Every finding on record at Seal Rock Healthcare

Based on interview and record review, the facility failed to ensure a resident remained free of misappropriation of property in the form of theft of a resident's personal credit card and multiple unauthorized purchases for 1 of 27 residents screened for abuse and misappropriation in the initial pool.Findings: On 3/30/26 at 10:30 a.m., in an interview with a surveyor, Resident #89 stated, I had someone take my credit card and my social security card on Christmas Eve (2025). She (Certified Nursing Assistant - CNA) also took the debit card of the resident across the hall, and someone downstairs, and another lost a necklace, $900 something on her card. I was lucky, she (CNA) got a lot out of the lady across the hall. Resident #89 stated there were all kinds of charges, (to a) motel, gas station, Target, etc. They (the stores) all had cameras and they caught them. Resident #89 stated he/she reported the charges on his/her credit card to the facility and staff acted on it immediately. Resident #89 stated I called the (credit card) company and they took the charges off. The CNA was arrested and is going to trial. On 3/30/26 at 11:05 a.m., in an interview with a surveyor, the facility's Administrator stated as soon as Resident #89 made him aware of the charges on his/her credit card, he contacted the local police department, and he initiated an investigation. The Administrator stated the employee was an agency staff (CNA) and that the local police department has kept him in the loop. The Administrator stated the CNA was arrested in Mississippi and is facing multiple charges and will be going to court soon. On 3/31/26 at 3:30 p.m., in an interview with a surveyor, the facility's, Senior Health Care Operations Consultant (Consultant) stated on 1/2/26, she was notified of the credit card theft of a resident. She reported this to the police and initiated an investigation. During the investigation, the Consultant noted all staff had returned her calls for interviews except one agency CNA. Approximately one week later, two other residents reported credit card losses, which were reported to the local police. The police informed the Consultant that there was an active warrant for the agency CNA's arrest, and approximately one week ago, the police informed the Consultant that the CNA had been arrested in Mississippi. The Consultant stated the CNA had worked a total of 3 times and then left the State. All residents were reimbursed for the unapproved charges by their credit card companies. The Consultant stated she was unaware of the theft of a necklace and that no resident had reported this. Review of the CNA's personnel file noted he/she had no disqualifying offenses at the time the Maine Background Check was completed. The CNA had also received training for abuse, neglect and misappropriation. As a result of the facility's investigation the following corrective actions were taken:Incidents were reported to the appropriate State Agencies and local police.All direct care staff were required to complete education on resident rights, abuse, neglect, and reporting requirements.The CNA was no longer employed and had left the State of Maine.

Based on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 10 of 23 residents reviewed for advance directives (Resident #1, #6, #8, #17, #36, #50, #89, #103, #107, and #110). 1.Resident #1 was admitted to the facility in January of 2026. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 2. Resident #6 was admitted to the facility in May of 2015. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 3. Resident #8 was admitted to the facility in February of 2024. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 4. Resident #17 was admitted to the facility in January of 2026. A review of the residents' electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 5. Resident #36 was admitted to the facility in February of 2026. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 6. On 3/30/26 during the record review, it was discovered that Resident #50 did not have documentation of an Advanced Directive being in place nor was there documentation that Advanced Directives were ever discussed with the resident. 7. Resident #89 was admitted to the facility in September of 2017. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 8. Resident #103 was admitted to the facility in March of 2026. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 9. Resident #107 was admitted to the facility in March 2026. A review of the resident's electronic medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 10. Resident #110 was admitted to the facility in March 2026. A review of the resident's electronic medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. On 3/31/26 five surveyors requested several advance directives from the Director of Social Services. On 4/1/26 at 11:30 a.m. in an interview with five surveyors, the Director of Social Services stated that she gave a list to the DON which included those who have advanced directives but there was some she could not find. She stated she would look back in her files for dates she offered advanced directives and that she is trying to change the way she does this process. On 4/1/26 at 2:15 p.m. in an interview with five surveyors, the Director of social services presented a list that stated she does not have any documentation for advance directives for these residents.

Based on observations, interviews, 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 a patient lift on 1 of 1 unit and the storage of chemicals being properly secured for 1 of 1 observation for 1 of 4 days of survey. (3/30/26 through 4/2/26)Findings:1. On 3/30/26 at 10:10 a.m., 2 surveyors observed an EZ Sit to Stand Lift missing both of its safety pins available for use outside of room [ROOM NUMBER].On 3/30/26 at 10:14 a.m., in an interview with Registered Nurse #1, who confirms that the sit to stand lift is missing it's safety pins. At this time, she removes the lift from the unit.On 3/30/26 at 2:08 p.m., in an interview with the Director of Nursing (DON), the above information was confirmed. At this time, she states maintenance has taken the machine off the floor and ordered new pins that should be here in a few days. 2. On 3/31/26 at 8:26 a.m., observation of an unsecured container of CaviWipes on the medication cart outside of room . There were no staff noted in sight.On 3/31/26 at 8:31 a.m., during an interview with Medication Technician #1, who confirms that the CaviWipes should have been in a secure location as there are vulnerable and ambulatory residents on this unit. At this time, she placed the wipes in a secure location.Review of the Safety Data Sheet for CaviWipes under the section First-aid Measures states; Inhalation: Move affected person to fresh air. Get medical attention if symptoms occur. Skin: Gently wash with plenty of soap and water. Seek medical attention if irritation develops. Eyes: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. If irritation persists: Get medical advice/attention. Ingestion: Rinse mouth thoroughly with water. Do not induce vomiting. Call a poison center or a doctor if you feel unwell. Symptoms/effects: May cause moderate irritation to the eyes. Repeated exposure may cause skin dryness or cracking. Inhalation of vapors may cause respiratory irritation.On 3/31/26 at 8:40 a.m., the above information was discussed with the DON.

Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to ensure that the CNA attended the mandatory yearly Abuse and Neglect along with Resident Rights training for 1 of 6 CNA's reviewed. Furthermore, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 1 of 6 randomly selected CNAs employed greater than 1 year. (CNA #1)Findings:CNA #1 was hired in June of 2023. Review of CNA #1 Employee In-service/attendance records lacked evidence of Resident Rights training and Abuse and Neglect training for 2025. Furthermore, the record lacked evidence of the required 12 hours for continuing education for the year 2025.On 4/2/26 at 1:30 p.m., in an interview with the Director of Nursing (DON) who confirmed CNA #1 did not have 12 hours of education, Abuse and Neglect training, and Resident Rights training. She then add that CNA#1 is a per-diem employee and is unsure how many hours she worked in 2025.On 4/2/26 at 4:00 p.m., in an interview with the Senior Healthcare Operations worker, she confirms that CNA #1 worked 199.25 hours in 2025.

Based on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain in good repair. On 4/1/26 at 12:40 an environmental tour was done with the Administrator and the Director of Maintenance and the following were found and confirmed at that time. First floor - room [ROOM NUMBER] - the floor threshold between the room and the bathroom has duct tape on each side, creating an uncleanable surface. Second floor - room [ROOM NUMBER], the wall on the right upon entrance has many small gouges in it from her wheelchair. The are also abrasions on the wall behind her lift chair from it rubbing the wall when it rises. room [ROOM NUMBER], the wall in the bathroom has a hole just below the towel rack.

Based on observations, interviews and record review, the facility failed to identify and implement isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis and failed to follow the Nurse Practitioner's recommendation to ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. In addition, the facility failed to ensure all staff were knowledgeable about which residents were experiencing these symptoms and ensure PPE were used while providing care. This resulted in the spread of gastroenteritis [nflammation that spreads from your stomach into your intestines, causing pain, vomiting and diarrhea symptoms] (GI) symptoms creating an immediate jeopardy situation to 17 out of 90 residents', on 6 of 7 units: Eagle Island, Ram Island, Bluff Island, [NAME] Islan, Beach Island and Gooseberry Island. (Resident #27 #26, #25, #22, #9, #10, #13, #14, #16, #34, #4, #32, #6, #5, #7, #33, and #3) Findings: 1. On 3/17/25 the Division of Licensing and Certification received a complaint regarding quality-of-care concerns and that a resident tested positive for Respiratory Syncytial Virus (RSV). The family was not notified of a resident being positive for RSV and the facility had not implemented isolations precaution with use of PPE and signage posted notifying staff and visitors of the precautions. On 4/1/25 during a telephone interview, the complainant stated Norovirus (contagious gastroenteritis) is currently active in the facility, there is no PPE out for use, staff are not utilizing PPE and there is no posted/signage of isolation precautions out. On 4/2/25 at 8:45 a.m., upon entry to facility, during an observation, there was no posting or signage on the door of any infections/symptoms occurring in the building. In an interview, the Administrator stated there is something GI going around, a few residents have had it and believed there is one resident who was having symptoms. She then stated that both the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionists (ADON/IP) were out sick with nausea, vomiting and diarrhea. On 4/2/25 at approx. 8:50 a.m., 2 surveyors completed an initial tour of the facility. During this tour, the following first floor units; Eagle Island, Ram Island, Bluff Island, [NAME] Island, were observed with no isolation/contact precautions in place requiring the use of PPE. The second-floor units: Beach Island, Gooseberry Island and [NAME] Island were observed with no isolation/contact precautions in place requiring the use of PPE. On 4/2/25 at 11:13 a.m., during an interview with the Family Nurse Practitioner (FNP) and the Advanced Practice Registered Nurse (APRN. The FNP provided the surveyor with a list of 30 residents, located on all units of the facility, who have had or currently have GI symptoms with the first symptoms reported on 3/24/25. The FNP stated the main symptoms were nausea, vomiting and diarrhea. Almost everybody had fatigue, lack of appetite and lethargy for 48-72 hours. She confirmed there was a stool sample pending for Resident #27. At this time, the FNP reviewed Nordex for the stool sample results. Resident #27 results were positive for Norovirus. She stated, she had notified the facility a week ago, via email, of the concern for a norovirus outbreak and asked them to ensure isolation precautions are put into place, cleaning and use soap and water for hands not hand sanitizer stating, I sent it to everyone, the Administrator, DON and the ADON, I asked them to stop activities, and I was told its residents rights, we can't do that. At this time, FNP stated she will notify the facility of Resident #27's positive norovirus results. Review of the email the FNP sent the facility, dated 3/26/25 stated, I believe we are about to have large norovirus outbreak here: already five people have nausea and vomiting, within a 24 hour period. We will be sending some stool samples, will keep you posted. If they are positive and this continues, suspect probable outbreak. Precautions should be in place. Gowns, gloves, signage, please. Isolation should be onset of symptoms/exposure to 2 days after s/s resolve. Treatment is supportive: antiemetics, push fluids. Hand sanitizer is ineffective. Soap and water for hands, bleach for surfaces, to clean. Can Seal Rock please communicate with housekeeping to alert his staff? On 4/2/25 at 11:24 a.m., observation of Resident #7, #25 and #26 rooms to now have a Contact precaution sign posted with a PPE cart near the door. Resident #27 did not have isolation/contact precaution sign posted or PPE cart near the door. On 4/2/25 at 2:18 p.m., 2 surveyors observed Resident #27's room again with no isolation/contact precautions posted or PPE available. Resident #27's significant other was observed visiting sitting with the resident. On 4/2/25 at 3:39 p.m. during an observation with the Administrator and the surveyor, Resident #27's room lacked isolation/contact precautions or a PPE cart by the room. At this time, the surveyor confirmed the Administrator was aware that Resident #27 was positive for norovirus. On 4/2/25 at 5:47 p.m., during an observation, Resident #27's room continued not to have isolation/contact precautions posted and PPE available in a cart near the door. The facilities Infections Prevention and Control Program policy and procedure last revised 3/2025 states, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 7. Prevention of infection . Important facets of infection prevention include: identifying possible infections or potential complications of existing infections Cortana instituting measures to avoid complications or dissemination, educating staff and ensuring that they adhere to proper techniques and procedures, communicating the importance of standard precautions and respiratory hygiene to visitors and family members, screening for possible significant pathogens . implementing appropriate enhanced barrier or transmission-based precautions when necessary and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). 2. Additional interviews with facility staff confirmed the lack of isolation/contact precautions being initiated upon first GI symptoms and knowledge of what residents were having these symptoms requiring isolation precautions and use of PPE: On 4/2/25 at 9:04 a.m., during an interview with Certified Nurses Aid (CNA#3) stated, we had norovirus going around, for the most part, it's cleared up. The surveyor asked if she was given a report of any residents with current GI symptoms. She stated Resident #22 did have symptoms but was not having any right now and Resident #17 had symptoms a few days ago but nothing yesterday or today. At this time, CNA #3 confirmed she had worked on 4/1/25 on the unit and both yesterday and today she was unaware of any new GI symptoms. On 4/2/25 at 9:16 a.m., during an interview, the Certified Nurses Aid (CNA#1) on Beach Island and Gooseberry Island, stated she was unaware of any resident's experiencing GI symptoms of nausea/vomiting/diarrhea (n/v/d). The surveyor asked how she would be made aware if a resident was on isolation precautions requiring PPE for care. She stated it would be posted on the resident's door. On 4/2/25 at 9:23 a.m., during an interview with Licensed Practical Nurse (LPN#1), stated he is the nurse in charge of Beach Island, Gooseberry Island and [NAME] Island (the nurse in charge of Resident #27). The surveyor asked if any residents were experiencing GI symptoms of n/v/d. He stated, he was aware of Resident #26 had n/v/d that started this weekend, Resident #25 started with loose stools yesterday and Resident #22 started with loose stools last night. He stated there has not been any testing since it started, and he is unaware of any current testing being completed. The surveyor asked if the [NAME] Island unit had any GI symptoms, he stated, a few days back but nothing since. When asked what he would do if a resident showed signs of GI symptoms, he stated he would notify the provider, put in a change of condition in the resident's chart, notify the family, and put up PPE. At this time, the surveyor asked why the residents he mentioned did not have Isolation/Contact precautions posted and a PPE cart outside of their room. He stated, he relies the Unit Coordinator/CNA (on Eagle/Ram unit, first floor) to put up the PPE for residents needing to go on precautions and he was going to be putting up precaution signs on the rooms however he is busy but will do it this morning. When asked the follow up question if there are any difficulties obtaining PPE, he stated that finding a cart to hold the PPE and the signage is very challenging. On 4/2/25 at 9:37 a.m., during an interview with Certified Nurses Aid - Medication technician (CNA-M #2) on Beach Island, Gooseberry Island and [NAME] Island, stated she is unaware of any residents having GI symptoms of n/v/d or the need to wear PPE. The surveyor asked how she would know if a resident was on isolation/contact precautions and PPE was required. She stated it would be on their door, posted with gloves and gowns. On 4/2/25 at 9:40 a.m., during an interview, with Housekeeper on Beach Island and Gooseberry Island, stated she just returned from 3 days off. The Surveyor asked if she was aware of any residents having GI symptoms of n/v/d, she stated, nope, The surveyor asked how she would know if she needed to wear PPE prior to going into the rooms, she stated, it would tell you, on the door what you have to wear. On 4/2/25 at 9:45 a.m., during an interview, with CNA #2 on Beach Island, Gooseberry Island and [NAME] Island, stated she was not given any report regarding residents having GI symptoms or anyone on precautions other than Enhanced Barrier Precautions (EBP). On 4/2/25 at 9:50 a.m., during an interview with Registered Nurse (RN#1) on the Bluff Island and [NAME] Island, stated that there are a few residents who are experiencing GI symptoms, Resident #9 is experiencing nausea and diarrhea, Resident #10 has vomiting and diarrhea with a stool sample sent out and they are awaiting results, Resident #13 is experiencing nausea and dry heaves that started last night, Resident #14 has been vomiting since last night, Resident #16 has been vomiting since yesterday and there are orders to collect a stool sample. At this time, RN#1 stated she cannot confirm if there are PPE carts available or at these residents' rooms, but they all should be on precautions. On 4/2/25 at 9:55 a.m., during an interview with LPN #2 on Bluff Island and [NAME] Island, stated she would only get a report when she is the nurse in charge. She confirmed she was not the nurse in charge, only passing medications and did not receive a report. The surveyor asked if she was aware of any residents having GI symptoms of n/v/d, she stated, Yes, Resident #14 had emesis yesterday, nobody else as far as I know .Resident #34 had signs and symptoms of norovirus. The doctor said to go ahead and get a stool. Nobody I know of on Bluff side. On 4/2/25 at 10:05 a.m., during an interview, with RN #2 on the Ram Island, stated she believes that the facility has a lot of Noro cases; Resident #4 was sent out to the hospital yesterday for GI issues, Resident #32 had symptoms over the weekend which have resolved, Resident #6 started having stomach cramps this morning, Resident #5 started having diarrhea this morning and Resident #7 started vomiting this morning. RN #2 then stated that she herself had GI issues on Friday 3/28/25, called out Saturday but returned to work Sunday 3/30/25. During the week of 3/28/25 she had Resident #33 who had GI symptoms. She then stated, a lot of staff have been getting it along with the residents. On 4/2/25 at 10:15 a.m., during an interview, with LPN #3 working on Eagle Island, stated Resident #3 started to have nausea about a half hour ago and denies anyone else having GI symptoms. The surveyor asked if she gets a report on who requires PPE and/or isolation precautions, she stated, we don't, there's a sign on the door for people on precautions that we follow. On 4/2/25 at approx. 10:18 a.m., during an interview with the Administrator, 2 surveyors discussed the lack of Isolation/Contact precautions posted, the lack of available PPE carts, the lack of staff knowledge of residents who are experiencing GI symptoms, staff entering the rooms of residents with GI symptoms without the use of PPE and are unaware of the risks and the GI symptoms have been spreading throughout the facility. At this time, the Administrator stated again that both the Director of Nursing (DON) and Assistant Director of Nursing/Infection Preventionist (ADON/IP) were out sick. On 4/2/25 at 10:22 a.m. during an interview with both CNA #6 and CNA #7 on Eagle Island and Ram Island. CNA #6 stated he does not know of any residents, on his side, that are having GI symptoms or anyone needing contact precautions. CNA #7 then stated that she knows Resident #7 having symptoms and Resident #4 being sent to the hospital yesterday due to GI symptoms. The surveyor asked both CNA's which residents are on contact precautions. CNA #7 stated, the only one on my side is Resident #2 who is on EBP. Based on the above information, IJ was called on 4/2/25 for the facility's failure to to identify and implement isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis, failed to follow the Nurse Practitioner's recommendation to ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents, and failed to ensure all staff were knowledgeable about which residents were experiencing these GI symptoms and ensure PPE was available. The facility's failure to provide these services constituted an immediate jeopardy situation. Please see F-0000 Initial Comments related to the IJ removal plan.

Based on observations, interviews and record review the facility failed to ensure nursing staff immediately initiated isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis (GI) (i.e. diarrhea, vomiting, abdominal pain, and/or fever) and ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. This has resulted in the spread of GI symptoms throughout the facility which began on 3/24/25 and Norovirus being confirmed on 4/2/25. Findings: 1. On 4/2/25 at 8:45 a.m., upon entry to the facility, 2 surveyors observed no posting or signage on the door of any infections/symptoms occurring in the building. In an interview, the Administrator stated there is something GI going around, a few residents have had it and believed there is one resident who was having symptoms. She then stated that both the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionists (ADON/IP) were out sick with nausea, vomiting and diarrhea. On 4/2/25 at approx. 8:50 a.m., 2 surveyors completed an initial tour of the facility. During this tour, the following first floor units; Eagle Island, Ram Island, Bluff Island, [NAME] Island, were observed with no isolation/contact precautions in place requiring the use of PPE. The second-floor units: Beach Island, Gooseberry Island and [NAME] Island were observed with no isolation/contact precautions in place requiring the use of PPE. On 4/2/25 at 11:13 a.m., during an interview with the Family Nurse Practitioner (FNP) and the Advanced Practice Registered Nurse (APRN. The FNP provided the surveyor with a list of 30 residents, located on all units of the facility, who have had or currently have GI symptoms with the first symptoms reported on 3/24/25. The FNP stated the main symptoms were nausea, vomiting and diarrhea. Almost everybody had fatigue, lack of appetite and lethargy for 48-72 hours. She confirmed there was a stool sample pending for Resident #27. At this time, the FNP reviewed Nordex for the stool sample results. Resident #27 results were positive for Norovirus. She stated, she had notified the facility a week ago, via email, of the concern for a norovirus outbreak and asked them to ensure isolation precautions are put into place, cleaning and use soap and water for hands not hand sanitizer stating, I sent it to everyone, the Administrator, DON and the ADON, I asked them to stop activities, and I was told its residents rights, we can't do that. At this time, FNP stated she will notify the facility of Resident #27's positive norovirus results. Review of the email the FNP sent the facility, dated 3/26/25 stated, I believe we are about to have large norovirus outbreak here: already five people have nausea and vomiting, within a 24 hour period. We will be sending some stool samples, will keep you posted. If they are positive and this continues, suspect probable outbreak. Precautions should be in place. Gowns, gloves, signage, please. Isolation should be onset of symptoms/exposure to 2 days after s/s resolve. Treatment is supportive: antiemetics, push fluids. Hand sanitizer is ineffective. Soap and water for hands, bleach for surfaces, to clean. Can Seal Rock please communicate with housekeeping to alert his staff? 2. Additional interviews with facility nursing staff confirmed the lack of isolation/contact precautions being initiated upon GI symptoms and knowledge of what residents were having these symptoms requiring isolation precautions and use of PPE: On 4/2/25 at 9:23 a.m., during an interview with Licensed Practical Nurse (LPN#1), stated he is the nurse in charge for the second-floor units which included Resident #27. The surveyor asked if any residents were experiencing GI symptoms of n/v/d. He stated he was aware of one that had n/v/d that started this weekend, one who started with loose stools yesterday and another who started with loose stools last night. He stated there has not been any testing since it started, and he is unaware of any current testing being completed. When asked what he would do if a resident showed signs of GI symptoms, he stated he would notify the provider, put in a change of condition in the resident's chart, notify the family, and put up PPE. At this time, the surveyor asked why the residents he mentioned did not have Isolation/Contact precautions posted and a PPE cart outside of their room. He stated, he relies the Unit Coordinator/CNA (on Eagle/Ram unit, first floor) to put up the PPE for residents needing to go on precautions and he was going to be putting up precaution signs on the rooms however he is busy but will do it this morning. When asked the follow up question if there are any difficulties obtaining PPE, he stated that finding a cart to hold the PPE and the signage is very challenging. On 4/2/25 at 9:50 a.m., during an interview with Registered Nurse (RN#1) on the first floor, she stated there are a few residents who are experiencing GI symptoms, one with nausea and diarrhea, another with vomiting and diarrhea with a stool sample sent out and they are awaiting results, one who is experiencing nausea and dry heaves that started last night, one who has been vomiting since last night and another one who had been vomiting since yesterday and there are orders to collect a stool sample. At this time, RN#1 stated she cannot confirm if there are PPE carts available or at these residents' rooms, but they all should be on precautions. On 4/2/25 at 9:55 a.m., during an interview with LPN #2 on the first floor, she stated she would only get a report when she is the nurse in charge. She confirmed she was not the nurse in charge, only passing medications and did not receive a report. The surveyor asked if she was aware of any residents having GI symptoms of n/v/d, she stated one had emesis yesterday, and another resident had signs and symptoms of norovirus, and the doctor said to get a stool. On 4/2/25 at 10:05 a.m., during an interview, with RN #2 on the first floor she stated, the facility has a lot of Noro cases; one resident was sent out to the hospital yesterday for GI issues, another had symptoms over the weekend which have resolved, one who started having stomach cramps this morning, one who started having diarrhea this morning and one who started vomiting this morning. RN #2 then stated that she herself had GI issues on Friday 3/28/25, called out Saturday but returned to work Sunday 3/30/25. She then stated, a lot of staff have been getting it along with the residents. On 4/2/25 at 10:15 a.m., during an interview, with LPN #3 working on first floor, she stated one resident started to have nausea about a half hour ago and denies anyone else having GI symptoms. The surveyor asked if she gets a report on who requires PPE and/or isolation precautions, she stated, we don't, there's a sign on the door for people on precautions that we follow. On 4/2/25 at approx. 10:18 a.m., during an interview with the Administrator, 2 surveyors discussed the lack of Isolation/Contact precautions posted, the lack of available PPE carts, the lack of staff knowledge of residents who are experiencing GI symptoms, staff entering the rooms of residents with GI symptoms without the use of PPE and are unaware of the risks and the GI symptoms have been spreading throughout the facility.

Based on interviews, observations and record review the Administration failed to follow the facility's Infection - Clinical Protocol policy and procedures by not following the Family Nurse Practitioner's (FNP) recommendation of isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis (GI) (i.e. diarrhea, vomiting, abdominal pain, and/or fever) and ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. In addition, Administration failed to ensure the infection Preventionist was following the facilities Infection prevention and Control Program which included oversight, outbreak management, prevention of infection and monitoring employee health and safety. This has resulted in the spread of GI symptoms throughout the facility. The administration was notified of the potential outbreak on 3/26/25 and Norovirus being confirmed on 4/2/25 Finding: On 4/2/25 at 8:45 a.m., upon entry to the facility, 2 surveyors observed no posting or signage on the door of any infections/symptoms occurring in the building. In an interview, the Administrator stated there is something GI going around, a few residents have had it and believed there is one resident who was having symptoms. She then stated that both the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionists (ADON/IP) were out sick with nausea, vomiting and diarrhea. On 4/2/25 at approx. 8:50 a.m., 2 surveyors completed an initial tour of the facility. During this tour, the following first floor units; Eagle Island, Ram Island, Bluff Island, [NAME] Island, were observed with no isolation/contact precautions in place requiring the use of PPE. The second-floor units: Beach Island, Gooseberry Island and [NAME] Island were observed with no isolation/contact precautions in place requiring the use of PPE. On 4/2/25 at 11:13 a.m., during an interview with the Family Nurse Practitioner (FNP) and the Advanced Practice Registered Nurse (APRN. The FNP provided the surveyor with a list of 30 residents, located on all units of the facility, who have had or currently have GI symptoms with the first symptoms reported on 3/24/25. The FNP stated the main symptoms were nausea, vomiting and diarrhea. Almost everybody had fatigue, lack of appetite and lethargy for 48-72 hours. She confirmed there was a stool sample pending for Resident #27. At this time, the FNP reviewed Nordex for the stool sample results. Resident #27 results were positive for Norovirus. She stated, she had notified the facility a week ago, via email, of the concern for a norovirus outbreak and asked them to ensure isolation precautions are put into place, cleaning and use soap and water for hands not hand sanitizer stating, I sent it to everyone, the Administrator, DON and the ADON, I asked them to stop activities, and I was told its residents rights, we can't do that. Review of the email the FNP sent the facility, dated 3/26/25 stated, I believe we are about to have large Norovirus outbreak here: already five people have nausea and vomiting, within a 24 hour period. We will be sending some stool samples, will keep you posted. If they are positive and this continues, suspect probable outbreak. Precautions should be in place. Gowns, gloves, signage, please. Isolation should be onset of symptoms/exposure to 2 days after s/s resolve. Treatment is supportive: antiemetics, push fluids. Hand sanitizer is ineffective. Soap and water for hands, bleach for surfaces, to clean. Can Seal Rock please communicate with housekeeping to alert his staff? The facilities Infections - Clinical Protocol policy and procedure last revised on 3/2025 states, under Assessment and Recognition, 1. The physician or provider will help identify individuals who have had a recent infection or who are at high risk for developing an infection. 2. Infection may be suspected based on clinical signs and symptoms and/or temperature. 3. Nursing staff will notify the physician or provider of all pertinent details about the residents condition. Under section Cause Identification, 1. Based on the preceding information, the physician or provider and staff will discuss and determine whether an infection exists or is likely, whether additional evaluations or testing is indicated, and whether other active conditions related to an infection also need to be managed simultaneously. 3. Based on the overall clinical picture, including the severity of the current illness, the physician or provider will help the staff address the following issues: whether an infection is present . 4. The physician or provider and staff will identify infection transmission risks and (in conjunction with the Infection Preventionist) will implement relevant precautions. The facilities Infections Prevention and Control Program policy and procedure last revised 3/2025 states, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Under Elements of the IPCP, 1. Coordination and oversight . Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: documented IPCP incidents and corrective actions taken, whether provider management of infection is optimal, whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion and whether there is appropriate follow up of acute infections. 2. Surveillance and reporting . Surveillance tools are used for identifying the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. 6. Outbreak Management . Outbreak management is a process that consists of: determining the presence of an outbreak, managing the affected residents, preventing the spread to other residents, documenting information about the outbreak, quoting the information to the appropriate public health authorities, educating the staff and the public, monitoring for reoccurrences . 7. Prevention of infection . Important facets of infection prevention include: identifying possible infections or potential complications of existing infections Cortana instituting measures to avoid complications or dissemination, educating staff and ensuring that they adhere to proper techniques and procedures, communicating the importance of standard precautions and respiratory hygiene to visitors and family members, screening for possible significant pathogens . implementing appropriate enhanced barrier or transmission-based precautions when necessary and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). 8. Monitoring employee health and safety . The facility has established policies and procedures regarding infection preventions and control among employees, contractors, vendors, visitors, and volunteers, including: . situations when these individuals should report their infections or avoid the facility (for example . active respiratory infections with considerable coughing and sneezing, or frequent diarrhea stools). Please see F880 for details related to Norovirus

Based on record review and interviews, the facility failed to ensure a physician order was followed for 1 of 1 resident reviewed for diabetes management. (Resident #29) Findings: On 4/2/25 a surveyor reviewed Resident #29 clinical record which showed an active physician order initiated on 11/5/24 for blood glucose monitoring one time a day every Tuesday and to call the provider if blood sugars are less than 100 or above 200. Further review shows the blood sugar levels on 3/4/25 was 285, on 3/11/25 was 311, on 3/25/25 was 298, and on 4/1/25 was 253. The clinical record lacked evidence of physician notification for the above levels. On 4/2/25 at 4:38 p.m. and at 5:50 p.m., during an interview, the Family Nurse Practitioner stated that she was aware of Resident #29 blood sugar being elevated on 4/1/25. However, she was unable to recall if she was made aware of any other elevated glucose levels for Resident #29. On 4/2/25 at 4:38 p.m., during an interview, Licensed Practical Nurse #1 stated, when he gets a high blood sugar reading, he will either call the provider, if the provider was in the facility he would speak to them in person, and if the glucose reading was elevated overnight, he would call the on-call provider. He then stated he would document this information in the residents' chart. On 4/2/25 at 6:00 p.m., during an interview, the Facility Administrator confirmed that the residents clinical record lacked evidence of physician communication for the elevated sugars on the dates above.

Based on record review and interview, the facility failed to ensure that resident's Power of Attorney (POA) was notified of a significant change in medical condition for 1 of 2 residents reviewed for Respiratory Syncytial Virus (RSV) (Resident #29). Findings: On 3/17/25 Division of Licensing received a complaint that Resident #29, was transported to the Hospital on 3/15/25 due to mental status changes. The hospital notified the POA that, according to the facility records, Resident #29 had tested positive for RSV on 3/7/25. The POA was not made aware of this diagnosis. On 4/2/25, a review of Resident #29's medical record lacked evidence of nursing documentation and/or labs to verify that he/she was tested or positive for RSV. At 3:25 p.m., during an interview with the Advance Practice Registered Nurse (APRN) she confirmed that Resident #29 was seen by the provider and swabbed for RSV on 3/7/25, which resulted in him/her testing positive for RSV. The APRN was able to obtain the positive lab results through the lab documentation. The medical record lacked evidence of his/her POA being notified of the positive RSV results. On 4/2/25 at 3:35 p.m., during an interview with the facility Administrator the above information was confirmed.

Based on record review and interview, the facility failed to ensure that the facility's Bowel Maintenance Program was followed, and the staff did not notify the physician of resident's condition for 1 of 8 sampled residents (#1). Finding: Review of Resident #1's clinical record indicated on Physician's Notes from 6/5/2023 to 7/24/2023 list diagnosis of Chronic Diarrhea and Constipation. Resident #1's Stool Output record demonstrated that the resident had no documented bowel movement (BM) for a period of 5 days (7/10/2023, 7/11/2023, 7/12/2023, 7/13/2023, and 7/14/2023. Medical record indicates resident was hospitalization on [DATE]. The Medication Admission Record (MAR) demonstrated that the resident continued to receive Imodium 2mg (milligrams) twice daily until the resident was hospitalized on [DATE]. The Bowel Maintenance Program states: If no bowel movement for 3 days, follow physicians orders for bowel management. Constipation: No BM times 3 days check for impaction. If impacted, notify MD, if not impacted, Give MOM (Milk of Magnesia) 30cc PO (by mouth) 1st day. If no results from MOM. On 2nd day may repeat MOM 30cc x1 (times one) or Administer Dulcolax 10mg suppository PR (rectally) x1. If no results on 3rd day from Dulcolax or MOM give Mineral Oil enema PR x1, if no results call physician. The resident's clinical record contained no documentation of communication to the provider the lack of BMs, as stated in the facilities Bowel Maintenance Program. On 8/8/2023 at 9:35 a.m., the surveyor confirmed the facility failed to implement their Bowel Maintenance Program after the Resident #1 was without a BM for five days days with the Director of Nursing and the Administrator

Based on interviews and record review, the facility failed to serve residents meals in a homelike manner by serving meals on paper/plastic dishware plates and plastic cutlery. That has the ability to effect all residents in facility. Findings: On 8/8/2023, during and interview with Resident #3, the resident stated I am tired of always being served on paper plates and plastic. It makes me feel like a kid, and not in a good way. On 8/08/2023, during an interview with Resident #4, the resident stated It is very bad, and everyone knows it. And then they serve it to you in 'doggie dishes' which makes it even worse. On 8/8/2023 at 11:10 a.m., during an interview with Food Service Manager( FSM) he stated , the dishwasher is broken and are awaiting on a new dishwasher. The FSM also stated We have not had the staff for that for a long time. For over a year. FSM said that he had no idea and no documentation of when the dishwasher might be repaired. On 8/8/2023 at 11:20 a.m., a surveyor discussed the finding of plastic/paper dishware and plastic cutlery with the Administrator.

Based on record reviews and interviews, the facility failed to provide residents a whirlpool/shower as directed by a residents plan of care/shower schedule for 5 of 6 sampled residents (Resident #2, #3, #4, #5 & #6). Findings: 1. The Certified Nursing Assistant (CNA) Assignment sheet indicates that Resident #2's scheduled shower/whirlpool day is every Monday on the 7-3 shift. Review of Resident #2's current Care Plan, dated 2/9/23, indicates the following: [Resident #2] requires 1 assist to help bathe and 2 assist to transfer to the shower chair. Electronic clinical records reviewed from 5/15/23 to 7/8/23 indicated Resident #2 did not receive a scheduled shower on 5/15/23, 5/22/23, 5/29/23, 6/5/23, 6/12/23, 6/19/23, 6/26/23, 7/3/23 and 7/10/23. 2. The CNA Assignment sheet indicates that Resident #3's scheduled shower/whirlpool day is every Thursday on the 3-11 shift. Review of Resident #3's current Care Plan, dated 3/6/23, indicates the following: [Resident #3] bathes with the help of 2 people, to transfer and 1 assist for washing. I prefer showers. Electronic clinical records reviewed from 5/15/23 to 7/8/23 indicated Resident #3 did not receive a scheduled shower on 5/18/23, 5/25/23, 6/1/23, 6/8/23 6/15/23, 6/22/23, 6/29/23 and 7/6/23. 3. On 7/12/23 at 10:24 a.m., during an interview with the surveyor, the family member of Resident #4, stated I don't think he/she is getting his/her weekly showers. The CNA Assignment sheet indicates that Resident #4's scheduled shower/whirlpool day is every Tuesday on the 7-3 shift. Electronic clinical records reviewed from 5/15/23 to 7/8/23 indicated Resident #4 did not receive a scheduled shower on 5/16/23, 5/23/23, 5/30/23, 6/6/23, 6/13/23, 6/20/23, 6/27/23, 7/4/23 and 7/22/23. 4. The CNA Assignment sheet indicates that Resident #5's scheduled shower/whirlpool day is every Friday on the 3-11 shift. Review of Resident #5's Significant change Minimum Data Set 3.0 (MDS) dated [DATE] shows Section F: Preferences for Customary Routine and Activities: F0400-How important is it to you to choose between tub bath, shower, bed bath or sponge bath? SOMEWHAT IMPORTANT(Resident response). Review of Resident #5's current Care Plan dated 6/12//23 indicates the following: [Resident #5] I bathe with the help of 1 person, to help me transfer, to help me wash. I transfer with the help of 2 people, not bearing my weight, transfer me with a full body mechanical lift. Electronic clinical records reviewed from 5/15/23 to 7/8/23 indicated Resident #5 did not receive a scheduled shower on 5/19/23, 5/26/23, 6/2/23, 6/9/23, 6/16/23, 6/23/23, 6/30/23 and 7/7/23. 5. The CNA Assignment sheet indicates that Resident #6's scheduled shower/whirlpool day is every Monday on the 7-3 shift. Review of Resident #6's Annual MDS 3.0, dated 5/18/23, shows Section F: Preferences for Customary Routine and Activities: F0400-How important is it to you to choose between tub bath, shower, bed bath or sponge bath? SOMEWHAT IMPORTANT (Resident response). Review of Resident #6's current Care Plan, dated 5/23/23, indicates the following: [Resident #6] I bathe with the help of 1 person doing 100% of the effort. Electronic clinical records reviewed from 5/15/23 to 7/8/23 indicated Resident #6 received a shower on 6/5/23 and did not receive a scheduled shower/whirlpool on 5/15/23, 5/22/23, 5/29/23, 6/12/23, 6/19/23, 6/26/23, 7/3/23 and 7/10/23. On 7/12/23 at 2:00 p.m., a surveyor discussed the above findings in an interview with the Administrator.

Based on observation and interview, the facility failed to ensure a treatment cart containing multiple medicated creams, powders, ointments, syringes, insulin and inhalation treatment medications was locked on 1 of 7 units. Finding: On 7/12/23 at 12:15 p.m., a surveyor noted an unattended, unlocked treatment cart outside the Bluff [NAME] nurses station containing multiple medicated creams, powders, ointments, syringes, insulin and inhalation treatment medications in corridors where residents and unauthorized personnel cross through. A surveyor confirmed the above finding, at the time of observation, with the Administrator and Director of Nursing (DON).

Based on review of the 8/17/2022 statement of deficiencies and plan of correction (POC) in effect from the annual Long Term Care Survey Process, record review and interview, the facility's Quality Assurance Performance Improvement committee failed to ensure that the plan of correction was followed and effective for F761. Finding: On 7/25/2022 through 7/27/2022, during the annual Long Term Care Survey Process (LTCSP), a deficiency was cited at F761 for the failure to ensure expired medications were removed from medication carts and refrigerators. On 10/4/2022, during the survey revisit, a surveyor observed expired stock medications in medication carts on the Beach/Gooseberry and Eagle/Ram units. In addition, expired medications were observed in the medication room refrigerators on the Bluff/[NAME] and Eagle Ram units. Unit charge nurses confirmed the findings as they occurred, and the Interim Director of Nursing was notified. On 10/4/2022 at 1:00 pm, the findings were discussed with the Administrator.

Based on record review, observation and interviews, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked in 1 of 2 medication rooms observed, failed to date and/or store biological's after opened and according to manufacturer specifications and failed to dispose of expired medications on 3 of 3 units observed. (Eagle Island/Ram Island, Bluff Island/[NAME] Island and Beach Island/Gooseberry Island) Finding: PharMerica policy and procedure for Controlled Medication Storage, revised 11/17 states: #3 The access system (key, security codes) used to lock controlled medications and other medications subject to abuse cannot be the same access system used to obtain the non-scheduled medications. #4 Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. On 7/25/22 the following was observed: 1. At 11:08 a.m., observation of the Skilled unit (Eagle Island and Ram Island) medication room with the Registered Nurse (RN), a refrigerator containing 2 opened multiuse vials of [MEDICATION(S)] (TB) with manufacturer's directions to discard opened product after 30 days, further observation revealed one TB vial had an open date of 3/16/22 and the other vial with open date of 5/20/22. In addition, an opened and not dated vial of [MEDICATION(S)] insulin with manufacturer specifications to Discard unused portion after 28 days. These findings were confirmed at this time with the RN. 2. At 11:15 a.m., observation of the Skilled Unit medication cart with the Licensed Practical Nurse (LPN), contained the following expired medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Famotidine 40 milligram (mg) tabs with expiration date of 6/22, Vitamin B-6 100 mg tabs with expiration date 5/22, [MEDICATION(S)] Vitamin B-1 100 mg with best by date of 4/22, Multivitamin tabs with best by date of 5/22, Famotidine 10mg with expiration date of 6/22, Vitamin B complex with expiration date of 2/22, Acidophilous probiotic with expiration date of 5/22, These findings were confirmed at this time with the LPN 3. At 1:20 p.m., observation of Beach Island and Gooseberry Island nurse medication carts with the LPN. Beach Island medication cart contained 2 opened and unlabeled vials of [MEDICATION(S)] insulin with manufacturer specifications of store up to 42 days after opening. Gooseberry Island medication cart contained an opened and unlabeled vial of [MEDICATION(S)] insulin with manufacturer specifications to discard unused portion 28 days after first opening. These findings were confirmed at this time with the LPN 4. At 1:28 p.m., observation of the Beach Island and Gooseberry Island Medication Technician cart with the Certified Nurse Technician (CNA-M). Beach Island CNA-M cart contained an opened bottle of Famotidine 20mg tabs with expiration date of 6/22. This findings were confirmed at this time with the CNA-M 5. At 1:46 p.m., observation of Bluff Island and [NAME] Island medication room with the LPN contained a refrigerator which had an unlocked, pad lock. The refrigerator contained 12 bottles of liquid [MEDICATION(S)] (Controlled substance), 2 packages containing 4 syringes each of [MEDICATION(S)] ([MEDICATION(S)]) Gel, that was not stored within a locked, permanently affixed box within the refrigerator. In addition, 2 opened and unlabeled multiuse vials of TB, with manufacturer's directions to discard opened product after 30 days. These findings were confirmed at this time with the LPN On 7/25/22 at 3:10 p.m., the surveyor confirmed the above findings with the Director of Nursing

Based on record reviews and interviews, and Facility Reported Incident review, the facility failed to ensure that clinical records were complete and contained accurate information for 4 of 4 sampled residents reviewed for medications (Resident(s)#24, #31, #48 and #374). Findings: Review of Resident #24's signed provider orders for June 2022 revealed the following: -order with start date on 6/2/22 for [[MEDICATION(S)] HCI 5 milligrams (mg) Give one tablet by mouth three times a day x 30 days]. Review of Resident #24's MAR lacked evidence this was completed on 6/9/22 at 1400, 6/15/22 at 1400, 6/25/22 at 1400, 7/6/22 at 2200. -order with start date 6/11/22 for ([MEDICATION(S)] Sodium 1% Gel (2 gram) apply to right knee four times a day. Review of Resident #24's MAR lacked evidence this was completed on 6/15/22 at 8:30 a.m. and 12:30 p.m., 6/25/22 at 12:30 p.m. and 6/6/22 at 2100 -Order with start date of 5/18/22 for MCR/skilled charting, chronic lower extremity wounds/right sacral wound daily, Review of Resident #24's TAR lacked evidence this was completed on 6/13/22, 6/19/22, 6/21/22, 6/23/22, 7/1/22, 7/2/22, 7/7/22, 7/15/22, 7/18/22 and 7/23/22 -Order with start date of 5/18/22 for Do daily wound documentation, Left lower extremity ulcers daily a.m. Sunday, Monday, Tuesday, Thursday, Friday, Saturday. Review of Resident #24's TAR lacked evidence this was completed on 6/10/22, 6/21/22, 6/23/22, 7/1/22, 7/7/22, 7/15/22, 7/16/22, 7/18/22 and 7/19/22 -Order with start date of 6/6/22 for Cleanse bilateral feet with warm soap and water. Please clean between toes. Pat dry. Apply antifungal cream on toenails as ordered daily. Review of Resident #24's TAR lacked evidence this was completed on 6/10/22, 6/21/22 and 6/23/22, 7/1/22, 7/2/22, 7/3/22, 7/7/22 and 7/18/22 -Order with start date of 6/6/22 for Cleanse wounds on bridge of nose with normal saline, pat dry, apply [MEDICATION(S)] dot dressing 2x a week. Monday Thursday a.m. Review of Resident #24's TAR lacked evidence this was completed on 6/23/22, 6/7/22, 6/18/22, 7/1/22, 7/7/22, 7/15/22, 7/16/22, 7/18/22 and 7/19/22 -Order with start date of 6/8/22 for Cleanse sacrum wound with vashe, pat dry and apply [MEDICATION(S)] cut to size in wound bed, cover with silicone adhesive bordered foam dressing Sunday, Monday, Wednesday, Friday. Review of Resident #24's TAR lacked evidence this was completed on 6/10/22.7/15/22 and 7/18/22 -Order with start date of 5/18/22 for Do daily wound documentation, right lower extremity ulcers daily a.m. Sunday, Monday, Tuesday, Thursday, Friday, Saturday. Review of Resident #24's TAR lacked evidence this was completed on 7/7/22. -Order with start date of 6/22/22 for Do daily wound documentation, sacral wound until resolved x 6 weeks a.m. Sunday, Monday, Tuesday, Thursday, Friday, Saturday. Review of Resident #24's TAR lacked evidence this was completed on 6/23/22, 6/24/22, 7/1/22, 7/2/22, 7/3/22, 7/4/22, 7/7/22, 7/15/22, 7/16/22, 7/18/22 and 7/19/22. 2. Resident #31 was admitted to facility on 5/30/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #31's signed provider orders for July 2022 reveled the following: -order with start date on 5/30/22 for [[MEDICATION(S)] insulin Detemir 100 unit/ml solution dose (0.22 ml/22 unit) [subcut] two times a day 0600 1800 for Type 2 diabetes mellitus]. Review of Resident #31's MAR lacked evidence this was completed on 7/26/22 at 0800. -order with date of 6/7/22 for blood glucose checks fasting four times a day 0600 1130 1630 and 2000. Review of Resident #31's MAR/TAR lacked evidence this was completed on 7/26/22 0600. -order with start date 6/23/22 for [MEDICATION(S)] insulin [MEDICATION(S)] 100 unit/ml solution dose: (1 unit) [subcut t.i.d ]0600, 1130 and 1630. for Type 2 diabetes melitus. 61-150=0 units, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units >400=12 units call MD. Review of Resident #31's MAR lacked evidence this was completed on 2/26/22 at 0600. 3. Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #48's signed provider orders for July 2022 reveled the following: -Order with start date of 6/24/22 for, Miconazole Powder dose (1 application) topical, apply to groin and testicles two time a day 0800 2000 x 14 days for Intertigo. Review of Resident #48's TAR lacked evidence this was completed on 7/5/22. -Order with start date of 3/14/22 for, [[MEDICATION(S)]]Skin Protectants, Misc. Cream dose: (1 application) topical apply to body daily 1000 for skin procedure. Review of Resident #48's TAR lacked evidence this was completed on 7/8/22. -Order with start date of 7/5/22 to, Apply Miconozole Powder 2% to affected area(s) (yeast infection/[CONDITION(S)]) two times a day AM PM. Review of Resident #48's TAR lacked evidence this was completed on 7/9/22. -Order with start date of 6/27/22 to, Do daily wound documentation*Left top hand skin tear until resolved RM 6 x week. Sunday Monday, Tuesday Thursday Friday Saturday. Review of Resident #48's TAR lacked evidence this was completed on 7/9/22 and 7/11/22. -Order with start date of 3/14/22 to, Check daily weight NOC Review of Resident #48's clinical record lacked evidence this was completed on 7/11/22. 4. Resident #374 was originally admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #374's signed provider orders for July 2022 reveled the following: -order with start date 7/14/22 to please pre-medicate with [MEDICATION(S)] at least a half hour before dressing changes, daily. Review of Resident #374's Medication Administration Record (MAR) lacked evidence this was completed on 7/14/22 and 7/17/22. -order with start date of 7/14/22 for daily wound documentation right shin wound until healed AM 6 x week, Sunday, Monday, Tuesday, Thursday, Friday and Saturday. Review of Resident #374's Treatment Administration Record (TAR) lacked evidence this was completed on 7/14/22 or 7/19/22 -order 7/20/22 for weekly skin check, Wednesday. Review of Resident #374's TAR lacked evidence this was completed on 7/20/22 -Order with start date of 7/11/22 for daily wound documentation, left hip surgical incision until resolved. AM 6x week Sunday, Monday, Tuesday, Thursday, Friday and Saturday. Review of Resident #674's TAR lacked evidence this was completed on 7/15/22 and 7/17/22. -720/22 weekly non-pressure wound documentation. Right lower extremity wounds until resolved AM 1 x wk. Wednesday not documented completed on 7/20/22 -7/13/22 cleanse left elbow skin tears with normal saline, pat dry, apply [MEDICATION(S)] cut to size in the wound bed of the two large skin tears, cover with double layer xeroform, cover with silicone border comfort foam dressing, date and initial 3 x week M, W F not documented as completed 7/15/22 -7/13/22 cleanse left lower leg surgical site with normal saline, pat dry, apply thin layer of Santyl. During an interview on 7/27/22 at approximately 2:26 pm Gooseberry Island Unit Manger (GUM) indicated that nurses are responsible to sign the MAR/TAR immediate after giving a medications or performing a treatment. At this time GUM confirmed the above findings were not documented as completed.

Based on review of the 8/17/2022 statement of deficiencies and plan of correction (POC) in effect from the annual Long Term Care Survey Process, record review and interview, the facility's Quality Assurance Performance Improvement committee failed to ensure that the plan of correction was followed and effective for F761. Finding: On 7/25/2022 through 7/27/2022, during the annual Long Term Care Survey Process (LTCSP), a deficiency was cited at F761 for the failure to ensure expired medications were removed from medication carts and refrigerators. On 10/4/2022, during the survey revisit, a surveyor observed expired stock medications in medication carts on the Beach/Gooseberry and Eagle/Ram units. In addition, expired medications were observed in the medication room refrigerators on the Bluff/[NAME] and Eagle Ram units. Unit charge nurses confirmed the findings as they occurred, and the Interim Director of Nursing was notified. On 10/4/2022 at 1:00 pm, the findings were discussed with the Administrator.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 8 of 27 residents reviewed for care plans (#24, #31, #52, #57, #58, #65, #324 and #374). Findings: 1. In review of Resident #24's medical record, he/she was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #24's clinical record revealed his/her baseline care plan failed to include the gluten allergy. 2. In review of Resident #31's medical record, he/she was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #31's clinical record revealed his/her baseline care plan was not initiated until 6/16/22 (18 days after admission) and failed to include goals and interventions to meet his/her immediate care needs. 3. In review of Resident #52's medical record, he/she was admitted on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #52's clinical record reveled his/her baseline care plan was not initialized until 6/21/22 (6 days after admission) and failed to include goals and interventions to meet his/her immediate care needs. 4. In review of Resident #57's medical record, he/she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked evidence that the baseline care plan was completed within 48 hours to include the instructions necessary to properly care for Resident #57's immediate health and safety needs for the above diagnoses. On 7/27/22 at approximately 2:22 p.m. a surveyor confirmed the above findings with the Director of Nursing. 5. In review of Resident #58's medical record, he/she was admitted on [DATE] for skilled services from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #58's clinical record revealed his/her baseline care plan was not initiated until 7/19/22. The clinical record lacked evidence that the baseline care plan was completed within 48 hours to include the instructions necessary to properly care for Resident #58's immediate health and safety needs for the above diagnoses. 6. In review of Resident #65's medical record, he/she was admitted on [DATE] for skilled services from acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #65's clinical record lacked evidence that a baseline care plan to include goals and interventions for the immediate care of him/her was completed. 7. In review of Resident #324's medical record, he/she was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #324's clinical record lacked evidence that a baseline care plan to include goals and interventions for the immediate care of him/her was completed. On 7/27/22 at 11:15 a.m. the Admissions Coordinator confirmed with the surveyor that there was no evidence of a baseline care plan. 8. In review of Resident #374's medical record, he/she was originally admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The baseline care plan: initiated 7/25/22 (6 days after admission) did not included goals and interventions for his/her immediate care needs in the areas to address, dementia, cardiac concerns, wound care, or skin cancer. During an interview on 7/27/22 at 7:20 a.m., Licensed Practical Nurse (LPN) indicated that baseline care plans are supposed to be completed upon admission and that the care the Certified Nursing Assistants (CNA)'s provide is largely driven from information on those care plans. During an interview on 7/26/22 at 7:23 a.m., Gooseberry Island Unit Manager (GUM) indicated that she was responsible to complete baseline care plans within 48 hours of admission, and they should reflect residents' active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #65 or #374. -

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition on 2 of 7 units, for 1 of 1 Environmental Tours. (Bluff Island and [NAME] Island). Findings: On 7/27/22 at 9:28 a.m., an environmental tour was conducted with the Administrator in which the following findings were observed: Bluff Island: Room 131A - the wall beside the recliner was gouged and had chipped/missing paint with exposed sheetrock. Room 132A and B - the wall behind both recliners were large areas of gouged wall with chipped/missing paint exposing sheetrock. Room 133B- the bed foot board had gouged and peeling laminate exposing rough wood. [NAME] Island: Room 142- the bathroom door frame was deeply marred exposing rough wood causing sharp and uncleanable surface, The above concerns were confirmed with the Administrator at the time of observations. On 7/26/22, at 8:20 a.m., during observation of laundry room, with the Administrator, it was observed that there were no staff in the laundry due to staff member being out due to COVID-19. There is no cleaning schedule posted for the area. There was a light to moderate level of dust on most flat surfaces in the room, and heavy level of dust on all washing machines and dryers. This was confirmed with the Administrator at that time.