Every finding on record at Sedgewood Commons

Based on record review, facility policy, and interview, the facility failed to ensure required members of the Quality Assessment and Assurance Committee (QAA) participated in Quarterly QAA meetings for 3 of 4 quarterly meetings reviewed. Findings: Review of the facility policy titled Center Quality Assurance Performance Improvement Process revised 3/24/25 indicated the QAA committee meets at least quarterly. The policy indicated the committee is composed of the Administrator, Director of Nursing (DON), Medical Director and the Infection Preventionist (IP). Review of the QAA Committee attendance documentation dated 10/1/25 indicated the DON was not in attendance. Review of the QAA Committee attendance documentation dated 4/9/26 indicated the Administrator and Medical Director were not in attendance. Review of QAA committee attendance documentation dated 7/8/26 indicated the IP was not in attendance.On 9/2/26 at 4:30 p.m., during an interview with a surveyor, the Administrator, DON and the Market Clinical Lead, confirmed the findings.

Based on record review and interviews, the facility failed to monitor temperature controls for 2 of 3 refrigerators observed and 3 of 3 months of medication refrigerator logs reviewed. Findings: 1. On 6/2/25 at 1:30 p.m., observation of the [NAME] medication storage room refrigerator with Registered Nurse #1 (RN) which contained 1 Pneumococcal 20 (PCV 20) vaccination, 6 multi-use vials of influenza vaccinations (Afluria), and a multi-use vial of Tuberculin Purified Protein. On 6/2/25 a surveyor reviewed the facilities Temperature Log For Medication/Vaccine Refrigerators for months of March, April, and May. March 1st through March 31st lacked evidence of twice daily temperature readings for 15 out of the 31 days. April 1st through April 30th lacked evidence of twice daily temperature readings for 24 out of the 30 days. May 1st through May 31st lacked evidence of twice daily temperature readings for 25 out of the 31 days. 2. On 6/2/25 at 2 p.m., observation of the [NAME] medication storage room refrigerator with RN #1, which contained 1 Pneumococcal 20 (PCV 20) vaccination and a multi-use vial of Tuberculin Purified Protein. On 6/2/25 a surveyor reviewed the facilities Temperature Log For Medication/Vaccine Refrigerators for months of March, April, and May. March 1st through March 31st lacked evidence of twice daily temperature readings for 31 out of the 31 days. April 1st through April 30th lacked evidence of twice daily temperature readings for 28 out of the 30 days. May 1st through May 31st lacked evidence of twice daily temperature readings for 30 out of the 31 days. On 6/2/25 at 2:30 p.m., during an interview, the above findings were confirmed with the Market Clinical Advisor at this time she states they follow Center of Disease and Control (CDC) guidelines for vaccination and medication storage. Review of the CDC guidelines regarding vaccine storage, last revised 3/19/24, states facilities should check and record current temperatures a minimum of 2 times daily.

Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 36 of 56 resident rooms and on 3 of 3 units ([NAME], [NAME], and [NAME]). Findings: On 6/4/25 at 8:00 a.m. a surveyor conducted an environmental observation tour with the Administrator, and the Maintenance Supervisor following were observed: [NAME] Unit: -The room divider curtains are off track and do not fully close to allow for resident privacy in the following rooms: 2, 3, 5, 9, 14, and 15. -The closet doors are misaligned and do not fully close in the following rooms: 3, 8, and 9. -The window curtains are off track and do not fully close in the following rooms: 7, 9, 10, and 11. -room [ROOM NUMBER]: Bathroom toilet is on a [NAME] sticking out from the base. -room [ROOM NUMBER]: There is a stained ceiling tile outside the room. [NAME] Unit: -The room divider curtains are off track and do not fully close to allow for resident privacy in the following rooms: 21, 28 and 31. -The closet doors are misaligned and do not fully close in the following rooms: 19, 20, 21, 25, 26, 28, 29, 31, 34, and 35. -room [ROOM NUMBER]: Wall inside of door has holes from previous TV. -room [ROOM NUMBER]: Has a strong urine-like odor. -room [ROOM NUMBER]: The room privacy curtain is torn. -room [ROOM NUMBER]: The base of toilet has a large brown ring around it. -room [ROOM NUMBER]: The bathroom sink countertop has two chips in the edge creating an uncleanable surface. -room [ROOM NUMBER]: The toilet has a large [NAME] at the base. -room [ROOM NUMBER]: The bathroom floor has a stain. -room [ROOM NUMBER]: The bathroom floor has a stain, and the window curtains are off track and do not fully close. -room [ROOM NUMBER]: Stain on the wall outside of room. -There is a stained ceiling tile in the common TV area. [NAME] Unit: -Just inside unit to the right has hole and torn wallpaper. -The room divider curtains are off track and will not fully close to allow for resident privacy in the following rooms: 40, 41, 42, 43, 44, 47, 49, 53, and 56. -room [ROOM NUMBER]: Stained bathroom floor. -room [ROOM NUMBER]: Outside of the room there are two holes near the baseboard, and there is a stain on the bathroom floor. -room [ROOM NUMBER]: Outside of the room there is a stained ceiling tile. -room [ROOM NUMBER]: Has a strong urine-like odor. -room [ROOM NUMBER]: Stain on bathroom floor On 6/4/25, at approximately 9:30 a.m., at the end of the observational tour the Administrator stated that he knows that there is a lot of work to be done and confirmed all the above findings.

Based on observations, interviews and record reviews, the facility failed to have an effective infection prevention and control program (IPCP) for the surveillance and transmission prevention of Gastrointestinal disease for 1 out of 6 residents reviewed for infection control. Findings: Reviewed Facility Policy Infection Control Policies and Procedures IC306 Transmission Based Precautions last revised 5/1/25. 8. Initiating Transmission Based Precautions: 8.1 Nursing Staff may place patients with suspected or confirmed infectious diarrhea, influenza or symptoms consistent with a communicable disease on Transmission Based Precautions/isolation (TBP) empirically while awaiting confirmation. 8.2 Notify the attending physician or Medical Director (in the absence of the attending physician) and the Infection Preventionist if there is reason to believe that an individual has an infectious disease. 8.3 An order for Transmission Based Precautions will be obtained for patients who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. A review of U.S. Centers for Disease Control and Prevention document titled C-Diff: Facts for Clinicians states: If a patient has had three or more stools in 24 hours: isolate patients with possible C-Diff immediately, even if you only suspect CDI (C-Diff Infection) and Order a C-diff test if other etiologies of diarrhea such as a stool softener or laxative were not used. On 6/4/25 a surveyor reviewed the progress notes in Resident #62 's Electronic Medical Record (EMR) and found the following nursing note dated 6/1/25 at 7:08 a.m., Resident had 3 episodes of watery stool with significant mucous and foul odor this night shift. Declined any oral (P.O.) fluids offered. On 6/4/25 at 12:40 p.m., a surveyor interviewed Certified Nursing Assistant (CNA) #1 and learned that they were told Resident #62 didn't need precautions because they were colonized but they suspected the resident had real C-diff again because of the smell and appearance of the stool and they didn't know what to do because they were told not to use TBP or do anything different but it smells so bad. On 6/4/25 at 12:45 p.m., surveyor observed Resident #62's room and found no transmission-based precaution sign posted and no personal protective equipment available. There was a strong fecal-like odor noted in the room and detectable from the doorway of the room. Resident #62 was in the common room. On 6/4/25 at 12:48 p.m. surveyor interviewed CNA #2 and learned that Resident #62 always had frequent loose stools but lately it has been much smellier with mucous like when she had C-diff before. It smells and looks like C-diff. CNA #2 stated that they had used Contact Precautions for resident before but they were told she didn't need precautions anymore. On 6/4/25 at 1:00 pm a surveyor interviewed CNA - Medication Tech #1 and was told that Enhanced Barrier Precautions (EBP) signs went up all over the unit Monday morning and no one told us why. For Resident #62, we were told to not use Contact Precautions, but it sure looks and smells like C-diff. They never tell us anything. On 6/4/25 at 1:20 p.m. surveyor interviewed the Infection Preventionist (IP) Nurse and the Market Clinical Advisor and stated they were unaware that Resident #62 was showing acute symptoms of gastrointestinal disease but that note could indicate the possibility of an active infection. Contact Precautions were immediately initiated, and a stool sample was ordered. On 6/4/25 at 2:14 p.m., a surveyor observed outside Resident #62's room Contact precaution signage with PPE and a bleach odor was present. A review of Resident #62's EMR found an order for Contact Precautions and a stool sample. On 6/4/25 at 2:37 p.m., surveyors interviewed the facility provider and was told that Resident #62 was complicated because they had chronic diarrhea and was considered colonized with C-diff but changes to the stool described in the note from 6/1/25 would warrant initiation of transmission-based precautions and another stool sample to rule out an active infection. They were not notified of the changes described in the note on 6/1/25 and had not seen the note. On 6/4/25 at 3:00 p.m. a surveyor discussed the above findings with the Market Clinical Advisor and the IP Nurse.

Based on observations, record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification, dated 6/4/25, were effective. The Federal citations F761 and F880 were cited again during the re-visit for the Annual Long Term Care Recertification Survey, completed 9/10/25.Finding:During the follow-up survey on 9/10/25, it was determined that F761 and F880 would be re-cited: F761 for failure to monitor medication refrigerator temperatures daily and F880 for failure to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to apply appropriate interventions relating to the use of Enhanced Barrier Precautions (see F761 and F880).On 9/10/25 at 2:55 p.m., the above was discussed during the exit conference with the Administrator and the Region [NAME] President of Operations.

Based on observations 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 on 1 of 3 units ([NAME]) for 1 of 3 days of survey (6/2/25). Findings: 1. On 6/2/25 at 10:14 a.m., observation of an unsecured container of CaviWipes on a bedside table in room [ROOM NUMBER]. At this time, the Director of Nursing removed the CaviWipes from the resident's room, stating that these wipes should not be in resident rooms or care areas. The Safety Data Sheet for CaviWipes Section 4. First Aid Measures states Inhalation: Move the 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 so. Continue rinsing. If eye irritation persists: get medical advice/attention . Ingestion: Rinse mouth thoroughly with water. DO NOT induce vomiting. Call poison control or a doctor if you feel unwell.

Based on record reviews and interviews, the facility failed to issue a written bed hold notice to a resident, known family member or legal representative for 2 of 3 sampled residents who had been transferred to an acute care facility (Resident #13 and #66). Findings: 1. in Resident #13's clinical record indicated that he/she transferred to an acute care hospital on 4/2/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. 2. Documentation in Resident #66's clinical record indicated that he/she transferred to an acute care hospital on 5/7/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. On 5/25/25 at 10:30 a.m., in an interview with the Market Clinical Advisor confirmed that she was unable to locate evidence that the facility issued a written bed hold notice to the resident, a family member, or a legal representative upon transfer for Resident #13 and #66.

Based on record reviews and interviews, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 2 of 3 sampled residents transferred/discharged to an acute care facility. ( Resident #13 and #66) Findings: 1. Documentation in Resident 13's clinical record indicated that he/she was transferred to an acute hospital on 4/2/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written transfer/discharge notice to the resident and/or legal representative. 2. Documentation in Resident 66's clinical record indicated that he/she was transferred to an acute hospital on 5/7/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written transfer/discharge notice to the resident and/or legal representative. On 6/4/25 at 10:30 a.m., in an interview with the surveyor, the Market Clinical Advisor confirmed that she was unable to locate evidence that a transfer/discharge form for Resident #13 and Resident #66 was completed and provided to the resident or resident representative at the time of transfer to the hospital.

Based on interviews, observations, and record reviews, the facility failed to have a working system in place to communicate, separate and carry out the disposition of controlled substances. In addition, the facility failed to ensure that all scheduled medications were being received from the pharmacy by 2 licensed staff. Findings: 1. On 7/16/24 Division of Licensing received a complaint which a nurse gave Resident #1 a dose of morphine from Resident #2's morphine bottle using Resident #2's oral syringe was given another residents morphine on 7/12/24. On 7/24/24 at 10:30 a.m., a surveyor reviewed the Narcotics Logbook for the [NAME] unit medication cart, Page 169, a log for Resident #2's morphine showing it was in use on 7/12/24 and continued to be used until 7/18/24. The log failed to document the error from 7/12/24. On 7/24/24 at 10:55 a.m.,during an interview with the Unit Director for [NAME], stated the response to the incident on 7/12/24 was to immediately remove from use the bottle of morphine involved. The Unit Manager had been unaware that the bottle of morphine had not been removed immediately or that the bottle continued to be used until 7/18/24 or that the bottle was still in the medication cart. There is a lack of evidence that the oral syringe was disposed of after being used for Resident #1 and with the bottle remaining in use for 6 more days, On 7/24/24 at 11:15 a.m. a surveyor discussed the above findings with the Director of Nursing. 2. During review of the Narcotic Log book, documentation on page 198, dated 7/17/24, stated a 15 ml bottle of morphine had been delivered from the pharmacy and logged in by 1 staff member; on page 214, dated 7/22/24, a 15 ml bottle of morphine had been delivered by pharmacy and logged in by 1 staff member; on page 215, dated 7/22/24, fentanyl patch 12 mcg x 2 patches had been delivered by pharmacy and logged in by 1 staff member. Facility Policy NSG300 Controlled Drugs: Management: states the following Storage: Two licensed nurses and/or authorized nursing personnel, per state regulations are required to document placement of controlled substances into inventory. This was confirmed with the Administrator and the Unit Manager on [NAME].

Based on performance evaluations and interview, the facility failed to complete annual performance evaluations at least every 12 months for 3 of 5 sampled Certified Nursing Assistants (CNA #3, CNA #4, and CNA #5). Findings: 1. CNA #3 was hired on 3/4/20. CNA #3's last performance evaluation was a 90-day progress report completed on 8/14/20. The facility was unable to provide evidence of a completed annual performance evaluation for 2021, 2022, 2023, or 2024. 2. CNA #4 was hired on 5/11/15. CNA #4's last performance evaluation was completed on 5/3/19. The facility was unable to provide evidence of a completed annual performance evaluation for 2020, 2021, 2022, or 2023. 3. CNA #5 was hired on 7/31/18. CNA #5's last performance evaluation was completed on 9/26/19. The facility was unable to provide evidence of a completed annual performance evaluation for 2020, 2021, 2022, or 2023. On 3/27/24 at 4:15 p.m., in an interview with a surveyor, the Administrator, the Clinical Market Advisor, and the Market President confirmed staff performance evaluations had not been completed annually.

Based on review of the facility's COVID-19 Vaccination policy and procedures, interviews and record review the facility failed to ensure each resident, or the resident representative received education regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine prior to immunizing a resident with the COVID-19 vaccine for all residents who received the COVID-19 vaccine. In addition, the facility failed ensure staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine. Findings: The facilities COVID-19 Vaccination policy and procedure revised, 2/7/24 states, Centers will provide the opportunity to receive COVID-19 vaccinations following Centers for Disease Control and Prevention (CDC) recommendation and the facility will obtain consent using the Patient Informed Consent or Declination COVID-19 form. On 3/27/24 at 11:43 a.m., during an interview, the facility's Infection Preventionist (IP) confirmed that the facility does offer the recommended COVID-19 vaccine for those residents who are illegible and upon admission stating, the admission packet contains the COVID-19 (Spikevax) vaccine education and consent form. The surveyor and IP reviewed the admission packet which contained the Patient Informed Consent or Declination COVID-19 vaccine form which states, I have read or had explained to me the Emergency Use Authorization Fact Sheet or Vaccine Information Statement for the COVID-19 vaccine and understand the risks and benefits. At this time, the IP confirmed the admission packet lacked evidence of education regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine. In addition, the IP confirmed that staff are not provided education regarding the benefits and potential risks associated with COVID-19 vaccine. Stating, there's nothing formal and upon hire in October of 2023 she was not provided COVID-19 vaccine education however did decline the vaccine. On 3/27/24 at 12:24 p.m., during an interview, the Nurse Practice Educator (NPE) stated, she has not done any education for COVID and was unable to provide evidence of staff education regarding the benefits and potential risks associated with COVID-19 vaccine (Spikevax). At this time, a Registered Nurse (RN) was in the office with the NPE for day 2 of orientation. She stated, she has already provided her vaccinations but has not had any education on the new Spikevax COVID-19 vaccine. On 3/27/24 at 12:36 p.m., during an interview, the surveyor asked the Licensed Practical Nurse (LPN) if she was educated on the new Spikevax, COVID-19 vaccine. The LPN stated, I can't say for sure, typically when stuff like that comes out we get the sheets to sign. On 3/27/24 at 2:24 p.m., during an interview, the Marketing Clinical Advisor confirmed the facility has not provided residents and/or resident representatives with the VIS education on the COVID-19 vaccine upon admission to the facility and/or prior to administration of these vaccine. At this time. Both the surveyor and the Marketing Clinical Advisor looked in the employee break room and around the common area/time clock for any COVID-19 (Spikevax) education but was unable to find any.

Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 2 of 3 units ([NAME] and [NAME]) for 1 of 1 environmental tour (3/29/24). Findings: On 3/29/24 from 8:30 a.m. to 9:01 a.m., an environmental tour was conducted with the Maintenance Director in which the following was observed: [NAME] Unit: >The shower room had a laydown shower chair with orange colored coating under the chair edge and rim, the floor next to shower stall was raised with cracks and cove base peeling away from the wall. >Resident #32 wheelchair seat is coated with dirt/debris. >room [ROOM NUMBER] the bedroom bottom door sticks making it difficult to open. >room [ROOM NUMBER] wall light near room door is missing the light cover. >Wallpaper peeling up and stapled to wall next to room [ROOM NUMBER]. >Wallpaper peeling up across from the TV viewing room. [NAME] Unit: >The shower room had a bariatric shower chair and lay down shower chair both with orange colored coating under the chair edge and rim. >room [ROOM NUMBER] bathroom has 2 cracked tiles under the sink, black built-up substance around the base of the toilet. >room [ROOM NUMBER] bathroom has a urine hat stored on top of the toilet wedged between the toilet and wall. >room [ROOM NUMBER]-27 shared bathroom has an unlabeled urinal hanging on the toilet grab bars. On 3/29/24 at 9:01 a.m., in an interview, the Director of Maintenance confirmed the findings.

Based on observations, record reviews and interviews, the facility failed to properly store medications and biologicals in 2 out of 3 medication rooms refrigerators surveyed. ([NAME] House and [NAME] House) Findings: 1. On 3/26/24 at 11:38 a.m., a surveyor observed the [NAME] House medication room refrigerator with the Unit Manager and noted a dormitory style refrigerator with a freezer. Inside the refrigerator were influenza vaccines and a pneumococcal vaccine. A review of the recorded temperatures for the refrigerator showed an out-of-range temperature on 3/24/24 of 70.8 (F). A surveyor asked the unit manager what happened following the discovery of the out-of-range temperature, and they did not know. They were unable to deny or confirm that the vaccinations in the refrigerator were in the refrigerator at the time of the out-of-range temperature. 2. On 3/26/24 at 11:40 a.m., a surveyor observed the [NAME] House medication room refrigerator with a Licensed Practical Nurse (LPN), and found 2 opened and unlabeled vials of Purified Protein Derivative (PPD) which is used to test for tuberculosis for staff and residents. A surveyor confirmed with the LPN during the observation that these should have an open date and be discarded 30 days after opening. They were immediately removed. It was also noted that the refrigerator had significant ice buildup along the back inside surface. Also stored in the refrigerator were pneumococcal, respiratory syncytial virus (RSV), Spikevax (Covid-19), and influenza vaccines. On 3/26/24 at 11:45 a.m., during an observation of the [NAME] House and [NAME] House medication room refrigerators with the Interim Director of Nursing (IDON), the vaccines in the [NAME] medication room refrigerator had been removed, but the IDON confirmed they were not removed at the time the out-of-range temperature was discovered. The IDON also confirmed that a dorm style refrigerator with a freezer section was not appropriate for storing vaccinations. The IDON also confirmed that ice build up in the back of a refrigerator. On 3/27/24 at 11:50 a.m., a surveyor reviewed the facility policy titled: Infection Control Policies and Procedures IC401 Medication and Vaccine refrigerator/freezer temperatures last revised 8/7/23 which states: If temperatures fall outside the acceptable range: 2.1 Notify Maintenance and Director of Nursing Immediately 2.2 Move medications and/or vaccines to another refrigerator/freezer. 2.3 Contact pharmacist for guidance regarding handling of medications or vaccines 2.4 Do not discard medication or vaccine unless directed to by pharmacist. 2.5 Notify vaccine distributor. 2.6 Complete Medication/Vaccine Storage Troubleshooting record and discuss at QAPI On 3/27/24 at 12:20 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. Also confirmed that ice buildup in a fridge, confirmed the facility policy was not followed after the discovery of the out-of-range temperature leading to incorrect storage of vaccinations.

Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 1 of 1 initial kitchen tour completed on 3/26/24. Additionally, the facility failed to ensure that food temperatures were recorded at the time of cooking breakfast on the morning of 3/26/24. Findings: 1. On 3/26/24 at 9:10 a.m., a surveyor conducted an initial tour of the kitchen with the Cook in which the following findings were observed and confirmed. - A light amount of dust, debris, and staining on the ceiling vents - A sticky, dusty film on all flat surfaces of the Kitchen - A lack of documentation of food temperatures being taken during dinner on 3/23/24, all day on 3/24/24, all day on 3/25/24 and breakfast on 3/26/24. The above findings were confirmed with the cook at that time.

Based on review of the facility's Pneumococcal Vaccination policy and procedure, interviews, and record review the facility failed to provide the Resident and/or the Resident's Representatives with the Vaccine Information Statement (VIS) prior to immunizing a resident with the pneumococcal vaccine (Prevnar) for all residents receiving the Prevnar vaccine. Findings: The facilities Pneumococcal Vaccination policy and procedure, revised on 11/1/23 states, Provide the patient/representative education (Vaccine Information Statement (VIS)) regarding benefits and potential side effects of vaccination. On 3/27/24 at 11:43 a.m., during an interview, the facility's Infection Preventionist (IP) confirmed that the facility does offer the recommended pneumonia vaccines (PPSV23, PCV13, PCV15, PCV20) for those residents who are illegible and upon admission. She then stated the admission packet contains the consent forms with information explaining the risks versus the benefits (called the VIS) for having the pneumococcal vaccination. The surveyor and the IP reviewed the facilities admission packet which contained the VIS sheet for only the PPSV23 and the Pneumococcal Vaccine Informed Consent for Pneumovax (PPSV23), Prevnar 13 (PCV13), Prevnar 15 (PCV15) and Prevnar 20 (PCV20) which states, VIS provided to patient/representative and questions answered, as needed. The admission packet lacked evidence of VIS sheets for the PCV13, PCV15 and PCV20 vaccines. At this time the IP confirmed the Residents and/or Resident Representatives have not received the required VIS sheets upon admission. On 3/27/24 at 2:24 p.m., during an interview, the Marketing Clinical Advisor confirmed the facility has not provided residents and/or resident representatives with the Prevnar vaccine VIS sheet upon admission to the facility and/or prior to administration of these vaccines. The facility is currently only providing the Pneumococcal Polysaccharide vaccine (PPSV23) VIS sheet.

Based on employee record review and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on Resident Rights for 2 of 5 Certified Nursing Assistant (CNA) staff reviewed (CNA #1, CNA #2). Findings: On 3/27/24, the following employee records were reviewed: 1. CNA #1 was hired on 12/26/23. There was no documented training regarding Resident Rights. 2. CNA #2 was hired on 12/4/23. There was no documented training regarding Resident Rights. On 3/27/24 at 4:15 p.m., in an interview with a surveyor, the Clinical Market Advisor confirmed there was no documentation of the staff attending the required annual training regarding Resident Rights.

Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment (Resident #32). Finding: On 3/26/24 at 9:34 a.m., during an interview, Resident #32 stated he/she is not invited or remembers having care plan meetings. Review of Resident #32's medical record, the surveyor noted Minimum Data Set (MDS) Quarterly assessments, dated 11/2/23 and 2/2/24 were completed. The medical record lacked evidence that a care plan meeting had been held by the IDT after both assessments. On 3/28/24 at 1:31 p.m., during an interview, the Licensed Social Worker confirmed the above findings.

Based on observations, record review and interviews, the facility failed to ensure that a resident received treatment and services in accordance with the standards of practice for 1 of 2 residents reviewed for skin conditions (#343). Findings: On 3/26/24 at 12:27 p.m., during an interview with Resident #343's representative, the surveyor observed Resident #343 scratching/itching several small, scabbed areas on his/her upper right arm. At this time, the Resident Representative stated, the resident has a rash and was given a cream from the dermatologists that he will bring in. On 3/27/24 at 12:25 p.m., the surveyor observed Resident #343 wearing a long sleeve shirt and scratching/ itching at his/her right shoulder through the collar opening. On 3/28/24 at 11:37 a.m., during an additional interview with Resident #343's representative, the surveyor observed the resident continuing to scratch/itch at his/her right shoulder through the collar opening. At this time, the Resident Representative stated he had brought in the cream and gave it to nursing this morning stating, [he/she] itches a lot, [he/she] got the dry skin pretty bad. Review of Resident #343's skilled documentation from admission on 3/22/24 through 3/28/24 lacked evidence of the nursing staff identifying the resident's rash. A review of the case line care plan initiated on 3/24/24 instructs nursing to Observe skin condition daily with ADL care and report abnormalities. On 3/28/24 at 11:46 a.m., during an interview, the Registered Nurse (RN) confirmed she was not aware of a rash on his/her shoulders, stating. Nurses do skin checks weekly, not sure when his/hers is due and the Certified Nurses Aids (CNA) generally report any skin concerns. The RN then reviewed the Electronic Medical Record and confirmed she did not see any documentation of a rash and then stated, the family brought in cream for which she needs to get a provider order to use. At this time, both the surveyor and RN observed the rash to Resident #343's upper bilateral extremities. The RN stated she will have the provider take a look. On 3/28/24 at 11:57 a.m., during an interview with the interim Director of Nursing the above was discussed, confirming the resident's rash was assessed after surveyor intervention.

Based on observations, record review, and interviews, the facility failed to meet the personal hygiene preferences for 1 of 6 residents who are dependent on staff to complete Activities of Daily Living needs. (Resident #49) Findings: On 3/26/24 at 11:22 a.m., a surveyor observed Resident #49 with an unshaven face, and long fingernails with a dark substance built up under the nails. The resident was dressed in day clothing asleep on the bed. Record review revealed Resident #49 was admitted to the facility on [DATE] with a diagnosis of dementia and lower extremity amputation. Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #49 was assessed to need staff assistance for personal hygiene which includes nail care and shaving. On 3/26/24 at 12:30 p.m., a surveyor interviewed Resident #49's Certified Nursing Assistant (CNA) who confirmed that Resident #49 hasn't been shaved for several days and they weren't sure about when the nails were last done. The CNA confirmed that Resident #49 was dependent upon staff for nail care and shaving. On 3/27/24 at approximately 11:00 a.m., a surveyor interviewed Resident #49 and the Resident Representative together. Resident #49 had still not been shaved or provided nail care. The surveyor asked Resident #49 if he was growing a beard and he answered, No, it needs to come off. The Resident representative stated, I asked several days ago if he could be shaved. He doesn't like beards and makes fun of mine all the time. On 3/27/24 at approximately 12:50 p.m., a surveyor interviewed the Unit Manager and was told that there wasn't a way to specifically document completed nail care or shaving but staff should document when a resident refused. There was no documentation available that Resident #49 had ever refused nail care or shaving. The surveyor confirmed with the unit manager that a resident should be shaved daily if that is a preference.

Based on record review and interview, the facility failed to coordinate assessments for Pre-Admission Screening and Resident Review (PASRR) Level I and Level II programs for 1 of 1 residents reviewed for PASRR (#46). Findings: A review of the clinical record for Resident #46 revealed he/she was admitted to the facility on [DATE], and had diagnoses including Dementia and Post Traumatic Stress Disorder. The clinical record lacked evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority to determine if the resident met the State of Maine's definition of a serious mental health disorder and to determine if a Level II assessment was needed. On 3/27/24 at 1:35 p.m., in an interview with a surveyor, the facility's Social Worker confirmed that the PASRR Level I screening had not been completed and he/she would proceed with the PASSR at that time. On 3/27/24 at 2:19 p.m., the finding was discussed with the Market President.

Based on observations, interviews, and review of the Scabies Data Collection Line Listing, the facility failed to maintain an environment to prevent the development and transmission of an infectious disease Sarcoptes scabiei (scabies) in 12 of 84 residents who were identified with rashes (#2, #3, #4, #5, #7, #8, #10, #11, #12, #13, #14, & #15). In addition, the facility failed to prohibit 17 of 75 employees with a suspicious skin rash from direct contact with residents (Employee #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 & #17). Findings: On 10/23/18 and 10/25/18 the Department of Health & Human Services received two anonymous reports indicating a concern for an outbreak of scabies, claiming that the facility was refusing to acknowledge the outbreak. On 10/26/18 between 1:15 p.m. and 4:00 p.m., in a staff interview with the Infection Preventionist, he/she said that the suspected outbreak of scabies occurred about 4 weeks ago. On 10/29/18 between 8:10 a.m. and 8:30 a.m. in a second staff interview with the Infection Control Nurse, he/she said to be honest, no precautions were ever put in place. Centers for Disease Control and Prevention (CDC) Scabies Resources for Health Professionals-Institutional Setting indicates under Control section, Infection control personnel and dermatologist should be involved as soon as scabies is suspected in an institution. An institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread. All suspected and confirmed cases, as well as all potentially exposed patients, staff, visitors and family members should be treated at the same time to prevent reexposure. A review of the Scabies Data Collection Line Listing dated (MONTH) (YEAR) notes the following: -Resident #2 noted have a rash on arms and upper body with an onset date of 10/12/18. -Resident #3 noted to have a rash under breast with an onset date of 10/12/18. -Resident #4 noted to have a rash with an onset date of 10/24/18. -Resident #5 noted to have a rash on torso and arms with an onset date of 10/14/18. -Resident #7 noted to have a rash on back with an onset date of 10/24/18. -Resident #8 noted to have a rash on abdomen with an onset date of 10/5/18. -Resident #10 noted to have a rash with an onset date of 10/4/18. -Resident #11 noted to have a rash on stomach with an onset date of 10/23/18. -Resident #12 noted to have a rash on chest and neck with an onset date of 10/5/18. -Resident #13 noted to have a rash on left buttock with an onset date of 10/17/18. -Resident #14 noted to have a rash on left side with an onset date of 10/16/18. -Resident #15 noted to have a rash with an onset date of 10/11/18. In addition, a review of the Scabies Data Collection Line Listing report also indicated the following: -Employee #1, rash on torso. -Employee #2, rash on whole body with onset date of 10/3/18. -Employee #3, rash on arms/torso with onset date of 10/17/18. -Employee #4, rash on hand with onset date of 10/22/18. -Employee #5, rash on sides with onset date of 10/17/18. -Employee #6, rash on whole body with onset date of 10/24/18. -Employee #7, rash on whole body with onset date of 10/3/18. -Employee #8, rash on whole body with onset date 10/15/18. -Employee #9, rash on arms. -Employee #10, rash on abdomen/arms with onset date 10/16/18. -Employee #11, rash on whole body. -Employee #12, rash on arm with onset date 10/17/18. -Employee #13, rash on chest with onset date 10/20/18. -Employee #14, rash on back of legs with onset date 10/26/18. -Employee #15, rash on hand with onset date 10/22/18. -Employee #16, rash on hand with onset date 10/17/18. -Employee #17, rash on arm with onset date 10/8/18. On 10/26/18 between 1:15 p.m. and 4:00 p.m. in an interview with the attending physician, he/she stated that he/she had been attempting to treat for scabies after a conversation with Dermatology Associates and a representative from the CDC. He/she stated that there was conflicting information on whether or not to treat for scabies which included the guidelines from the CDC and a lack of facility support. On 10/30/18 at 12:33 p.m. in an interview with the facility's Medical Director, he/she stated that on 10/16/18 was the first he/she heard of probable scabies on the Millay Unit. On 10/16/18, he/she went to the Administrator and said, Can we do what needs to be done to treat the rash either by looking at the environment and put policies into place. On 10/23/18 the facility had not put any policies into place, no occupational health in place for employees, and ordered more scrapings. He/she stated to a surveyor that he/she encouraged the facility administration that a policy and procedure was needed to manage the rashes. In addition, the Medical Director stated that there was a lack in institutional support in treating the rash as scabies. On 10/29/18 at 12:20 p.m. in an interview with the Administrator, two surveyors confirmed the finding in the break of infection prevention and control.

Based on observation, record review and interviews, the facility failed to enhance the quality of care for residents when they failed to timely diagnose and treat Sarcoptes scabiei (scabies) in 12 of 84 residents affected with scabies (#2, #3, #4, #5, #7, #8, #10, #11, #12, #13, #14 & #15). Finding: The facility's policy and procedure for scabies with a revised date of 5/1/18 indicated ways to identify signs and symptoms of scabies, page 1: intense itching .Elderly persons, persons in institutions and persons whose immune system is weak may not feel itching, maculopapular rash, tiny, irregular reddish lines (burrows) most commonly seen between fingers, hands, wrists, toes, ankles, elbow fold, genitals, buttocks, anterior axillary folds, beltline or abdomen, face and scalp on immunocompromised individuals, geriatric patients, scabies often appears as excoriations and tends to be present on the back. Centers for Disease Control and Prevention (CDC) recommendations for prevention of scabies in institutional settings are early detection, treatment and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreak. On 10/26/18, a surveyor observed a rash on Resident #14. On 10/29/18, a surveyor observed the following: Resident #12 with rash on right arm and chest; Resident #14 with rashes on bilateral arms and legs; Resident #15 for rashes on bilateral legs and abdomen. Additionally, a surveyor observed Resident #4 rubbing his/her back against the furniture, repeatedly scratching his/her arms and pulling up his/her pan legs to scratch his/her legs. 1. During a medical record review, Resident #2's progress note, dated 10/19/18, indicated rash .small scabs on abdomen and shoulders. 2. During a medical record review, Resident #3's progress note, dated 10/23/18, indicated rash, raised bumps on left hand and right side of torso. 3. During a medical record review, Resident #4's progress note, dated 10/21/18, indicated red, raised rash on upper and lower bilateral extremities and abdomen. 4. During a medical record review, Resident #5's progress note, dated 10/16/18, indicated rash on upper chest and arms, raw skin on groin area. Progress note dated 10/17/18 looked at by infection control for suspicious rash on torso and arm; and progress note, dated 10/23/18 rash .torso, chest, arms, upper back, face. 5. During a medical record review, Resident #10's progress note dated 10/8/18, indicated scab right forearm; 10/22/18 rash .lower extremities. 6. During a medical record review, Resident #12's progress note dated 9/6/18 indicated, rash to upper back and neck. Notes dated 9/28/18 indicated rash to left clavicle. Notes dated 10/2/18 indicated rash around neck. Notes dated 10/9/18 indicated rash on chest and neck and notes 10/16/18 indicatedrash on chest and neck area. 7. During a medical record review, Resident #14's progress note dated 10/16/18, indicated multiple rashes along chest and arms. 8. During a medical record review, Resident #15's progress note dated 10/12/18 indicated small red bumps all over abdomen, not raised. In addition, a review of the Scabies Data Collection Line Listing dated (MONTH) (YEAR) notes the following: 9. Resident #7 noted to have a rash with an onset date of 10/24/18. 10. Resident #8 noted to have a rash on abdomen with an onset date of 10/5/18. 11. Resident #11 noted to have a rash on stomach with an onset date of 10/23/18. 12. Resident #13 noted to have a rash on left buttock with an onset date of 10/17/18. On 10/26/18 between 1:15 p.m. and 4:00 p.m. in an interview with the attending physician, he/she stated that he/she had been attempting to treat for Scabies after a conversation with Dermatology Associates and a representative from the CDC. He/she stated that there was conflicting information on whether or not to treat for scabies which included the guidelines from the CDC and a lack of facility support. On 10/29/18 between 8:10 a.m. and 8:30 a.m., the Infection Preventionist stated in an interview with two surveyors that he/she was not allowed to talk with the Medical Director or with the corporate physician so that he/she could accurately share that the criteria met the treatment for [REDACTED]. On 10/30/18 at 12:33 p.m. in an interview with the facility's Medical Director, he/she stated that on 10/16/18 was the first he/she heard of probable scabies on the Millay Unit. On 10/16/18, he/she went to the Administrator and said, Can we do what needs to be done to treat the rash either by looking at the environment and put policies into place. On 10/23/18 the facility had not put any policies into place, no occupational health in place for employees, and ordered more scrapings. He/she stated to a Surveyor that he/she encouraged the facility administration that a policy and procedure was needed to manage the rashes. In addition, the Medical Director stated that there was a lack in institutional support in treating the rash as scabies.

Based on observations, record review, and interviews, the facility failed to provide timely treatments for 12 of 84 residents affected with Sarcoptes scabiei (scabies) when first rash suspected on 9/6/18 and treatments not administered until 10/26/18 resulting in residents discomfort and an outbreak of scabies in the facility. (Residents #2, #3, #4, #5, #7, #8, #10, #11, #12, #13, #14, & #15 and 16 employees). Finding: A review of the facility's policy and procedure guidelines for scabies, with a revised date of 5/1/18, revealed on Page 1, Section 2 that verifying [DIAGNOSES REDACTED]. 1. During a medical record review, Resident #2's progress note, dated 10/19/18, indicated rash .small scabs on abdomen and shoulders. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 8 days later. 2. During a medical record review, Resident #3's progress note, dated 10/23/18, indicated rash, raised bumps on left hand and right side of torso. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 4 days later. 3. During a medical record review, Resident #4's progress note, dated 10/21/18, indicated red, raised rash on upper and lower bilateral extremities and abdomen. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 6 days later. 4. During a medical record review, Resident #5's progress note, dated 10/16/18, indicated rash on upper chest and arms, raw skin on groin area. Progress note dated 10/17/18 indicated looked at by infection control for suspicious rash on torso and arm. Progress note dated 10/23/18 indicated rash .torso, chest, arms, upper back, face. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 11 days later. 5. During a medical record review, Resident #10's progress note, dated 10/8/18, indicated scab right forearm; 10/22/18 rash .lower extremities. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 19 days later. 6. During a medical record review, Resident #12's progress note, dated 9/6/18 indicated, rash to upper back and neck, notes dated 9/28/18 rash to left clavicle, notes dated 10/2/18 rash around neck, notes dated 10/9/18 rash on chest and neck, and notes dated 10/16/18 rash on chest and neck area. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 51 days later. 7. During a medical record review, Resident #14's progress note, dated 10/16/18, indicated multiple rashes along chest and arms. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 11 days later. 8. During a medical record review, Resident #15's progress note, dated 10/12/18 indicated small red bumps all over abdomen, not raised. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 15 days later. In addition, a review of the Scabies Data Collection Line Listing dated (MONTH) (YEAR) notes 12 residents with a pruritic rash associated with scabies and notes the following: 9. Resident #7 noted to have a rash with an onset date of 10/24/18. A review of the facility's order listing report for the month of (MONTH) notes at treatment date of 10/26/18, 3 days later. 10. Resident #8 noted to have a rash on abdomen with an onset date of 10/5/18. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/24/18 and held until 10/26/18, for a total of 22 days later. 11. Resident #11 noted to have a rash on stomach with an onset date of 10/23/18. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 4 days later. 12. Resident #13 noted to have a rash on left buttock with an onset date of 10/17/18. A review of the facility's order listing report for the month of (MONTH) notes a treatment date of 10/26/18, 10 days later. In addition, A review of the Scabies Data Collection Line Listing report also indicated the following employees: -Employee #1, rash on torso. -Employee #2, rash on whole body with onset date of 10/3/18. -Employee #3, rash on arms/torso with onset date of 10/17/18. -Employee #4, rash on hand with onset date of 10/22/18. -Employee #5, rash on sides with onset date of 10/17/18. -Employee #6, rash on whole body with onset date of 10/24/18. -Employee #7, rash on whole body with onset date of 10/3/18. -Employee #8, rash on whole body with onset date 10/15/18. -Employee #9, rash on arms. -Employee #10, rash on abdomen/arms with onset date 10/16/18. -Employee #11, rash on whole body. -Employee #12, rash on arm with onset date 10/17/18. -Employee #13, rash on chest with onset date 10/20/18. -Employee #14, rash on back of legs with onset date 10/26/18. -Employee #15, rash on hand with onset date 10/22/18. -Employee #16, rash on hand with onset date 10/17/18. -Employee #17, rash on arm with onset date 10/8/18. On 10/29/18 a surveyor observed the following residents: Resident #12 with rash on right arm and chest; Resident #14 rashes on bilateral arms and legs, Resident #15 for rashes on bilateral legs and abdomen, Resident #4 who was rubbing his/her back against furniture, repeatedly scratching his/her arms and pulling up his/her pant legs to scratch his/her legs. On 10/26/18 between 1:15 p.m. and 4:00 p.m. in an interview with the attending physician, he/she stated that he/she had been attempting to treat for Scabies after a conversation with Dermatology Associates and a representative from the Centers for Disease Control (CDC). He/she stated that there was conflicting information on whether or not to treat for scabies which included the guidelines from the CDC and a lack of facility support. On 10/29/18 at 12:20 p.m. in an interview with the Administrator, two surveyors confirmed the finding of delayed treatment for 12 of 84 residents affected with a suspicion of scabies. On 10/30/18 at 12:33 p.m. in an interview with the facility's Medical Director, he/she stated that on 10/16/18 was the first he/she heard of probable scabies on the Millay Unit. On 10/16/18, he/she went to the Administrator and said, Can we do what needs to be done to treat the rash either by looking at the environment and put policies into place. On 10/23/18 the facility had not put any policies into place, no occupational health in place for employees, and ordered more scrapings. He/she stated to a surveyor that he/she encouraged the facility administration that a policy and procedure was needed to manage the rashes. In addition, the Medical Director stated that there was a lack in institutional support in treating the rash as scabies. The facilities Order Listing Report reveals that Ivermectin 3 milligram tablets were ordered for residents between the dates of 10/26/18 and 10/30/18.

Based on interviews and record review, the facility failed to ensure a resident's safety in the area of bed mobility, resulting in a resident rolling off the bed during Activities of Daily Living (ADL). The result of this fall was the resident fracturing his/her right humerus for 1 of 1 sampled resident (#1). Finding: Resident #1 was admitted on [DATE]. During a review of the medical record, the ADL's documentation indicated that Resident #1 required 2 staff for assistance in bed mobility since admission. The Admission Minimum Data Set (MDS) 3.0 dated 3/9/18, indicated in Section G: Function Status, G011A- Bed Mobility (how resident moves to and from lying position, turns side to side and positions body while in bed), indicated the resident was an extensive assistance of 2 plus staff. During a review of a facility reported incident report and review of medical record, documentation indicated a Certified Nursing Assistant (CNA) provided care to Resident #1 independently on 4/30/18. As the CNA rolled Resident #1 over to provide care, Resident #1 rolled off of the bed and onto the floor, resulting in Resident #1 obtaining a fracture to humerus. On 5/8/18 at 9:15 a.m., in an interview with the surveyor, the Registered Nurse stated that Resident #1 is not a one assist by any stretch of the imagination and that Resident #1 has always needed 2 staff assistance for bed mobility. On 5/8/18 at 9:32 a.m., in an interview with the surveyor, Resident #1's CNA #1 stated that Resident #1 required 2 assistance for bed mobility. In addition, CNA #1 stated that Resident #1 requires 2 assistance with all care. On 5/11/18 at 12:17 p.m., a surveyor confirmed the above finding with the Director of Nursing.