Every finding on record at Waterville Center for Health and Rehab

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 4 Units (Harbor, Cove and Memory Care). Findings:1. On 8/25/25 at 12:09 p.m., a surveyor and the Memory Unit Manager observed, in Resident room [ROOM NUMBER]-R, a soiled wedge cushion against the wall across from Resident #86's bed and that both Resident #86's wheelchair armrests were ripped. At this time, in an interview with a surveyor, the Memory Unit Manager confirmed the findings. 2. On 8/25/25 at 12:15 p.m., two surveyors observed food particles and debris in two lower cabinets in the kitchenette on Cove Unit. On 8/25/25 at 12:20 p.m., in an interview with two surveyors present, the Cove Unit Manager confirmed the findings. 3. On 8/27/25 at 3:04 p.m., a surveyor and the Harbor Unit Manager observed the following findings:- Resident room [ROOM NUMBER] - There were two wall fans that were heavily soiled with dust and were both blowing on Resident #10.- Resident room [ROOM NUMBER] - There was a wall fan at the foot of Resident #6's bed that was heavily soiled with dust. At this time, in an interview with a surveyor, the Harbor Unit Manager confirmed the findings. 4. On 8/28/25 from 10:50 a.m. to 11:20 a.m., a surveyor did an Environmental Tour with the Administrator and the Director of Facility Operations in which the following findings were observed/discussed: - Resident room [ROOM NUMBER] - The bathroom floor had six floor tiles that were dirty and stained under the toilet. The room's metal baseboard heater cover was broken apart and hanging down. Resident #81's wheelchair brakes, where they hook to the wheelchair, had white tape on them that was dirty and stained a brownish color. On 8/28/25 at 11:20 a.m., in an interview with a surveyor, the Administrator and the Director of Facility Operations confirmed the findings.

Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the unsecured storage of a container of germicidal disposable wipes for 1 of 4 days of survey. (8/25/25), In addition the facility failed to provide adequate supervision resulting in a resident elopement for 1 of 1 residents reviewed (Resident #3 [R3]). Findings: 1. The Safety Data Sheet for Sani-Cloth Germicidal Disposable Wipes stated the following: 5. Emergency and First Aid Procedure: Skin Contact: If rash or irritation develops, discontinue use. Eye Contact: Flush with cool water for 15 minutes. Inhalation: Remove to fresh air. Ingestion: Consult Physician. On 8/25/25 at 12:15 p.m., two surveyors observed a 1 pound 13 ounce container of Sani-Cloth Germicidal Disposable Wipes in a lower, unlocked cabinet in the kitchenette on the Cove Unit. This was accessible to residents. On 8/25/25 at 12:20 p.m., in an interview with two surveyors present, the Cove Unit Manager confirmed the finding. 2. R3 resides on the secured Memory Care Unit and has diagnoses to include dementia, anxiety, and disorganized schizophrenia. During observations on 8/25/25 at 3:45 p.m., and 8/27/25 at 8:28 a.m., R3 was observed aimlessly wandering around the secured Memory Care Unit with a helmet on. Review of R3's care plan updated 8/5/25 states Focus: R3 is an elopement risk/wander due to dementia, impaired safety awareness and Resident wanders aimlessly. Goal: .safety will be maintained through the next review date. Intervention: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. I identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. On 8/28/25 at 8:15 a.m., a surveyor pushed the elevator button in the lobby on the first floor. The elevator door opened and the surveyor observed R3 in the elevator, aimlessly walking in circles with no helmet on. At this time surveyor called out for Business Office Manager (BOM) who was at the reception desk to come help get R3 back up to the secured unit. During an interview on 8/28/25 at 9:09 a.m., Certified Nursing Assistant (CNA) stated they were passing breakfast trays this am, and R3 was wandering over by the elevator but he did not notice anyone getting off the elevator and had no idea how R3 got in the elevator. During an interview on 8/28/25 at 9:10 a.m., Licensed Practical Nurse (LPN) stated that R3 did wander a lot and was able to confirm R3 most likely got onto the elevator after another family member came up to the third floor and did not make sure that the elevator doors closed before they walked away. At this time LPN confirmed R3 was most likely stuck in the elevator for approximately 10 minutes before the surveyor noticed him. During an interview on 8/28/25 at 9:11 a.m., a family member stated he/she arrived at the unit around 8:05 a.m., and did notice Resident 3 by the elevators, but did not wait for the elevator doors to close before going to visit with his/her family member. During an interview on 8/28/25 at 8:25 a.m., the Administrator stated she was already aware of the above findings.

Based on observations and interviews, the facility failed to ensure the kitchen/kitchenettes were maintained in a clean and sanitary manner for fans, air conditioners, a food mixer, air vents, and walls. Additionally, the facility failed to ensure that foods were stored, dated and labeled properly for 2 of 6 kitchen/kitchenettes tours (Cove Unit Kitchenette and Kitchen)Findings:The facility's Food Receiving and Storage policy, revised October 2017, noted under Policy Interpretation and Implementation:7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ( used by date).8. All food stored in the refrigerator or freezer will be covered, labeled and dated ( used by date). 1. On 8/25/2025 at 11:30 a.m., a surveyor observed the following findings in the Cove Unit kitchenette: - The far right upper cupboard had a plastic bottle of grape jelly and a jar of strawberry preserves, which had been previously opened and used, with directions to refrigerate after opening.- The kitchenette had no drinking cups and the staff were using paper cups to serve residents beverages. On 8/25/2025 at 11:40 a.m., in an interview with a surveyor, the Cove Unit Manager confirmed that the grape jelly and strawberry preserves should have been refrigerated and that residents were using paper cups. 2. On 8/25/25 from 11:15 a.m. to 11:45 a.m., a surveyor completed a Kitchen Tour with the Food Service Director in which the following findings were observed:-The box floor fan, by the office, was dusty/dirty.-The box floor fan by the coffee machine was dusty/dirty.-The dish room ceiling air vent, by the clean dish rack, was dusty/dirty. -There were two wall mounted air conditioning units, by the three bay sink, that were heavily soiled with dust.-The wall behind the steamer unit was heavily soiled with dried liquid residue.-The food mixer had chipped/missing paint and dried food particles on the mix arm and base.-The circular fan, by a food preparation area, was dusty/dirty.-The dry storage area had eight large bags of cornbread mix that were not dated.-The walk-in freezer had a bag of French toast, two packages of hot dog buns and two packages of Eggos that were not dated and labeled.On 8/25/25 at 11:45 a.m., in an interview with a surveyor, the Food Service Director confirmed the findings.

Based on observations and interviews, the facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 3 of 4 survey days. (8/25/25, 8/26/25 and 8/27/25) Findings:1. On 8/25/25 at 1:00 p.m., a surveyor observed loose trash in a wheeled cart without a lid and a dumpster that had the back top lid open exposing trash, outside the kitchen area. 2. On 8/26/25 at 1:30 p.m., a surveyor observed loose trash in a wheeled cart without a lid and a dumpster that had the back top lid open exposing trash, outside the kitchen area.3. On 8/27/25 at 8:05 a.m., a surveyor and the Food Service Director observed loose trash in a wheeled cart without a lid and a dumpster that had the back top lid open exposing trash, outside the kitchen area. At this time, in an interview with a surveyor, the Food Service Director confirmed the findings.

Based on observation, record reviews, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 6 of 33 sampled residents (Resident #5 [R5], R7, R13, R4, R86, and R48). Findings: 1. Review of Resident #5's medical record stated in the current care plan: Range of motion[ROM] (active or passive) with am/pm care daily. ON HOLD WHILE GETTING THERAPY Date Initiated: 09/12/2024 Revision on: 05/27/2025. The medical record lacked evidence that Range of motion (active or passive) was documented twice daily for the following dates in 2025: June: 1, 3, and 4. July: 1, 2, 4-10, 13, 15, 16, 18, 20, and 25. The clinical record lacks documentation that the resident completed or refused ROM exercises. August 1, 2, 7-9, 11, 14, 16-19, 21, 22, and 23-26. The clinical record lacks documentation that the resident completed or refused ROM exercises. Bathing documentation shows missing/inaccurate documentation with no resident baths given and no resident refusal for the following dates in 2025: June: 3, 12, 19, and 26. July: 10, 24 and 31 August: 10, 24 and 31. On 8/27/2025 at 3:54 p.m., in an interview with a surveyor, the Cove Unit Manager and the Administrator confirmed that there was missing/inaccurate documentation on the resident's ROM and Bathing Documentation. 2. Review of Resident #7's medical record indicated R7 receives a bath/shower on Mondays and Thursdays. Bathing documentation shows missing/inaccurate documentation with no resident baths given and no resident refusal for the following dates in 2025: June: 2, 5, 9, 12, 16, 26, and 30. August: 2, 5, 9, 12, 16 and 26. On 8/28/2025 at 2:30 p.m., in an interview with five surveyors present, the Director of Nursing and the Administrator stated that charting/documentation was not completed accurately and it should have been completed accurately in the resident's clinical records. 3. On 8/26/25 at 8:15 a.m., during an observation of R13's room, the Memory Unit Manager (UM1) entered the room with a surveyor and encouraged R13 to drink fluids from his/her breakfast tray and stated that R13 needs frequent encouragement because he/she forgets to drink fluids. UM1 then stated that R13’s blood pressure is low today, and he/she is complaining of feeling dizzy, so the doctor will be seeing him/her today. Review of R13’s care plan states “…at risk for fluid volume deficit .Monitor/document/report to MD [Medical Doctor] PRN [as needed] s/sx [signs/symptoms] of dehydration…” Review of R13’s clinical record revealed a physician progress note, dated 8/27/25, that states, .seen today for an acute visit for hypotension. This morning [he/she] was reported to have blood pressure of 80s/50s. [He/she] felt lightheaded. Staff encouraged oral fluids and [his/her] blood pressures normalized. [He/she] is now asymptomatic…” Further review of R13’s clinical record revealed his/her last documented blood pressure was 119/84 on 8/5/25, and the clinical record lacked evidence of the low blood pressure taken on 8/26/25 for the above symptoms. On 8/27/25 at 8:56 a.m., during an interview, Licensed Practical Nurse #1 (LPN1) stated she took R13's blood pressure yesterday, and it was low, so she encouraged fluids and re-checked the blood pressure, and it improved and that she verbally notified the physician. LPN1 then stated she did not document the initial low blood pressure, the re-check, or that she notified the physician. At this time, a surveyor discussed the above concerns with UM1. At this time, UM1 stated that vital signs are documented in the electronic medical record (EMR) and that R13’s blood pressures and a nursing progress note should have been documented in the EMR. 4. R4 has diagnoses to include dementia with behavior disturbance and bladder incontinence. Review of R4’s clinical record revealed a physician progress note dated 8/12/25 that states, “…Assessment and Plan…Presumed urinary infection. Patient is incontinent. Patient reports feeling ill today but is unable to articulate why. Physical exam revealed suprapubic tenderness without rebound or guarding. Ordered UA [urinalysis] with reflex culture to evaluate for possible UTI [urinary tract infection] . Review of R4’s active physician orders revealed an order dated 8/12/25 for .UA with reflex culture; suprapubic tenderness on exam + reports of feeling fatigued/ill . Further review of R4’s clinical record lacked evidence of urinalysis results or that the urine sample was collected and sent or that the resident refused. On 8/27/25 at 8:52 a.m., during an interview, LPN1 stated R4 was combative with the attempt to collect the urine sample, and she was unable to obtain a sample, so she passed it onto the night nurse, who was also unable to obtain a sample. LPN1 then stated she notified Nurse Practitioner (NP) 1 that the specimen was unable to be obtained. At this time, a surveyor discussed the above finding with UM1, and she stated it is her expectation that the nurse enter a nursing progress note to reflect the refusal(s) and that the provider was notified. 5. R86 has diagnoses to include dementia. R86’s care plan states, .has a POA [Power of Attorney]-Care and POA Financial .has a POA that will remain in effect through next review date . Review of R86’s Interdisciplinary Team (IDT) meeting note, dated 7/17/25, indicates R86’s “…[representative]/POA attended via phone…” and states, .Advanced Directives reviewed, no changes at this time . Further review of R86’s clinical record lacked evidence of POA documentation or Advance Directive documentation. On 8/27/25 at 9:10 a.m., the above finding was discussed with the Memory Unit Social Worker (SW). At this time, the SW stated R86's [representative] is not his/her POA, that R86 does not have an Advance Directive, and that the IDT meeting note and care plan are labeled wrong. 6. Review of R48’s clinical record revealed a nursing Change in Condition (CIC) Evaluation, dated 8/1/25, that indicated R48 sustained an unwitnessed fall at 4:15 p.m. The assessment section of the CIC Evaluation indicated the most recent vital signs taken after the change in condition occurred were documented at 4:10 p.m. Review of R48’s Neurologic Screen Form, dated 8/1/25, indicated that neuro checks were not initiated until 6:00 p.m., however, the vital signs documented under the 6:00 p.m. entry on the Neurologic Screen Form are identical to the vital signs documented at 4:10 p.m. on the CIC Evaluation. Review of the Incident Report for the above fall, dated 8/1/25 at 6:00 p.m., lacked evidence of the actual time of R48’s fall. On 8/28/25 between 9:12 a.m.-10:13 a.m., during an interview, the Director of Nursing reviewed R48's entire clinical record and confirmed that it does does not accurately reflect the time of R48’s fall and stated that she cannot determine what time R48 fell or if neurologic checks should have been started at 4:10 p.m. or 6:00 p.m.

Based on record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #45 [R45]).Findings:Review of facility policy Medication Regiment Review (MRR) dated 6/5/24 states .Facility should encourage physician/prescriber or other responsible parties receiving the MMR and the director of nursing to act upon the recommendations contained in the MRR for those that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. The attending physician should document in the residents health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner . The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, per facility policy and state or federal regulations .R45 was originally admitted in 2023 and has diagnoses to include dementia, anxiety, and a major depressive disorder.Review of Pharmacy Consultant Report dated 5/22/25 states .please attempt a gradual dose reduction (GDR) to Sertraline 12.5 mg [milligram] daily. Review of provider response dated 7/20/25 (182 days after Pharmacy review) states Not clinically appropriate at this time due to increase anxiety/agitation. The provider failed to respond to pharmacy recommendation in a timely manner.Review of facility policy Psychotropic Medication Use dated 3/1/25 states The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences .Review of pharmacy consultant report dated 1/19/25 states, .recently began receiving Haloperidol 2 mg twice daily for dementia with behavioral disturbance. This first generation antipsychotic has an unfavorable risk profile. [He/She] has experienced more than one fall since initiation of haloperidol. A resident to resident interaction is attributed as the precipitating factor per facility progress note. Please consider a gradual dose reduction of Haloperidol to 2 mg once daily, with the end goal of discontinuation. Perhaps non-pharmacological interventions could be used to minimize or eliminate precipitating factors? Review of provider response dated 4/30/25 (108 days after Pharmacy review) states D/c Haldol, I have removed it from the med list. Review of R45's Orders revealed Haldol was discontinued on 4/30/25. Review of R45's care plan updated 5/17/25 states [R45] uses psychotropic medications [related to (r/t)] management of her aggressive behavior and agitation.Consult with pharmacy, MD to consider dosage reduction when clinically appropriate.Review of clinical record revealed Provider Recertification Note dated 1/29/25. There is no evidence pharmacy report was reviewed at this time.During a review of R45's clinical record on 8/26/25 at 3:32 p.m., the Director of Nursing (DON) stated the provider should review a pharmacy recommendations withing 24-48 hours. At this time DON reviewed the above and stated at that time, they had a different provider group and agreed they did not review pharmacy requests in a timely manner.

Based on interviews and record reviews, the facility failed to review and revise the care plans by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 33 residents reviewed for care planning (Resident #125 [R125], R2, R45, R57, and R1).Findings: 1. Review of R125's clinical record revealed an MDS admission Assessment was completed on 11/8/24. Further review of R125’s clinical record indicated an Interdisciplinary Team (IDT) meeting was held 11/25/24 and lacked evidence that an IDT meeting was held within 7 days following the assessment. On 8/28/25 at 12:22 p.m. during an interview, the above finding was discussed with the Social Services Director. 2. Review of R2’s clinical record revealed the quarterly MDS was completed on 5/29/25. Further review of R2’s clinical record indicated, the Interdisciplinary Team meeting (IDT) was held on 6/15/25 (19 days after MDS completion). 3. Review of R45’s clinical record revealed the quarterly MDS was completed on 6/3/25. Further review of R45’s clinical record revealed the IDT was held on 5/29/25 (6 days prior to completed MDS). Review of R45’s quarterly MDS completed on 2/18/25. Review of R45’s clinical record revealed the IDT was held 2/27/25 (9 days after completed MDS). 4. Review of R57’s clinical record revealed quarterly MDS completed on 12/16/24. Further review of R57’s clinical record revealed the IDT was held on 1/8/25 (24 days after completed MDS). Review of R57’s clinical record revealed significant change MDS completed on 12/16/24. Further review of R57’s clinical record revealed the IDT was held on 1/8/25 (23 days after completion of MDS). Review of R57’s clinical record revealed quarterly MDS completed on 5/9/25. Further review of R57’s clinical record revealed the IDT was held on 5/8/25 (1 day before the completed MDS). During an interview on 8/26/25 at 4:04 p.m., in presence of 5 surveyors Minimum Data Set (MDS) Coordinator stated she uses the Assessment Reference Date (ARD) date to schedule IDT meetings. During an interview with Director of Nursing and Administrator on 8/28/25 at 12:45 p.m., the Director of Nursing stated that the IDT meetings are held within 7 days after the completion of the MDS. 5. On 8/28/25, R1’s clinical record was reviewed. R1’s diagnosis list includes, atrial fibrillation ([afib] an irregular and often very rapid heart rhythm), Chronic Pain and a history of genital herpes and Methicillin-Resistant Staphylococcus Aureus ([MRSA] bacteria that does not get better with the type of antibiotics that usually cure staph infections). R1’s Order Summary states, “Foley [Catheter] wash site with soap and water daily as needed”. The Care Plan states, “[R1] has acute/chronic pain [related to (r/t)]”, the Care Plan does not identify what the acute/chronic pain is related to or the location of the chronic pain. R1’s Care Plan does not address the monitoring and management of afib, or R1’s history of genital herpes and MRSA. On 8/28/25 at 2:36 p.m., during an interview with a surveyor, the Director of Nursing (DON) and the Administrator, R1's clinical record was reviewed. The DON stated the last episode of genital herpes resolved in April of 2025 but is unsure why that was removed from the care plan. She also stated R1 had afib in June of 2025. At this time the surveyor confirmed R1's care plan was not updated to address the monitoring and / or management R1’s diagnoses including afib, Chronic Pain or R1’s history of genital herpes and MRSA.

Based on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to formulate an advanced directive for 4 of 33 residents reviewed (Residents R43, R74, R73 and R58). Findings: 1. Resident #43 was admitted in July of 2025. A review of the entire electronic record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 2. Resident #74 was admitted in July of 2025. A review of the entire electronic record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. On 8/26/25 at 1:35 p.m., in an interview with 5 surveyors present, the Social Services Director confirmed that the residents did not have and/or did not decline an Advance Directives. 3. On 8/26/25 the clinical record for R73 was reviewed. The clinical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 4. On 8/26/25 the clinical record for R58 was reviewed. The clinical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. On 8/26/25 at 2:03 p.m., during an interview with the Social Services Director, the surveyor confirmed the facility failed to offer or provide the residents and/or resident representatives with written information concerning the right to formulate an advanced directive.

Based on facility policy review, record review, and interview the facility failed to document and adequately assess and monitor a resident after an unwitnessed fall for 1 of 5 residents reviewed for unnecessary medications (Resident #48 [R48]).Finding: Review of the policy, Fall Prevention and Response Policy, revised 7/14/25, states, .Immediate Response.Head-to-toe nursing assessment.vitals.anticoagulant use, anticoagulant last dose.Neurological Monitoring Protocol.Unwitnessed fall OR suspected head impact OR ON anticoagulant.Frequency & duration of neuro check.Q [every] 15 min [minutes] x 1h [hour], Q 30 min x 1 h, Q1 h x 4h, Q4 h x 24 h, Q8 h until 72 h total.Record completion of each neuro check in flowsheet. Resident #48 has diagnoses to include long term use of anticoagulant (blood thinner) and falls. Review of R48's clinical record revealed he/she sustained an unwitnessed fall on 6/3/25. Review of R48's Change in Condition Evaluation, dated 6/3/25 and SBAR [Situation, Background, Assessment, Response] nursing progress note, dated 6/3/25, lacked evidence that vital signs were taken at the time of R48's fall and lacked evidence that the provider was made aware that R48 was on an anticoagulant. Additionally, review of R48's Neurologic Screen Form, dated 6/4/25, lacked evidence that neurological checks were initiated on the date and time of the fall. On 8/28/25 at 9:12 a.m., the above finding was discussed with the Director of Nursing (DON). At this time, the DON stated the facility has a Performance Improvement Plan (PIP) in place for falls. Surveyor review of the PIP Summary indicated that the PIP addressed fall prevention and reduction in falls and lacked evidence that documentation, assessing, and monitoring were included in the PIP.

Based on record review and interviews, the facility failed to ensure that a resident's physician was notified of the discontinuance of a medical device that uses negative pressure to promote wound healing (Wound Vacuum-Assisted Closure [Wound VAC]) for 1 of 1 resident reviewed for notification of change. (Resident #111 [R111]). Finding: On 8/27/25, during a clinical record review for R111, Documentation indicates he/she was admitted with an order for a wound vac. Review of a Health Status Note, dated 7/9/25 at midnight, shows documentation that at 11:30 p.m. on 7/8/25, R111's wound vac canister was full and needed to be changed. The nurse was unable to replace the canister and discontinued the wound vac. She then applied a wet to dry dressing, covered it with an abdominal pad, and secured it with Kerlix. Upon further review of R111's clinical record there is no evidence that his/her physician was made aware of the discontinuation of the wound vac and did not provide an order for the wet to dry dressing that was applied. A Provider's progress note, dated 7/9/25, indicated the wound vac was still applied when it was documented as being removed at 11:30 p.m. on 7/8/25. This shows the Provider was not aware of the discontinuation of the wound vac treatment. On 8/28/25, during an interview with a surveyor, R111's primary Provider stated that she was not made aware of the wound vac being removed until she saw R111 on 7/11/25. Her progress note dated 7/11/25 documents the wound vac was reapplied the evening prior on 7/10/25. On 8/28/25 at 12:00 p.m. during an interview with the Director of Nursing and the Unit Manager for Cove and Harbor units, the surveyor confirmed that the facility did not have the needed wound vac supplies to continue with a wound vac treatment for R111, the Provider was not made aware of the discontinuance of the wound vac, and a nurse started a treatment for the wet to dry dressing without a physician order.

Based on interviews and record review, the facility failed to develop and/or implement an effective discharge planning process by failing to send referrals to appropriate entities timely, to involve the interdisciplinary team in discharge planning process, and to update the comprehensive care plan with goals and preferences regarding discharge, with referrals to appropriate entities made for this purpose and /or responses to information received from referrals to appropriate entities, for 1 of 4 residents reviewed for Discharge (Resident #88 [R88]).Findings: On 8/25/25 at 2:24 p.m., during an interview with a surveyor, R88 stated he/she has wanted to transfer to another facility for the past 3 years but has not had the help he/she needs to achieve this goal. On 8/27/25, R88's clinical record was reviewed and revealed the following:-Review of the R88's Care Plan indicated the focus discharge: [R88 will] remain in the facility through the next review date, revised on 12/01/2022. The intervention for this focus stated, Discuss with [R88] appropriate options through the next review date, revised on 06/16/23. The clinical record lacks evidence that R88's comprehensive care plan was updated to address R88's goals and preferences regarding discharge, documentation of referrals to appropriate entities made for this purpose and /or response to information received from referrals to appropriate entities.- On 9/13/24, A Social Service Note stated that R88 was anxious to hear if he/she was approved to transfer to another facility. The clinical record lacks evidence that R88's comprehensive care plan was updated in response to information received from the referral.-On 9/24/24, R88's Interdisciplinary Care Meeting indicated that R88's Care Plan was reviewed and updated. The summary note states [R88] has an incentive to move to a new placement. The clinical record lacked evidence that the Interdisciplinary Team was involved in the process of developing the discharge plan, or that R88's comprehensive care plan was updated to include R88's goals and preferences regarding discharge, referrals to appropriate entities made for this purpose and /or updated in response to information received from referrals to appropriate entities.-On 12/23/24, R88's Interdisciplinary Care Meeting indicated that R88's Care Plan was reviewed and updated. The clinical record lacked evidence that the Interdisciplinary Team was involved in the process of developing the discharge plan, or that R88's comprehensive care plan was updated to include R88's goals and preferences regarding discharge, referrals to appropriate entities made for this purpose and /or updated in response to information received from referrals to appropriate entities.-On 3/13/25, a social service note indicates a Social Worker sent R88's Case Manager (not employed by the facility) a list of referrals to facilities already explored and indicated the Case Manager would help make referrals. The clinical record lacked evidence that the Interdisciplinary Team was involved in the process of developing the discharge plan, or that R88's comprehensive care plan was updated to include R88's goals and preferences regarding discharge, referrals to appropriate entities made for this purpose, collaboration with R88's Case Manager, and/or responses to information received from referrals to appropriate entities.-On 3/26/25, R88's Interdisciplinary Care Meeting indicated that R88's Care Plan was reviewed and updated. The summary indicated Referrals are continuing to be completed for other facility options. The clinical record lacked evidence that R88's comprehensive care plan was updated to include R88's goals and preferences regarding discharge, referrals to appropriate entities made for this purpose and /or updated in response to information received from referrals to appropriate entities.-On 6/24/25, R88's Interdisciplinary Care Meeting indicated that R88's Care Plan was reviewed and updated. The summary indicated Referrals are continuing to be completed for other facility options. The clinical record lacked evidence that R88's comprehensive care plan was updated to include R88's goals and preferences regarding discharge, referrals to appropriate entities made for this purpose and /or updated in response to information received from referrals to appropriate entities. On 8/27/25, the facility's policy Discharge of Resident: Home [or] Other Facility dated 6/12/14 was reviewed. The policy does not address the discharge planning process. On 8/27/25 at 12:40 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated there is not a specific policy for discharge planning regarding a resident's requesting to transfer to another facility. The DON confirmed that it is the expectation that the facility will make referrals to appropriate entities when requested by residents. The DON stated that this was made clear to the Director of Social Services. She stated the Director of Social Services has made referrals to appropriate entities since that discussion (2/24/25). On 8/27/25 at 4:30 p.m., during an interview with the DON and the Administrator, a surveyor confirmed the above findings. The Administrator stated there is a policy within the Care Plan policy to include transfers to other facilities. On 8/28/25, the facility's policy Care Plans, Comprehensive Person-Centered, Revised December 2024, was reviewed and stated 8. The comprehensive, person-centered care plan will: . f. include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; . 14. The interdisciplinary team must review and update the care plan: . b. when the desired outcome is not met; . 16. Discharge Planning: a. The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them post discharge. The clinical record lacks evidence that the comprehensive care plan was updated to include R88's goals and preferences regarding discharge, referrals to appropriate entities made for this purpose and /or updated in response to information received from referrals to appropriate entities. On 8/28/25, the facility's Discharge Planning Protocol, (undated), was reviewed and stated 4. If a resident is requesting to. be transferred to another facility, initiate referral to. facility of choice. The clinical record lacks evidence that referrals to appropriate entities were made for R88 to transfer to another facility between September 2024 and 2/24/25. On 8/28/25 at 12:15 p.m., during an interview with the Administrator and the Social Services Director, the Social Services Director confirmed that the facility failed to make referrals to appropriate entities after R88's request to transfer, between September 2024 and 2/24/25. At this time the surveyor confirmed the above finding.

Based on record review and interview, the facility failed to ensure a resident with a specialized mental health diagnosis had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review (PASRR) evaluation and determination for 1 of 1 resident reviewed for PASRR evaluation (Resident #81).Finding:On 8/26/25, clinical record review indicated Resident #81 was admitted to the facility in October of 2024 from a hospital, with a specialized mental health diagnosis. The clinical record lacked evidence that that the resident had been screened for a PASRR Level I determination and that it was submitted to the State-designated authority prior to admission. On 8/28/25 at 12:23 p.m., in an interview with five surveyors present, the Social Services Director and the Administrator confirmed that Resident #81's clinical record lacked evidence that that the resident had been screened for a PASRR Level I determination and that it was submitted to the State-designated authority when the resident was admitted in October of 2024.

Based on record review and interview, the facility failed to develop a care plan in the area of anticoagulant (blood thinner) use for 1 of 5 residents reviewed for unnecessary medications (Resident #48 [R48]). In addition, the facility failed to update a care plan for 1 of 1 residents reviewed for Coronavirus 19 (COVID 19) (Resident #45 [R45]).Findings: 1. R48 has diagnoses to include chronic embolism (blockage in a blood vessel) and thrombosis (blood clot formation) of right popliteal vein (a deep vein located behind the knee joint). Review of R48's active physician orders revealed an order for Eliquis Oral Tablet 5MG [milligram] Give 5mg by mouth two times a day for R/O [rule out] Clot. Review of R48's comprehensive care plan lacked evidence that goals and interventions were developed or implemented for the use of an anticoagulant (Eliquis). On 8/27/25 at 3:00 p.m., during an interview, the Memory Unit Manager reviewed R48's care plan and confirmed it did not include the use of an anticoagulant. 2. Review of facility Covid line listing revealed R45 tested positive for COVID 19 on 2/13/25. Review of R45's care plan updated 7/21/25 states COVID: [R45] has a Respiratory Infection with a congested cough. (Covid19) Date Initiated: 02/13/2025 . During an interview with the Director of Nursing (DON) and the Infection Preventionist on 8/27/25 at 9:00 a.m., the DON confirmed R45 tested positive for COVID 19 on 2/13/25 and would have been quarantined for up to 10 days. At this time DON confirmed no residents in the facility are COVID 19 positive. During an interview on 8/27/25 at 9:03 a.m., the above was confirmed with DON.

Based on record review and interview, the facility failed to monitor for side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident [R] 86).Finding:R86 has diagnoses to include depression.R86's care plan states, .uses psychotropic medications r/t [related to] Behavior management: for dx [diagnosis] of Depression.will be/remain free of drug related complications.Monitor/document for side effects and effectiveness . Monitor/record/report to MD [Medical Doctor] prn [as needed] side effects.Review of R86's clinical record revealed the following active physician orders:Order for Sertraline HCl Oral Tablet 50 MG [milligram] Give 1 tablet by mouth 1 time a day for Depression.Order for Venlafaxine HCl ER [extended release] Oral Tablet.75MG.Give 1 tablet by mouth one time a day for Depression.Further review of R86's clinical record lacked evidence he/she was monitored for side effects of the above medications.On 8/28/25 at 10:13 a.m., during an interview, the Director of Nursing (DON) reviewed R86's entire clinical record and confirmed R86 was not being monitored for side effects of the above medications.

Based on observations, interviews and record reviews, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the storage of a urinary catheter drainage bag for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #66 [R66]). Additionally, the facility failed to ensure proper notification was given to resident representatives during 1 of 1 Covid-19 outbreak in the facility.Findings: 1. R66 has diagnoses to include obstructive uropathy (a blockage in urine flow), indwelling suprapubic urinary catheter, and chronic urinary tract infection. Review of R66's care plan states, .has Suprapubic Catheter for OBSTRUCTIVE AND REFLUX UROPATHY and I get chronic urinary tract infections . On 8/25/25 at 12:38 p.m., R66 was observed foot-propelling in his/her wheelchair from the Memory Unit dining room to the day room area, and his/her urinary catheter drainage bag was hanging under the wheelchair, with the catheter tubing and drainage bag dragging on the floor. On 8/26/25 at 7:55 a.m., R66 was observed seated in his/her wheelchair in the Memory Unit dining room, and his/her urinary catheter drainage bag was hanging below his/her wheelchair, touching the floor. On 8/27/25 at 9:00 a.m., a surveyor discussed the above observations with the Memory Unit Manager (UM1) and at this time, a surveyor and UM1 observed R66 in the day room area with his/her urinary catheter drainage bag hanging on the bottom of his/her wheelchair and the drainage bag and catheter tubing touching the floor. The UM1 then stated there is a spot on the wheelchair to hang the bag so it does not touch the floor and adjusted R66's drainage bag. 2. Based on record review, and interview the facility failed to notify residents and families of a Coronavirus (COVID 19) outbreak. This has the potential to affect all residents residing in the facility. Review of the provided facility COVID Line List revealed the following: Between 1/6/25 and 2/10/25, 18 residents tested positive for COVID 19 on the Cove unit, 4 residents tested positive on Memory Lane, 2 housekeepers, one activities staff member and 1 Minimum Data Set (MDS) Coordinator (whose office is on the skilled unit). During an interview with Director of Nursing (DON) and Infection Preventionist (IP) on 8/27/25 at 9:00 a.m., the DON stated that the Cove unit was shut down during the COVID outbreak, they tried to keep the same staff in that area (unit), and everyone was on 10 days of precautions. The DON further stated that as staff and residents tested positive, all staff were notified via the facility messaging system through scheduling, and only the residents and families residing on the Cove unit were notified of the outbreak. When asked if the residents and families for the other units were notified of the COVID outbreak, the DON replied that a notice of outbreak was posted on the main entrance to notify visitors of the COVID outbreak, but every resident and every family member in the facility was not notified because it was contained to the Cove unit. The facility failed to provide evidence that the residents and families of the skilled unit and Memory Lane were notified of the COVID outbreak.

Based on record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed during an investigation of a facility-reported incident. (Resident #1) Findings: Resident #1 was admitted on [DATE] and had diagnoses to include venous stasis ulcers and deep vein thrombosis (DVT). Review of Resident #1's Care plan, initiated on 12/19/24, states, .history of Deep Vein Thrombosis r/t [related to] Immobility .at risk of developing another DVT . Inspect legs and feet for Skin color/temperature (calf/thigh): pale, cool, edematous (DVT); pinkish red, warm along the course of the vein (superficial) . Review of Resident #1's active physician orders, dated January 2025, lacked evidence that Resident #1 was being monitored for signs and symptoms related to a DVT. Review of Resident #1's daily skilled assessments dated 1/12/25, 1/16/25, and 1/17/25 lacked evidence that a cardiovascular assessment was completed, and assessments dated 1/12/25 and 1/13/25 lacked evidence that a skin assessment was completed. There is no evidence that daily skilled assessments were completed on 1/7/25 and 1/14/25. During an interview with 2 surveyors on 2/11/25 at 11:39 a.m., the Cove Harbor Unit Manager (UM) stated it was her expectation that monitoring for signs of a DVT would be documented on the Treatment Administration Record (TAR) or in the skin and cardiovascular sections in the daily skilled note and that all sections of the assessment should be complete. At this time, UM further reviewed Resident #1's clinical record and confirmed that the TAR lacked evidence of monitoring for signs of a DVT and that the skilled assessments were incomplete for the above dates.

Based on interviews, facility policy review, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act, resulting in failure to protect the resident from further potential harm from the perpetrator. In addition, the facility failed to report to law enforcement or the State Survey Agency (SA) an incident of possible abuse including the violation of a resident's right to be free from a physical restraint in accordance with S483.12, which kept the resident from ambulating from a wheelchair [Resident #99 (R99)]. This had the potential to affect all residents in the facility. Findings: The facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property Prohibition Policy last revised on April 21, 2023 indicated under the Definitions heading: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It also states Timing: incidents and/or allegations of abuse . should be reported to the Administrator and/or his/her designee immediately. The Administrator or his/her designee will notify the State Agency of alleged violations involving abuse, neglect . and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time the incident/allegation was made known to them. The Restraint Use Policy dated 6/24/2014 states The resident has the right to be kept from any chemical/physical restraint imposed for discipline or convenience and not requested to treat his/her medical condition. On 7/31/24 at 12:35 p.m., the State of Maine, Division of Licensing and Certification received an anonymous complaint alleging the facility was short staffed and CNAs (Certified Nursing Assistants) were tying residents to chairs. On 9/10/24 at 10:45 a.m. in an interview with a surveyor the Life Enrichment and Pastoral Care staff member stated, I have never seen or noticed a resident tied to their chairs, but I think I know what you're talking about. That resident passed away. I can't remember what staff or what resident were involved but they were on Cove [Unit]. The surveyor was directed to ask Registered Nurse #1 (RN1). On 9/10/24 at 11:15 a.m., in an interview with the surveyor, RN1 stated she did not remember who the resident was or when the incident happened, but did remember she last saw the resident in bed around 5:00p.m.-5:30p.m., at which time the resident had visitors who were preparing to leave. RN1 stated she remembers the prior Interim Director of Nursing (IDON) asked about the resident being tied to a wheel chair in the days following the incident, RN1 told the prior IDON that she believed the family had restrained the resident. On 9/10/24 at 12:47 p.m., in an interview with a surveyor, the Certified Nursing Assistant -Medications #2 (CNA-M2) stated that she was aware of the possibility of someone having been tied to the bed or chair, and that CNA3 had been placed on administrative leave because of that, but that CNA3 returned quickly, and heard it was the family that had restrained the resident. On 9/12/24 at 2:22 p.m., in an interview, CNA3 stated she last saw R99 in bed around 5:30 p.m., there were no visitors in the room at that time. CNA3 stated she was investigated for 1 to 2 days but was told it wasn't her fault. On 9/12/24 at 8:52 a.m., in an interview with a surveyor the Director of Nursing (DON) stated she knows of the incident but was not here at the time. The DON provided the surveyor with the name of the resident and a folder containing the facility's handwritten notes regarding the incident. The folder lacked evidence that the facility reported the incident to law enforcement agencies or to the SA . On 9/12/24 from 8:58 a.m.- 9:40 a.m., interviews were completed with a surveyor and the DON. During the interview: The Director of Clinical and Quality Assurance confirmed she did not report this incident to law enforcement or the SA. The IDON at the time of the incident joined the interview by phone, and confirmed she did not report this incident to law enforcement or the SA. The Interim Administrator at the time of the incident joined the interview by phone and confirmed she did not report this incident to law enforcement or the SA. On 9/12/24 at 9:40 a.m., in an interview with the DON a surveyor confirmed that the facility failed to report the incident to law enforcement or the SA within 24 hours and failed to report a Follow-Up Investigation within 5 working days. The immediate jeopardy began on 7/25/24 when the facility failed to report the violation of R99's right to be free from a physical restraint. All residents remained at risk of such reports not being made as the facility failed to implement policy and procedures to ensure reasonable suspicion of a crime against a resident is reported. Immediate Jeopardy was identified on 9/13/24. The Administrator, Director of Nursing, and Director of Clinical and Quality Assurance were notified of the immediate jeopardy at 2:25 p.m. on 9/13/24. Please See F-000 Initial Comments related to the IJ removal plan.

Based on interviews, policy review and record review, the facility failed to ensure a resident's right to remain free from a physical restraint in accordance with S483.12, resulting in an immediate jeopardy situation with psychosocial harm and the risk of physical harm including the potential to cause death [Resident #99 (R99)]. All residents remained at risk as the facility failed to develop and/or implement measures, to protect the residents from further use of unnecessary restraints. Findings: On 7/31/24 at 12:35 p.m., the State of Maine's Division of Licensing and Certification received an anonymous complaint alleging the facility was short staffed and CNAs (Certified Nursing Assistants) were tying residents to chairs. On 9/10/24 at 10:45 a.m., in an interview with a surveyor, the Life Enrichment and Pastoral Care staff member stated, I have never seen or noticed a resident tied to their chairs, but I think I know what you're talking about. That resident passed away. I can't remember what staff or what resident were involved but they were on Cove [Unit]. The surveyor was directed to ask Registered Nurse #1 (RN1). On 9/10/24 at 11:15 a.m., in an interview with the surveyor, RN1 stated she did not remember who the resident was or when the incident happened, but did remember she last saw the resident in bed around 5:00p.m.-5:30p.m., at which time the resident had visitors who were preparing to leave. RN1 stated she remembers the prior Interim Director of Nursing (IDON) asked about the resident being tied to a wheel chair in the days following the incident, RN1 told the prior IDON that she believed the family had restrained the resident. On 9/10/24 at 12:47 p.m., in an interview with a surveyor, the Certified Nursing Assistant -Medications #2 (CNA-M2) stated that she was aware of the possibility of someone having been tied to the bed or chair, and that CNA3 had been placed on administrative leave because of that, but that CNA3 returned quickly, and heard it was the family that had restrained the resident. On 9/12/24 at 8:52 a.m., in an interview the Director of Nursing (DON) stated she knows of the incident but was not here at the time. The DON provided the surveyor with a folder containing partial notes that appeared as a timeline . The notes did not indicate who wrote them or when, but did include a copy of the visitor log on the day of the incident, and 2 witness statements from facility employees CNA6 and CNA7 both dated 7/25/24. According to CNA6's witness statement dated July 25th, 2024, at approximately 6:30 p.m., CNA6 and CNA7 found R99 sitting in [his/her] wheelchair attempting to get out of it. This was due to a sheet wrapped around [his/her] waist, we witnessed that it was double knotted in the back of [his/her] wheelchair . The sheet seemed to act as a restraint due to the fact [he/she] couldn't get out of [his/her] wheelchair. According to CNA7's witness statement dated 7-25-24, at approximately 6:30 p.m., CNA7 and CNA6 found [R99] in [his/her] wheelchair trying to stand up but couldn't because there was a sheet tied around her waist then double knotted to the back of [his/her] wheelchair . the sheet seemed to act as a restraint. On 9/12/24 at 9:40 a.m., a surveyor confirmed with the DON that a physical restraint was used to confine R99 to a wheelchair without a physician's order, evaluation/assessment, monitoring or informed consent, and the clinical record lacked documentation regarding the medical need for a physical restraint. On 9/12/24 at 2:22 p.m., in an interview, CNA3 stated R99 was known for getting out of his/her wheelchair and walking from his/her room to the nurse station. CNA3 stated she last saw R99 in bed around 5:30 p.m., there were no visitors in the room at that time. CNA3 stated she was investigated for a day or two but was told it wasn't her fault. The facility's Restraint Use policy, dated 6/24/2014, states the resident has the right to be kept from any chemical/physical restraint imposed for discipline or convenience and not requested to treat his/her medical condition. For residents requiring some level of physical restraint use the following documentation must be in place: -Medical reason or use and type of device with a signed physician order. PRN (as needed) orders are not acceptable. -Documentation indicating the assessment of risk, the interdisciplinary process that determined the least restrictive device, and plan of care for the restrictive device. -Documentation must reflect either the MDS (Minimum Data Set)/Triggers CAA's (Care Area Assessments), continued assessment of the need for, or the medical improvement of the resident that may support a reduction in the means of restraint. -A daily documentation tool indicating the release of the restraint every 2 hours for a minimum of 15 minutes and the type of activity in which the resident participates to enhance mobility. -The resident and/or representative will be informed of risk and benefits and possible negative outcomes and a written consent for use will be obtained. -The consent must be signed by a competent resident, responsible party, or legal representative. -The resident / responsible party has the right to refuse a restraint. The medical record had no such documentation. The immediate jeopardy began on 7/25/24 when the facility failed to ensure R99's right to freedom from physical restraint, and all residents remained at risk of not being free from the use of unnecessary restraints. The immediate jeopardy was identified on 9/13/24. The Administrator, Director of Nursing, and Director of Clinical and Quality Assurance were notified of the immediate jeopardy at 2:25 p.m. on 9/13/24. Please See F-000 Initial Comments related to the IJ removal plan.

Based on interviews, record review, and policy review, the facility failed to fully investigate an incident involving possible abuse including the use of an unnecessary physical restraint on a resident, which kept the resident from ambulating from a wheelchair (Resident #99 (R99). This had the potential to effect all residents in the facility. Findings: On [DATE] at 12:35 p.m., the State of Maine, Division of Licensing and Certification received an anonymous complaint alleging the facility was short staffed and CNAs (Certified Nursing Assistants) were tying residents to chairs. On [DATE] at 10:45 a.m., in an interview with a surveyor, the Life Enrichment and Pastoral Care staff member stated, I have never seen or noticed a resident tied to their chairs, but I think I know what you're talking about. That resident passed away. I can't remember what staff or what resident was involved but they were on Cove. The surveyor was directed to ask Registered Nurse #1 (RN1). On [DATE] at 11:15 a.m., in an interview with the surveyor, RN1 stated she did not remember who the resident was or when the incident happened, but did remember she last saw the resident in bed around 5:00p.m.-5:30p.m., at which time the resident had visitors who were preparing to leave. RN1 stated she remembers the prior Interim Director of Nursing (IDON) asked about the resident being tied to a wheel chair in the days following the incident, RN1 told the prior IDON that she believed the family had restrained the resident. On [DATE] at 12:47 p.m., in an interview with a surveyor, the Certified Nursing Assistant -Medications #2 (CNA-M2) stated that she was aware of the possibility of someone having been tied to the bed or chair, and that CNA3 had been placed on administrative leave because of that, but that CNA3 returned quickly, and heard it was the family that had restrained the resident. On [DATE] at 2:22 p.m., in an interview, CNA3 stated she last saw R99 in bed around 5:30 p.m., there were no visitors in the room at that time, she believed the visitors had gone home. CNA3 stated she was investigated for 1 to 2 days but was told it wasn't her fault. The facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property Prohibition Policy last revised on [DATE] indicates under the Investigation heading it states: As part of the investigation, the Administrator or his/her designee, shall coordinate the investigative process .and take the following action(s): Interview the resident, the accused, and potential witnesses. Witnesses may include anyone who: Witnessed or heard the incident; Came in close contact with either the resident the day of the incident (including other residents, family members, etc.); and Colleagues who worked closely with the accused colleague(s) and/or alleged victim the day of the incident. To the extent possible, all interviews should be summarized into a written statement, which is signed and dated. On [DATE] at 8:52 a.m., in an interview the Director of Nursing (DON) stated she knows of the incident but was not here at the time. The DON provided the surveyor with a folder containing partial notes that appeared as a timeline . The notes did not indicate who wrote them or when. The folder also contained a copy of the visitor log on the day of the incident, and 2 witness statements from facility employees CNA6 and CNA7 both dated [DATE]. Review of the documents indicated: - the resident was able to independently transfer from her bed to her chair . -The visitor log showed only one person had signed in to visit R99 on [DATE]. The visitor returned the visitor's badge at 2:02 p.m. - CNA3 last saw the resident in a wheelchair between 4:,d+[DATE]:30 p.m. when CNA3 went into R99's room to pick up a meal tray . There is no mention in the documents of R99 being restrained at this time. - RN1 last saw R99 in bed between ,d+[DATE]:30 p.m., when R99 received their evening meal tray. There is no mention in the documents of R99 being restrained at this time. -RN3 was notified at approximately 6:30 p.m. that R99 was trying to stand up while restrained to a wheelchair. The evening meal tray was observed on the floor. -There was a change for the worse in the resident's condition at 6:30 p.m., for which hospice was notified. - The resident was resisting the restraint but unable to get out of it. - The facility notes have no information about any visitors other than the one who returned the visitor's badge at 2:02p.m., when R99 transferred from the bed to the wheelchair, or who restrained R99 to the wheelchair. On [DATE] from 8:58 a.m.- 9:40 a.m., interviews were completed with a surveyor and the DON. During the interview: -The Unit Manager denied investigating the incident. She stated RN3 had texted her at 6:41 p.m. to inform her that R99 was found in the chair tied with the sheet behind it and like a double knot, that they had let [him/her] out. The UM notified the prior IDON and from there the Director of Clinical and Quality Assurance and the prior IDON took control of the incident. -The Director of Clinical and Quality Assurance denied investigating this incident. -The IDON at the time of the incident joined the interview by phone and confirmed that she had not spoken with the family or fully investigated this incident. -The Interim Administrator at the time of the incident joined the interview by phone and confirmed she had not spoken with the family or full investigated this incident. - The resident had a Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment; and was thus unable to be interviewed at the time of the incident. The resident died on [DATE] and was not available to be interviewed by surveyors. On [DATE] at 9:40 a.m., in an interview with the DON, a surveyor confirmed that the facility failed to fully investigate this incident, and at the time it was still unknown who had restrained R99 to the wheelchair. A surveyor requested the Incident Policy, and the DON provided the Accidents/Incidents Involving Residents policy dated [DATE] which requires each incident or accident must be detailed in the medical record of the resident, and each incident, accident, or medication error must be investigated immediately for determination of root cause. Review of the facility Incident Report #1944 dated [DATE] and timed as having been written at 8:38 p.m., states [6:30 p.m.]- [Certified Nursing Assistants] called nurse into [patient's ] room where [he/she] was found restrained to [his/her] wheelchair by wrapping a bedsheet around [his/her] waist and the wheelchair ending with a double knot. Resident unable to give Description . There was no documentation in the medical record to indicated this incident occurred or was fully investigated. The immediate jeopardy began on [DATE] when the facility failed to fully investigate the violation of R99's right to be free from a physical restraint in accordance with S483.12. All residents remained at risk as the facility failed to implement its policy and procedures to report and thoroughly investigate an incident involving possible abuse including the use of an unnecessary physical restraint on a resident . Immediate Jeopardy was identified on [DATE]. The Administrator, Director of Nursing, and Director of Clinical and Quality Assurance were notified of the immediate jeopardy at 2:25 p.m. on [DATE]. Please See F-000 Initial Comments related to the IJ removal plan.

Based on record reviews and interviews , the facility failed to protect and promote a resident's right be free from a physical restraint in accordance with S483.12 [Resident #99 (R99)]. A reasonable and prudent person would suffer anxiety, distress, and fear from the involuntary loss of independent movement. Findings: On 7/31/24 at 12:35 p.m., the State of Maine, Division of Licensing and Certification received an anonymous complaint alleging the facility was short staffed and CNAs (Certified Nursing Assistants) were tying residents to chairs. The following is a result of the investigation: R99 was admitted on [DATE] to the facility on hospice. The resident had a Brief Interview for Mental Status (BIMS)which indicated severe cognitive impairment and was unable to make his/her needs known. Diagnoses included dementia, lung cancer, acute respiratory failure with hypoxia, and anxiety disorder with a history of panic attacks. The Care Plan initiated on 7/19/24 indicated the resident has difficulty breathing (dyspnea) on exertion. Remind me not to push beyond endurance. Review of the facility-provided Incident Report #1944 dated 7/25/24 and timed as having been written at 8:38 p.m ., states [6:30pm.] -[Certified Nursing Assistants] called nurse into Pt's (patient's) room where [he/she] was found restrained to [his/her] wheelchair by wrapping a bedsheet around [his/her] waist and the wheelchair ending with a double knot. Resident Unable to give Description . On 9/12/24 at 8:52 a.m., in an interview with a surveyor the Director of Nursing (DON) stated she knows of the incident but was not here at the time. The DON provided the surveyor with a folder which contained handwritten notes, 2 witness statements, and a copy of the visitor log for 7/25/24. Review of folder contents indicated: - the resident was able to independently transfer from her bed to her chair. -The resident had a change in condition at 6:30 p.m. on 7/25/24 for which hospice was notified. -Witness statements indicate the resident was found restrained at approximately 6:30 p.m. and was observed resisting the restraint by attempting to stand and get out of it. On 7/26/24 at 12:07 a.m., RN3's nurse note indicated he contacted hospice because R99 had changed from [his/her] baseline to severe anxiety and agitation, constantly shouting, and the Doctor had called back with new orders for Effexor [used to treat anxiety ] and Clonidine [treats high blood pressure, withdrawal symptoms, anxiety, and post-traumatic stress disorder]. This behavior had started at 6:30 p.m., per the facility's hand written notes, when R99 was found by staff attempting to stand while restrained. On 9/13/24 at 2:25 p.m., during an interview with the DON, the Administrator, and the Director of Clinical and Quality Assurance 2 surveyors reviewed and confirmed R99 had increased anxiety and distress after the use of a physical restraint.

Based on record reviews and interviews, the facility's failure to notify the physician of a significant change in a pressure ulcer status for 1 of 1 sampled residents (#4) resulted in this resident being admitted to the hospital for an evaluation of [MEDICAL CONDITION]. In addition, the facility's failure to notify the physician of Resident's #4's increased pain resulted in the resident experiencing uncontrolled pain from 02/16/2011-02/28/2011. Findings: On 2/7/2011, documentation in Resident #4's care plan indicated the resident had a Stage I pressure ulcer and deep tissue injury to the buttock. On 2/16/2011, a "Nursing Progress Notes," indicated "areas on buttocks now showing deep tissue injury." Also, two "Pressure Ulcer Progress Reports" dated 2/16/2011, indicated an unstageable 3.0 centimeter (cm) by 2.5 cm ulcer on the sacral area. Further documentation indicated pain, moderate amount of tan drainage, with wound bed with 75% slough. However, a "Fax Memo" dated, 2/16/2011, which was sent to the physician, described the area on the buttock and coccyx has having only peeling skin, deep purple discoloration and being slightly moist. The fax lacked evidence of the physician being notified of the resident's pain, type and amount of drainage and the amount of slough present on the wound. On 02/25/2011, the nursing notes indicated the resident's temperature was 101.8 - "med. with Tylenol." On 2/26/2011, the nursing notes (late entry) indicated "coccyx ulcer draining copious brown drainage - no odor." On 2/26/2011, daily documentation on a "Pressure Ulcer Progress Report," contained documentation that the sacral area had "large amount brownish drainage noted. Base of wound blackened. During pressure ulcer dressing change by a nurse, resident had signs of pain." During an interview with the Registered Nurse (RN) who worked on 2/26/2011 and 2/27/2011, he stated, "the biggest concern the family had was that the resident was in pain." The RN indicated when he asked the resident if he/she was having pain, the resident had said, "No" except when he/she was being turned and repositioned. The resident was on scheduled Extra Strength Tylenol 2(500 mg (milligrams)) and [MEDICATION NAME] 50 mg by mouth (po) two times daily (bid). There was no evidence in the record to indicate the nurse administered an, as needed (prn) pain medication prior to or after the dressing change. The only documentation of a (prn) pain medication being administered was Tylenol 650 mg which was given on 2/26/2011 at 0045, for "groans when turned." There was no evidence the physician was notified of a change in the resident's pain status. On 02/27/2011 at 4 a.m., the nursing notes indicated "large amount of brown foul drainage from wound. Tissue mostly eschar - wound margins dark pink - very tender to touch." On 02/27/2011 at 9 a.m., the nursing notes indicated "brown slough - odor - Resident warm, very sensitive to touch, temperature 101.6 - Tylenol given." On 02/27/2011 6 p.m. - 6 a.m., the nursing notes indicated "0.3 pressure areas - one measuring 1.8 X 3 with a 0.3 cm opening draining copious amounts foul smelling, grayish reddish drainage. Smells, looks like old blood. 2 smaller unstageable areas below on same buttocks cheek. Temperature 102 - medicate with Tylenol suppositories. Large area of blanchable redness surrounding areas. Rechecked at 5 a.m. - fax sent to Doctor." On 02/28/2011, a fax to the physician at 1:45 a.m. indicated, "declined profoundly. Stage 4 pressure area. There is a Stage 4 pressure area 1.8 X 3 and .3 opening (Tunnel/Fissure) that is draining copious amounts of foul smelling grayish/reddish drainage (looks and smells like old blood)...has large amount of blanchable redness surrounding. Has pain with turning. Temperature tonight is 102.0 auxiliary. Face is flushed. Have medicated with Tylenol suppository. Question need for wound nurse consult to debride and question IV antibiotics (I think . . . is going septic)?" On 02/28/2011 at 8 a.m., the nursing progress notes indicated that "Color sallow. Skin warm to the touch, temperature 101.4 medicate with Tylenol for temperature and comfort. Lethargic, but arousable to both verbal and tactile stimuli. Facility wound nurse asked to see resident regarding wound change to coccyx. Area has shown significant change with very foul smelling drainage. Brown in color." On 02/28/2011 (time unknown) 'Fax for Physician Orders;' indicated "Facility wound nurse follow up with change in wound status - area to coccyx has shown significant change just over this past weekend. Small opening in slough covering and able to measure 2.5 cm in depth. Increase surrounding redness and warmth, drainage brown thin and foul smelling. Increase in pain. Need better pain control currently only Tylenol and Tramodol. Change treatment to cleanse with safecleanse pat dry - protect surrounding skin with [MEDICATION NAME] Barrier apply collagenease to all wound areas bid and prn/debridement. Question IV antibiotic and [MEDICAL CONDITION] secondary to this and/or UTI currently treating with Bactrim DS. Please respond ASAP." On 02/28/2011, the nursing progress notes indicated that the facility received a call back from the physician's office at 11 a.m. The physician directed the facility to send the resident to the emergency room for an evaluation to rule [MEDICAL CONDITION], The resident was transported to the emergency room via ambulance at 11:45 a.m. The hospital's admitting, "history and physical examination noted to have, as will be described below, UTI, a probable new right pleural effusion and infected substantial Stage 4 sacral decubiti with foul-smelling discharge." The "Physical Examination: Skin: The skin of the back revealed an approximately 10 cm area of [DIAGNOSES REDACTED] with several areas up to 2 to 4 cm across of deep ulceration extending at least to fascial layers with brownish, purulent, foul smelling discharge." The resident was admitted with Urosepsis. The resident passed away at the hospital on [DATE]. On 8/3/2011 at 11:17 a.m., in an interview with the facility wound nurse, she stated that she had seen the resident on Monday, 02/28/2011, "first thing in the morning" and she was usually in by 8 a.m. She stated that there was drainage that was brown, thin and foul smelling. She stated that she filled out the "Fax for Physician Orders" but is unsure when or if the nurses faxed it to the physician. On 08/03/2011 at 10:55 a.m., in an interview with the Director of Nursing, she stated "They (Doctor's office) would not have received any faxes until Monday morning (02/28/2011) when they opened. The physician was not notified until Monday. The nurses should have called the Doctor. They should have called, there is nothing more I can say about that." As of 08/03/2011, there was no evidence in the resident's clinical record to indicate the facility notified the physician when the resident developed a temperature, an increase in pain, a significant change in behavior and the resident's wound deteriorated with foul smelling drainage from 02/16/2011 to 02/28/2011.

Based on record review and interviews, the facility failed to provide treatment and services to promote healing and prevent complications associated with pressure ulcers for 1 of 1 Stage II sampled residents with a pressure ulcer (#4). This failure resulted in the resident exhibiting signs and symptoms of infection and the resident being admitted to the hospital with [REDACTED]. Findings: On 2/7/2011, documentation in Resident #4's care plan indicated the resident had a Stage I pressure ulcer and deep tissue injury to the buttock. On 2/16/2011, a "Nursing Progress Notes," indicated "areas on buttocks now showing deep tissue injury." Also, two "Pressure Ulcer Progress Reports" dated 2/16/2011, indicated an unstageable 3.0 centimeter (cm) by 2.5 cm ulcer on the sacral area. Further documentation indicated pain, moderate amount of tan drainage, with wound bed with 75% slough. However, a "Fax Memo" dated, 2/16/2011, which was sent to the physician, described the area on the buttock and coccyx has having only peeling skin, deep purple discoloration and being slightly moist. The fax lacked evidence of the physician being notified of the resident's pain, type and amount of drainage and the amount of slough present on the wound. On 02/25/2011, the nursing notes indicated the resident's temperature was 101.8 - "med. with Tylenol." On 2/26/2011, the nursing notes (late entry) indicated "coccyx ulcer draining copious brown drainage - no odor." On 2/26/2011, daily documentation on a "Pressure Ulcer Progress Report" contained documentation of sacral area with "large amount brownish drainage noted. Base of wound blackened. During pressure ulcer dressing change by a nurse, resident had signs of pain." During an interview with the Registered Nurse (RN) who worked on 2/26/2011 and 2/27/2011, he stated, "the biggest concern the family had was that the resident was in pain." The RN indicated when he asked the resident if he/she was having pain, the resident had said, "No" except when he/she was being turned and repositioned." The resident was on scheduled Extra Strength Tylenol 2(500 mg (milligrams)) and [MEDICATION NAME] 50 mg by mouth (po) two times daily (bid). There was no evidence in the record to indicate the nurse administered an, as needed (prn) pain medication prior to or after the dressing change. The only documentation of a (prn) pain medication being administered was Tylenol 650 mg which was given on 2/26/2011 at 0045, for "groans when turned". There was no evidence the physician was notified of a change in the resident's pain status. On 02/27/2011 at 4 a.m., the nursing notes indicated "large amount of brown foul drainage from wound. Tissue mostly eschar - wound margins dark pink - very tender to touch." On 02/27/2011 at 9 a.m., the nursing notes indicated "brown slough - odor - Resident warm, very sensitive to touch, temperature 101.6 - Tylenol given." On 02/27/2011 6 p.m. - 6 a.m., the nursing notes indicated "0.3 pressure areas - one measuring 1.8 X 3 with a 0.3 cm opening draining copious amounts foul smelling, grayish reddish drainage. Smells, looks like old blood. 2 smaller unstageable areas below on same buttocks cheek. Temperature 102 - medicate with Tylenol suppositories. Large area of blanchable redness surrounding areas. Rechecked at 5 a.m. - fax sent to Doctor." On 02/28/2011, a fax to the physician at 1:45 a.m. indicated, "declined profoundly. Stage 4 pressure area. There is a Stage 4 pressure area 1.8 X 3 and .3 opening (Tunnel/Fissure) that is draining copious amounts of foul smelling grayish/reddish drainage (looks and smells like old blood)...has large amount of blanchable redness surrounding. Has pain with turning. Temperature tonight is 102.0 auxiliary. Face is flushed. Have medicated with Tylenol suppository. Question need for wound nurse consult to debride and question IV antibiotics (I think . . . is going septic)?" On 02/28/2011 at 8 a.m., the nursing progress notes indicated that "Color sallow. Skin warm to the touch, temperature 101.4 medicate with Tylenol for temperature and comfort. Lethargic, but arousable to both verbal and tactile stimuli. Facility wound nurse asked to see resident regarding wound change to coccyx. Area has shown significant change with very foul smelling drainage. Brown in color." On 02/28/2011 (time unknown) 'Fax for Physician Orders; indicated "Facility wound nurse follow up with change in wound status - area to coccyx has shown significant change just over this past weekend. Small opening in slough covering and able to measure 2.5 cm in depth. Increase surrounding redness and warmth, drainage brown thin and foul smelling. Increase in pain. *Need better pain control currently only Tylenol and [MEDICATION NAME]. *Change treatment to cleanse with safecleanse pat dry - protect surrounding skin with [MEDICATION NAME] Barrier apply [MEDICATION NAME] to all wound areas bid and prn/debridement. *Question IV antibiotic and [MEDICAL CONDITION] secondary to this and/or UTI currently treating with Bactrim DS. Please respond ASAP." On 02/28/2011, the nursing progress notes indicated that the facility received a call back from the physician's office at 11 a.m. The physician directed the facility to send the resident to the emergency room for an evaluation to rule [MEDICAL CONDITION], The resident was transported to the emergency room via ambulance at 11:45 a.m. The resident was admitted with Urosepsis. The hospital's admitting "history and physical examination noted to have, as will be described below, UTI, a probable new right pleural effusion and infected substantial Stage 4 sacral decubiti with foul-smelling discharge." The "Physical Examination: Skin: The skin of the back revealed an approximately 10 cm area of [DIAGNOSES REDACTED] with several areas up to 2 to 4 cm across of deep ulceration extending at least to fascial layers with brownish, purulent, foul smelling discharge." On 8/3/2011 at 11:17 a.m., in an interview with the facility wound nurse, she stated that she had seen the resident on Monday, 02/28/2011, "first thing in the morning" and she was usually in by 8 a.m. She stated that there was drainage that was brown, thin and foul smelling. She stated that she filled out the "Fax for Physician Orders" but is unsure when or if the nurses faxed it to the physician. On 08/03/2011 at 10:55 a.m., in an interview with the Director of Nursing, she stated "They (Doctor's office) would not have received any faxes until Monday morning (02/28/2011) when they opened. The physician was not notified until Monday. The nurses should have called the Doctor. They should have called; there is nothing more I can say about that." As of 08/03/2011, there was no evidence in the resident's clinical record to indicate the facility had provided necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing which resulting in the resident being hospitalized with infected substantial Stage 4 sacral decubiti with foul-smelling discharge. The Resident's 'history and physical examination a UTI (urinary tract infection), a probable new right pleural effusion, and infected substantial stage 4 sacral decubiti with foul-smelling discharge." The Resident's 'Discharge Summary' listed among his/her Diagnoses: [REDACTED].

Based on record review and interviews, the facility failed to ensure an assessment of pain and pain medication needs was completed before conducting a dressing change to a Stage IV pressure ulcer and before repositioning for 1 of 1 Stage II sampled residents reviewed with a pressure ulcer (#4). This failure resulted in the resident experiencing pain during dressing changes and with repositioning. In addition, the facility failed to ensure a physician was informed when changes began occuring in a resident's pressure ulcer and pain levels. Findings: On 2/7/2011, documentation in Resident #4's care plan indicated the resident had a Stage I pressure ulcer and deep tissue injury to buttock. On 2/16/2011, a "Nursing Progress Notes," indicated "areas on buttocks now showing deep tissue injury." Also, two "Pressure Ulcer Progress Reports" dated 2/16/2011, indicated a unstageable 3.0 centimeter (cm) by 2.5 cm ulcer on the sacral area. Further documentation indicated pain, moderate amount of tan drainage, with wound bed with 75% slough. However, a "Fax Memo" dated, 2/16/2011, which was sent to the physician, described the area on the buttock and coccyx being only peeling skin, deep purple discoloration and being slightly moist. This fax lacked evidence of the physician being notified of pain, type and amount of drainage and the amount of slough present on the wound. On 02/25/2011, the nursing notes indicated the resident's temperature was 101.8 - "med. with Tylenol." On 2/26/2011, the nursing notes (late entry) indicated "coccyx ulcer draining copious brown drainage - no odor." On 2/26/2011, daily documentation on a "Pressure Ulcer Progress Report" contained documentation of sacral area with "large amount brownish drainage noted. Base of wound blackened. During pressure ulcer dressing change by a nurse, resident had signs of pain." During an interview with the Registered Nurse (RN) who worked on 2/26/2011 and 2/27/2011, he stated, "the biggest concern the family had was that the resident was in pain. The RN indicated when he asked the resident if he/she was having pain, the resident had said, "No" except when he/she was being turned and repositioned. The resident was on scheduled Extra Strength Tylenol 2(500 mg (milligrams)) and [MEDICATION NAME] 50 mg by mouth (po) two times daily (bid). There was no evidence in the record to indicate the nurse administered an, as needed (prn) pain medication prior to or after the dressing change. There was no evidence the physician was notified of a change in the resident's increased pain. On 02/27/2011 at 4 a.m., the nursing notes indicated "large amount of brown foul drainage from wound. Tissue is mostly eschar - wound margins dark pink - very tender to touch." On 02/27/2011 at 9 a.m., the nursing notes indicated "brown slough - odor - Resident warm, very sensitive to touch, temperature 101.6 - Tylenol given." On 02/27/2011 6 p.m. - 6 a.m., the nursing notes indicated "0.3 pressure areas - one measuring 1.8 X 3 with a 0.3 cm opening draining copious amounts foul smelling, grayish reddish drainage. Smells, looks like old blood. 2 smaller unstageable areas below on same buttocks cheek. Temperature 102 - medicate with Tylenol suppositories. Large area of blanchable redness surrounding areas. Rechecked at 5 a.m. - fax sent to Doctor." On 02/28/2011, a fax to the physician at 1:45 a.m. indicated, "declined profoundly. Stage 4 pressure area. There is a Stage 4 pressure area 1.8 X 3 and .3 opening (Tunnel/Fissure) that is draining copious amounts of foul smelling grayish/reddish drainage (looks and smells like old blood)...has large amount of blanchable redness surrounding. Has pain with turning. Temperature tonight is 102.0 auxiliary. Face is flushed. Medicated with Tylenol suppository. Question need for wound nurse consult to debride and question IV antibiotics (I think . . . is going septic)?" On 02/28/2011 at 8 a.m., the nursing progress notes indicated that "Color sallow. Skin warm to the touch, temperature 101.4 medicate with Tylenol for temperature and comfort. Lethargic, but arouse-able to both verbal and tactile stimuli. Facility wound nurse asked to see resident regarding wound change to coccyx. Area has shown significant change with very foul smelling drainage. Brown in color." On 02/28/2011 (time unknown) 'Fax for Physician Orders; indicated "Facility wound nurse follow up with change in wound status - area to coccyx has shown significant change just over this past weekend. Small opening in slough covering and able to measure 2.5 cm in depth. Increase surrounding redness and warmth, drainage brown thin and foul smelling. Increase in pain. Need better pain control currently only Tylenol and [MEDICATION NAME]. Change treatment to cleanse with safecleanse pat dry - protect surrounding skin with [MEDICATION NAME] Barrier apply [MEDICATION NAME] to all wound areas bid and prn/debridement. Question IV antibiotic and [MEDICAL CONDITION] secondary to this and/or UTI currently treating with Bactrim DS. Please respond ASAP." On 02/28/2011, the nursing progress notes indicated that the facility received a call back from the physician's office at 11 a.m. The physician directed the facility to send the resident to the emergency room for an evaluation to rule [MEDICAL CONDITION]. The resident was transported to the emergency room via ambulance at 11:45 a.m. The resident was admitted with Urosepsis. The hospital's admitting "history and physical examination noted to have, as will be described below, UTI, a probable new right pleural effusion and infected substantial Stage 4 sacral decubiti with foul-smelling discharge." The "Physical Examination: Skin: The skin of the back revealed an approximately 10 cm area of [DIAGNOSES REDACTED] with several areas up to 2 to 4 cm across of deep ulceration extending at least to fascial layers with brownish, purulent, foul smelling discharge." The resident passed away at the hospital on [DATE]. On 8/3/2011 at 11:17 a.m., in an interview with the facility wound nurse, she stated that she had seen the resident on Monday, 02/28/2011, "first thing in the morning" and she was usually in by 8 a.m. She stated that there was drainage that was brown, thin and foul smelling. She stated that she filled out the "Fax for Physician Orders" but is unsure when or if the nurses faxed it to the physician. On 08/03/2011 at 10:55 a.m., in an interview with the Director of Nursing, she stated "They (Doctor's office) would not have received any faxes until Monday morning (02/28/2011) when they opened. The physician was not notified until Monday. The nurses should have called the Doctor. They should have called; there is nothing more I can say about that." As of 08/03/2011, there was no evidence in the resident's clinical record to indicate the facility had notified the physician regarding the residents increased pain. The facility failed to assess, notify the physician and treat a resident's pain [MEDICATION NAME]. On 8/23/2011 at 11:15 PM, a surveyor discussed this finding with the Administrator and Director of Nurses.

Based on record reviews and interviews, the facility failed to ensure that a physician was notified of changes in condition for 1 of 1 Stage II sampled residents reviewed for pressure ulcers (#4). This failure resulted in a physician not being promptly when changes began to occurr in the status of the resident's pressure ulcer and resulted in the resident being admitted to the hospital with [REDACTED]. Findings: On 2/7/2011, documentation in Resident #4's care plan indicated the resident had a Stage I pressure ulcer and deep tissue injury to the buttock. On 2/16/2011, a "Nursing Progress Notes," indicated "areas on buttocks now showing deep tissue injury." Also, two "Pressure Ulcer Progress Reports" dated 2/16/2011, indicated an unstageable 3.0 centimeter (cm) by 2.5 cm ulcer on the sacral area. Further documentation indicated pain, moderate amount of tan drainage, with wound bed with 75% slough. However, a "Fax Memo" dated, 2/16/2011, which was sent to the physician, described the area on the buttock and coccyx has having only peeling skin, deep purple discoloration and being slightly moist. The fax lacked evidence of the physician being notified of the resident's pain, type and amount of drainage and the amount of slough present on the wound. On 2/22/2011, "Nursing Progress Notes," indicated the weekly skin assessment indicated - buttocks and coccyx with redness and open areas - [MEDICATION NAME] dry and intact." On 02/25/2011, the nursing notes indicated the resident's temperature was 101.8 - "med. with Tylenol." On 2/26/2011, the nursing notes (late entry) indicated "coccyx ulcer draining copious brown drainage - no odor." On 2/26/2011, daily documentation on a "Pressure Ulcer Progress Report," contained documentation of sacral area with "large amount brownish drainage noted. Base of wound blackened. During pressure ulcer dressing change by a nurse, resident had signs of pain." During an interview with the Registered Nurse (RN) who worked on 2/26/2011 and 2/27/2011, he stated, "the biggest concern the family had was that the resident was in pain." The RN indicated when he asked the resident if he/she was having pain, the resident had said, "No" except when he/she was being turned and repositioned." The resident was on scheduled Extra Strength Tylenol 2(500 mg (milligrams)) and [MEDICATION NAME] 50 mg by mouth (po) two times daily (bid). There was no evidence in the record to indicate the nurse administered an, as needed (prn) pain medication prior to or after the dressing change. The only documentation of a (prn) pain medication being administered was Tylenol 650 mg which was given on 2/26/2011 at 0045, for "groans when turned." There was no evidence the physician was notified of a change in the resident's pain status. On 02/27/2011 at 4 a.m., the nursing notes indicated "large amount of brown foul drainage from wound. Tissue mostly eschar - wound margins dark pink - very tender to touch." On 02/27/2011 at 9 a.m., the nursing notes indicated "brown slough - odor - Resident warm, very sensitive to touch, temperature 101.6 - Tylenol given." On 02/27/2011 6 p.m. - 6 a.m., the nursing notes indicated "3 pressure areas - one measuring 1.8 X 3 with a 0.3 cm opening draining copious amounts foul smelling, grayish reddish drainage. Smells, looks like old blood. 2 smaller unstageable areas below on same buttocks cheek. Temperature 102 - medicate with Tylenol suppositories. Large area of blanchable redness surrounding areas. Rechecked at 5 a.m. - fax sent to Doctor." On 02/28/2011, a fax to the physician at 1:45 a.m. indicated, "declined profoundly. Stage 4 pressure area. There is a Stage 4 pressure area 1.8 X 3 and .3 opening (Tunnel/Fissure) that is draining copious amounts of foul smelling grayish/reddish drainage (looks and smells like old blood)...has large amount of blanchable redness surrounding. Has pain with turning. Temperature tonight is 102.0 auxiliary. Face is flushed. Have medicated with Tylenol suppository. Question need for wound nurse consult to debride and question IV antibiotics (I think . . . is going septic)?" On 02/28/2011 at 8 a.m., the nursing progress notes indicated that "Color sallow. Skin warm to the touch, temperature 101.4 medicate with Tylenol for temperature and comfort. Lethargic, but arousable to both verbal and tactile stimuli. Facility wound nurse asked to see resident regarding wound change to coccyx. Area has shown significant change with very foul smelling drainage. Brown in color." On 02/28/2011 (time unknown) 'Fax for Physician Orders; indicated "Facility wound nurse follow up with change in wound status - area to coccyx has shown significant change just over this past weekend. Small opening with slough covering and able to measure 2.5 cm in depth. Increase surrounding redness and warmth, drainage brown thin and foul smelling. Increase in pain. Need better pain control currently only Tylenol and Tramodol. Change treatment to cleanse with safecleanse pat dry - protect surrounding skin with [MEDICATION NAME] Barrier apply collagenease to all wound areas bid and prn/debridement. Question IV antibiotic and [MEDICAL CONDITION] secondary to this and/or UTI currently treating with Bactrim DS. Please respond ASAP." On 02/28/2011, the nursing progress notes indicated that the facility received a call back from the physician's office at 11 a.m. The physician directed the facility to send the resident to the emergency room for an evaluation to rule [MEDICAL CONDITION]. The resident was transported to the emergency room via ambulance at 11:45 a.m. The resident was admitted with Urosepsis. The hospital's admitting, "history and physical examination noted to have, as will be described below, UTI, a probable new right pleural effusion and infected substantial Stage 4 sacral decubiti with foul-smelling discharge." The "Physical Examination: Skin: The skin of the back revealed an approximately 10 cm area of [DIAGNOSES REDACTED] with several areas up to 2 to 4 cm across of deep ulceration extending at least to fascial layers with brownish, purulent, foul smelling discharge." The resident passed away at the hospital on [DATE]. On 8/3/2011 at 11:17 a.m., in an interview with the facility wound nurse, she stated that she had seen the resident on Monday, 02/28/2011, "first thing in the morning" and she was usually in by 8 a.m. She stated that there was drainage that was brown, thin and foul smelling. She stated that she filled out the "Fax for Physician Orders" but is unsure when or if the nurses faxed it to the physician. On 08/03/2011 at 10:55 a.m., in an interview with the Director of Nursing, she stated "They (Doctor's office) would not have received any faxes until Monday morning (02/28/2011) when they opened. The physician was not notified until Monday. The nurses should have called the Doctor. They should have called, there is nothing more I can say about that." As of 08/03/2011, there was no evidence in the resident's clinical record to indicate the facility had obtained a change in treatment when the resident developed a temperature, an increase in pain, a significant change in behavior and the resident's wound deteriorated with foul smelling drainage from 02/16/2011 to 02/28/2011.