Every finding on record at Stillwater Health Care

Based on record reviews and interviews, the facility failed to ensure that clinical record(s) contained complete and accurate information for 6 of 10 sampled residents reviewed on survey (Resident #7 [R7], R8, R51, R2, R36, and R17).Findings: 1. On 2/25/26, R7's clinical record was reviewed. R7's Order Summary indicated, Check monthly weights every day shift every 1 month(s) starting on the 1st for 7 day(s) for Monitoring with a start date of 8/1/25, Check monthly vital signs every day shift every 1 month(s) starting on the 1st for 7 day(s) for Monitoring with a start date of 8/1/25, and Weekly [blood pressure (B/P)] and [heart rate (HR)] checks. every day shift every [Sunday] for [Monitoring] B/P meds with a start date of 8/17/25. The Treatment Administration Record [TAR] indicated R7's vital signs (weight, blood pressure, temperature, pulse, respiratory rate, and oxygen saturation rate) were identical on 2/1/26, 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26 and 2/7/26, 7 days. 2. On 2/25/26, R8's clinical record was reviewed. R8's Order Summary Report indicated an order, start dated 11/1/24, Vital Signs [and] Weights monthly every day shift every 1 month(s) starting on the 1st for 7 day(s) for vital signs. The TAR indicated R8's vital signs (weight, blood pressure, temperature, pulse, respiratory rate, and oxygen saturation rate) were identical on 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26 and 2/7/26, 7 days. The provider progress note, dated 2/24/26, states Blood pressures this month [he/she] has had 3 recordings that were all recorded as exactly the same at 152/88, previous numbers were systolics ranging from the 100s to 120s over the last 3 months. Will wait to see ongoing trends before making any changes to [his/her] [blood pressure] medications at this time. Heart rates have been within normal limits, O2 saturations normal on room air and patient has been [without fever (afebrile)]. On 2/26/26 at 10:22 a.m., during an interview with a surveyor and the Director of Nursing (DON), R8's clinical record was reviewed. The DON stated the order directs the vitals to be taken once per month but was unsure why the vitals appear to be replicated over several days. At this time the surveyor confirmed the clinical record contained inaccurate information. 3. On 2/25/26, R51's clinical record was reviewed. R51's TAR, indicated, Check monthly vital signs every day shift starting on the 1st and ending on the 7th of every month with a start date of 9/1/25. The TAR indicated R51's vital signs (temperature, pulse, respiratory rate, and oxygen saturation rate) were identical on 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26 and 2/7/26, 6 days. 4. On 2/25/26 R2's clinical record was reviewed. R2's TAR indicated, Vital Signs & Weights monthly every day shift every 1 month(s) starting on the 1st for 7 day(s) for vital signs with a start date of 11/1/24. The TAR indicated R2's vital signs (weight, blood pressure, temperature, pulse, respiratory rate, and oxygen saturation rate) were identical on 2/4/26, 2/5/26, 2/6/26, and 2/7/26, 4 days. 5. On 2/26/26 R36's clinical record was reviewed. R36's TAR indicated, Vital Signs & Weights monthly every day shift every 1 month(s) starting on the 1st for 7 day(s) for vital signs - Start Date – 11/01/2024. The TAR indicated R36's vital signs (weight, blood pressure, temperature, pulse, respiratory rate, and oxygen saturation rate) were identical on 2/1/26 through 2/7/26, 7 days. 6. On 2/26/26 R17's clinical record was reviewed. R17's TAR indicated, Monthly weight and Vitals every day shift every 1 month(s) starting on the 1st for 7 day(s) for vital signs – Start Date – 05/01/2025. The TAR indicated R17's vital signs (weight, blood pressure, temperature, pulse, respiratory rate, and oxygen saturation rate) were identical on 2/2/26 through 2/7/26, 6 days. On 2/26/26 at 10:34 a.m., during an interview with the DON and four surveyors, the DON stated that the computer system is pulling information from the previous results when new data is not entered by staff. At this time a surveyor confirmed the above findings.

Based on observations and interviews the facility failed to ensure the kitchen was maintained in a clean manner on 2 of 3 days of survey (2/24/26 and 2/25/26), the facility failed to ensure that dented cans were removed from use and the facility failed to discard expired products in the reach-in refrigerator and the walk in refrigerator located in the kitchen that were available for use on 1 of 3 days of survey (2/24/26), Findings: On 2/24/26 at 10:45 a.m., during the initial tour of the kitchen a surveyor observed a built-in air conditioner that was heavily covered in dirt and grime, also observed were dust webs from the top corners right and left of the air conditioner to the ceiling. In the dry food storage room on the shelves and in the can rack the surveyor and Food Service Director observed the following dented cans2 cans of crushed pineapples in juice, 6 pounds, 12-ounce cans that were dented near the bottom seal. 4 cans of mushrooms, pieces and stems 3-pound, 14-ounce cans that were dented near the bottom and top seals. In the reach-in refrigerator there was a carton of half and half that was half empty with a best by date of 2/23/26, next to it there was a full carton of half and half with a best by date of 2/23/26 available for use.In the walk-in refrigerator there were 2 full cartons of half and half available for use on the shelf with a best by date of 2/23/26. These findings were confirmed by the surveyor during the initial tour with the Food Service Director.On 2/25/26 at 8:30 a.m. during a second tour of the kitchen, the surveyor observed the built-in air conditioner that was still heavily covered in dirt and grime, also observed were dust webs from the top corners right and left of the air conditioner to the ceiling. The Food Service Director stated she will have it cleaned today on 2/25/26.

Based on observations and interviews, the facility failed to ensure expired medications were removed from the available for use supply, for 2 of 3 Medication Storage Areas reviewed (A Wing Treatment Cart and B Wing Treatment Cart).Findings:On 2/25/26 at 3:16 p.m., a surveyor and the Director of Nursing Services (DON) observed and confirmed the following were in the A Wing treatment cart and available for use:-1 box of 12 rectal Acetaminophen Suppositories 650 milligrams (mg) with an expiration date of 01/2026-1 multi-use vial containing 10 milliliter (ml) of Insulin glargine 100 units (u)/10ml, open but unlabeled with an open date or an expiration date. The DON stated insulin is good for 28 days after opening, and was unable to determine when the vial would expire.-2 open vials, 10mL insulin lispro 100u/ml, with an open date of 1/14/26. The insulin expired on 2/11/26 and was available for use 14 days past expiration.On 2/25/26 at 3:35 p.m., a surveyor and the DON observed and confirmed the following were in the B Wing treatment cart and available for use:-1 open vial, 10mL insulin lispro 100u/ml, the box was labeled with an open date of 2/2/26, the vial was labeled as opened on 2/12/26. The DON was unable to determine when the vial would expire.-1 pre-filled 3ml insulin pens containing Lantus Solostar (Insulin Glargine) 100u/mL, open and undated. The DON was unable to determine the expiration date. The DON stated the pre-filled insulin pens expire 28 days after opening.-1 pre-filled 3ml insulin pens containing Lantus Solostar (Insulin Glargine) 100u/mL, the packaging was dated open 2/19/26, the insulin pen was labeled opened 2/20/26. The DON was unable to determine when the insulin pen would expire.

Based on facility policy review, record review, and interviews, the facility failed to ensure allegations of abuse and neglect was investigated for 1 of 4 complaints reviewed.Findings:A review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program effective: 6/2016, revised 03/2025 states, 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.A review of a facility-provided written statement that the Director of Nursing (DON) received from a staff member dated 9/25/25 states, .a handful of residents are scared. and . has neglected some residents care., referring to another staff member.A review of a facility-provided written statement that the DON received, not signed, or dated states, resident looked so scared.(he's/she's) so rough and mean to me, referring to another staff member.On 2/25/26 at 4:47 p. m. in an interview with the DON, a surveyor confirmed that during the facility's recertification survey and this investigation, the facility was not able to provide evidence that the allegations of abuse or neglect was investigated.On 2/25/26 at 7:00 p.m., in an interview with the Administrator, a surveyor confirmed that the facility did not complete investigations for the allegations of abuse and neglect that was brought to their attention by facility staff.

Based on employee record reviews and interviews, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on dementia management by failing to ensure that 1 of 5 Certified Nursing Assistant (CNA) staff employed completed their required training (CNA3).Finding:On 2/26/26 the following employee record was reviewed:CNA3 was hired on 7/3/23. There was no documented training on dementia in over 12 months.On 2/26/26 at 8:00 a.m., in an interview with a surveyor, the Administrator stated that she was unable to find any documented trainings listed above, and a surveyor confirmed that CNA3 lacked evidence that mandatory training on dementia was completed within the past 12 months.

Based on review of the facility Infection Control Program (ICP) and interview, the facility failed to complete an annual review of the ICP and update/revise the program if needed for 1 of 1 ICP.Finding: On 2/25/26 at 9:00 a.m., in an interview with the Infection Preventionist (IP), she stated she did not know if the ICP had been annually reviewed. A review of the ICP was completed and there was no evidence that an annual review of the ICP had been completed.On 2/25/26 at 9:53 a.m., in an interview with the surveyor, the Administrator, confirmed that the facility has not completed an annual review of the ICP.

Based on observation, record review, and interviews, the facility failed to ensure that a physician ordered medication was available for use to meet the needs for 1 of 4 residents observed during medication administration pass (Resident #64 [R64]).Finding:On 2/26/26 at 7:56 a.m., a surveyor observed Registered Nurse #1 (RN1) complete a medication administration pass for R64. RN1 stated she could not administer Testosterone Gel (a medication used to treat low testosterone levels not due to normal aging) to R64 because the facility did not have any.On 2/26/26, R64's clinical record review indicated an order, dated 2/20/26, for Testosterone Transdermal Gel 20.25 [milligram (MG)] per (/) Actuation (ACT)] (1.62%) (Testosterone) Apply 1 pump [applied to the skin (transdermally)] one time a day for [HYPOGONADISM (a condition in which the body doesn't make enough of the hormone testosterone)] APPLY TO UPPER ARM. Review of the Medication Administration Record indicated that R64's Testosterone Gel was not available and R64 had not received Testosterone Gel as physician ordered, from 2/20/26 through 2/26/26, for a total of 7 days (7 missed doses).On 2/26/26 at 10:18 a.m., during an interview with a surveyor and the Director of Nursing (DON), R64's clinical record was reviewed. The DON stated he would have to look into why this medication was not received from pharmacy. At this time, the surveyor confirmed the facility failed to ensure a physician ordered medication was available for use to meet the needs for R64.

Based on record reviews and interviews, the facility failed to provide resident/resident representative's with a summary of their baseline care plan for 3 of 4 residents reviewed for baseline care plans (Resident #3 [R3], R5, R61). Findings: 1. On 2/25/26, a review of R3's clinical record was completed. A baseline care plan was completed within 48 hours of R3's admission. There was no evidence that a summary of the baseline care plan was provided to the resident or the resident representative. On 2/25/2026 at 12:35 p.m., in an interview with the surveyor, the Director of Nursing [DON] stated that they do not provide a copy of the baseline care plan to the resident or the resident representative. The surveyor confirmed at this time that the resident/resident representative did not receive a summary of the baseline care plan. 2. On 2/25/26, a review of R5s clinical record was completed. A baseline care plan was completed within 48 hours of R5's admission. There was no evidence that a summary of the baseline care plan was provided to the resident or the resident representative. On 2/25/26 at 12:35 p.m. in an interview with the surveyor, the DON confirmed that the resident/resident representative did not receive a summary of the baseline care plan. 3. On 2/26/26, a review of R61's clinical record was completed. A baseline care plan was completed within 48 hours of R61's admission. There was no evidence that a summary of the baseline care plan was provided to the resident or the resident representative. On 2/26/26 at 9:55 a.m., in an interview with the surveyor, the DON confirmed that the resident/resident representative did not receive a summary of the baseline care plan.

Based on record reviews and interviews, the facility failed to notify (at least monthly) the Ombudsman office of transfer/discharges for 1 of 1 resident reviewed for discharge (Resident #63 [R63]), and the facility failed to issue a written transfer/bed hold notice to a resident and their legal representative for a facility-initiated transfer/discharge for 1 of 1 resident reviewed for hospitalization (R61). Findings:1. On 2/26/26, a review of R63's clinical record was completed. Documentation indicated R63 was transferred home with services on 12/29/25. On 2/26/26 at 8:42 a.m., in an interview with the surveyor, the Licensed Social Worker stated she has not been sending notifications to the Ombudsman's office for any transfers or discharges. 2. On 2/26/26, a review of R61's clinical record was completed. Documentation indicated R61 was transferred to the hospital on [DATE] for respiratory distress. There was no evidence that the resident or resident representative had been provided a written copy of the transfer/discharge notice. In addition, the Ombudsman Program was not notified of the transfer/discharge.On 2/26/26 at 9:55 a.m., in an interview with the surveyor, the Director of Nursing confirmed that the resident/resident representative did not receive a copy of the transfer/discharge notice.

Based on record review and interviews, the facility failed to provide interventions outlined in the resident's care plan to ensure that two-person assist was provided during activities of daily living (ADL) for 1 of 2 sampled residents (Resident #12 [R12]), reviewed for falls. The failure to have supervision (two-person assist) as directed by the care plan resulted in an avoidable accident; R12 falling out of bed during evening ADL care, requiring transfer to the emergency room [ER] with admission to the hospital, sustaining a laceration to the head, and rib fractures with increased pain. In addition, based on record review, and interview, the facility failed to adequately supervise a fall risk resident for 1 of 2 sampled residents (R30), reviewed for falls. Findings: R12 was admitted on [DATE] with diagnosis to include diabetes mellitus, peripheral vascular disease with history of right above-the knee amputation, most recently a left toe amputation, and history of deep vein thrombosis on Coumadin (a blood thinner). Review of R12's Report a Facility Incident or Complaint form, dated 5/29/24 at 12:22 p.m. from the facility, indicates that on 5/28/24 at 21:00 (9:00 p.m.), while providing incontinent care to R12, Certified Nursing Assistant #4 (CNA4) had to change his gloves, while he stepped away to get clean gloves R12 rolled out of bed. R12 had laceration above left eye. Pain reported in left torso/rib area. R12 was admitted for follow-up and reported rib fracture per imaging report. Review of R12's follow-up report Report of Facility Incident or Complaint form, dated 5/31/24 at 3:28 p.m. from the facility, indicates that, CNA4 tasked with R12's care did not follow his/her plan of care. It is noted that R12 was a 2 person assist in bed and for incontinence care. CNA4 provided care on his own. CNA4 will go back on orientation to ensure that he is providing safe resident care to our residents. This same CNA will also be receiving a disciplinary write up for this infraction. He will also be required to complete safe resident handling education. R12 received a laceration above his/her left eye, and fractured ribs 2 - 6 on the left side. R12 was admitted to the hospital. Review of R12's Baseline Care Plan (CP) dated 5/24/24, indicates under Baseline CP: I NEED: some assistance can't complete my cares on my own; BECAUSE I: have below knee amputation; I REPOSITION IN BED: with 2 helpers providing more than half the effort. Review of R12's Kardex Guidelines for Daily Care indicates under MOBILITY: I reposition in bed: with 2 helpers providing more than half the effort. Review of R12's fall charting indicates on 5/28/24: 21:00 (9:00 p.m.) resident room. Laceration left forehead c/o (complain of) pain left side torso hit head. Review of R12's injury report indicates that on 5/28/24 21:00 (9:00 p.m.) R [12], (CNA4), lac (laceration) left forehead c/o (complain of) pain left side torso hit head, ER . Bed height: higher for hygiene, incontinence care .CNA [4] cleaning resident for incontinence care, he stepped away for a second to grab a clean pair of gloves. R [12] yelled; I'm going. CNA [4] saw R [12] roll out of bed. - ran for additional staff assistance. Resident found on the right side of the bed (on floor, per Administrator interview on 1/15/25). Small amount of blood coming from his/her left eyebrow and forehead area. Vitals taken; ems [emergency medical services] called. c/o (complain of) pain on left side of his/her torso (rib area) and left arm more than c/o pain in his/her head. On 1/16/25 at 8:35 a.m. in an interview with a surveyor via telephone, CNA4 states, R12 rolled out of bed. I was performing care, patient care hygiene. R12 couldn't hold his/her balance, he/she only has one leg, and his/her weight got to him/her. CNA4 states, I think R12 was a two person assist. CNA4 did admit to caring for R12 by himself when the care plan and Kardex states R12 is a 2 person assist. On 1/15/24 at 12:23 p.m. in an interview with a surveyor, CNA7 stated that R12 needs 2-person assistance, and stated that this can be found in the Kardex, and pointed to a binder in the nurses station on A wing where the Kardex, Guidelines for daily care, on each resident is kept. Review of CT Abdomen and Pelvis with Contrast report findings on 5/29/24 at 1:31 a.m., Chest Findings: Displaced acute appearing fractures of the left anterior lateral 2nd through 6th ribs. On 1/15/25 at 10:34 a.m. in an interview with the Director of Nursing (DON), a surveyor confirmed that the baseline care plan for R12 states he/she needs 2-person assistance with repositioning. The failure to have two staff members present during care for R12 resulted in the resident falling out of bed and sustaining injuries. 17282 2. On 1/15/25, a review of R30's clinical record was completed. R30 is diagnosed with Alzheimer's Disease/Dementia. Nurse's notes indicated that R30 had several unwitnessed falls, mostly in the late afternoon and evening time; On 6/12/24 at 12:23 p.m., R30 was found on their bedroom floor and had sustained a fracture of the right femur. On 8/19/24, R30 found in bedroom and apparently had slid from their wheelchair onto their bedroom floor. On 9/14/24, R30 fell to the bedroom floor. When found, R30 told staff they were reaching for the TV remote. On 10/25/24, R30 found on floor next to the bed. On 11/13/24, R30 found on bedroom floor, slid to the floor from his/her bed while staff in room. On 12/11/24, R30 found on bedroom floor after falling from wheelchair. On 1/3/25, R30 found on bedroom floor after getting up from his/her wheelchair and falling to the bedroom floor. A review of R30's care plan, dated 6/13/24, indicated for the problem of safety and the potential for falls, interventions were to use non-skid footwear, monitor for medication side effects, report behaviors, and keep call bell in reach. A review of R30's care plan, dated 9/7/24, indicated for the problem of at risk for falls, interventions were to keep call bell in reach, use non-skid footwear, fall mat to each side of bed and use fall risk strategies. The highlighted fall strategies for R30 were to use fall mats, low bed, call light in reach, personal items in reach. On 1/16/25 at 7:15 a.m., in an interview with Certified Nurse Assistant-Medication (C.N.A.-M), she stated she works from 6 a.m. to 6 p.m. She stated she most always works on the A-Wing, where R30 lives. CNA-M stated R30 is a 'sun downer'. [R30] gets more agitated and anxious in the late afternoon and evening. The C.N.A.-M stated they try to keep an eye on R30, but they aren't always able too. C.N.A.-M stated most of the falls occur during late afternoons, dinner time and evening in R30's room and are unwitnessed. On 1/16/25 at 10:20 a.m., in an interview with the surveyor, the Director of Nursing confirmed that he has not evaluated the times and causes for R30's falls and has not put in place a plan for supervision and monitoring of R30 during the times of day that the resident experiences greater anxiety and is at a higher risk for falls.

Based on observations, record reviews, and interviews, the facility failed to maintain oxygen filled tanks while in use, failed to maintain a physician ordered oxygen setting on an air concentrator, and failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 residents reviewed for respiratory care (Resident #10 [R10], R15 and R1). Findings: 1. On 1/13/25 at 12:10 p.m., the surveyor observed Resident #10 (R10) in his/her wheelchair that held a portable oxygen tank on the back of the wheelchair. R10 was using a nasal cannula to receive the extra oxygen. Upon observation of the oxygen tank, it registered empty. After the observation, the surveyor reviewed R10's clinical record under the physician order section. R10 had a physician order for continuous oxygen to be kept at a range between 2-5 liters per minute (LPM) to maintain an oxygen saturation of 90%. At 12:25 p.m., RN1 was observed changing the oxygen tank. At 12:25 p.m., in an interview with the surveyor, R1 confirmed that the oxygen tank had been empty. 2. On 1/16/25 at 8:20 a.m., a surveyor observed R10 in the front lobby sitting in his/her wheel chair. Upon observation, R10's portable oxygen tank registered empty. A Nurse showed up at 8:28 a.m., with new tank and exchanged them. On 1/16/25 at 8:28 a.m., in an interview with the surveyor, the Director of Nursing confirmed that the oxygen tank had been empty. 3. On 1/15/25 at 2:45 p.m., a surveyor observed R10's oxygen concentrator and the air intake filter located on the back on the concentrator was heavily soiled with dust. On the front of the concentrator was the manufacturer's directions that directed the air intake filter needed to be cleaned weekly. On 1/15/25 at 2:50 p.m., in an interview with the Director of Nursing, a surveyor confirmed this finding. 33242 4. On 1/14/25 at 8:45 a.m., a surveyor observed R15's oxygen concentrator set on 1.5 liters per minute (LPM); the front of the oxygen concentrator was dusty and the intake filter located on the back on the concentrator was dusty. On the front of the concentrator was the manufacturer's directions that directed the air intake filter needed to be cleaned weekly. R15's physician order indicated that the oxygen order was for 2-4 LPM. On 1/14/25 at 3:07 p.m., during an interview with a surveyor, Licensed Practical Nurse (LPN) stated that R15's oxygen should be at 2 LPM. During this interview, the surveyor confirmed that the concentrator setting was not per physician order and that the front of the concentrator and the filter in the back was dusty. 35904 5. R1 was admitted on [DATE] and has an order dated 10/11/24 for a continuous positive airway pressure (CPAP) machine (used to treat obstructive sleep apnea, uses mild pressure to keep the breathing airways open during sleep) for evening use. On 1/13/25 at 11:58 a.m., a surveyor observed R1's CPAP machine on the table beside his/her bed. R1 states that staff set it up for him/her at night, but nobody has come in to clean it or order new supplies for it, and R1 states he/she's been here for three months and knows some supplies need to be replaced. On 1/14/25 at 3:03 p.m. in an interview with a surveyor, RN3 states she doesn't know if R1's CPAP has been cleaned because she doesn't work nights. She states it would be on the Treatment Administration Record (TAR), usually scheduled cleaning once a week. RN4 looked on the TAR and on the physician orders and did not see any orders for cleaning R1's CPAP. During this interview, the surveyor confirmed that the CPAP machine does not have an order or treatment scheduled for cleaning the CPAP machine. On 1/14/25 at 3:09 p.m., during an interview with the RN-Nurse Manager, a surveyor confirmed that there is no order for R1's CPAP machine, tubing, and mask for cleaning or replacing supplies.

Based on employee record reviews and interviews, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, and on dementia management by failing to ensure that 5 of 5 Certified Nursing Assistant (CNA) staff employed completed their required training (CNA1, CNA2, CNA4, CNA5, and CNA6). Findings: On 1/16/25 the following employee records were reviewed: 1. CNA1 was hired on 5/17/23. There was no documented training in over 12 months. 2. CNA2 was hired on 9/25/23. There was no documented training in over 12 months. 3. CNA4 was hired 2/28/24. There was no documented orientation, or training on dementia, and there is no documented reorientation as outline in a performance correction notice dated 6/11/24. 5. CNA5 was rehired on 9/26/24. There was no documented training on dementia. 6. CNA6 was hired on 5/8/23. There was no documented training on dementia. On 1/16/25 at 11:27 a.m., in an interview with a surveyor, the Administrator stated that she was unable to find any documented trainings listed above, and a surveyor confirmed that CNA1, CNA2, CNA4, CNA5, and CNA6 lacked evidence that mandatory training was completed.

Based on the observations, facility policy reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and during two medication administration observations and for a Resident on Enhanced Barrier Precautions (Resident #25 [R25] on 2 of 4 days of survey (1/14/25 and 1/15/25). Findings: The facility's policy, Administering Oral Medications, revised 2/2022, noted that for tablets or capsules from a bottle - do not touch the medication with your hands. 1. On 1/14/25 at 6:50 a.m., a surveyor observed Certified Nursing Assistant - Medications #1 (CNA-M1) preparing medications. There were already 2 pills in the plastic cup when the surveyor started the observation. CNA-M1 popped a pill from the medication card into her hands and placed the pill in the plastic cup. The surveyor confirmed during this observation with CNA-M1 that she had touched the medication with her hand at this time. 2. On 1/15/25 at 6:50 a.m., during a medication pass observation with CNA-M1 for Resident #55 (R55), a surveyor observed that CNA-M1 popped a pill from the medication card and it fell on to the top of the medication cart; CNA-M1 picked up the pill using 2 medication cups (not touching with her hands) and placed the pill into the medication cup for administration. The surveyor confirmed that the top of the medication cart is not considered a clean area because you don't know who or what has touched the top of your cart, even if you had cleaned it at the beginning of your shift at this time. 3. The facility's policy, Enhanced Barrier Precaution, revised 2/2024, directs that Enhanced Barrier Precautions (EBP) are indicated for residents with wounds .and remain in place for the duration of the stay or until the resolution of the wound. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs included changing linens. On 1/14/25, before 10:00 a.m., a surveyor observed Certified Nursing Assistant #2 (CNA2) in a resident room changing the bed linen for R25 and was observed not wearing a gown. The surveyor observed an Enhanced Barrier Precaution sign that indicated that staff must wear gloves and gown when changing bed linens. At 10:02 a.m., during an interview with a surveyor, CNA2 stated that R25 has a leg wound that is wrapped; CNA2, Licensed Practical Nurse (LPN), and the surveyor observed the sign on the wall outside of R25's room that indicated gown and gloves much be worn when changing bed linens. The surveyor confirmed that EBP were not followed at this time. On 1/15/25 at 7:37 a.m., during an interview with a surveyor, the Director of Nursing (DON) stated that CNA2 came to him and discussed the above observation; the DON stated that he explained to CNA2 that personal protective equipment (PPE) should be worn when changing bed linens for R25 and that additional education would be provided.

Based on observations and interviews, the facility failed to ensure the proper storage and labeling of foods in the walk-in refrigerator located in the kitchen, failed to ensure a vegetable sink had the proper air gap and failed to ensure kitchen staff properly wore hairnets by leaving hair uncovered and unrestrained for 2 of 4 days of survey (1/13/25, 1/15/25). Findings: 1. On 1/13/25 at 10:30 a.m., during the initial kitchen tour, a surveyor observed the Food Service Director (FSD) with a hairnet that did not contain all her hair. In the walk-in refrigerator there was a large cup of [NAME] Donuts beverage that was not labeled with a name or date, and a 1-pound (lb.) brick of Gold'N'Sweet butter that was noted to have a torn cover exposing the butter and showing marks of scrapes and punctures along the edges and on the top of the butter brick. The vegetable sink was observed with an improper air gap on the drainpipe. The 10-114 State of Maine Rules Chapter 226, definition Section A, defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils. All the above findings were confirmed with the FSD at the time of the observations. 2. On 1/15/25 at 7:50 a.m., during a second tour of the kitchen, the surveyor observed that the FSD had a hairnet that did not contain all her hair, and two kitchen aides/cooks did not have a beard/mustache cover on while performing food preparation/distribution tasks. The vegetable sink did not have the proper 1-inch air gap on the drainpipe. On 1/15/25 at 8:00 a.m., the surveyor confirmed with the FSD that her hair was not contained in her hairnet and the cook and kitchen aide did not have their facial hair covered and the vegetable sink remained with the improper 1-inch air gap.

Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the fourth quarter of 2024 (July 1 - September 30). On 1/14/25 at 2:35 p.m., in an interview with a surveyor and review of weekend staffing for July 1, 2024, through September 30, 2024, the Administrator confirmed the facility did not have enough staff to meet resident needs on the weekends.

Based on record review, review of the facility's 'Fall Policy and Procedure' and interview, the facility failed to re-evaluate fall interventions and the relevance of the current fall interventions for 1 of 2 sampled residents (Resident #30 [R30]) reviewed for 7 falls within 8 months timeframe. Finding: On 1/15/25, a review of R30's clinical record was completed. R30 is diagnosed with Alzheimer's Disease/Dementia. Nurse's notes indicated that from 6/3/24 through 1/3/25, R30 has had several unwitnessed falls, mostly in the late afternoon and evening time, in his/her bedroom. On 6/12/24 at 12:23 p.m., R30 was found on their bedroom floor and had sustained a fracture of the right femur. On 8/19/24, R30 found in bedroom and apparently had slid from their wheelchair onto their bedroom floor. On 9/14/24, R30 fell to the bedroom floor. When found, R30 told staff they were reaching for the TV remote. On 10/25/24, R30 found on floor next to the bed. On 11/13/24, R30 found on bedroom floor, slid to the floor from his/her bed while staff in room. On 12/11/24, R30 found on bedroom floor after falling from wheelchair. On 1/3/25, R30 found on bedroom floor after getting up from his/her wheelchair and falling to the bedroom floor. A review of R30's care plan, dated 6/13/24, indicated for the problem of safety and the potential for falls, interventions were to use non-skid footwear, monitor for medication side effects, report behaviors, and keep call bell in reach. A review of R30's care plan, dated 9/7/24, indicated for the problem of at risk for falls, interventions were to keep call bell in reach, use non-skid footwear, fall mat to each side of bed and use fall risk strategies. The highlighted fall strategies for R30 were to use fall mats, low bed, call light in reach, personal items in reach. On 1/16/25, a review of the facility's Fall policy and Procedure (Clinical Protocol) indicated under Cause Identification: Number 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Under Treatment/Management: Number 1: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continued (for example, if the individual continues to try to get up and walk without waiting for assistance). Under Monitoring and Follow-Up: Number 2. The staff and physician will monitor and document the interventions intended to reduce falling or the consequences of falling. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (bedsides those that have already been identified) and will re-evaluate the continued relevance of current interventions. On 1/16/25 at 10:20 a.m., in an interview with the surveyor, the Director of Nursing confirmed that R30 continues to have unwitnessed falls. He stated has not re-evaluated the effectiveness of the current fall interventions, has not tried other interventions to attempt to reduce the falls, and confirmed that he has not followed the facility's fall policy and procedures.

Based on observations and interviews, the facility failed to maintain a comfortable air temperature for 3 of 4 days of survey. Findings: On 1/13/25, during an initial tour of A-Wing and B-Wing, the air temperature was observed to be chilly. On 1/13/25, between 11:15 a.m. and 12:00 p.m., in an interview with the surveyor, Resident #5 (R5), R10, R11, R17 and R36 stated they feel cold and at night, it is colder. On 1/14/25, the facility air temperature was observed to be chilly on A-Wing. On 1/15/25 at 12:30 p.m., the air temperature was observed to be chilly on A-Wing. The thermostats on A and B-Wing and in the main dining room were observed to be set at 70 degrees Fahrenheit (F). On 1/15/25 at 1:00 p.m., the air temperature was taken in front of the nurse's station on A-Wing and registered at 69.9 Degrees F; in front of room [ROOM NUMBER] the air temperature was 70.1 degrees F, in front of room [ROOM NUMBER] the air temperature was 70.1 degrees F, and in front of room [ROOM NUMBER] the air temperature was 70.1 degrees F. On 1/15/25 at 2:00 p.m., in an interview with the Maintenance Director (and observation of thermostats), he confirmed he was unaware that the regulation indicated the air temperature must be maintained between 71 degrees F and 81 degrees F. He turned the thermostats up to 73 degrees F at the time of the interview. On 1/15/25 at 2:30 p.m., the air temperature at A-Wing nurse's station registered at 73 F, in front of room [ROOM NUMBER] the air temperature was 73.5 F, and in front of room [ROOM NUMBER] the air temperature was 73.4 F. On 1/15/25, while taking the air temperatures, random residents on A-wing were asked if they could feel a difference in the air temperature and they answered that they felt warmer. ,

Based on record reviews and interviews, the facility failed to ensure that a resident's record contained the Power of Attorney paperwork, 2 months after admission, for 1 of 2 residents reviewed for Advance Directives (Resident #55 [R55]). Finding: On 1/14/25, R55's clinical record was reviewed and noted that R55 was admitted to the facility on [DATE] and that a family member was the Power of Attorney. The Acknowledgement of Important Information and Policies document uploaded in R55's electronic clinical record indicated that R55 has an Advanced Directive and have provided the facility with a copy of the document but the surveyor could not find this document. On 1/15/25 at 11:58 a.m., during an interview with a surveyor, the Licensed Social Worker (LSW) stated that she did not have a copy of an Advance Directive or the Power of Attorney (POA) paperwork. On 1/15/25 at 1:15 p.m., LSW handed the surveyor a copy of the Power of Attorney paperwork that she just received from the hospital. The surveyor confirmed that the POA paperwork has missing from R55's clinical record for 2 months.

Based on observations and interview, the facility failed to post the nurse staffing information in an area visible to residents for 4 of 4 days of survey (1/13/25, 1/14/25, 1/15/25, and 1/16/25). Finding: On 1/14/25 through 1/16/25, a surveyor observed that the nurse staffing information was not posted in an area visible to residents. On 1/16/25 at 11:27 a.m., in an interview with a surveyor, the Administrator and Director of Nursing stated the nurse staff information was posted outside of the main entrance door to the facility, and the surveyor confirmed that it was not posted in an area that residents had visible access too.

Based on interviews and facility policy review, the facility failed to ensure an alleged violation involving fall with major injury was thoroughly investigated for 1 of 2 facility reported incidents reviewed (Resident #1 (R1). Finding: On 4/10/24, the Division of Licensing and Certification received from the facility a Reportable Incident Form which indicated an allegation of fall with major injury of R1. A review of the closed clinical record for R1 revealed an admitted [DATE] from private residence. Diagnoses included a history of heart disease and Alzheimer's disease and was admitted with hospice services. R1 sustained a fracture and was discharged to acute care hospital on 4/10/24. The facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation - Reporting and Investigating, revised 2/23, indicated that, Investigating Allegations. 1. All allegations are throughly investigated. There is no evidence that staff were interviewed. On 5/7/24 at 12:02 p.m., in an interview with a surveyor, a hospice registered nurse stated that R1 stated he/she fell , and when asked how he/she got into bed, R1 stated, I put me, and then stated they threw me. On 5/7/24 at 3:49 p.m., in an interview with a surveyor, a Certified Nursing Assistant stated that R1 stated he/she fell , then stated he/she said a group of people picked him/her up and threw him/her up in the bed. On 5/7/24 at 12:52 p.m., in an interview with a the Director of Nursing (DON), a surveyor confirmed that the allegation of fall with major injury was not thoroughly investigated.

Based on interviews, review of the facility reportable incident form, and review of the medical record, the facility failed remove a bed pan timely from 1 of residents reviewed. This resulted in harm when a resident was left on a bed pan for approximately 45 minutes and sustained a Stage 2 pressure ulcer (Resident 1). Finding: A Nursing Facility Reportable Incident form was faxed to Division of Licensing and Certification office indicating on 7/25/23 at approximately 4:00 a.m., a Certified Nurse Aide (CNA) placed a resident on a bed pan, left resident on bedpan and failed to monitor the resident per policy. At approximately 4:45 a.m., when resident asked to be taken off the bedpan while removing the bed pan, the resident had 2 open areas on left buttock creating a Stage II injury. A review of Resident #1's medical record stated, in a nursing note, on 7/25/23, Certified Nursing Assistant (CNA) #1 at approximately 4:00 a.m., placed a bed pan under [Resident #1] for toileting. At approximately 4:45 a.m. CNA #2 answered Resident #1's call bell. Upon removing the bedpan, skin came off with the bedpan causing a Stage 2 injury. Partial thickness loss of skin layers that presents as an abrasion or blister. Location: left upper buttock, surface area length times width (L X W): 1.5 x 1, Depth: 0.1 centimeters (cm). Location: left lower buttock area, surface area (L X W): 0.5 x 0.5, Depth: 0.1 cm. Skin Monitoring Treatment sheet indicated that the Stage 2 injury was monitored and treated per physician order; Calmospetine to be applied twice a day (BID) until resolved. On 8/3/23 Stage 2 wound had resolved. On 8/9/23 at approximately 10:30 a.m., in an interview with a surveyor, the Nurse Manager and Administrator stated on 7/25/23 Resident #1 was left on the bed pan from approximately 4:00 a.m. until 4:45 a.m., approximately 45 minutes. It was stated that at approximately 4:00 a.m., three CNAs and a RN were assisting a patient for an emergent situation, when the RN noticed a call light at the end of the hall. The RN asked CNA #1 to respond to call light. Approximately, at 4:45 a.m. the assigned CNA #2 answered a call light for Resident #1, removed the bed pan and observed a red imprint on the buttocks from the bed pan with two open areas, Stage 2 injury. On 8/9/23 at approximately 10:55 a.m., in an interview with a surveyor. Resident #1 stated she was left on the bed pan by a CNA. Resident #1 stated she was not familiar with the CNA and only remembered that she was on the bed pan for a long time until her assigned CNA answered her call light and removed her from the bed pan. Resident #1 stated she was relieved her CNA #2 removed the bed pan because she was very uncomfortable. Review of Stillwater Bed Pan Policy (not dated) states, No resident placed on a bedpan will be left alone in their room until the bed pan is removed from underneath them. No exceptions. If the resident requires privacy, shut the curtain and stay behind it until the bedpan needs to be removed from the resident. If the resident tells you that they do not want you in the room, shut the curtain and step outside the door of the room, shut the curtain and step outside the door of the room, keeping the bed in sight until the bedpan needs to be removed from the resident. Do not leave the doorway until the resident is removed from the bedpan unless there is a true medical emergency. All other needs can wait until the resident is removed from the bedpan. On 8/9/23 at 11:55 a.m., in an interview, the surveyor confirmed with the Nurse Manager and Administrator that Resident #1 was left on the bed pan from approximately 4:00 a.m. until 4:45 a.m. Resident #1 had a reddened area; outline of the bed pan with a Stage 2 injury which was treated with Calmospetine twice a day (BID).

Based on review of the Nursing Facility Reportable Incident Form, the facility's internal investigation, the facility transfer policy and procedure, and interviews, the facility failed to ensure a resident's safety during a Hoyer lift transfer which caused harm to the resident. The facility failed to follow their Hoyer lift policy and procedure which resulted in the resident falling to the floor from the Hoyer lift. From this fall, the resident sustained [REDACTED].#1). Finding: A review of the Nursing Facility Reportable Incident Form submitted to the Division of Licensing and Certification on 2/8/21 stated that on 2/7/21 at 11:55 a.m., Certified Nursing Assistants #1 (C.N.A.#1) and C.N.A. #2 were transferring Resident #1 from bed to wheelchair via a Hoyer lift (electronic mechanical lift) that has a digital weight scale attached to the lifting boom (crane-like feature) of the Hoyer. The report stated that Resident #1's buttocks was dragging on the mattress as the C.N.A.'s were assisting the resident away from the bed. C.N.A. #1 was pulling the Hoyer lift away from the bed as C.N.A. #2 was lifting the resident's legs to assist in clearing the mattress. When the resident was away from the bed, the top right strap of the Hoyer sling detached and the resident fell to the floor. Resident #1 was sent to the Emergency Department and diagnosed with [REDACTED]. The facility's follow up to the accident stated the C.N.A.'s were following facility policy and procedures for mechanical lift/transfers. No determination was made as to how one of the four strap loops popped out of the Hoyer holding hook. A review of the facility's 'Lifting Machine-Using a Portable' stated: Under Section Steps in the Procedure, Page 3, number 19, stated, Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. On 2/18/21 at 2:25 p.m., C.N.A.#2 stated in an interview that she doubled checked the Hoyer sling straps for proper placement. C.N.A.#2 stated that Resident #1's buttocks were dragging on the bed mattress because since the digital weighing scales were attached to the Hoyer lifts, they can't lift the Hoyer high enough to get the residents buttocks off the bed mattress. C.N.A. #2 stated as soon as Resident #1 was away from the bed, the resident fell to the floor. She stated she did not know how the sling strap loop came out of the Hoyer hook. C.N.A. #2 stated the strap loop that popped out of the Hoyer ring was one that C.N.A. #1 applied. She stated with the weight scale on the lift, it makes it harder to maneuver the Hoyer. She stated butts are dragging on the bed and we can't raise the lift high enough to clear the bed. C.N.A.#2 confirmed that there was no distance between the mattress and Resident #1. On 2/19/21 at 3:00 p.m., in an interview with C.N.A.#3, she stated she had done a Hoyer lift transfer with Resident #2 after the weight scales were taken off. She stated that she and C.N.A.#4 were able to maneuver the Hoyer and the resident a lot easier without the scales on. C.N.A.#3 stated the resident's bottom did not touch the mattress. C.N.A.#3 stated that with the scales on the Hoyer it was harder to maneuver the lift and C.N.A.#3 confirmed she couldn't get the resident's bottoms off the bed high enough. On 2/19/21 at 3:10 p.m., in an interview with C.N.A.#5, she stated the lift with the scale on it made it harder to lift the resident up high enough to clear the bed. It took more work to get the resident into the wheelchair. She stated we would have to lift the resident's legs up while the other aide is pulling harder on the lift to get the resident off the bed. C.N.A.#5 confirmed that there was no space between the resident and the resident's mattress. On 2/19/21 at 3:19 p.m., in an interview with C.N.A.#1 she stated she was assisting C.N.A. #2 in transferring Resident #1. C.N.A.#1 stated she did not double check the Hoyer sling straps to ensure placement. C.N.A.#1 stated she thought the straps were good. C.N.A. #1 stated as soon as she moved Resident #1 away from the bed, she fell to the floor hitting his/her head. C.N.A. #1 stated the strap loop that came loose was one that she had applied. C.N.A.#1 confirmed that she did not double check the Hoyer sling straps for proper placement before moving Resident #1 off the bed.

Based on record and documentation review, review of the facility's investigation, and interviews, the facility failed to ensure that 1 of 1 sampled resident (Resident #22) was free from physical abuse when staff forced Resident #22 to have a rectal suppository. This failure resulted in harm to Resident #22 causing Resident #22 to suffer pain and fear at the time of the abuse/assault. Finding: A Nursing Facility Reportable Incident Form dated 9/8/16, indicated that at 5:00 a.m., the Licensed Practical Nurse (LPN) went into Resident #22's room and without waking Resident #22 up or explaining the procedure for the treatment of [REDACTED].#22's rectum. Documentation in Resident #22's clinical record indicated that the resident was diagnosed with [REDACTED]. According to the most recent Minimum Data Set (MDS) 3.0 Assessment, dated 05/15/16, the Brief Interview for Mental Status (BIMS) was coded that Resident #22 and had long and short term memory deficits with a score of 04, indicating that the resident is not interviewable. According to documentation in the facility's internal investigation report and interviews, the physical abuse occurred on 9/8/16, on the night shift, in the residents' room on B-Wing. The Certified Nurse Assistant (C.N.A.) was assisting the LPN in the resident's room on 9/8/16 at 5:00 a.m. On 9/19/16 at 9:23 a.m., in a telephone interview with the surveyor, a Detective from the Attorney General Office stated that the LPN admitted to administering a rectal suppository and not giving Resident #22 the opportunity to refuse. The LPN admitted the resident started yelling and continued to yell afterwards. On 9/20/16 at 4:23 p.m., in a telephone interview with the surveyor, the Certified Nursing Assistant (CNA) stated that she was in the room with the LPN when the incident occurred. The LPN told her not to tell Resident #22 what she was going to do. The CNA observed the LPN pushing Resident #22 over, quickly pulling open the resident's brief, and inserting a rectal suppository without letting Resident #22 know. The CNA stated that the resident yelled out that the LPN hurt her and that the LPN was trying to kill her. On 9/21/16 at 12:29 p.m., in an interview with the surveyor, a Certified Nursing Assistant-Medication (CNA- M), stated that at the beginning of his shift, the LPN stated she had given Resident #22 a rectal suppository without telling him/her. The LPN was making jokes that she thought it was funny how Resident #22 got mad and how she was told to get out of the room and not to come back. The CNA-M stated that he knows that Resident #22 would have refused the suppository as he/she had refused one the day before (9/7/16) when he had asked Resident #22. On 9/21/16 at 1:50 p.m., the surveyor confirmed this finding with the Administrator and Director of Nursing Services.

Based on interviews and documentation review, the facility failed to ensure staff honored a resident's right to refuse a rectal suppository treatment for 1 of 1 resident reviewed for Abuse (#22). Finding: A Nursing Facility Reportable Incident Form dated 9/8/16 indicated that at 5:00 a.m., Licensed Practical Nurse (LPN) #1 went into Resident #22's room and without waking Resident #22 up or explaining the procedure for the treatment of [REDACTED].# 1 swiftly turned the resident on his/her side and quickly forced the rectal suppository into Resident #22's rectum. LPN #1 was overheard by the Certified Nursing Assistant - Medication Aide #1 (CNA-M#1) at the nursing station bragging and laughing about how she woke up Resident #22 with a suppository, and how Resident #22 screamed and was upset. On 9/20/16 at 4:23 p.m., in a telephone interview with the surveyor, Certified Nursing Assistant (CNA) #1 stated that she was in the room with LPN #1 when the incident occurred. LPN #1 told her not to tell Resident #22 what she was going to do. CNA #1 observed LPN #1 pushing Resident #22 over, quickly pulling open the resident's brief, and putting a rectal suppository in without letting Resident #22 know. CNA#1 stated that the resident yelled out that LPN#1 hurt her and that LPN#1 was trying to kill her. On 9/21/16 at 12:29 p.m. in an interview with the surveyor, CNA- M #1 stated that at the beginning of his shift, LPN #1 stated she had given Resident #22 a rectal suppository without telling him/her. LPN #1 was making jokes that she thought it was funny how Resident #22 got mad and how she was told to get out of the room and not to come back. CNA-M #1 stated that he knows that Resident #22 would have refused the suppository as he/she had refused one the day before (9/7/16) when CNA-M#1 had asked Resident #22. On 9/21/16 at 1:50 p.m., the surveyor confirmed this finding with the Administrator and Director of Nursing Services.