cell Phones and Handheld Devices: Use of policy, revision date 11/27/19, noted Process 2. The following are prohibited: 2.3 Keeping, sending, posting, or distributing patient and/or employee photographs or recordings of any kind through multimedia messages or on social media networks. As a result of the facility's investigation, the following corrective actions were initiated. The CNA was immediately suspended, the facility reported the incident to the CNA registry, local law enforcement, the Attorney General's office (via the local law enforcement), the State Survey Agency, and Adult Protective Agency. From 4/13/22 to 4/19/22, the Center Nurse Executive and the Nurse Practice Educator, held in-services reviewing abuse/neglect (resident rights), transfers, patient lift use, posting on social media, cell phone use, falls, safe resident handling, and the incident/accident process. The Center Nurse Executive documented on a check off list, which contained all staffs' names, the completion of the in-services attended.

Based on a review of the Nursing Facility Reportable Incident Form submitted to the Division of Licensing and Certification on 7/14/20, the facility's Internal investigation, dated 7/17/20, 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 avoidable injuries, experiencing emotional distress, and experiencing increased pain for 1 of 4 residents requiring mechanical lift transfers. Finding: A review of the Nursing Facility Reportable Incident form submitted to the Division of Licensing and Certification on 7/14/20 revealed that on the evening of 7/13/20 Certified Nursing Assistant (CNA) #1, transferred the resident (#1) into bed without assistance from staff. The Nursing Facility Reportable Incident form indicated that CNA #1 admitted to transferring Resident #1 alone, and stated that he used the mechanical lift. Further, the reportable incident form noted that Resident #1, has a skin tear measuring approximately 6.0 centimeters on the right forearm and bruising noted from the fingers to the upper arm. A review of the facility's internal investigation dated 7/17/20 revealed the following: On the evening in question, the agency CNA (CNA #1) disregarded facility education/ instruction by transferring the resident independently subsequently causing injury to the resident. A review of the facility's policy NSG234, Safe Resident Handling/ Transfer Equipment, revised on 3/17/20, noted the following: Genesis Policy Requires the use of two trained persons when using a total lift or sit-to stand lift. A review of the Agency Nurse Assistant Checklist dated 7/2/20 and signed by the Nurse Practice Educator (NPE) noted that part of agency nurse assistant (CNA) orientation/ training includes safe resident handling/lift training. A review of a written statement signed by Registered Nurse (RN) #1 dated 7/8/20 noted the following: I, (RN #1),provided education to (CNA #1) the traveling CNA, on proper lift transfers, reading a Kardex, and where to find it. He acknowledged the information and stated understanding. A review of the documentation in Resident #1's current care plan, page 1, with the focus, assistance for Activities of Daily Living (ADL's) included the following intervention: resident transfers with total lift with gray colored sling. A review of the Skin Integrity Report of 7/14/20 stated the following: A skin tear to the right arm with moderate bloody drainage, surrounding tissue inflamed/ indurated, measuring 6 centimeters in length and 0.3 centimeters in width, and less than 0.2 centimeters in depth. A review of the provider encounter note dated 7/14/20 revealed the following: A skin tear of right upper extremity occurred on 7/13/20 as a result of an improper transfer by a CNA, and, patient as a result has bruising to right upper extremity as well as skin tears to forearm as well as tears to skin tags on (his/her) right upper arm x 2. (He/ She) also has bruising to (his/her) left forehead. (He/she) has no complaints for provider but staff report increased pain on movement. A review of a statement written by the Nurse Manager during the facility's internal investigation dated 7/17/20 noted the following: It was reported to this writer that (CNA #1) was not using lifts for transfers. A review of a statement written by Licensed Practical Nurse (LPN) #2 during the facility's internal investigation dated 7/17/20 noted the following about an incident on the evening shift on 7/13/20: Staff reported that (CNA #1) was transferring residents by himself. (CNA #1) was spoken to (reminded) that it was against facility policy to do this for the safety of the residents. 7:30 (Resident #1) was screaming and crying that (his/her) legs hurt, was not able to console resident. Resident repositioned, medicated, and consoled until he/she was more comfortable and calmer. Skin tear was noted on right forearm. (CNA #1) was spoken to regarding the importance of always having two staff with all Hoyer transfers. On 7/23/20 at 8:45 a.m., a surveyor interviewed the Nurse Manager in reference to the facility reportable incident of 7/13/20. The Nurse Manager stated, It was suspected that (CNA #1) had transferred (Resident #1) alone, and suspected that (CNA #1) may not have used a lift for the transfer. The Nurse Manager further stated that she had spoken to CNA #1 about the facility policy, Safe Resident Handling/ Use of Transfer Equipment, in the past and had instructed CNA#1 that two assist was always required for safety during mechanical lift transfers. On 7/23/20 at 10:40 a.m., a surveyor confirmed in an interview with the Center Nurse Executive (CNE) and the Center Executive Director (CED) that the facility had neglected Resident #1 by failing to provide the necessary assistance with a transfer, resulting in Resident #1 sustaining avoidable injuries,experiencing emotional distress, and experiencing increased pain. On 7/24/20 at 9:07 a.m., a surveyor conducted a telephone interview of CNA #1 in which CNA #1 admitted that he had transferred Resident #1 to bed alone the evening of 7/13/20 and claimed he had used the mechanical lift. CNA #1 admitted he had not followed the facility policy for mechanical lift use, and he had not followed Resident #1's care plan in the area of transfers when transferring Resident #1 to bed that evening. CNA #1 further admitted that Resident #1 had been upset and yelling, Don't you people touch me., after the transfer. The surveyor confirmed that CNA #1 failed to provide the necessary assistance with a transfer for Resident #1, resulting in Resident #1 experiencing injuries, emotional distress, and pain. On 7/24/20 at 10:05 a.m., during a telephone interview with the Nurse Practice Educator(NPE), the NPE confirmed that she had oriented CNA #1 to the policy, Safe Resident Handling/ Transfer Equipment when CNA #1 had oriented to the facility on [DATE] . The NPE stated, Every orientee is given a packet of information, including the lift policy. Two person assist with all lift transfers is stressed. CNA #1 was aware of the policy. On 7/24/20 at 10:11 a.m., a surveyor conducted a telephone interview of LPN #2 in which LPN #2 stated that when she entered Resident #1's room the evening of 7/13/20 at approximately 7:30 p.m., Resident #1 was in bed, crying and inconsolable and CNA #1 was at Resident #1's bedside. LPN #2 stated that she asked CNA #1, if he had transferred Resident #1 to bed alone, to which he replied that he had transferred Resident #1 alone, and had used the mechanical lift. LPN #2 further stated that Resident #1's right forearm was bleeding, and that she observed a large skin tear on Resident #1's right forearm. The surveyor confirmed the following during the interview: The facility had neglected Resident #1 by failing to provide the necessary assistance with a transfer. Further, the surveyor confirmed that CNA#1's failure to provide resident #1 with the necessary type of assistance had caused Resident #1 to experience an avoidable injuries, emotional distress and pain.

Based on a review of the Nursing Facility Reportable Incident Form submitted to the Division of Licensing and Certification on 7/14/20, the facility's internal investigation, dated 7/17/20, written statements by staff, facility policy, clinical record review, and interviews, the facility failed to ensure a resident's safety in the area of transfers by not following the resident's care plan resulting in the resident sustaining avoidable injuries, experiencing emotional distress, and experiencing increased pain for 1 of 4 residents requiring mechanical lift transfers (#1). Finding: A review of the Nursing Facility Reportable Incident form submitted to the Division of Licensing and Certification on 7/14/20 revealed that on the evening of 7/13/20 Certified Nursing Assistant (CNA) #1, transferred the resident (#1) into bed without assistance from staff. The Nursing Facility Reportable Incident indicated that CNA #1 admitted to transferring Resident #1 alone, and stated that he used the mechanical lift. Further, the reportable incident form noted that Resident #1, has a skin tear measuring approximately 6.0 centimeters on the right forearm and bruising noted from the fingers to the upper arm. A review of the facility's internal investigation dated 7/17/20 revealed the following On the evening in question, the agency CNA (CNA #1) disregarded facility education/ instruction by transferring the resident independently subsequently causing injury to the resident. A review of the facility's policy NSG234, Safe Resident Handling/ Transfer Equipment, revised on 3/17/20, noted the following: Genesis Policy Requires the use of two trained persons when using a total lift or sit-to stand lift. A review of the Agency Nurse Assistant Checklist dated 7/2/20 and signed by the Nurse Practice Educator (NPE) noted that part of agency nurse assistant (CNA) orientation/ training includes safe resident handling/lift training. A review of a written statement signed by Registered Nurse (RN) #1 dated 7/8/20 noted the following: I, (RN #1),provided education to (CNA #1) the traveling CNA, on proper lift transfers, reading a Kardex, and where to find it. He acknowledged the information and stated understanding. A review of the documentation in Resident #1's current care plan, page 1, with the focus, assistance for Activities of Daily Living (ADL's) included the following intervention: resident transfers with total lift with gray colored sling. A review of the Skin Integrity Report of 7/14/20 stated the following: A skin tear to the right arm with moderate bloody drainage, surrounding tissue inflamed/ indurated, measuring 6 centimeters in length and 0.3 centimeters in width, and less than 0.2 centimeters in depth. A review of the provider encounter note dated 7/14/20 revealed the following: A skin tear of right upper extremity occurred on 7/13/20 as a result of an improper transfer by a CNA, and, patient as a result has bruising to right upper extremity as well as skin tears to forearm as well as tears to skin tags on (his/her) right upper arm x 2. (He/ She) also has bruising to (his/her) left forehead. (He/she) has no complaints for provider but staff report increased pain on movement. A review of a statement written by the Nurse Manager during the facility's internal investigation dated 7/17/20 noted the following: It was reported to this writer that (CNA #1) was not using lifts for transfers. A review of a statement written by Licensed Practical Nurse (LPN) #2 during the facility's internal investigation and dated 7/17/20 stated the following note about an incident on the evening shift on 7/13/20: Staff reported that (CNA #1) was transferring residents by himself. (CNA #1) was spoken to (reminded) that it was against facility policy to do this for the safety of the residents. 7:30 (Resident #1) was screaming and crying that (his/her) legs hurt, was not able to console resident. Resident repositioned, medicated, and consoled until he/she was more comfortable and calmer. Skin tear was noted on right forearm. (CNA #1) was spoken to regarding the importance of always having two staff with all Hoyer transfers. On 7/23/20 at 8:45 a.m., a surveyor interviewed the Nurse Manager in reference to the facility reportable incident of 7/13/20. The Nurse Manager stated, It was suspected that (CNA #1) had transferred (Resident #1) alone, and suspected that (CNA #1) may not have used a lift for the transfer. The Nurse manager further stated that she had spoken to CNA #1 about the facility policy, Safe Resident Handling/ Use of Transfer Equipment, in the past and had instructed CNA#1 that two assist was always required for safety during mechanical lift transfers. On 7/23/20 at 10:40 a.m., a surveyor confirmed that the facility failed to ensure Resident #1's safety in the area of transfers by not following the resident's care plan resulting in the resident sustaining avoidable injuries, experiencing emotional distress, and experiencing increased pain in an interview with the Center Nurse Executive (CNE) and the Center Executive Director (CED). On 7/24/20 at 9:07 a.m., a surveyor conducted a telephone interview of CNA #1 and confirmed that the facility had not ensured Resident #1's safety in the area of transfers resulting in injuries to Resident #1, emotional distress, and pain. CNA #1 admitted that he had transferred Resident #1 to bed alone the evening of 7/13/20 and claimed he had used the mechanical lift. CNA #1 admitted he had not followed the facility policy for mechanical lift use, and he had not followed the resident's current care plan in the area of transfers when transferring Resident #1 to bed that evening. CNA #1 further admitted that Resident #1 had been upset and yelling, Don't you people touch me., after the transfer. CNA #1 admitted that LPN #2 had spoken to him and was upset that he had transferred Resident #1 alone, and admitted that he hadn't noticed the skin tear or bruising on Resident #1 during or after the transfer. CNA #1 speculated that the skin tear may have happened when Resident #1 became resistive to care after the transfer, and pulled his/her arm away from CNA #1. Finally, CNA #1 admitted that Resident #1 had sustained injuries on 7/13/20 while in his care. On 7/24/20 at 10:05 a.m., during a telephone interview with the Nurse Practice Educator(NPE), the NPE confirmed that she had oriented CNA #1 to the policy, Safe Resident Handling/ Transfer Equipment when CNA #1 had oriented to the facility on [DATE] . The NPE stated, Every orientee is given a packet of information, including the lift policy. Two person assist with all lift transfers is stressed. CNA #1 was aware of the policy. On 7/24/20 at 10:11 a.m., a surveyor conducted a telephone interview of LPN #2 in which LPN #2 stated that when she entered Resident #1's room the evening of 7/13/20 at approximately 7:30 p.m., Resident #1 was in bed, crying and inconsolable and CNA #1 was at Resident #1's bedside. LPN #2 stated that she asked CNA #1, if he had transferred Resident #1 to bed alone, to which he replied that he had transferred Resident #1 alone, and had used the mechanical lift. LPN #2 further stated that Resident #1's right forearm was bleeding, and that she observed a large skin tear on Resident #1's right forearm. LPN #2 further stated that CNA #1 speculated that the skin tear must have happened when his/her fingernail caught Resident #1's arm when Resident #1 was resistive to care after the transfer. The surveyor confirmed the following during the interview: The facility failed to ensure a resident's safety in the area of transfers Further, the surveyor confirmed that CNA#1's actions had resulted in avoidable injuries to Resident #1 and had caused Resident #1 to experience emotional distress and pain.