Every finding on record at Winship Green Center for Health & Rehab, LLC

Based on record review and interviews, the facility failed to have as needed medication readily available for resident use in a timely manner and failed to follow physician orders related to medication administration for 2 of 4 residents reviewed for medications (Resident #1 and #12).Findings:1. On 3/10/26 the Division of Licensing received a complaint regarding Resident #1 not having access to his/her respiratory medication (Acetylcysteine) in a timely manner. The complainant states Resident #1 had asked for this medication multiple days before he/she was able to receive it.Review of Resident #1 clinical record contained the following physician orders; Acetylcysteine Inhalation Solution 10% with instructions reading 200 milligram inhale orally every 6 hours as needed for PNA (pneumonia), ordered on 2/19/26 and discontinued on 2/25/26. A new order for Acetylcysteine Inhalation Solution 10% with instructions to inhale 10 ml orally every 6 hours as needed for PNA on 2/25/26. Ipatropium-Albuterol Solution 0.5-2.5 (3) MG/3ML with instructions to inhale 1 vial orally 4 times a day for COPD (Chronic Obstructive Pulmonary Disease) with a start date of 2/19/26 and Doxycycline Monohydrate Oral Capsule with instructions to Give 100 mg by mouth 2 times a day for a Upper Respiratory Infection for 7 days with a start date of 3/7/26.A review of progress notes indicated Resident #1 was sent to the emergency room for difficulty breathing on 3/6/26 at 8:44 p.m. and returned back to the facility on 3/7/26 at 10:40 a.m A review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked evidence that Acetylcystine was available for use or administered from 2/19/26 to 2/25/26, Ipatropium-Albuterol Solution's noon dose was given on 3/7/26, and the nighttime dose of Doxycycline Monohydrate Oral Capsule was given on 3/7/26.Review of the facilities PIXUS (Automated Medication Dispensing System) shows they 50 mg capsules of Doxycycline Monohydrate are available for use.On 3/23/26 at 3:40 p.m., during an interview with the Director of Nursing (DON), she stated the Acetylcystine and Ipatropium-Albuterol Solution were not administered per provider orders upon admission. In addition, she stated it is the expectation of the nurses to utilize the PIXUS, in the event medications were needed prior to pharmacy delivery. She then states the nurse should have used 2 of the 50 mg Doxycycline Monohydrate Oral Capsules to give his/her evening dose.2. Review of Resident #12's clinical record shows a physician order dated 3/6/26 for Metoprolol Tartrate Oral Tablet 12.5 mg with instructions to; Give 1 tablet by mouth two times a day for HTN (Hypertension) Hold for systolic blood pressure less than 110 and heart rate less than 60.Resident #12's MAR/TAR showed the evening of 3/14/26 the Metoprolol Tartrate was given to the resident outside of the physician orders with a blood pressure of 95/56.On 3/23/26 at 4:45 p.m., during an interview, the DON confirmed that Resident #12 metoprolol should have been held as it was outside of the physician order parameters.

Based on observations and interviews, the facility failed to ensure the confidentiality of protected health information for 10 of 67 residents during 1 of 1 day of survey (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11).Findings:1. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff members assignment sheet on it, face up. The assignment sheet contained personal medical information regarding Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11. It was visible and easily accessible to residents, visitors, and unauthorized personnel. Environmental Service staff and Certified Nursing Assistance were noted nearby.On 3/23/26 at 8:16 a.m., through surveyor intervention, the assignment sheet was properly taken care of by a Licensed Practical Nurse, who at this time confirmed the assignment sheet should not be left in the open and should have been in a secure location.2. On3/23/26 from 3:35 p.m. to 3:41p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with a staff members assignment sheet on it, face up. The assignment sheet contained personal medical information regarding Resident #2, #3, #6, and #8. It was visible and easily accessible to residents, visitors, and unauthorized personnel. Environmental Service staff, Certified Nursing Assistances, ambulatory residents, and residents' family members were noted nearby. At 3:42 p.m., the Housekeeping and Laundry Manager secured the staff members assignment sheet.On 3/23/26 at 3:45 p.m., the above information was discussed with the Director of Nursing.

Based on record reviews and interviews, the facility failed to ensure written bed hold and transfer/discharge notices were provided to the resident or their legal representative for a facility-initiated transfer/discharge for 1 of 3 sampled residents who were transferred/discharged to an acute care facility (Residents #1). Findings:1. Review of Resident 1's clinical record indicated that he/she was transferred to an acute hospital on 3/8/26 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice and a transfer/discharge notice to the resident and/or legal representative. On 3/23/26 at 1:30 p.m., the above was confirmed with the Director of Nursing.

Based on record review and interview, the facility failed to notify the physician of a significant change in condition for 1 of 3 residents reviewed for a significant change in condition. (Resident #1)Findings:A review of Resident #1's entire clinical record showed he/she was transferred to the emergency room on 3/8/26 and was subsequently admitted to the hospital for difficulty breathing. Further review of the clinical record lacked evidence that the physician was notified of Resident #1's transfer to the hospital.Review of the facilities Change of Condition Policy and Procedure states The facility must inform the resident, consult with the resident's healthcare provider, and if known, notify the resident's legal representative or family member when there is. A decision to transfer or discharge the resident from the facility Further review of the policy states Physician/family notification must be documented in the electronic health record.On 3/23/36 at 1:30 p.m., the Director of Nursing confirmed there is no documentation in the resident's electronic medical record that showed a physician was notified.

Based on record review and interviews, the facility failed to provide evidence that the Resident Representative was informed of a physician order for an antipsychotic medication, informed of the side effects of that medication and given the opportunity to agree or disagree with the use of medication for 1 of 3 sampled residents reviewed for unnecessary medications (#1). Finding: A review of the clinical record Resident #1 had been admitted to the facility on [DATE] from an acute care hospital. Admission diagnoses included Urinary Tract Infection, Metabolic Encephalopathy, Delirium, Insulin Dependent Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, Obsessive Compulsive Disorder, Congestive Heart Failure, Aortic Stenosis, and a history of frequent falls. On 12/25/24, Resident #1 experienced agitation, increased confusion and became aggressive and combative to staff and other residents. Efforts to redirect were ineffective and Resident #1 was transferred to the Emergency Department via ambulance for evaluation. Resident #1 was treated for a urinary tract infection, prescribed antibiotics, and returned to the facility. Over the next 5 days, Resident #1 continued to display an altered mental status with confusion, wandering, and combative behaviors at times. A provider note, dated 12/26/24, stated the discharge summary included the addition of Risperidone (an antipsychotic) 0.5 mg (milligrams) tablets twice daily as needed, without clarification of diagnosis. A review of facility admission orders, dated 12/24/24, included an order for Risperdone 0.5 mg by mouth every 12 hours as needed for behavioral disturbances X(times) 14 days. On admission, Resident #1 signed a facility Psychoactive Medication Consent Form, dated 12/24/24. The form was signed by the facility representative, a licensed practical nurse (LPN). It was noted to have been incorrectly completed with Risperidone entered as a Mood Stabilizer and listed possible side effects for the wrong class of medications. The form noted the Food and Drug Administration had issued a Black Box Warning for antipsychotic medication use in the elderly, however, the form did not indicate this was the type of medication prescribed. On 12/30/24, a brief interview for mental status (BIMS) test was completed. Resident #1 scored 12, indicating moderate cognitive impairment. A provider note, dated 12/30/24 stated Patient definitely with altered mental status at times. Will follow closely. Risperidone started at hospital for behavioral disturbances. Nursing not using appropriately. Will schedule twice daily and follow for improvement in behaviors. The medication order was changed to Risperidone 0.5 mg by mouth twice daily for anxiety and agitation. There was no evidence in the clinical record that Resident #1's representative had been informed of this change or the potential risks and benefits of the medication. On 1/13/25 at 12:25 p.m., the prescribing provider stated that Resident #1 had been given Risperidone at the hospital and continued to demonstrate behavioral disturbances. Staff were not giving the medication as needed, therefore the provider scheduled Risperidone twice daily. The surveyor asked if the dosing change had been discussed with Resident #1's family. The provider stated he/she had not had the opportunity. On 1/13/25 at 3:30 p.m., at the exit interview with the facility's Administrator and the Corporate Nurse Practice Educator, the surveyor discussed that Resident #1's clinical record showed no evidence that the representative was aware of and involved in the decision to prescribe a scheduled antipsychotic. Additionally, Resident #1 had been experiencing delirium due to infection and although he/she was his/her own decision maker, was not demonstrating the ability to make an informed decision when he/she signed the psychoactive medication consent form, nor was there evidence that Resident #1 understood or consented to an increase in dosage. A review of the facility's policy for Psychotropic Medications, last revised 5/2023, stated The resident and/or responsible party will be notified when the dose of the psychoactive medication has been changed by the Healthcare Provider.

Based on interviews, the facility failed to deliver resident mail in a timely manner to 2 out of 4 residents who receive mail in the facility. ( #48 and #63) Findings: Reviewed Policy titled: Therapeutic Recreation last revised 10/2023 that states Ensure that mail is delivered to the person unopened or postmarked (for outgoing mail) within 24 hours, including Saturday. On 7/11/24 at 10:45 a.m., in an interview with with Resident #48 and Resident #63, stated they are not receiving their mail for 2 or 3 days after it arrives at the facility. On 7/11/24 at 11:00 a.m., in an interview with the Activities Director, stated that Activities deliver the mail but they have to wait until the Business Office sorts it and that can take a few days. On 7/11/24 at 11:20 a.m., in an interview with the Business Office Manager, the staff confirmed that sometimes mail doesn't get delivered within 24 hours, especially Saturday's mail. They stated that getting the mail sorted and out to residents timely has been a known challenge because residents have complained.

Based on record review and interviews the facility failed to provide/obtain residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 8 of 23 residents reviewed for advanced directives ( #10, #35, #46, #67, #37, #9, #63 and #23). Findings: 1. Resident #10 was admitted to the facility on [DATE]. Review of Resident #10's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 7/9/24 at 11:10 a.m., Resident #10's family member indicated he/she is legal guardian and has documentation but has never been asked to supply it. 2. Resident #35 was admitted to the facility on [DATE]. Review of Resident #35's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and or formulate an advance directive. 3. Resident #46 was admitted on [DATE]. Review of Resident #46's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and or formulate an advance directive. 4. Resident #63 was admitted on [DATE]. Review of Resident #63's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and or formulate an advance directive. 5. Resident #23 was admitted on [DATE]. Review of Resident #23's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and or formulate an advance directive. 6. Resident #9 was admitted to the facility on [DATE]. Review of Resident #9's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 7. Resident #37 was admitted to the facility on [DATE]. Review of Resident #37's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 8. Resident #67 was admitted to the facility on [DATE]. Review of Resident #67's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 7/10/24 at 11:43 a.m., with 2 surveyors, Regional Director of Operations confirmed advanced directives were not obtained and/or offered/declined for above residents. 50218 48648

Based on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain the facility in good repair and sanitary condition for the ceiling air vents and surrounding ceiling tiles, all unit shower rooms, and bathrooms in rooms [ROOM NUMBER] on the [NAME] Unit. Findings: 1. On 7/9/24 at 8:00 a.m., a surveyor observed that all the ceiling vents in all hallways and in the main dining room have a moderate to heavy buildup of black material on the vents and on the ceiling surrounding the vents for 3 of 3 Resident units. This was confirmed with the Administrator at that time. 2. On 7/10/24 at 10:00 a.m., during the facility tour with the Administrator and the Maintenance Manager, the following were observed: Passport Unit - The Shower room has a moderate to heavy buildup of black substance on shower grout. Pemaquid Unit - The Shower room has brown stain on shower room floor and buildup of black substance on shower grout. room [ROOM NUMBER], the bathroom contains unlabeled salad tongs on the back of the toilet. Also, the shared bathroom for Rm 35 and 33 has a glove box holder that is broken and has sharp edges. [NAME] Unit - The Shower room has a heavy amount of black substance on shower grout and the doorframe going into shower room has a large chip out of paint that has a sharp edge. All these findings were confirmed with the Administrator upon the conclusion of the facility tour at approximately 11:00 a.m.

Based on interviews and record review, and policy review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessments, for 6 of 6 residents whose care plans were reviewed (#16, #10, #13, #26, #23, #31). Findings: 1. A surveyor reviewed the clinical documentation of Resident #16, which included review of a comprehensive Quarterly MDS dated [DATE], 3/8/24 and 6/8/324. The surveyor could not locate evidence, after completion of the above 3 MDS assessments, that a care plan meeting was held by the IDT that included, to the extent possible, participation of Resident #16 and/or his/her representative to review and revise the care plan. On 7/10/24 at 9:46 a.m., during an interview with the Social Services Director (SW), she confirmed the above IDT meetings were not completed. 42531 2. A surveyor reviewed the clinical documentation of Resident #10, which included a review of quarterly MDS's dated 10/25/23, 1/25/24 and 4/26/24. Review of Resident #10's clinical record lacked evidence that a care plan meeting was held by the IDT that included, to the extent possible, participation of Resident #10 and/or his/her representative to review and revise the care plan. During a telephone interview on 7/9/24 at 11:10 a.m., Resident #10's guardian indicated that someone at the facility informed him/her that they only held care plan meetings every 6 months and has not been invited to once since 2023. 3. A surveyor reviewed the clinical documentation of Resident #13's, which included a review of quarterly MDS's dated 9/4/23 and 12/4/23. Review of Resident #13's clinical record lacked evidence that a care plan meeting was held by the IDT that included, to the extent possible, participation of Resident #13 and/or his/her representative to review and revise the care plan. During an interview on 7/10/24 at 11:26 a.m., Resident #13 family member indicated he/she can't remember when the last care plan meeting was, but it has been quite a while. During an interview on 7/9/24 at 2:19 p.m., SW confirmed care plan meetings were not held for Resident's #10 and #13. 50218 4. A surveyor reviewed the clinical documentation of Resident #31, which included review of a comprehensive Quarterly MDS dated [DATE] and 6/13/24. The surveyor could not locate evidence, after completion of the above 2 MDS assessments, that a care plan meeting was held by the IDT that included, to the extent possible, participation of Resident #31 and/or his/her representative to review and revise the care plan. 5. A surveyor reviewed the clinical documentation of Resident #23, which included review of a comprehensive Quarterly MDS dated [DATE], 10/24/23, 11/28/23, 2/28/24, 5/27/24 and 6/17/24. The surveyor could not locate evidence, after completion of the above 6 MDS assessments, that a care plan meeting was held by the IDT that included, to the extent possible, participation of Resident #23 and/or his/her representative to review and revise the care plan. 6. A surveyor reviewed the clinical documentation of Resident #26, which included review of a comprehensive Quarterly MDS dated [DATE], 2/29/24, and 5/31/24. The surveyor could not locate evidence, after completion of the above 3 MDS assessments, that a care plan meeting was held by the IDT that included, to the extent possible, participation of Resident #26 and/or his/her representative to review and revise the care plan. On 7/10/24 at 2:25p.m., during an interview Resident #26's guardian indicated that the family has not been invited to any IDT meetings in the last year. On 7/11/24 at 11:28 a.m., during an interview with the Director of Social Services, she confirmed the above IDT meetings were not completed for Resident's #31, #23, and #26. Review of Baseline/Comprehensive Person Centered Care Plan dated 3/23 states .The Comprehensive Person Centered Care Plan (CPCCP) will be developed after the completion of the comprehensive assessment (MDS). The CPCCP will be reviewed by an interdisciplinary team that includes the following representatives: The resident, The resident's family or legal representative, Therapeutic Recreation, Specialized Rehab and Healthcare provider . The resident and or representative has the right to participate in the development/implementation of the planning process, request meetings and has the right to request revisions to the plan of care . The CPCCP will be reviewed and revised as follows: quarterly following MDS completion .

Based on observations, interviews, record review, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, failed to ensure foods were dated/ labeled and stored appropriately for 2 of 3 survey days (kitchen and Pemaquid dining room), failed to ensure that the freezers and refrigerator's temperatures were monitored appropriately. This has the potential to affect all residents that eat food prepared by kitchen staff. Findings: 1. On 7/8/24 between 6:04 p.m., and 6:21 p.m., a surveyor and the cook completed an initial tour of the kitchen which revealed the following: Observation of 3 door refrigerator noted the following: - Individual sliced yellow cheese wrapped in saran wrap, undated, unlabeled and available for use. -clear squeeze bottle of yellow substance, undated, unlabeled and available for use. -plastic container of chopped red chili peppers, undated, unlabeled and available for use. -Clear plastic container containing biscuits covered with saran wrap unlabeled, undated and available for use. -Gallon jar of ranch dressing undated and available for use. -Gallon jar containing relish undated and available for use. - Jar of chopped garlic, undated and available for use. -Gallon jug of [NAME] slaw 1/4 full, undated and available for use. -1/2 gallon whole milk, undated and available for use. -1 pitcher of orange juice; 1 pitcher of apple juice; 1 pitcher of tomato juice; and 1 pitcher of purple juice undated and available for use. - large gray dish basin containing 14, 8 oz cups full of fluid, undated, unlabeled and available for use. -large gray dish basin containing 12, 8 oz cups full of liquid, undated, unlabeled and available for use. The bottom of bottom of the basin contains obvious spilled liquid. - Plastic container of what was identified as tuna salad, undated, unlabeled and available for use. Observation of dry storage room revealed the following items on shelving units: -Box of cream of wheat undated, opened to air and available for use. -Bag of sliced almonds undated, opened to air and available for use. -Small bag of peanut butter crackers opened, individual crackers directly on shelf, open and available for use. -8 ox plastic glass 1/4 full of a brown liquid, uncovered, unlabeled and available for use. -Bag of vanilla cake mix dated 5/15, opened to air and available for use. -Bag of plain breadcrumbs, undated, open to air, and available for use -Bag of mashed potatoes undated, open to air and available for use. -Floor had obviously soiled grout, obvious debris. Surveyor and cooks shoes sticking to ground. Observation of walk in refrigerator revealed the following: -Large plastic gray basin on refrigerator shelf with 8 plastic containers of unknown substance, undated, unlabeled and available for use. -Large metal tray approximately 11x14 inches in diameter, covered with foil, undated, unlabeled and available for use. Note on top states leftovers please use -Block of yellow sliced cheese wrapped in saran wrap, undated and available for use. -Unknown white substance wrapped in saran wrap undated, unlabeled and available for use. Observation of walk in freezer revealed: -Box of pork sausage patties undated, opened to air and available for use. -Box of frozen pizza dough undated, opened to air, and available for use. -Box of frozen broccoli with obvious freezer burn undated, open to air and available for use. -Floor in freezer, had obvious stains on grout between tiles, obvious debris. Review of policy Food Storage dated 9/19 states It is the policy of this facility that food will be stored in a manner so as to maintain high quality, avoid spoilage and prevent contamination. All perishable foods will be stored at proper temperatures, refrigerated at 35 to 41 degrees and frozen at 0 to -10 degrees F All food will be dated upon stocking if taken out of its original packaging and re-wrapped or secured in containers with tightly fitted lids. If not in the original packaging, all food items must be covered, dated and labeled with the name of the contained food .All food will be stored in areas protected from contamination by condensation, leakage, drainage, rodents or vermin During an interview on 7/11/24 at 8:02 a.m., (DA#2) indicated when food is opened for the first time you are supposed to document an opening date and make sure it's properly sealed and stored. 2. On 7/8/24 at 6:04 p.m., an initial tour of the kitchen revealed the following: -Stand mixer with black cover over it had visible debris. During an interview on 6/8/24 at 6:05 p.m., [NAME] indicated that the mixing bowl is cleaned after every use and if it is covered it means that it's been thoroughly cleaned and is ready to be used again. At this time the cook confirmed the area behind and above mixing bowl had obvious debris. -2 large flour containers noted to have visible caked on debris on top. There is a brown soup bowl located on top of one flour container, visibly soiled. At this time cook confirmed dietary staff use the soup bowl to take flour out of the container and is not sure why they don't use a scoop. Observation of dishwashing room on 7/8/24 revealed the following: -30 gallon trashcan noted next to counter with obvious caked on, dried on debris on top and outside surfaces. -All 4 walls and baseboards are visibly dirty. -Dishwasher top and sides had visibly caked on debris. -Pipes directly under sink have obvious dust and debris. On 7/8/24 at 6:21 p.m., [NAME] indicated kitchen staff have stickers that they are supposed to be putting on all items they place in refrigerator which should be dated and labeled when they are put in refrigerator, but no one really does; Refrigerator and freezer temperatures are supposed to be taken twice daily; staff sweep the floors, but don't usually wash them at the end of each shift; and staff are supposed to ensure entire kitchen in clean before the end of their shift. During follow-up kitchen observation on 6/10/24 at 7:05 a.m., with Food Service Director (FSD), the following was observed: -Observation of walk in refrigerator contained block of yellow sliced cheese wrapped in saran wrap undated, and available for use. [NAME] substance covered in saran wrap, undated, unlabeled available for use. -Observation of Dish Room revealed trash can in dish room top and sides had obvious debris. Top and sides of dishwasher visibly soiled and All 4 walls of dish room visibly soiled with obvious debris. -Observation of food preparation area revealed that the top and sides of trash can visibly soiled. -Observation of dry storage room reveled bag of vanilla cake mix dated 5/15 on shelf open to air and available for use. At this time FSD confirmed above concerns. During an interview on 7/10/24 at 8:43 the above concerns were discussed with the Administrator in the presence of 2 surveyors. Review of temperature logs reveled the flowing: Review of Main Dining Room temperature Log dated June 2024 lacked evidence of documented temperature on 6/10/24 during the PM shift. Review of Walk -In Temperature Log/refrigerator-freezer dated July 2024 lacked evidence of documented temperatures on 6//3/24, 6/4/24, 6/5/24, and 6/6/24 during the PM shift. Review of 3 Door Refrigerator Temperature Log dated July 2024 lacked evidence of documented temperatures on 6/3/24, 6/4/24, 6/5/24, 6/6/24 or 6/7/24 during the PM shift. Review of Walk-In temperature logs dated July 2024 lacked evidence of documented temperatures on 6/3/24, 6/4/24, 6/5/24, 6/6/24, 6/7/24 and 6/8/24 during the PM shift. Review of Pemaquid Dining Room Temperature Log dated June 2024 revealed documented temperature of 42 degrees on 6/6/24, 6/8/24, 6/14/24, 6/17/24, 6/21/24 and 6/27/24 during the AM shift. Further review of refrigerator temperature log lacked evidence of any follow -up regarding these temperatures. Review of Pemaquid Dining Room Temperature Log dated April 2024 revealed documented refrigerator temperature of 43 degrees on 4/18/24, and 42 degrees on 4/19/24 during the PM shift. Further review of refrigerator temperature log lacked evidence of any follow -up regarding these temperatures. Review of facility policy Kitchen Sanitation dated 1/20 states Cleaning will be done daily, weekly, monthly, or as needed within the Kitchen. All assignments will follow the proper procedures listed in this manual and will be reviewed by the food Service Manager or Designee . All food contact surfaces shall be cleaned with detergent and sanitized with an approved food safe sanitizer and allowed to air dry. The Manager is responsible for assigning the cleaning duties to the appropriate staff and to ensure that appropriate safety equipment is available. Utilizing a checklist for the tasks assigned the kitchen is to be clean at the end of the shift. In the absence of the Food Service Manager, [NAME] or designee is responsible to ensure that cleaning responsibilities have been completed at the end of the shift. During an interview on 7/11/24 at 7:59 a.m., Dietary Aide (DA#1) indicated that if a refrigerator temperature is too high or too low, he just documents the temp on the page because he figures the Dietary Manager reviews it anyway and has no idea what else is supposed to be done. During an interview on 7/11/24 at 8:02 a.m., DA#2 indicated if a refrigerator temperature were out of range, he would notify Dietary Manager and get his guidance. During an interview on 7/11/24 at 8:07 a.m., DM indicated if temps are off staff are to notify him or the maintenance staff. If there is a problem, they will attempt to fix it and take the temperature again. 3. On 7/9/24 at 8:23 a.m., Observation of dining room kitchenette refrigerator/freezer revealed the following: -Refrigerator contained container of sour cream, small glass jar with unknown red substance, 1/4 gallon of whole milk, and 1 plastic container of cupcakes undated, unlabeled and available for use. - Freezer was visibly heavily soiled with a brown substance and contained unlabeled and undated popsicles. Review of facility policy Use & Storage of food brought to residents by family and visitors dated 3/22 states .Perishable foods must be stored in the nursing unit kitchen nourishment refrigerator and identified with resident's name, food item and use by date. Facility staff are responsible to discard perishable foods within 72 hours of being brought in from outside . During an interview on 7/9/24 at 8:23 a.m., Dietary Manager (DM) indicated the refrigerator contains resident's personal food and snacks and it is locked to prevent residents from opening it without staff and per policy personal food is to be discarded after 72 hours. DM further indicated that dietary staff are supposed to ensure items are dated, refrigerator is clean, and items are discarded after 72 hours. On 7/9/24 at 8:32 a.m., Administrator indicated that only staff have access to the refrigerators, and it is the dietary staff's responsibility to clean the refrigerator.

Based on observations and interviews, the facility failed to ensure that a call bell was accessible to 1 of 24 sampled residents observed for 2 of 3 days of survey (#10). Findings: During medical record review, Resident #10 has diagnoses to include quadriplegia and is totally dependent on staff for all Activities of Daily Living. He/she is only able to rotate his/her head from left to right and uses a tap call bell by the right side of his/her head to ask for assistance. Review of Resident #10's care plan updated 4/4/24 states Ensure/provide .Call light in reach . On 7/09/24 at 9:53 a.m. Resident #10 was observed lying in bed, touch call bell observed on right side behind pillow and not in reach. On 7/10/24 at 7:38 a.m., Resident #10 was observed lying in bed, touch call bell observed on top of pillow to right side of resident's head and not in reach. During an interview, resident was asked to demonstrate how he/she would call for help if needed. Resident #10 moved his/her head in an attempt to use the bell but was unable to reach it. During an interview on 7/10/24 at 7:41 a.m., Certified Nursing Assistant (CNA1) indicated that the only way Resident #10 can call for help is to use his/her tap call bell and it has to be on the right side of his/her head and in reach. At this time CNA1 entered the room and confirmed call bell was not in reach. During an interview on 7/10/24 at 8:43 a.m., in the presence of 2 surveyors the above was discussed with Administrator.

Based on record reviews and interviews, the facility failed to update/implement goals and interventions in the area of depression for 1 of 4 residents reviewed ( #10), In addition facility failed to ensure care plan was updated/implemented on the areas of elopement, and diabetes for 1 of 4 care plans reviewed ( #13). Findings: 1. Resident #10 was originally admitted on [DATE] with diagnoses to include traumatic brain hemorrhage, quadriplegia, depression, bilateral extremity contractures and expressive aphasia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 has bilateral hand/arm contractures and is totally dependent on staff for all Activities of Daily Living and is dependent on G-tube [gastronomy tube] for all nutrition needs. Review of Resident #10's care plan, updated 4/4/24, states [Resident #10] has depression r/t physical limitations secondary to quadriplegia, TBI . Intervention: Monitor/document/report PRN any risk for harm to self: suicidal plan, risky actions (stockpiling pills . or writing a note), intentionally harmed or tried to harm self . During an interview on 7/10/24 at 8:43 a.m., in presence of 2 surveyors, the Administrator indicated Resident #10 does not have the ability to independently move his/her hands/arms and would have no ability to harm/hurt him/herself, and does not have access to any pills. At this time Administrator confirmed Resident #10's care plan has not been updated to accurately reflect his/her needs. 2. Resident #13 was originally admitted on [DATE] with diagnoses to include dementia, history of traumatic brain injury (TIA), and seizure disorder. Further review of Resident #13's care plan updated 5/21/24 states '( #13) at a High Risk for Elopement r/t wandering risk scale, wandering behavior pattern, attempts at opening doors to outside he demands to be brought to store at times with difficulty redirecting; Wanderguard to wheelchair EXP 10/14/23 9000-0139I. Observation of wander guard on Resident #13's wheelchair on 7/11/24 at 10:01 a.m., Revealed Resident #13's wander guard expiration date 3/5/24 9000-01391. Further review of Resident #13's clinical record lacked evidence his/her care plan was updated to appropriately reflect wander guard expiration date. During an interview on 7/11/24 at 10:16 a.m., Licensed Practical Nurse (LPN #1) indicated it was nursing's responsibility to ensure wander guard expiration date is correct. Further review of Resident #13's care plan updated 5/21/24 states [Resident #13] has Diabetes Mellitus, Wash feet daily with mild soap and water. Dry thoroughly. Apply lotion. During an interview on 7/11/24 at 10:17 a.m., LPN#1 confirmed Resident #13's order to wash feet was discontinued a while ago and that was an old order that never got updated in the care plan.

Based on record review, policy review, observations and interviews, the facility failed to provide residents with a continuous resident centered activities program for 1 of 1 resident reviewed for activity participation ( #10). Findings: Review of facility policy Participation Record dated 5/14 states An individual's level of involvement in recreation programming will be documented on the Recreation Participation Record . The current Participation Record will be maintained daily, organized, and easily accessible to all Recreation . Review of facility policy Individual Program Planning dated 10/23 states Regularly scheduled programming will be provided to all patients who are not able to tolerate or prefer not to participate in group or independent leisure opportunities and/or at risk of a lack of meaningful recreational and/or social engagement. An individualized program will: Include interactions and experiences that support the resident's patient's overall wellbeing . The patient's engagement in individual (one-to-one) programs will be recorded on the Resident Participation Record indicating which preference was met and the patient's response to the intervention. Review of Resident #10's clinical record reveled Activities -Initial Review completed 8/7/23 states: Past activities Interest Spending time with her family and watching movies, listening to music . Review of Resident #10's Activity Participation Record dated May 2024 revealed he/she was offered/refused activity participation 7 of 30 days, Review of June 2024 revealed he/she was offered/refused activity participation 3 of 30 days, and July 2024 revealed he/she was offered/refused activity participation 5 of 10 days. Review of Resident #10 care plan updated 4/24/24 states The resident is dependent on staff etc. for meeting emotional, intellectual, physical, and social needs r/t (if dependent). The resident will maintain involvement in cognitive stimulation, social activities as desired through review date . On 7/10/24 at 2:05 p.m., live music was playing in the dining room. Observation of participating residents noted Resident #10 was not present. During an interview on 7/10/24 at 2:10 p.m., In presence of 2 family members, Resident #10 indicated that he/she was not asked if he/she wanted to attend the music activity and would have liked to attend. Family member indicated they had been there a while, and no one asked him/her if he/she wanted to go to listen to music. During an interview on 7/10/24 at 2:15 p.m., Certified Nursing Assistant (CNA1) indicated she was aware that Resident #10 enjoyed music and he/she should have been asked if he/she wanted to participate. During an interview on 7/10/24 at 10:06 a.m., Activity Director indicated that all residents should be asked if they want to attend activities and if they refuse it should be documented in their chart. Bed bound residents and residents that don't like group activities should get a 1:1. Care plans should reflect residents' choices appropriately and be updated quarterly. Review of Resident #10's activity participation logs lacked evidence that 1:1 activities were offered or refused. During an interview on 7/10/24 at 2:17 p.m., Activity Assistant (AA) indicated that she goes in every room and asks every resident if they want to attend the activity. AA further indicated she did go in Residents #10's room but didn't ask if he/she wanted to attend because he/she was in bed. At this time AA confirmed Resident #10 was not invited to attend music activity.

Based on observation and interview, the facility failed to ensure that the resident's safety when the residents wander guard was expired for 1 of 1 resident reviewed for elopement (#13). In addition, the facility failed to a blocked fire door on 1 of 3 units ([NAME] Unit), on 2 of 3 survey days. Findings: 1. Resident #13 was admitted on [DATE] and has diagnoses to include dementia, anxiety, and is legally blind. Review of significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status of 4 of 15 indicating he/she is not cognitively intact. Review of Resident #13's care plan updated [DATE] states [Resident #13] is at a High Risk for Elopement r/t wandering risk scale, wandering behavior pattern, attempts at opening doors to outside [Resident #13] demands to be brought to store at times with difficulty redirecting- Observations of Resident #13 between [DATE] at 7:49 p.m., [DATE] at 9:53 a.m., and [DATE] at 10:01 a.m., revealed Resident #13's self propelling wheelchair in halls. Observation of Resident #13's wander guard located under his/her wheelchair was noted to have expiration date of [DATE]. During an interview on [DATE] at 10:16 a.m., Licensed Practical Nurse (LPN1) indicated it was nursing's responsibility to check wander guard expiration date and at this time LPN1 confirmed Resident #13's wander guard was expired. On [DATE] at 11:31 p.m., the above concerns were discussed with Director of Nursing. 48648 2. On [DATE] at 6:15 p.m., a surveyor observed a standing fan obstructing an open fire door in the [NAME] Hallway. The fan was moved without surveyor intervention by 7:00 p.m. On [DATE] at 9:19 a.m., a surveyor observed a standing fan obstructing an open fire door in the [NAME] Hallway. Staff was alerted by the surveyor and the fan was moved. On [DATE] at 11:26 a.m., the fan obstructing the fire door was discussed with the Regional Director of Operations.

Based on record review and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 2 of 190 days reviewed for RN coverage. Findings: On 7/10/24 a surveyor reviewed the nursing working schedules from 1/1/24-7/8/24 and found that on Sunday 2/4/24 and Friday 7/5/24 the facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours. On 7/10/24 at 10:39 a.m. a surveyor met with the Administrator about the days listed above with no RN on duty.

Based on observation, interview, and facility policy, the facility failed to ensure an outdated vaccine was removed from the supply available for use in medication refrigerator in 1 of 1 medication storage rooms reviewed for 1 of 4 days of survey. Finding: On 7/10/24 at 8:49 a.m., a surveyor observed the medication refrigerator in the medication storage room with Registered Nurse (RN) #2. The Surveyor observed a Covid-19 vaccine with and expiration date of 6/28/24. The RN confirmed the vaccine was expired and disposed of the vaccine immediately. The facilities policy titled Medication Storage Regulation states, .Facility must have a system in place to regularly check the entire Medication Refrigerator for .expired medications which includes the removal of these medications from the regular stock PRIOR to the expiration date .

Based on observation, record review and interview, the facility failed to ensure that the resident's record contained accurate information (#13). Findings: During a medical record review of Resident #13's Treatment Administration Record (TAR) dated [DATE] revealed order with start date of [DATE] to Check [wanderguard] expiration date one time weekly every day shift every Friday for [wanderguard]. Further review of Resident #13's TAR revealed it was checked on [DATE] on 7a-3p shift. Review of Resident #13's care plan updated [DATE] states [Resident #13] is at a High Risk for Elopement r/t wandering risk scale, wandering behavior pattern, attempts at opening doors to outside (Resident #13) demands to be brought to store at times with difficulty redirecting- Wander guard to wheelchair EXP [DATE] ,d+[DATE]I. On [DATE] at 10:01 a.m., a surveyor observed Resident #13's wander guard located under wheelchair to have expiration date of [DATE] ,d+[DATE]. Review of Resident #13's Kardex revealed Wander guard to wheelchair EXP [DATE] [DATE]. During an interview on [DATE] at 10:16 a.m., in presence of 2 surveyors, Licensed Practical Nurse (LPN1) indicated it was nursing's responsibility to check wander guard is working, and to check expiration date. At this time LPN1 confirmed Resident #13's clinical record did not contain accurate information and wander guard is expired. On [DATE] at 11:31 p.m., the above concerns were discussed with Director of Nursing.

Based on interviews and observations, the facility failed to ensure a resident's wheelchair was clean on 2 of 3 survey days (#13). Findings: On 7/08/24 at 7:49 a.m., 7/9/24 at 9:54 a.m., and 7/10/24 at 9:53 a.m., Resident #13 was observed in the hall, sitting in his/her wheelchair. The wheelchair was observed to be soiled on each observation. During an interview on 7/10/24 at 11:21 a.m., Administrator confirmed Resident #13's wheelchair is soiled.

Based on record review and interview, the facility failed to readmit 1 of 1 Resident (#1) back to the facility following a hospital emergency department/hospital visit. Finding: On 1/5/24 the Department of Licensing & Certification received an anonymous complaint indicating on 1/3/24 Resident #1 was transferred to an acute care hospital and the facility refused to take [him/her] back, indicating that it was unclear why the facility would not allow him/her to return to the facility. On 1/17/24 a review of Resident #1's clinical record indicated that Resident #1 was admitted to the facility on [DATE] for rehabilitation after a hospitalization for an ORIF (Open Reduction and Internal Fixation) revision of the left hip. Progress notes dated 1/3/24 9:41 p.m. indicate that Resident #1 requested to be sent to the hospital emergency department for pain in his/her left hip and lower leg. A review Bed Hold/Transfer and Discharge Notification/Authorization dated 1/3/24 signed by the resident and a facility representative indicates the resident was hospitalized per resident request. Mainecare benefit entitles resident to have room [ROOM NUMBER]B held during hospitalization for up to 7 days through date 1/10/24, providing return to the facility is expected and providing we are able to meet the residents' care needs. Arrangements may be made to retain the bed privately should the time exceed 7 days. All eligible Mainecare residents who remain out of the facility beyond the 7 days and who do not retain privately, will be readmitted to the first available semi-private accommodation. On 1/17/24 at 11:15 a.m., during an interview, the Business Office Manager stated that Resident #1 had a managed care insurance when he/she was sent to the hospital emergency department on 1/3/24 and since he/she did not return to the facility the same day (1/3/24) he/she would've needed a new prior authorization to return to the facility. Resident #1 did not have a payment source so the facility was unable to allow the resident to return. The above finding was discussed with the Administrator on 1/17/24 at 11:45 a.m.

Based on observations and interviews, facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use on 2 of 3 units observed (Passport and [NAME]). Findings: 1. On 4/3/23 at 7:52 a.m., observation of the Passport treatment cart with a Licensed Practical Nurse #1, the surveyor noted an opened Lantus insulin pen not labeled with an open or discard date with manufacturer's directions to use within 28 days after initial use. 2. On 4/3/23 at 7:58 a.m., observation of the [NAME] treatment cart with a Licensed Practical Nurse #2, the surveyor noted an opened Novolog insulin vial labeled with an open date of 2/27/23 and manufacturer's directions of should be discard after 28 days after opening. On 4/5/23 at 12:21 p.m., the above concerns were discussed with the Director of Nursing.