How many inspection deficiencies does WINDWARD GARDENS have?

WINDWARD GARDENS has 76 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

Where is WINDWARD GARDENS located?

WINDWARD GARDENS is located in CAMDEN, ME. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does WINDWARD GARDENS have?

WINDWARD GARDENS has 58 certified beds.

Who owns WINDWARD GARDENS?

WINDWARD GARDENS is a for profit - limited liability company facility and is part of the GENESIS HEALTHCARE chain.

What questions should families ask when visiting WINDWARD GARDENS?

Families visiting WINDWARD GARDENS should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does WINDWARD GARDENS compare to other nursing homes?

WINDWARD GARDENS does not have enough inspection data for a CMS star rating yet. This may be a newer facility.

WINDWARD GARDENS

Name: WINDWARD GARDENS
Address: 105 MECHANIC ST, CAMDEN, ME, 04843, US
Telephone: (207) 236-4197
Rating: 3.0

105 MECHANIC ST, CAMDEN, ME 04843 · (207) 236-4197

For profit - Limited Liability company 58 Beds GENESIS HEALTHCARE Data: November 2025

Trust Grade

3/100

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Last Inspection: April 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Windward Gardens has received a Trust Grade of F, indicating significant concerns regarding the quality of care provided, which is poor compared to other facilities. It ranks at the bottom in both the state and county, suggesting there are no better options available in Maine or Knox County. While the facility is improving, having reduced issues from 34 to 22 in the past year, it still has a high staffing turnover rate of 74%, which is concerning as it exceeds the state average. Although there is good RN coverage, more than 87% of Maine facilities, there have been serious incidents, such as a resident falling during a transfer due to insufficient staff assistance, which ultimately contributed to their death. Additionally, there are ongoing concerns about inadequate staffing on weekends and subpar cleanliness, as indicated by multiple deficiencies in housekeeping and maintenance.

Trust Score: F
In Maine: #112/223
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 74% turnover. Very high, 26 points above average. Constant new faces learning your loved one's needs.
Penalties: $7,901 in fines. Higher than 96% of Maine facilities. Major compliance failures.
Skilled Nurses: Each resident gets 70 minutes of Registered Nurse (RN) attention daily — more than 97% of Maine nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations: 76 deficiencies on record. Higher than average. Multiple issues found across inspections.

☆☆☆☆☆

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Overall Rating

☆☆☆☆☆

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Staff Levels

☆☆☆☆☆

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Care Quality

☆☆☆☆☆

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Inspection Score

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Stable

2024: 34 issues

2025: 22 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

Staff Turnover: 74%

27pts above Maine avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $7,901

Below median ($33,413)

Minor penalties assessed

Chain: GENESIS HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is very high (74%)

26 points above Maine average of 48%

The Ugly 76 deficiencies on record

1 actual harm

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to follow provider orders for wound care and failed to follow the facilities Skin Integrity and Wound Management policy for 1 of 2 Residents reviewed for pressure ulcer management. (Resident #310) Findings: The facilities Skin Integrity and Wound Management policy revised 5/1/25 states under Practice Standards, the Licensed nurse will: Evaluate any reported or suspected skin changes or wounds. Document newly identified skin/wound findings and the 24-hour report. Perform and document skin inspections on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition. Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, within unanticipated decline in wounds . Perform daily monitoring of wounds or dressings for presence of complications or declines. Document daily monitoring of ulcer/wound site with or without dressing. Monitor: signs of decline in would status. On 6/10/25, Adult Protective Services notified the Division of Licensing and Certification of the following. [Resident #310] was sent to the emergency room on 6/8/25 for an evaluation and was noted to have pressure sores on his/her heels due to not being moved by facility staff. On 6/17/25 review of Resident #310's medical record, showed he/she was admitted on [DATE] with a nursing admission note stating, resident's right heel was pinkness/boggy and he/she had an open wound dorsal R. foot. Provider orders, dated 5/27/25, instructed nursing to Apply skin prep to bilateral heels and ensure that heels are offloaded. Monitor skin for any changes to skin integrity, everyday shift and Wound Care treatment to the right dorsal/lateral foot. Cleanse with wound cleanser, gently pat dry. Apply calcium alginate to the wound bed only and cover with Kerlix daily and PRN(as needed) until resolved. A wound care consult note, dated 6/4/25 stated under Patient seen for initial evaluation and management of wound as requested by the primary medical team . Wound #1 Right, Dorsal Foot is a chronic [NAME] Grade 2 Diabetic Ulcer and has received a status of Not Healed . Wound #2 Right, Plantar Heel is an acute Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed . Wound #3 Right, Lateral Foot is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Under section Wound Orders instructs nursing staff for the following daily care: Cleanse wound #1, #2 and #3 with a wound cleanser, apply Betadine and leave the wounds open to air/no dressing needed. Review of the Treatment Administration Records (TAR) from 6/4/25 through 6/8/25 revealed nursing failed to initiate the new orders from the wound consult on 6/4/25 and continued with the previous wound care orders. The nursing skilled evaluation notes from 5/21/25 through 6/8/25 lacked evidence of the pressure ulcer change in condition as nursing continued to document the right heel was pinkness/boggy. In addition, the weekly skin checks completed on 5/28/25 and on 6/4/25 stated his/her right heel was pinkness/boggy and lacked a description of the wound on the dorsal right foot. On 6/18/25 at 2:52 p.m., the above was discussed via email with the Clinical Lead Registered nurse.

Apr 2025 10 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on record review, interview and facility policy, the facility failed to ensure the resident's representative was notified timely of a significant change and/or incident for 1 of 3 residents reviewed for falls (Resident #56). Finding: On 2/26/25 the Division of Licensing and Certification received a complaint that after a resident obtained a fall, the family was not notified. On 4/17/25, review of Resident #59's medical record contained an Interdisciplinary Team (IDT) meeting dated 1/23/25 at 12:10 p.m., which stated, family was updated about the recent unwitnessed fall which happened night of 01/22/25. The family mentioned that they were not informed of the fall from last night. Review of the nursing documentation dated 1/22/25 at 7:37 p.m. stated, Called to patient room for fall in the bathroom, observed patient lying on the floor on [his/her] back with pants down below the waist, patient stated [he/she] was going to the bathroom and slipped and fell, no obvious bone deformities, no redness or bruising at this time, c/o low back pain 3/10. Further review of the medical record lacked evidence of the family being notified of the fall until the next day approximately 17 hours later. The facilities Change in Condition: Notification of policy and procedure revised on 7/1/24 states, The center must immediately inform the patient, consult with the patient's' physician, and notify, consistent with the their authority, the patient's representative, when there is: An incident involving the patient which results in injury and has the potential for requiring physician intervention . Purpose: To provide appropriate and timely information about changes relevant to the patient's condition. The facilities Falls Management Policy and Procedure, revised 3/24 states Patients experiencing a fall will receive appropriate care and post fall interventions will be implemented . Post fall management: . The patients representative will be notified of the fall in any follow up treatment noted. On 4/17/25 at 9:29 a.m., the above, the lack of family notification of fall on 1/22/25 until the next day at IDT was discussed with the Market Clinical Advisor.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure that 1 of 3 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #18). Finding: 1. Resident #18 was re-admitted to the facility in May 2024 with diagnoses of generalized anxiety and bipolar disorder. Resident #18's clinical record contained a PASRR Level I Screen, dated 5/22/24, and indicated the screen was for a change in condition and that Resident #18 would reside in the facility for permanent placement (LTC) [Long Term Care]. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed. On 4/15/25 at 11:15 a.m. the above findings were discussed with the Market Clinical Advisor.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 4 of 4 wings (North Wind, Spring Gardens, Windward Center and Penobscot House), the laundry room and a hallway for 2 of 2 facility tours. Findings: 1. On 4/14/25 at 9:05 a.m., a surveyor and the Administrator observed a large open top, wheeled garbage bin outside the facility with trash in it. At this time, the Administrator confirmed the trash storage bin didn't have a cover and the trash was not maintained in a condition to prevent the harborage and feeding of pests. 2. On 4/17/25 from 8:10 a.m. to 8:45 a.m., an Environmental tour was conducted with the Senior Maintenance Director and the Administrator in which the following findings were observed and discussed: Support Service Hallway > The hallway had 2 ceiling tiles that had brown stains on them. Laundry Room > An open window by a washing machine had a screen with a large tear/hole in it. Additionally, the entire floor was soiled and dirty. North Wind > Resident room [ROOM NUMBER] - The bathroom walls were marred with black marks. Both armrests on the resident's wheelchair were ripped/torn. > Resident room [ROOM NUMBER] - The base board heater metal cover was hanging down off the unit. The bathroom wall had chipped/missing paint by the sink. The resident nightstand had missing sealant exposing bare wood. > Resident room [ROOM NUMBER] - The floor was dirty around the base of the toilet and the toilet had liquid around the base. > Resident room [ROOM NUMBER] - There was a wash basin on the bathroom floor under the sink. Spring Gardens > Resident room [ROOM NUMBER]-2 - The bilateral grab bars were very loose on the bed. The sink counter was stained and faded and the front edge and side edge laminate was broken and missing. > A lower cabinet in the kitchenette had a bottom section approximately five inches by two inches of the wooden door and wooden corner that were missing. Windward Center > The Unit entrance doors had chipped/missing paint by the push bars and black marks on the lower sections. > The room entrance door frames, for resident Rooms 201, 202, 203, 204, 205, 206, 207 and 208 had chipped/missing paint creating uncleanable surfaces. > > Resident room [ROOM NUMBER] -The privacy curtain was missing hooks, hanging down and in disrepair. > Resident room [ROOM NUMBER] - The privacy curtain was missing hooks, hanging down and in disrepair. > Resident room [ROOM NUMBER] - The privacy curtain was missing hooks, hanging down and in disrepair. > room [ROOM NUMBER] - The bathroom sink counter was stained and faded and also had chipped/broken laminate on the front left edge. > room [ROOM NUMBER] - The wall above bed B had chipped/peeled paint above the bed. > The sit-to-stand patient lift outside resident room [ROOM NUMBER], had food debris and dirt in the foot base area. Penobscot House > The Unit entrance doors had chipped/missing paint by the push bars and black marks on lower sections. > The wall by the sitting area bookcase was marred with black marks. > Resident room [ROOM NUMBER] - The privacy curtain was missing hooks, hanging down and in disrepair. On 4/17/25 at 8:45 a.m., in an interview, the Senior Maintenance Director and the Administrator confirmed the findings.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on care plan review, observations, interviews, and facility policy, the facility failed to provide a resident with a continuous resident centered activities program. This failure has the potential to affect all residents that would normally participate in activities. Findings: Review of facility policy Recreation Participation Record dated 8/7/23 states Recreation Participation Records: are maintained monthly; Document each person's involvement and response in specific opportunities/experiences in accordance with the person's preferences, interest, routines, and plan of care. Independent, individual, and group recreation participation will be documented on the participation record. the Current participation record will be maintained daily, organized, and easily accessible . 1. Resident #13(R13) was admitted in the fall of 2022 and has diagnoses to include schizoaffective disorder, major depression and is considered bedbound and reliant on staff for activities of daily living. Review of annual Minimum Data Set (MDS), dated [DATE] revealed R13 had a Brief Interview for Mental Status (BIMS) 15 of 15 indicating he/she is cognitively intact. Further review of MDS revealed Section-F: Preferences for Customary Routine and Activities indicated he/she felt it was very important too, keep up with news, attend favorite activities and listen to music he/she likes, and participate in religious services or practices. Review of R13's care plan initiated updated 3/3/25 revealed .While in the facility, [R13] states that it is important . has the opportunity to engage in daily routines that are meaningful relative to [his/her] preferences .I am of the Christian faith and would like to participate in religious services/practices as they become available in the center. Review of Activity Calendar, dated March 2025 revealed the following scheduled activities: BINGO on 3/5/35, 3/8/35, 3/12/25, 3/19/25, 2/22/25, and 3/26/25. Church services were held on 3/2/25, 3/5/35, 3/9/25, 3/19/25, and 3/23/25. Live music was held on 3/21/25. Review of R13's March 2025 activity participation sheet lacked evidence that he/she was invited/refused to go to these activities. Review of April 2025 Activity Calendar dated April 2025 revealed the following scheduled activities: BINGO 4/1/25 and 4/9/25. Live music on 4/2/25, 4/3/25, 4/10/25, and 4/15/25, and church service on 4/6/25. Review of R13's April 2025 activity participation sheet lacked evidence he/she was invited/refused to attend these activities. On 4/9/25 at 10:15 a.m., observation of activity room revealed residents participating in BINGO. During a follow-up interview on 4/9/25, at this time R13 was found in bed and informed a surveyor that he/she was not aware that they were playing BINGO this morning and it would have been nice to know. R13 further stated he/she loves music and is very religious. Observation of R13's room revealed activity calendar posted on closet door, close to room entrance and not in view of R13. During an interview on 4/15/25 at 11:25 a.m., the Activity Director (AD) stated that residents that are bed bound or those that don't enjoy group activities should have a 1:1 at least 2 times a month and should still be invited to activities of choice. At this time AD confirmed that she does not have any documentation that R13 was asked/refused to go to activities or had been offered/refuses 1:1. During an interview on 4/15/25 at 11:45 a.m., Market Clinical Advisor stated that residents should be invited to activities of choice and offers/refusals should be documented daily.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assess and monitor a resident after a fall, and failed to follow their own Fall management and Neurological evaluation policies and procedure by obtaining neurological assessments a resident who has an unwitnessed fall for 1 of 3 residents reviewed for falls. (Resident #18). In addition, the facility failed to ensure a resident received wound care/orders for 1 of 1 residents reviewed for pressure ulcers. (Resident #37). Findings: 1. On 3/16/25 Resident #18 had an unwitnessed fall and was found lying on the floor. The post fall neurological evaluation flow sheet lacked continued neurological assessments with only 3 of the 9 shifts completed for the 72 hour monitoring. On 3/22/25 Resident #18 had an unwitnessed fall and was found on the bathroom floor. The nurses note dated 3/22/25 at 5 a.m., stated, per patient he/she hit the post auricular area [behind the ear] on the right, no c/o (complaint) pain at this time, small raised bump on the right post auricular . Further review of the post fall neurological evaluation flow sheet lacked continued neurological assessments after the first 2 hours and only 3 of the 9 shifts completed for the 72 hour monitoring. The facilities Falls Management Policy and Procedure, revised 3/24 states Patients experiencing a fall will receive appropriate care and post fall interventions will be implemented . Post fall management: . any patient who sustains an injury to the head from a fall and or has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check, per policy . The facilities Neurological Evaluations policy and procedure, reviewed on 2/23 states, Neurological evaluation will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed: Every 15 minutes x (times) two hours, then every 30 minutes for 2 hours, then every 60 minutes x four hours, then every eight hours until at least 72 hours has elapsed. On 4/17/25 at 8:16 a.m., the above was confirmed with the Market Clinical Advisor. 2. On 4/14/25 the Department of Licensing received a complaint stating the facility failed to provide wound care for Resident #37's pressure ulcers. Resident #37 has diagnoses to include and diabetic ulcers on his/her bilateral feet, congestive heart failure, Diabetes type II and tinea cruis (imbedded penis) requiring an indwelling foley catheter. Review of Resident #37's admission: After Hours Telehealth Consult dated 3/7/25 lacked evidence that wound orders were addressed/obtained for Resident #37 upon admission. Review of Resident #37 After Hours Telehealth Consult dated 3/8/25 states History of Present Illness: CHIEF COMPLAINT: . 2. Wound management .HPI TODAY: 03/08/2025: ASSESSMENT AND PLAN: presenting with fluid overload, now stable. 1. Fluid Overload - Assessment: SHORT SUMMARY: .wound management, and strengthening Further review of Resident #37's clinical record lacked evidence that wound care orders were obtained. Review of Resident #37's care plan initiated 3/7/25 states Resident at risk for skin breakdown related to fragile skin and decreased mobility. Diabetic ulcer to Left 5th toe, Right foot, Left 1st Halux, DTI to Left heel.:. INTERVENTION : Provide wound treatment as ordered for Management of Pressure Ulcer : Wound Will Show Signs of Improvement INTERVENTION: Provide wound care per treatment order. Review of Resident #37's [ Hospital] Wound Care note dated 2/27/25 (8 days prior to his/her admission) states Reason for consult: bilateral feet diabetic ulcers. Recommendations: Continue plan of care as follows: Dressing change to bilateral foot ulcers every 2 days. 1. Cleanse with 1/40 strength Dakin's 5-minute soak (document in MAR), pat dry. 2. Protect peri-wound skin with Skin Prep 3. Tear off just enough Promogran Prisma (or equivalent antimicrobial collagen dressing) to cover wound base, press gently to make good contact with tissue. 4. cover with Mepilex Border (or equiv) reinforced with stretch netting. 5. Offload with Heel Medix foam boots in bed or modified footwear when OOB, minimize weight bearing. Return visit to wound clinic should be rescheduled within 2-3 weeks of discharge. Review of Resident #37s' clinical record lacked evidence that the above wound orders were implemented/ or new one obtained. Further review lacked evidence Resident #37 was taken to this follow-up wound care appointment. Review of Resident #37'sclinical record revealed order with start date of 3/20/25 for Wound care to bilateral foot ulcers:1. Cleanse with 1/40 strength Dakins 5-minute soak, pat dry 2. Protect peri wound skin with skin prep. 3. Tear off just enough [promogran prisma[ ( or equivalent antimicrobial collagen dressing) to cover wound base, press gently to make good contact with tissue. 4. Cover with mepilex border (or equivalent). Reinforce with stretch netting. 5. Offload with heel medix foam boots in bed or modified footwear when OOB(out of bed), minimize weight bearing. one time a day every other day for wound care. (Order obtained 13 days after admission). During an interview on 4/17/25 at 9:05 am. (Doctor) reviewed Resident #37's clinical record and confirmed he/she was admitted on [DATE], but did not receive wound care orders until 3/20/25. Further review of Resident #37's After Hours Telehealth Consult dated 3/7/25 states Chief complaint: fluid overload. Currently on 2L fluid restriction . Assessment/Plan: 1. Fluid overload: Daily weights ordered for monitoring. 3. Congestive heart failure: Continue fluid restriction to 2L(liters) daily weights for monitoring. there is no order/mention of Resident #37's indwelling catheter. Review of Resident #37's output measured lacked evidence this was completed on the evening shift on 3/22/25, 3/26/25, 4/4/25, 4/5/25, 4/7/25, 4/9/25, or 4/11/25. During the day shift on 3/26/25, 3/27/25, 3/28/25, 3/29/25, 3/31/25, 4/7/25, 4/9/25, or 4/11/25. and during the overnight shift on 3/22/25, 3/26/25, 4/4/25, 4/9/25, or 4/11/25. Review of Resident #37's care plan updated 3/18/25 states: Resident requires indwelling foley catheter due to Tinea Cruis: imbedded penis: Goal: Resident will have no signs and symptoms of urinary tract infection x 30 days. Interventions: Record output . Catheter care twice a day and PRN, monitor urine for sediment, cloudy, odor, blood and amount . Review of Resident #37's clinical record lacked evidence that this was done. During an interview on 4/17/25 at approximately 9:13 a.m., the Clinical Market Advisor confirmed above concerns.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 by ensuring room, closet and bathroom doors had laminate that was not gouged and splintered creating sharp edges on 2 of 4 units(North Wind and Windward Center) for 2 of 2 environmental tours (4/14/25 and 4/16/25). In addition, the facility failed to store oxygen tanks securely for 1 of 4 days. Findings: 1. On 4/14/25 at 8:10 a.m., 3 surveyors observed the following chemicals in the unlocked office on the Administrative wing which residents had access to. The Administrative unit is separated from the Windward Center unit by unlocked double doors that residents can access and get through. On 4/14/25, Resident #51 was observed on the administrative unit by a surveyor. - Poopsy [NAME] Pre-Toilet Spray/ 2 ounces bottle - Febreze Air Freshener/ 8.8-ounce bottle - Purell Hand Sanitizer/ 20-ounce bottle The Safety Data Sheet for Poopsy [NAME] Pre-Toilet Spray noted the following: 4. First Aid Measures: Eye Contact: immediately flush eyes with plenty of water, occasionally lifting the upper and lower eyelids. Check four and remove any contact lenses. Continue to rinse for at least 10 minutes. Get medical attention. Skin Contact: Flush contaminated skin with plenty of water. Remove contaminated clothing and shoes. Continue to rinse for at least 10 minutes. Get medical attention. Wash clothing before reuse. Clean shoes thoroughly before reuse. Inhalation: Remove victim to fresh air and keep at rest in a position comfortable for breathing. If not breathing, if breathing is irregular or if respiratory arrest occurs, provide artificial respiration or oxygen by a trained professional. May be dangerous to the person providing aid to give mouth to mouth resuscitation. Get medical attention if adverse health effects persist or are severe. If unconscious, place in recovery position and get medical attention immediately. Maintain an open airway. Loosen tight clothing such as a collar, tie, belt or waistband. Ingestion: Wash out mouth with water. Remove dentures if any. Remove victim to fresh air and keep at rest in a position comfortable for breathing. If material has been swallowed and the exposed person is conscious, give small quantities of water to drink. Stop if the exposed person feel sick as vomiting may be dangerous. Do not induce vomiting unless directed to do so by medical personnel. If vomiting occurs, the head should be kept low so that the vomit does not enter the lungs. Get medical attention if adverse health effects persist or are severe. Never give anything by mouth to an unconscious person. If unconscious, place in recovery position and get medical attention immediately. Maintain an open airway. Loosen tight clothing such as a collar, tie, belt or waistband. The Safety Data Sheet for Febreze Air Freshener noted the following: 4. First Aid Measures: Eye Contact: Rinse with plenty of water. Get medical attention immediately if irritation persists. Skin Contact: Rinse with plenty of water. Get medical attention if irritation develops and persists. Inhalation: Move to fresh air. If symptoms persist, call a physician. Ingestion: Drink one or two glasses of water. Do not induce vomiting. Get medical attention immediately if symptoms occur. The Safety Data Sheet for Purell Hand Sanitizer noted the following: 4. First Aid Measures: Eye Contact: In case of contact, immediately flush eyes with plenty of water for at least 15 minutes. If easy to do, remove contact lenses, if worn. Seek medical advice. Skin Contact: Wash with water and soap as a precaution. Get medical attention if irritation develops and persists. Inhalation: If inhaled, remove to fresh air. If symptoms persist, call a physician. Ingestion: If swallowed, do not induce vomiting. Rinse mouth with water. Obtain medical attention. On 4/14/25 at 10:50 a.m., in an interview, the Clinical Lead of Maine confirmed that the chemicals were not secured on the administrative wing and the resident had access to them. On 4/14/25 at 3:15 p.m.in an interview, a surveyor discussed the findings with the Clinical Market Advisor. 2. On 4/14/25, from 9:45 a.m. to 10:23 a.m., a surveyor observed the following on the North Wind Unit > The hallway closet door across from soiled utility room had chipped/splintered laminate by the handle and down the edge that was sharp, creating a hazardous and unsafe environment. > Resident room [ROOM NUMBER] - The bathroom door had chipped/splintered laminate along the edge and front that was sharp, creating a hazardous and unsafe environment. Additionally, the toilet was loose and not secured to the floor. > Resident room [ROOM NUMBER] - The bathroom door had chipped/splintered laminate that was sharp, creating a hazardous and unsafe environment. > > Resident room [ROOM NUMBER] - The bathroom door, inside, has chipped/splintered laminate that was sharp, creating hazardous and unsafe environment. > room [ROOM NUMBER]- The bathroom had a 32.5-ounce container of Oxi Clean Plus laundry detergent stored on the floor, creating a hazardous and unsafe environment. The Safety Data Sheet for Arm & Hammer Oxi Clean Plus laundry detergent noted the following: 4. First Aid Measures: Eye Contact: immediately rinsed with water for at least 15 minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Obtain medical attention. Skin Contact: Remove contaminated clothing. Wash affected area with soap and water for at least 15 minutes. Obtain medical attention if irritation/rash develops or persists. Inhalation: When symptoms occur: go into open air and ventilate suspected area. Obtain medical attention if breathing difficulty persists. Ingestion: Rinse mouth. Do not induce vomiting. Obtain medical attention. > Resident room [ROOM NUMBER] - The bathroom door had chipped/splinter laminate that was sharp, creating a hazardous and unsafe environment. > Resident room [ROOM NUMBER] - The bathroom door had chipped/splintered laminate that was sharp, creating a hazardous and unsafe environment. On 4/14/25 at 10:25 a.m., in an interview, the Administrator and the Senior Maintenance Director confirmed these findings created hazardous and unsafe environments and were accident hazards. 3. Windward Center > On 4/16/25 at 11:00 a.m., a surveyor observed in Resident room [ROOM NUMBER] that the room entrance door and the bathroom door had chipped/splintered laminate that was sharp and created a hazardous and unsafe environment. On 4/16/25 at 11:05 a.m., in an interview and observation, the Administrator confirmed the findings. 4. On 4/14/25 at 9:05 a.m., Resident #53 was observed seated in his/her wheelchair at a table in the [NAME] Center Unit dining room, and Licensed Practical Nurse (LPN) was observed removing Resident #53's oxygen tank from the holder located on the back of his/her wheelchair and then placed the unsecured oxygen tank (not in a portable cart) on the floor behind Resident #53's wheelchair and instructed him/her to not forget that the oxygen tank was behind him/her. 5. On 4/14/25 at 9:47 a.m., during an observation of room [ROOM NUMBER], an unsecured oxygen tank was observed standing upright against the wall next to the closet. On 4/14/25 at 9:50 a.m., during an interview, LPN stated oxygen tanks should not be left unsecured and that empty oxygen tanks should be stored in the storage closet. At this time, the Assistant Director of Nursing was observed removing the oxygen tank from room [ROOM NUMBER]. On 4/14/25 at 10:50 a.m. the above findings were discussed with the Clinical Lead.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and review of the Food Storage policy (dated 2013), the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a hood system, a fan, ceiling lights, ceiling tiles, ceiling vents, floors, a chemical hose, a food slicer and an exit door. Additionally, the facility failed to ensure that foods in the walk-in freezer were sealed, dated and labeled. Findings: On 4/14/25 from 8:15 a.m. to 9:00 a.m., during an initial kitchen tour, the following findings were observed and discussed with the Head [NAME] and Kitchen aide: > The hood over the dish washing machine was dusty and had rust build-up in it. > The dish room had a wall mounted fan, a ceiling vent and an entire ceiling grid system that was dusty/dirty. > There were 2 ceiling lights in the dish room that had dirt/debris in the lenses. > The floor in front of the dish machine had an approximately 2-foot by 2-foot section of laminate missing which exposed untreated cement. > The 3-bay pot sink had a long chemical hose hanging down inside the center bay. > The kitchen hallway had 2 ceiling tiles that had brown stains on them. > There were 2 kitchen ceiling vents that were heavily soiled with dust/dirt. > The food slicer had dried food particles on the blade and the shroud. > The cement floor in front of the stove had chipped/missing paint creating an uncleanable surface. > The walk-in freezer had a package of fish patties and a previously opened and unsecured/open bag of pizza crusts that were not labeled and dated. Additionally, there was trash and debris all over the floor. > One kitchen exit door had chipped/missing paint creating an uncleanable surface. > The kitchen office was missing 9 ceiling tiles. On 4/14/25 at 9:00 a.m., in an interview, the Head [NAME] and the Kitchen aide confirmed the findings. On 4/16/25 at 9:08 a.m., in an interview, the surveyor discussed the findings with the Food Service Director.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #258 was admitted 1/2025 with diagnoses to include severe vascular dementia, protein calorie malnutrition, and had a history of frequent falls. Review of Provider note dated [DATE] states: ASSESSMENT/PLAN: Sepsis/Encephalopathy- pt is poorly responsive? behavioral. Not eating and drinking some. Will .discuss goals of care with family. Further review of Resident #258's clinical record lacked evidence the family was contacted to discuss goals of care. During an interview on [DATE] at 5:15 p.m., discussed with Administrator and Market Director there was no evidence provider contacted family after [DATE] visit. Review of Resident #258's clinical record revealed progress note dated [DATE] at 9:58 a.m., states CNA found resident lying on the floor mat near [his/her] bed .neuros [neurological] initiated . Further review of R258's clinical record lacked evidence that neuro checks were done after this fall. During an interview on [DATE] at 2:35 p.m., Clinical Marketing Director (CMD) stated that after every unwitnessed fall, neuro checks have to be completed and documented in the clinical record. At this time CMD confirmed there was no evidence that neuro checks were completed after Resident #258's fall. 3. Resident #37 was admitted 3/2025 and has diagnoses to include congestive heart failure (CHF) with fluid overload, and tinea cruis (imbedded penis) requirring an indwelling foley cathether. Review of Resident #37 provider orders revealed order with start date of [DATE] for Weight in the morning for CHF. Notify the provider if gain>2 lbs in 1 day, or 5 lb in a week. Review of Resident #37's clinical record lacked evidence weights were obtained/offered and refused on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] or [DATE]. Review of Resident #37's After Hours Telehealth Consult dated [DATE] states Chief complaitn: fluid overload Currently on 2L (Liter) fluid restriction . Assessment/Plan: 1. Fluid overload: Daily weights ordered for monitoring. 3. Congestive heart failure: Continue fluid restriction to 2L Daily weights for monitoring. Review of Resident #37's care plan updated [DATE] states: Resident requires indwelling foley catheter due to Tinea Cruis: imbedded penis: Goal: Resient will have no signs and symptoms of urinary tract infection x 30 days. Interventions: Record output Catheter care twice a day and PRN, monitor urine for sediment, cloudy, odor, blood and amount . Review of Resident #37's clinical record lacked evidence this was done. Review of Resident #37's output measured lacked evidence this was completed on the evening shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. During the day shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. and during the overnight shift on [DATE], [DATE], [DATE], [DATE], or [DATE]. During an interview on [DATE] at 9:10 a.m., Nurse Practitioner stated Resident #37 was on daily weights and she had to tell staff to do them often. During an interview on [DATE] at 9:30 a.m., Clinical Market Advisor confirmed daily weights were not completed for Resident #37. Based on record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for palliative care/hospice (Resident #308), falls for 1 of 1 (Resident #258), and weights/catheter care and Activities of Daily Living (ADL) documentation for 1 of 9 resident's reviewed for a complaint (Resident #37). Findings: 1. Resident #308 was recently admitted with diagnoses to include severe protein calorie malnutrition and adult failure to thrive. Review of Resident #308's hospital discharge summary revealed, .Specialist appointment .Palliative care in 2 weeks . Review of Resident #308's clinical record revealed the following physician progress notes: -progress note, dated [DATE] states, . has been having weight loss and decreased appetite .A palliative care consult was obtained .determined with [his/her] son that [he/she] would be evaluated for possible Hospice therapy .Long conversation with family and will proceed with hospice consult. -progress note, dated [DATE], states, .Failure to thrive--been progressive. Goals of care was discussed by admitting physician with son .Agreement that quality of life is poor. hospice consult pending . -progress note, dated [DATE], states, .Goals of care-- was discussed .upon admission with son. Agreement that quality of life is poor. hospice consult pending will f/u [follow up] on this today . Review of Social Services progress note, dated [DATE] revealed, Spoke with [son] and updated on the care plan meeting and progress . We discussed Palliative Care referral and he agreed with this . Further review of Resident #308's clinical record lacked evidence that a palliative consult had been obtained or that a hospice consult had been ordered/obtained. On [DATE] at 9:41 a.m., during an interview, the Director of Social Services stated Resident #308 was receiving skilled services since admission and could not receive skilled services and hospice at the same time and that the hospital mentioned palliative in the discharge summary, but she is not sure if the referral was made. The Director of Social Services then stated she wanted to make the referral to palliative and hospice services but that Resident #308's condition changed quickly yesterday and he/she died yesterday afternoon, so the referral was not made. On [DATE] at approximately 10:15 a.m. during an interview, the Nurse Practitioner (NP) stated when she refers a resident for a palliative or hospice services, the decision is a team effort and that Resident #308 was still participating in physical therapy, so she intended to order the hospice evaluation once Resident #308 completed skilled services and that palliative consult obtained and hospice consult pending in her progress note meant that Resident #308 would be referred to palliative and hospice once skilled services were complete. At this time, the NP stated she should have worded her progress note to indicate this. On [DATE] at 10:45 a.m., the above finding was discussed with the Market Clinical Advisor.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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Based on record review, interview and Payroll Based Journal Report (PPJ), the facility failed to ensure it was sufficiently staffed on weekends for 1 of 1 quarter reviewed (10/1/24 through 12/31/24/ [39 days]). Findings: Review of Center for Medicare & Medicaid (CMS)PPJ Report revealed the facility triggered for low weekend staffing during the first quarter (10/1/24 through 12/31/24). During a review of first quarter weekend staffing with Administrator and Scheduler on 4/17/25 at 12:27 p.m., the Administrator confirmed the facility was not adequately staffed for 32 of 39 days reviewed.

MINOR (B)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

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Based on observation and interview, the facility failed to post the nurse staffing information in a prominent place, readily accessible and visible to all residents, for 3 days.( 4/12/25 , 4/13/25 and 4/14/25). Finding: On 4/14/25 at 8:00 a.m., 3 surveyors observed that the nurse staffing information posted in an area visible to residents and visitors was dated 4/11/25 (Friday). On 4/15/25 at 2:46 p.m., in an interview, the Market Clinical Advisor confirmed that the nurse staffing information was not posted on (Saturday- 4/12/25 , Sunday-4/13/25 and Monday-4/14/25).

Feb 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to review, revise and update a care plan for a newly discovered pressure ulcer for 1 of 1 resident reviewed for pressure ulcer (Resident #1 [R1]). Finding: On 2/19/25, R1's clinical record was reviewed. Documentation indicated that R1 had an admission care plan (dated 12/19/24) for at risk of skin breakdown. On 1/15/25, the resident was diagnosed with a Stage 3 pressure ulcer on the sacrum. there was no evidence that the care plan was updated to reflect the new skin care needs. On 2/19/25 at 12:30 p.m., this was confirmed with the Director of Nursing and Marketing Clinical Advisor.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure that a physician order for a wound clinic consultation was followed for 1 of 1 resident reviewed for pressure ulcer (Resident #1 [R1]). Finding: On 2/19/25, a review of R1's clinical record was completed. Documentation indicated that on 1/15/25, the resident had a Stage 3 pressure ulcer on the sacrum. On 1/16/25, the resident was sent to the hospital emergency department (ED) for an evaluation of lightheadedness. R1 returned to the facility with ED instructions for a referral to the hospital wound clinic. On 1/17/25, R1's primary physician signed the orders and the facility nurse noted the order. On 2/19/25 at 12:22 p.m., in an interview with the surveyor, the Licensed Practical Nurse-Nurse Manager confirmed that the order for a wound clinic referral was not done.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders (block orders) in a timely manner for 1 of 1 resident reviewed (Residents #1 [R1]). Finding: On 02/19/25, R1's clinical record was reviewed and included block orders (30 day) signed by the physician on 12/10/24. The next block order, including a 10-day grace period, needed review and the Physician's signature by 1/20/25; there are no further visits from the physician. On 2/19/25 at 2:50 p.m., in an interview with the surveyor, the Marketing Clinical Advisor confirmed that the last block order was signed on 12/10/24, making them 8 days late at the time of R1's discharge from the facility.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to ensure the attending physician made required visits, at least every 30 or every 60 days (depending on date of admission) and wrote a progress note for 1 of 1 sampled residents (Resident #1 [R1,]. Findings: On 2/19/25, a review of R1's clinical record indicated that R1 was admitted on [DATE] and had a physician visit on 12/10/24. The next 30 day physician visit, including a 10-day grace period, which needed a review and written progress note was due on 1/20/25; there are no further visits from the physician. On 2/19/25 at 2:50 p.m., in an interview with the surveyor, the Marketing Clinical Advisor confirmed that the last visit was on 12/10/24, making the review and progress note 8 days late at the time of R1's discharge from the facility.

Jan 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to notify the resident's representative (Resident #1 [R1]) of a fall with fracture. Finding: On 1/22/25, a review of R1's clinical record was completed. A nurse's note dated 12/23/24, indicated R1 had a fall and complained of right shoulder pain. A medical provider note dated 12/23/24, indicated that x-rays were order. A Radiology Report dated 12/24/24, indicated R1 sustained an acute right humeral neck fracture from the fall. There as no evidence to indicate that the resident's representative was immediately notified of the fall and fracture. On 1/22/25 at 3:00 p.m., in an interview with the surveyor, the Administrator stated he was unable to locate evidence that R1's representative was promptly notified of the fractured humerus.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure that a care plan was developed for a change in a resident's condition-fractured right humerus for 1 of 1 resident reviewed for a fracture. (Resident #1 [R1]) Finding: On 1/22/25, a review of R1's clinical record was completed. A nurse's note dated 12/23/24, indicated R1 had a fall and complained of right shoulder pain. A medical provider note dated 12/23/24, indicated that x-rays were order. A Radiology Report dated 12/24/24, indicated R1 sustained an acute right humeral neck fracture. A review of R1's care plan indicated there was no evidence that from 12/24/24 through to 1/19/25 (when R1 was discharged from the facility) a care plan was developed with interventions that would guide staff in the care of the fractured humerus and R1's decreased functional ability to use his/her upper extremity. On 1/22/25 at 3:00 p.m., in an interview with the surveyor, the Administrator confirmed there was no care plan problem or interventions that addressed R1's fractured arm.

Jan 2025 5 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician of significant change in condition when a resident was noted to have a change in meal intakes and significant weight loss for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Findings: Review of policy Change of Condition dated 7/1/24 states A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: .A significant change in patient's physical mental, or psychosocial status (that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). A need to alter treatment significantly (that is, a need to discontinue or change and existing form of treatment due to adverse consequences, or to commence a new forma of treatment) . Resident #1 was admitted on [DATE] and has diagnoses to include recent Urinary tract infection, congestive heart failure, dementia, severe anxiety, and delirium. Review of Resident #1's provider orders revealed order with start date of 12/18/24 for Weight: Daily for Congestive Heart Failure. Review of Resident #1's documented weights between 12/18/24 through 12/30/24 (13 days) revealed daily weights were only obtained 3 times during this stay. Review of Resident #1's Weights revealed admission weight dated 12/18/24 for 188.4 lbs., on 12/25/24 weighed 167.6 pounds, and on 12/28/24 weighted 165.4 pounds, indicating a 23 pound weight loss. (12.20% weight loss). Further review of Resident #1's clinical record lacked evidence a provider was notified of this significant weight change. Review of Resident #1's meal intakes between 12/18/24 and 12/19/24 revealed he/she ate 50% of breakfast and lunch, no documented intake for diner, 12/20/24 25 % of breakfasts and 50% of lunch and dinner, on 12/21/24 consumed 0% of breakfast, and 25% of lunch. There is no documented intake for diner. 12/22/24. 12/22/24 consumed 0% of breakfast and lunch and there are no documented intakes for diner. Review of Resident #1's clinical record lacked evidence that a provider was notified of the above concerns. Review of Resident #1's Review of Resident # 1's Nutritional assessment dated [DATE] states: Person completing the assessment is: Dietitian: .Most recent weigh 167.6 on 12/25/24; BMI: 32.7. admitted for continuing care. hospitalized with UTI, spinal stenosis, heart failure, anxiety, depression medical history. Per hospital notes + for appetite change . States her [ mother/father] likes most foods, denied any food dislikes. Recorded weights 12/18-188.4# 12/15-167.6 40 mg Lasix started on 12/19. Weight status: Resident has significant/severe loss/gain: [blank]; Resident has a weight loss/gain trend: [blank]; Resident BMI is less than 19 or equal to or greater than 25: yes; Intake: Most meals since admission</= 50% Dependent for feeding. Resident intake meeting needs compared to calculated needs: no; Evaluation/Nutrition Plan: [blank]; Is there a nutrition problem: yes, Nutrition Prescription: House shakes BID liquid protein x 1 /day . Further review of Resident #1's clinical record lacked evidence the Dietitian consulted with medical provider regarding the above concerns. Review of provided Provider Communication: dated 12/21/24 states Daughter is mildly concerned about patients' drowsiness. Patient didn't eat [his/her] breakfast and was sleepy most of the time: Review of Resident #1's After Hours Telehealth Consult dated 12/28/24 at 00:00 states Fall/agitation . Daughter concerned about intake: Daughter concerned that patient has not been eating or drinking. She is agitated and refusing fluids . Further review of Resident #1's entire clinical record lacked evidence that a provider was notified of these ongoing nutritional concerns until 12/28/24. During an interview with 2 surveyors on 1/2/25 at 12:01 p.m., Medical Doctor (MD) indicated it is his expectation that the provider be notified is a resident has not been eating appropriately as soon as possible. And would expect to be notified within 24-48 hours if someone isn't getting weights as ordered. At this time MD indicated he was only notified that Resident #1 had missed 1 meal when first admitted but had not been made aware of any further nutrition concerns, nor had he been made aware of any weight loss. During an interview on 1/2/24 at 2:28 p.m., Unit Manager (UM)1 indicated that the provider should be notified when a resident has weight loss or has not been eating well. During an interview on 1/2/24 at 1:08 p.m., Nurse Practitioner (NP) indicated that she had not been made aware of Resident 1's lack of nutrition intake or weight loss. During a telephone interview with 2 surveyors on 1/3/24 at 2:27 p.m., Registered Dietitian (RD) RD indicated the facility had not notified her that Resident #1 has not been eating adequately and wasn't receiving daily weights until she reviewed the clinical record on 12/25/24 and 12/26/24. RD further indicated she ordered a supplement, but did not notify a medical provider of the above concerns. During an interview with 2 surveyors on 1/3/24 at 2:26 p.m., the above was discussed with Director of Nursing.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Findings: Review of policy Person-Centered Care Plan dated 10/24/22 states .The Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident that includes the instructions needed to provide effective and person-centered care that meet professional instructions needed to provide effective and person-centered care that meet professional standards of quality care. a baseline care plan must be developed within 48 hours and include the minimum healthcare information necessary to properly care for a patient including, but not limited to: initial goals based on admission orders; physician orders; dietary orders; therapy services; social services; PASRR recommendation, if applicable . Resident#1 was admitted on [DATE] for skilled care services and has diagnoses to include heart failure. Review of Resident #1's provider orders revealed the following orders: -Order with start date of 12/19/24 for Furosemide Oral Tablet 40 MG (Furosemide) Give 40 mg orally one time a day for fluid overload. Review of Resident #1's baseline care plan dated 12/18/24 lacked evidence of goal and interventions in the areas of nutrition, or use of diuretic medications on admission. During an interview on 1/2/24 at 2:26 p.m., Director of Nursing (DON) indicated that it was her expectation that baseline care plans were completed within 48 hours of admission. At this time DON reviewed Resident 1's care plan and confirmed it did not contain goals and interventions for the above concerns.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility policy, the facility failed to follow-up on significant weight loss, and reduced meal intake for 1 of 3 residents reviewed during a compliant investigation (Resident #1). Findings: Review of policy Nutrition/Hydration Care and Services dated 2/1/23 states .Staff will provide nutritional and hydration care and services to each patient, consistent with the patient's comprehensive assessment . Use the Diet Order and Communication Form to initiate consult with Dietitian, when indicated. Obtain orders per recommendations. Contact physician/advanced practice provider (APP) to convey the recommendations. Develop .Plan of care for enhancing oral intake, promoting adequate nutrition and hydration, and identifying individualized goals, preferences, and choices. Maintain fluid and hydration balance. Monitor patient's weight as ordered . Address any changes in condition that affect or potentially affect the patient's nutritional status with Dietitian and physician/APP . Review Dietitian's progress notes to identify ongoing progress and recommendations. Resident #1 was admitted on [DATE] for skilled care services and had diagnoses to include recent history of urinary tract infection, congestive heart failure (CHF), severe anxiety, depression, and delirium. Review of Resident #1's Weights revealed admission weight, dated 12/18/24 for 188.4 lbs., on 12/25/24 weighed 167.6 pounds, and on 12/28/24 weighted 165.4 pounds, indicating a 23 pound weight loss. (12.20% weight loss). Review of Resident #1's Meal Intakes revealed he/she consumed 25% for 8 of 25 documented meals, and 6 of 25 documented meal intakes of 0%. Review of Resident #1's clinical record revealed Resident #1 was seen by a provider on 12/19/24,12/20/24, and 12/26/24. There is no evidence that weight loss or nutrition concerns were addressed during these visits. Review of Resident #1's clinical record reveled admission Dietary Screening for Malnutrition: At Risk for Malnutrition, Morbid Obesity was not completed until 12/25/24 (7 days after admission). Review of Resident #1's Nutritional assessment dated [DATE] states: Person completing the assessment is: Dietitian: .Most recent weigh 167.6 on 12/25/24; BMI: 32.7. admitted for continuing care . Per hospital notes + for appetite change . likes most foods, denied any food dislikes. Recorded weights 12/18-188.4# 12/15-167.6 40 mg Lasix started on 12/19. Weight status: Resident has significant/severe loss/gain: [blank]; Resident has a weight loss/gain trend: [blank]; Resident BMI is less than 19 or equal to or greater than 25: yes; Intake: Most meals since admission</= 50% Dependent for feeding. Resident intake meeting needs compared to calculated needs: no; Evaluation/Nutrition Plan: [blank]; Is there a nutrition problem: yes, Nutrition Prescription: House shakes BID liquid protein x 1 /day . Further review of Resident #1's clinical record lacked evidence the Dietitian consulted with medical provider regarding the above concerns. During an interview with 2 surveyors on 1/2/25 at 12:03 p.m. Medical Doctor (MD) indicted it is his expectation that all residents have a nutrition evaluation completed on admission, a nutrition care plan is established upon admission and he or another provider should be notified of any change in condition, weight loss/gain or lack of food/fluid intake sooner than later. As far as he can recall has only been notified of one missed meal. During an interview with 2 surveyors on 1/2/24 at 1:08 p.m., Nurse Practitioner (NP) indicated she had not been made aware of Resident 1's lack of nutrition intake or weight loss. During a telephone interview on 1/3/24 at 2:27 p.m., Registered Dietitian (RD) indicated that all residents should be seen as soon as possible by the dietary department upon admission and the nutrition care plan should be initiated at that time. At this time, Dietitian confirmed she was not aware of Resident #1's possible weight loss, or decreased meal intake until she did the initial record review on 12/25/24. RN further indicated she did not consult/notify provider of the above concerns. At this time RD confirmed above findings. During an interview with 2 surveyors on 1/3/24 at 2:43 p.m., the above was discussed with Director of Nursing. During a telephone interview on 1/7/25 at 3:15 p.m., emergency room Doctor ([NAME]): stated Resident #1 presented to Emergency Department on 12/30/34 in a near death state. His/her blood pressure was 50/20, was hypotensive, gray, ashen and cold to touch. He/she was barely responsive. Resident #1's family member notified him of what medication he/she had been receiving and after a couple of doses of Narcan, Resident #1 became responsive and kept asking for water over and over again. Resident #1's blood work suggested profound dehydration, severe enough that she was in renal failure with multi system organ failures. After receiving multiple liters of fluid, his/her labs did start to improve, but due to the damage that had already been made, the discussion was made with daughter, to put /him her on comfort care. [NAME] indicted he noticed Resident #1 had a fentanyl patch on upon arrival and stated when someone is in renal failure the body stops metabolizing the fentanyl and it keeps building up because the kidneys aren't working and can't flush it out. States Resident #1 essentially died from dehydration, which could have been prevented .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy, the facility failed to monitor for side effects of psychotropic medications for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Findings: Review of policy Medication Monitoring/Medication Management dated 1/24 states .When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications as well as look for potential adverse consequences . Resident #1 was admitted on [DATE] for skilled care services and had diagnoses to include severe anxiety, depression, and delirium. Review of Resident #1's care plan initiated on 12/19/24 states Resident is at risk for complications related to the use of psychotropic drugs : antipsychotic, anxiolytics, antianxiety Goal: Resident will have the smallest most effective dose without side effects throughout review period Intervention: .monitor for changes in mental status and functional level and report to MD as indicated. Review of active orders for December 2024 revealed the following: -Order with start date of 12/18/24 for anti-anxiety medication Buspirone HCL oral tablet 5 mg (Buspirone HCL) Give 5 mg orally three times a day for depression. -Order with start date of 12/19/24 for anti-anxiety medication Duloxetine HCL Oral Capsule Delayed Release Particles 20 mg (Duloxetine HCL) Give 40 mg orally one time a day for anxiety. -Order with start date of 12/19/24 for anti-anxiety medication Hydroxyzine HCL Oral Syrup 10 mg/5ml (Hydroxyzine HCL) Give 5 ml orally three times a day for anxiety- hold for sedation, notify provider. -Order with start date of 12/20/24 for anti-anxiety medication Lorazepam Oral concentrate 2 mg/ml (Lorazepam) Give 0.5 ml by mouth every 4 hours as needed for agitation. -Order with start date of 12/21/24 for anti-anxiety medication Lorazepam Oral concentrate 2 mg/ml (Lorazepam) give 0.5 ml by mouth two times a day for agitation. Lorazepam 1mg. -Order with start date of 12/19/24 for antianxiety medication Duloxetine HCL Oral Capsule Delayed Release Particles 20 mg (Duloxetine HCL) Give 40 mg orally one time a day for anxiety. -Order with start date of 12/19/24, 12/20/24, 12/23/24, and 12/26/24 for antipsychotic medication Olanzapine 2.5 mg tablet. Give 1 tablet twice daily for agitation. -Order with Start date of 12/18/24 Is resident free from side effects of psychotherapeutic medications?(if no, document side effects in [PN]Provider note) two times a day Review of Resident #1's entire clinical record lacked evidence he/she was monitored for side effects for the above medications. During an interview with 2 surveyors on 1/2/23 at 2:28 p.m., the Director of Nursing reviewed Resident 1's entire clinical record and confirmed Resident #1 was not being monitored for side effects of psychotropic medications.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information in the area of weights for 2 of 3 Residents (Resident #1, and #2), meal intakes for 3 of 3 Residents (Resident's #1, #2, and #3), palliative care for 1 of 3 Residents (Resident #1), falls for 1 of 1 Resident (Resident #1), and positioning for 1 of 1 Resident (Resident #2) reviewed during a complaint investigation. Findings: Review of policy Nutrition/Hydration Care and Services dated 2/1/23 states .Staff will provide nutritional and hydration care and services to each patient, maintain fluid and hydration balance. Monitor patient's weight as ordered. Resident #1 was admitted on [DATE] and has diagnoses to include heart failure, and dementia, and severe anxiety. Review of Resident #1's provider orders revealed the following orders: -Order with start date of 12/19/24 for diuretic Furosemide Oral Tablet 40 MG (Furosemide) Give 40 mg orally one time a day for fluid overload. -Order with start date of 12/18/24 for Weight: Daily for Congestive heart failure. Review of Resident #1's documented weights between 12/18/24 through 12/30/24 (13 days) revealed daily weights were only obtained 3 times during this stay. Review of Resident #1's meal intakes dated December 2024 lacked documentation of breakfast intakes on 12/7/24 12/16/24, 12/17/24, 12/24/24, 12/28/24 lunch intake on 12/8/24 and 12/15/24. 12/16/24, 12/17/24,12/22/24, 12/25/24, 12/29/24, 12/30/24, and dinner on 12/8/24, and 12/28/24. Review of Resident #1's clinical record revealed Hospital Discharge Summary dated 12/18/24 states Palliative care was discussed and the patient's daughter expressed interest in outpatient palliative care follow up . Palliative care referral has been placed and follow up may be helpful. Review of Resident #'1s entire clinical record lacked evidence he/she was placed on palliative care. During an interview with 2 surveyors on 1/2/24 at 12:04 p.m., Medical Doctor (MD) indicated he was aware that the hospital placed a referral for palliative care for Resident #1, but it was not followed through with at the facility. Review of policy Falls Management dated 3/5/24 states .any patient who sustains an injury to the head from a fall/or has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check per policy .The patient's representative will be notified of the fall and any follow-up treatment needed. Review of policy Neurological Evaluation dated 2/1/23 states .When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed: every1 15 minutes x two hours, then every 30 minutes x two hours, then every 60 minutes four hours, then every eight (8) hours until at least 72 hours has elapsed . Review of Resident #1's Revealed he/she had an unwitnessed fall on 12/28/24.Review of Resident #1's provided Neurological Evaluation Flow Sheet dated 12/23/24 reveled initial neurological exam was completed at 19:00. The flow sheet further states, dates and times for additional neurological exams, but the rest of the sheet is blank. Review of Resident #1's provider orders lacked evidence that an order was obtained to discontinue neurological checks. During an interview with 2 surveyors on 1/2/24 at 2:28 p.m., the Director of Nursing (DON) indicated that she retrieved Resident #1's Neurological Evaluation Flow Sheet out of the shred bin located at the nurse's station, but it is her expectation that neurological checks are completed according to policy, unless a provider gives an order to discontinue them. At this time DON confirmed there is no evidence Resident #1 received neurological checks after this fall, nor is there evidence that an order was obtained to discontinue them. 2. Resident #3 was admitted on [DATE] and has diagnoses to include Alzheimer's, dementia. Review of Resident #3's meal intakes dated December 2024 lacked documentation of breakfast intake on 12/7/24 12/16/24, 12/17/24, 12/24/24, 12/28/24 lunch intake on 12/8/24 and 12/15/24. 12/16/24, 12/17/24,12/22/24, 12/25/24, 12/29/24, 12/30/24, And dinner on 12/8/24, and 12/28/24. 3. Resident #2 was admitted on [DATE] and has diagnoses to include Alzheimer's disease, dementia, and heart failure. Review of Resident #2's active provider orders revealed the following: - An order with a start date of 12/2/24 to Weigh every day shift every Sun for 4 weeks AND every day shift every 1 month(s) starting on the 1st for 5 day(s). - An order with a start date of 11/28/24 for Furosemide 20mg tablet, Give 20 mg orally one time a day for CHF [Congestive Heart Failure]. Review of Resident #2's Medication Administration Record (MAR) for December 2024 revealed Resident #2 was not weighed on 12/8/24 and 12/15/24, and review of the nurse's progress notes for each of these dates lacked documentation indicating why Resident #2 was not weighed. Review of Resident #2's Care Plan, updated 12/2/24, revealed, [Resident #2] is at risk for decreased ability to perform ADL(s) in: .eating .Interventions: . Provide total assist of 1 for eating .; nutritional risk: due to Alzheimer's dementia, .10# wt [weight] loss over previous month . Review of Resident #2's documented meal intake(s) for December 2024 lacked documentation of breakfast intake(s) on 12/24/24, 12/29/24, and 12/30/24; lunch intake(s) on 12/29/24 12/30/24; and dinner intake(s) on 12/21/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, and 12/31/24; and documented drink intake for lacked evidence of fluids being offered between meals on 12/21/24, 12/22/24, 12/27/24, 12/28/24, 12/30/24, and 12/31/24. Review of Resident #2's clinical record revealed, Task, check and change resident after 2 hours. Further review revealed that Resident #2's clinical record lacked evidence that this was completed/offered and/or refused on 12/21/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, and 12/31/24. During a review of Resident #2's entire clinical record, with 2 surveyors, on 1/2/25 at 3:04 p.m., Unit Manager (UM) #1 confirmed the above findings, stating that documentation is a problem and has been for a while.

Jun 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy, the facility failed to assess a resident after returning from a surgical procedure for 1 of 3 residents reviewed during a complaint investigation (Resident #1), and failed to complete admission assessment for 1 of 3 residents (Resident #3). Findings: 1. Review of Resident #1's clinical record revealed progress note dated 5/15/24 stated Received call from [Doctor] at [Hospital], wants resident transferred to surgery ASAP for a pacemaker battery change, Resident returned at 1830 (6:30 p.m.), set up the Medtronic relay, device is on the nightstand and working properly, provided the dinner food tray resident ate 50%, increased confusion, not following restriction protocol, family informed back at facility. Review of Resident #1's clinical record lacked evidence that Resident #1' s surgical wounds were assessed upon his/her return to facility. On 5/23/24 the Department of Licensing received a complaint indicating Resident #1 underwent a surgical procedure for pacemaker battery replacement on 5/15/24 and cardiology department made multiple attempts to contact facility for post op wound care and did not get in contact with facility staff until 5 days later. When contact was made, the nurse was not aware the resident had 2 wound sites. During a telephone interview on 5/30/24 at 7:56 a.m., complainant indicated that Resident #1 had his/her pacemaker battery replaced on 5/15/24 and even though Resident #1 was returned to the facility would specific wound care orders for right groin area and left chest wall, they still expect to have a nurse to nurse report. Complainant further indicated that she had tried calling facility multiple times and left multiple messages and no one returned her call until 5 days later and at that time, it was evident that the nurse was not aware of the surgical site on Resident #1's left chest. Review of facility policy Skin Integrity & wound Management dated 5/1/24 states .For surgical wounds (e.g. flaps, grafts, donors, incisions, etc.) follow specific orders from the surgeon. Implement special wound care treatments/techniques, as indicated and ordered . Collaborate with the wound provider to review co-morbid conditions that may affect healing . Notify dietitian and/or rehabilitation services as indicated . Notify physician/APP to obtain orders . Review of facilty policy Pacemaker Care dated 6/1/21 states Upon admission of patient who has a pacemaker: Identify pacemaker type, serial number, and manufacturer of pacemaker, date and sit of implementation, and cardiologist's surgeon's name and document in medical record; .Determine date/time of next pacemaker follow-up/check-up appointment For post-operative patient (two to three weeks), provide and/or assist patient with daily care of pacemaker. Cleanse pacemaker site gently with soap and water when taking shower or bath. Leave incision line open to air; Inspect site daily. Notify physician/advanced practice provider (APP) of discomfort, redness, or discharge at site; Check apical pulse for one minute daily. Pulse rate should be the same as pacemaker rate or faster. Notify physician/APP if pulse is more than 5-10 beats lower than pacemaker's setting .Place pacemaker instructions (if available ) and copy of identification card in patient's health information record. These items must accompany patient if transferred or discharged ; Monitor for function of pacemaker. Perform pacemaker checks according to schedule and instructions of pacemaker clinic/physician/APP During an interview on 6/3/24 at 1:56 p.m. Licensed Practical Nurse (LPN)1 reviewed Resident #1's clinical record, confirmed there was no evidence that a nurse to nurse report was completed, no skin assessment, no wound orders obtained. During an interview on 6/3/24 at 2:31 p.m., Acting Director of Nursing confirmed the above concerns. 2. Resident #3 was admitted on [DATE] with diagnoses to include peripheral vascular disease, and hypertension. On 6/3/24 at 12:40 p.m., a pacemaker monitor was observed on Resident #3's bedside table. On 6/3/24 at 12:45 p.m., Resident #3 was observed in dining room wearing headphones for hearing assistance. When asked if he/she had a pacemaker, Resident #3 moved his/her shirt off his/her left side and stated, I have a pacer right here and my recorder is in my room . Review of Resident #3's entire clinical record lacked evidence of pacemaker. Review of Resident #3's clinical record revealed admission Assessment dated 5/22/24 Section: Cardiovascular: Pacemaker-Care Profile is blank. During a telephone interview on 6/3/24 at 1:00 p.m., Resident #3's family member indicated that he/she has had the pacemaker at least 5 years and the facility was made aware of its presence during his/her admission. During an interview on 6/3/24 at 1:45 p.m. Registered Nurse (RN) indicated that she was not aware that Resident #3 had a pacemaker, but it is something that she should have been made aware of. RN further indicated that when a resident is admitted or returns from the hospital a skin check should be performed by the nurse and there should be treatment orders for care. During an interview on 6/3/24 at 2:31 p.m. Acting Director of Nursing confirmed Resident #3's clinical record did not include information regarding a pacemaker but the admitting nurse should have noticed it during the admission assessment.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, the facility failed to update/implement goals and interventions for 3 of 3 care plans reviewed during a complaint investigation (Resident's #1, #2, and #3). Findings: 1. Resident #1 was admitted on [DATE] with diagnoses to include heart failure, hypertension, and complete atrioventricular block requiring pacemaker placement in 2010. Review of Resident #1's care plan, initiated 2/2/24, states Resident is at risk of complications related to pacemaker/internal defibrillator .Monitor for signs/symptoms of pacemaker complications i.e.: S.O.B., weakness, syncope, fatigue, cyanosis, bradycardia .Notify physician as needed. Review of Resident #1's clinical record lacked evidence that he/she was being monitored for above pacemaker complications. 2. Resident #2 was originally admitted on [DATE] with diagnoses to include osteoarthritis and recent total right hip replacement. Review of Resident #2's clinical record revealed Discharge Summary Orthopedics dated 3/13/24 states Status post total replacement of left hip .Patient has a surgical incision on the left hip. Dressing will be changed at the first post-op appointment . Review of Resident #2 care plan initiated 11/15/23 lacks evidence that care plan was updated after left total hip replacement on 3/13/24. 3. Resident #3 was admitted on [DATE] with diagnoses to include peripheral vascular disease, and significant hearing loss. During an observation of Resident #3's room on 6/3/24 at 12:40 p.m., a pacemaker monitor was observed on bedside table. On 6/3/24 at 12:45 p.m., Resident #3 was observed in dining room wearing hearing magnifying headphones. When asked if he/she had a pacemaker, Resident #3 moved his/her shirt off his/her left side and stated, I have a pacer right here and my recorder is in my room . Review of Resident #3's care plan initiated 5/22/24 lacked evidence that goals and interventions were put into place for pacemaker, and communication. During a telephone interview on 6/3/24 at 1:00 p.m., Resident #3's family member indicated that he/she informed nurse his/her father/mother had a pacemaker on admission. Review of facility policy Activities of Daily Living (ADLs) dated 5/1/23 states .the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) abilities are maintained or improved and do not diminish unless circumstances of the patient's clinical condition demonstrate that a change was unavoidable. Activities of Living (ADLs) include: .Communication-including speech, language, and other functional communication The care plan will address the patient's ADL needs and goals . During an interview on 6/3/24 at 2:31 p.m., Acting Director of Nursing confirmed the above findings.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy, the facility failed to adequately assess, and obtain wound care orders for 1 of 3 residents reviewed during complaint investigation (Resident #1). Findings: On [DATE] the Department of Licensing received a complaint indicating Resident #1 underwent a surgical procedure for pacemaker battery replacement on [DATE] and cardiology department made multiple attempts to contact facility for post op wound care and did not get in contact with facility staff until 5 days later. When contact was made, the nurse was not aware the resident had 2 wound sites. Review of Resident #1's clinical record revealed progress note, dated [DATE] stated Received call from [Doctor] at [Hospital], wants resident transferred to surgery ASAP for a pacemaker battery change, Resident returned at 1830 (6:30 p.m.). Review of Resident #1's clinical record lacked evidence that Resident #1' s surgical wounds were assessed upon his/her return. Review of Resident #1's clinical record revealed order, dated [DATE] at 20:09 (8:09 p.m.) states R groin area: Keep incision clean and dry for 2-3 days, no showers/baths 7-10 days. Monitor Right groin femoral site for redness/swelling/pain. Two times a day everyday BID 9a.5p for .Pacemaker battery insertion [DATE] . Further review of Resident s clinical record lacked evidence that orders were obtained or entered for wound care for pacemaker insertion site on left upper chest. Review of Resident #1's clinical record revealed progress note dated [DATE] states [nurse] from [Hospital} Cardiology called this nurse and states that she left message and never had a return call, then stated that resident needed a daily wound check and that our nurse needs to report to cardiology tomorrow to discuss [his/her] wound. [this] nurse agreed to call for wound check . During a telephone interview on [DATE] at 7:56 a.m., complainant indicated that Resident #1 had his/her pacemaker battery replaced on [DATE] and even though Resident #1 was returned to the facility would specific wound care orders for right groin area and left chest wall, they still expect to have a nurse to nurse report. Complainant further indicated that she had tried calling facility multiple times and left multiple messages and no one returned her call until 5 days later and at that time, it was evident that the nurse was not aware of the surgical site on Resident #1's left chest and indicated that the nurse informed her that Resident #1's bandied was still intact in his/her groin (7 days after the procedure). During an interview on [DATE] at 1:56 p.m. Licensed Practical Nurse (LPN)1 reviewed Resident #1's clinical record, confirmed there was no evidence that a nurse to nurse report was completed, no skin assessment, no wound orders obtained. Review of facility policy Skin Integrity & wound Management dated [DATE] states .For surgical wounds (e.g. flaps, grafts, donors, incisions, etc.) follow specific orders from the surgeon. Implement special wound care treatments/techniques, as indicated and ordered . Collaborate with the wound provider to review co-morbid conditions that may affect healing . Notify dietitian and/or rehabilitation services as indicated . Notify physician/APP to obtain orders . During an interview on [DATE] at 2:31 p.m., Acting Director of Nursing confirmed above concerns.

Apr 2024 21 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) Form 10055, which included appeal rights and liability of payment, were provided at least 2 days prior to the resident's last covered day, for 2 of 3 residents whose Medicare Part A services were discontinued, and remained in the facility (#274 and #276). Findings: 1. Resident #274's Medicare Part A coverage for skilled services ended on 11/24/23. The medical record lacked evidence that Resident #274 or his/her legal representative was provided a SNFABN when the Medicare A coverage for skilled services was discontinued. The resident remained living in the facility. 2. Resident #276's Medicare Part A coverage for skilled services ended on 3/14/24. The medical record lacked evidence that Resident #276 or his/her legal representative was provided a SNFABN when the Medicare A coverage for skilled services was discontinued. The resident remained living in the facility. On 4/25/24 at 8:28 a.m., during an interview, the Administrator confirmed the SNFABN notices were not provided to Resident #274 and #276.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure that 2 of 2 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #34 and Resident #52). Finding: 1. Resident #34 was admitted to the facility on [DATE] with diagnosis of Bipolar Disorder. Resident #34's clinical record contained a PASRR Level I determination letter dated 12/11/23 that stated further PASRR evaluation was not required due to Resident #34 met the criteria for a short-term convalescence admission. Resident #34 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after Resident #34's stay changed from short-term to long-term. 2. Resident #52 was admitted to the facility on [DATE] with diagnosis of Bipolar Disorder and Borderline Personality Disorder. Resident #52's clinical record contained a PASRR Level I determination letter dated 10/23/23 that stated further PASRR evaluation was not required due to Resident #52 met the criteria for a short-term convalescence admission. Resident #52 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after Resident #52's stay changed from short-term to long-term. On 4/25/24 at 12:25 p.m., in an interview, the Market Clinical Advisor confirmed that the PASRR Level I was not forwarded again to the State Mental Health Authority to determine if PASRR Level II evaluation and determination was needed for Resident #34 and Resident #52 after their stay changed from short-term to long-term.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on record reviews and interviews, the facility failed to update/implement goals and interventions in the area of antipsychotic medication use for 1 of 6 residents reviewed for medications (Resident #10) Finding: Resident #10 was admitted to facility on 11/17/22 and has diagnoses to include dementia, and major depressive disorder. Review of Resident #10's active orders effective April 2024 revealed order with start date of 2/29/24 for antipsychotic Risperdal oral tablet (Risperidone). Give 0.125 mg by mouth two times a day for mood stabilizer, agitation. On 4/23/24 at 2:51 p.m., during review of Resident #10's entire clinical record, the Senior Director of Nursing confirmed Resident #10's care plan lacked goals/interventions and monitoring of side effects for antipsychotic use.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on interview, observation and record review, the facility failed to revise the care plan to reflect a resident's current status for 1 of 3 residents reviewed for falls (#49). Findings: 1. On 4/23/24 at 8:01 a.m., during an interview, Resident #49 stated, I lost my balance and fell hit my head . I was getting up to take my walker to go to the dining room. The Surveyor asked if staff was with him/her when the fall occurred, resident stated, Yes, it happened so quick. At this time, the surveyor observed a rolling walker across the room. Resident #49's care plan initiated on 2/22/24 states, Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Recent illness, hospitalization, etc. resulting in fatigue, activity intolerance, confusion, etc. with intervention of: Provide resident/patient with extensive assist of 1 for ambulation using a wheelchair. Review of Therapy notes stated on 3/7/24 Resident #49 goals were met for Patient will safety ambulate on level surfaces 25 feet using two-wheeled walker with Contact Guard Assist (GCA). Review of the Interdisciplinary meeting that was held on 3/13/24 indicated Resident #49 was now using 2 wheeled walker .walking short distances 25'- 40' with CGA On 4/24/24 at 11:22 a.m., during an interview with the Senior Director of nursing, a surveyor discussed the above concerns that the care plan was not revised to reflect the current status of the residents need for ambulating after the Interdisciplinary meeting.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to follow physician orders for 2 of 11 sampled residents (Resident #219 and Resident #269). Findings: 1. On 4/24/24, Resident #219's clinical record was reviewed. Resident #219 had a medication order, dated 4/11/24, for Lorazepam Oral Tablet 0.5 MG (milligrams) Give 0.5 mg by mouth two times a day for anxiety. A review of Resident #219's Medication Administration Record indicated that Resident #219 did not receive Lorazepam on 4/20/24 and 4/21/24. On 4/24/24 at 12:05 p.m., in an interview, the Senior Director of Nursing confirmed that Resident #219 did not receive his/her Lorazepam on 4/20/24 and 4/21/24 as ordered. 2. Resident #269 was admitted to the facility on [DATE] with diagnosis of Benign non-nodular prostatic hyperplasia with lower urinary tract symptoms. A provider's note dated 3/8/24 stated, review of symptoms: genitourinary - frequency. Assessment/plan: urinary frequency- will check UA (urinalysis- urine sample). A Providers order dated 3/8/24 instructs nursing to, UA C&S (culture and sensitivity) one time only for 4 days, laboratory. Review of the Treatment Administration Record indicated on 3/8/24 a UA was obtained and signed off at 1405. Further review of the medical records lacked evidence of the UA C&S laboratory results. On 4/24/24 at 2:42 p.m., during an interview, the Senior Director of Nursing confirmed there are no records of the completed UA C&S in the resident's medical record or available through the laboratory they utilize.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to ensure that treatment plans were followed, and resident records were accurate for 1 of 1 resident reviewed for pressure and venous ulcers (Resident #60). Finding: Resident #60 was admitted on [DATE] with a Pressure ulcer to his/her right hip, and venous ulcers to bilateral lower extremities (shin). Review of the medical record contained the following Provider orders: - Order dated 4/17/24 for Venous - Right shin: Cleanse with wound cleanser, apply xeroform to wound base and cover with foam dressing. Every day shift for Wound care. - Order dated 4/17/24 for Venous - Left shin: Cleanse with wound cleanser, apply xeroform to wound base and cover with foam dressing. Every day shift for Wound care. - Order dated 4/16/24 for Pressure Injury - Right hip: Cleanse with wound cleanser, apply maxorb AG to wound base and cover with foam border. Every day shift for Wound care AND as needed. - Order dated 3/6/24 for Wound(s): Monitor site(s) (L) shin, hip, (R) calf Daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable Additional Documentation in NN if needed every day shift. On 4/22/24 at 2:06 p.m., a surveyor observed Registered Nurse #1 (RN #1) perform a dressing change to Resident #60's right hip pressure ulcer and both right and left shin venous ulcers. Upon removal of the old dressings, both surveyor and RN#1 observed all 3 wound dressings dated with the date of 4/20/24 and initialed. At this time, the RN#1 confirmed the dressings were not changed on 4/21/24 stating, the dressings are supposed to be changed daily and upon changing the dressing the nurse will put the date and his/her initials for when it was completed. Further review, the treatment administration record indicated, by initials and a check mark, that the nurse had completed and signed off that all three dressing were completed on 4/21/24. In addition, the care plan for pressure ulcer, initiated on 3/11/24 states, Provide wound care per treatment order. On 4/24/24 at 11:22 a.m., during an interview with the Senior Director of Nursing, the surveyor discussed the failure to follow the physician's orders, the current treatment plan and to ensure accurate resident records.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on record review, observations and interviews the facility failed to ensure that two people who are authorized to administer medications signed the Narcotic Bound Book Shift Count page indicating that they counted all the controlled substances at the change of shift for multiple shifts between 4/11/24 through 4/22/24 on 1 of 3 units observed. (North Wind) Findings: Genesis HealthCare policy titled Controlled Drugs: Management of states, A complete count of all Schedule II-IV controlled substances is required at the change of shifts per state regulation or at any time in which narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses and/or authorized nursing personnel, per state regulations. Review of bound medication book labeled WWG, NW, Book 2 revealed that oncoming nurse failed to sign the shift count page on 4/11/24 at 7:00 a.m., 4/17/24 at 7:00 a.m. and 4/18/24 at 7:00 a.m. The outgoing nurse failed to sign 4/18/24 at 1900 and on 4/21/24 evening shift. On 4/24/24 at 10:41 a.m., during an interview, the Licensed Practical Nurse (LPN) unit manager for North Wind unit demonstrated the process of shift change with the narcotic bound book. The LPN explained that count is to occur every shift. Oncoming shift will check the medication cards and outgoing shift will use the narcotic book index to confirm count. After the count is confirmed both staff would sign the shift count in the back of the book. At this time, the LPN stated that signatures are not currently audited but should be and acknowledged there were holes on signature page. On 4/24/24 at 11:31 a.m., during an interview, the Director of Nursing(DON) and Senior Director of Nursing with DON confirmed the above.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on record review, interview, and facility policy, the facility failed to show evidence of documentation to justify the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (#10). Findings: Review of facility policy Psychotropic Medication Use dated 11/28/16 states . All medications used to treat behaviors must have a clinical indication and be uses in the lowest dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: Efficacy, risks, benefits and harm or adverse consequences. Antipsychotic medications used to treat Behavioral or Psychosocial Symptoms of Dementia must be clinically indicated, be supported by adequate rational for uses, and may not be used for behavior with an unidentified causes .Facility should ensure that Physician/Prescriber has conducted a comprehensive assessment for the resident and has documented in the clinical record that the psychopharmacological medication is necessary .Facility staff should monitor the resident's behavior pursuant to facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitated or psychotic behaviors .Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with he use of psychotropic medications, per facility policy or applicable state regulations. Resident #10 was admitted to facility on 11/17/22 and has diagnoses to include dementia, depression, and major depressive disorder. Review of Resident #10's clinical record revealed active medication orders dated 4/2024 revealed the following: -Order with start date of 2/29/24 for antipsychotic medication, Risperdal oral tablet (Risperidone). Give 0.125 mg by mouth two times a day for mood stabilizer, agitation. -Order with start date of 11/3/23 for antidepressant Zoloft oral tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth in the morning for major depression . On 4/23/23 at 2:50 p.m., during a review with Senior Director of Nursing (Corporate) Resident #10's entire clinical record lacked evidence of psychotropic assessment for use, signed consents, or side effect/behavior monitoring for above medications.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record review, and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 14 of 17 residents reviewed for advanced directives (Resident's #5, #14, #19, #21, #22, #26, #27, #34, #44, #49, #52, #54, #58 and #219). Findings: Review of facility policy titled Review of facility policy Health Care Decision Making dated 1/8/24 states Centers must: Inform and provide written information to all patients concerning the rights to accept or refuse medical or surgical treatment and, at the patient's option, formulate an advance directive: .approach a capable patient who does not have an advance directive upon admission , . so that patient's rights will be honored and their wishes will be executed at the appropriate time .Upon admission, determine whether the patient has an advance directive and .If the patient/patient representative has copies with them, make copies, place in medical record, and notify the interprofessional team . 1. Resident #5 was admitted to the facility on [DATE]. A review of Resident #5's clinical record lacked evidence that the facility provided 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. 2. Resident #14 was admitted to the facility on [DATE]. A review of Resident #14's clinical record lacked evidence that the facility provided 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 #19 was admitted to the facility on [DATE]. A review of Resident #19's clinical record lacked evidence that the facility provided 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 #21 was admitted to the facility on [DATE]. A review of Resident #21's clinical record lacked evidence that the facility provided 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 #22 was admitted to the facility on [DATE]. A review of Resident #22's clinical record lacked evidence that the facility provided 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 #26 was admitted to the facility on [DATE]. A review of Resident #26's clinical record lacked evidence that the facility provided 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 #27 was admitted to the facility 5/22/23. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for Mental Status 14 of 15 indicating resident #27 is cognitively intact. During an interview on 4/24/24 at 12:48 p.m. Resident #27 indicated he/she does have an advanced directive and believed that it was provided to facility on admission. Review of Resident #27's clinical record lacked evidence of an advanced directive. 8. Resident #34 was admitted to the facility on [DATE]. A review of Resident #34's clinical record lacked evidence that the facility provided 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. 9. Resident #44 was admitted to the facility on [DATE]. A review of Resident #44's clinical record lacked evidence that the facility provided 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. 10. Resident #49 was admitted to the facility on [DATE]. A review of Resident #44's clinical record lacked evidence that the facility provided 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. 11. Resident #52 was admitted to the facility on [DATE]. A review of Resident #52's clinical record lacked evidence that the facility provided 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. 12. Resident #54 was admitted to the facility on [DATE]. A review of Resident #54's clinical record lacked evidence that the facility provided 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. 13. Resident #58 was admitted to the facility on [DATE]. A review of Resident #58's clinical record lacked evidence that the facility provided 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. 14. Resident #219 was admitted to the facility on [DATE]. A review of Resident #219's clinical record lacked evidence that the facility provided 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. On 4/23/24 a 1:30 p.m., during an interview, the Senior Director of Nursing confirmed the above findings.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 interior for the 4 of 4 units (Spring Gardens, North Wind, Penbscoto and Windward Center), the laundry room and hallways for 2 of 2 facility tours (4/22/24 and 4/25/24). Findings: 1. On 4/22/24 at 9:20 a.m., during a tour of Spring Gardens Unit, 2 surveyors, and the Corporate Nurse Educator (CNE) observed the following findings: > The shower room had a black headband, a white towel and a razor on the sink. > Resident room [ROOM NUMBER] - The toilet seat was visibly dirty/soiled and the call bell cord had blue yarn tied to it as an extender. > Resident room [ROOM NUMBER] - The toilet was continuously running. > Resident room [ROOM NUMBER] - The bathroom toilet was visibly dirty. There were 3 large holes in the wall above the toilet. The bathroom door was marred/gouged on the inside and outside of the door. > Resident room [ROOM NUMBER] - The room floor was dirty and cluttered. The bathroom sink was dirty/stained. On 4/22/24 at 9:20 a.m., in an interview, the Corporate Nurse Educator (CNE) confirmed the findings. 2. On 4/25/24 from 8:27 a.m. to 9:15 a.m., an environmental tour was conducted with the Senior Maintenance Director, the Administrator and the Housekeeping/Laundry Supervisor in which the following findings were observed: Laundry > The floor had numerous cracked/broken tiles and the walls had chipped/missing paint and missing cove base. North Wind > The wheelchair scale had ripped/missing non-skid surfaces creating an uncleanable surface. > There were multiple large stains on the hallway carpets throughout the unit. > The sitting area, across from the nurse's station, had 2 dried liquid spills on the wall near the window. The end table near the window had a worn off surface exposing untreated wood which created an uncleanable surface. > Resident room [ROOM NUMBER] - The bathroom toilet bar was broken and laying on the floor. > Resident room [ROOM NUMBER] - The bathroom floor had a quarter size hole in the linoleum. The wooden bathroom door was chipped/gouged. > Resident room [ROOM NUMBER]- The floor was dirty and the caulking dirty/stained around the base of the toilet. The bathroom exhaust fan was dusty/dirty. The bathroom light had debris in the lens. > Resident room [ROOM NUMBER]- There were 9 small holes in the bathroom floor linoleum by the toilet. There was a plunger and another wooden plunger handle on floor behind the toilet. > Resident room [ROOM NUMBER] - There was a wash basin on floor under the sink. The floor was dirty around the base of the toilet. The bathroom light had debris in the lens. > Resident room [ROOM NUMBER] - The shower stall had non-slip grip tape peeling up. Penobscot House > Resident room [ROOM NUMBER] - The sink countertop had he edging missing exposing untreated wood and creating an uncleanable surface. > Resident room [ROOM NUMBER] - The shower stall had non-slip grip tape peeling up. > Resident room [ROOM NUMBER] - Resident #271's wheelchair was dirty and had dried food and liquid residue on it. Windward Center > Resident room [ROOM NUMBER] - The bathroom door was marked/marred. > Resident room [ROOM NUMBER] - The bathroom floor was dirty and had debris/trash on it. The bathroom walls were marked/marred. > Resident room [ROOM NUMBER] - The bathroom floor was dirty and had debris/trash on it. The bathroom walls were marked/marred. > Resident room [ROOM NUMBER] - The bathroom floor was dirty and had debris/trash on it. The bathroom walls were marked/marred. > Resident room [ROOM NUMBER]: The bathroom floor was dirty and had debris/trash on it. The bathroom walls were marked/marred. > Resident room [ROOM NUMBER] - The floor was dirty and had debris/trash on it. The walls were marred and dirty. > Resident room [ROOM NUMBER] - The bathroom floor was dirty and had debris/trash on it. The bathroom walls were marked/marred. The toilet tank lid was missing, On 4/25/24 at 9:15 a.m., in an interview, the Senior Maintenance Director, the Administrator and the Housekeeping/Laundry Supervisor confirmed the findings.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on care plan review, observations, interviews, and facility policy, the facility failed to provide residents with a continuous resident centered activities program. This failure has the potential to affect all residents that would normally participate in activities. Findings: Review of facility policy Recreation Services Policies and Procedures dated 8/7/23 states Centers/Communities must provide, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of an and support the physical, mental, and psychosocial wellbeing of each patient, encouraging both independence and integration in the community.Programs will be scheduled seven days a week. Weekend activities include secular and non-secular opportunities. 1. Resident #10 was admitted to the facility on [DATE] and relies on staff for Activities of Daily Living. Review of Resident # 10's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) 15 of 15 indicating he/she is cognitively intact. Further review of MDS revealed Section-F: Preferences for Customary Routine and Activities indicated he/she felt it was very important to do group activities, keep up with news, attend favorite activities and listen to music he/she likes. Review of Resident #10's care plan initiated 11/17/22 revealed .While in the facility, [Resident #10] states that it is important . has the opportunity to engage in daily routines that are meaningful relative to [his/her] preferences . On 4/22/24 at 10:27 a.m., Resident #10 indicated that he/she really likes to go to BINGO, but never knows when it is. Observation of Resident #10's room lacked evidence of an Activity Calendar. Review of facility provided Activity Calendar April 2024 revealed BINGO was held on 4/1/24, 4/5/24, 4/6/24, 4/8/24, 4/10/24, 4/13/24, 4/15/24, 4/17/24, and 4/22/24. Review of Resident #10's Activity Participation log dated April 2024 lacked evidence that he/she was invited or declined to join activities. Further review of April 2024 activity calendar revealed the following scheduled activities: -4/22/24: Activity Cart; 10:30am- Coffee Social; 2pm: Bingo in AR (activity room); 4pm Room to Room, 5:15pm Crossword game. Observations of activity room between 10:30am and 2:45 p.m. lacked evidence that any activities were being held. -4/23/24: Activity Cart; 10am Coffee and Music Social; 2pm arts & Crafts (bring your own craft) 4pm Mail Delivery and Socializing. Observation of activity room between 10:00 a.m., and 3:00 p.m., lacked evidence that any activities were held. On 4/23/24 at 3:08 p.m., Activities Director (AD) confirmed that there were no activities provided 4/22/24 and 4/23/24 stating I've been out for 10 days and I'm not feeling well and had been out for 10 DAYS, so I'm taking the opportunity to play catch up and do assessments. Further review of Activity Calendar dated April 2024 revealed the following scheduled activities: - 4/24/24 Activity Cart 10am- Coffee and Music Social; 2pm BINGO; 4pm Room to room. Observation of activity room on 4/22/24 at 10:09 a.m., the activity room door was closed, upon entrance, 4 residents were observed sitting at the table with coffee, and the room was quiet. AD was sitting at desk in the corner. -4/25/24 at 10:00 a.m., Review of April 2024 Activity calendar revealed Activity Cart, 10am-Coffee and Music Social At 10:10 a.m., a surveyor observed activity room to be empty, Activity Assistant (AA) indicated that they just made coffee, and residents will trickle in as they want, and they will go around and encourage people to come in. -When asked why the activity hasn't started yet as it says it begins at 10 a.m., AA indicated they don't normally start to go around until after the activity is supposed to start. On 4/25/24 at 10:25 a.m., observation of activity room revealed 3 residents sitting at table drinking coffee and listening to oldies on the television. AA did not respond when asked if the residents in the other 3 units were asked if they wanted to attend. (Review of resident census dated 4/25/24 revealed there were 66 residents un the facility). On 4/23/24 at 3:12 p.m., during an interview with 2 surveyors, the Senior Director of Nursing indicated that the expectation is to have Activities offered daily and documented. On 4/24/24 at 10:10 a.m., The Director of Nursing indicated that it was her expectation that the residents should already be in the activity room when the activity starts. On 4/25/24 at 10:28 a.m., the Senior Activity Director indicated that it was his expectation that the activity calendar was followed, residents should be invited and, in the room, when it starts.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 base board hot water heating units for 2 of 2 observations and failed to ensure that that chemicals were properly secured for 1 of 4 days of survey. (4/22/24) Findings: 1. On 4/22/24 at 11:45 a.m., a surveyor observed the following on the Penobscot House Unit: > Resident room [ROOM NUMBER]- The base board heating unit cover was partially off exposing sharp metal edges and hot pipes. > Resident room [ROOM NUMBER] - The base board heating unit was missing approximately an 18 inch section of pipe covering which exposed hot piping. > Resident room [ROOM NUMBER] - The base board heating unit was missing approximately an 18 inch section of pipe covering which exposed hot piping. On 4/22/24 at 11:55 a.m., in an interview, the Administrator confirmed the findings. 2. On 4/22/24 at 12:40 p.m., a surveyor observed the following in Resident room [ROOM NUMBER]. > There was a 7.7 ounce container of Disinfectant wipes in the room. > There was a 12.2 ounce container of [NAME] Fabric Softener in the room. > There was a 50 ounce container of Woolite Laundry Detergent in the room. > Resident room [ROOM NUMBER] - The base board heating unit cover was partially off exposing sharp metal edges and hot pipes. The Safety Data Sheet for Disinfecting Wipes(Fresh Scent) noted the following: 4. First Aid Measures Inhalation: Not a normal route of exposure. If symptoms develop move victim to fresh air. Skin contact: Rinse skin with water/shower. Get medical attention if irritation develops and persists. Eye contact: Hold eye open and rinse slowly and gently with water for 15 to 20 minutes. Remove contact lenses, if present, after the first 5 minutes, and then continue rinsing eye. Call Poison Control Center or doctor for treatment advice. Ingestion: not a normal route of exposure. Called poison Control Center or doctor for treatment advice. The Safety Data Sheet for Downy Liquid Fabric Softener noted the following: 4. First Aid Measures Skin and eye, oral ingestion. Mild eye and skin irritant. Prolonged skin contact or installation into the eye may result in transient, superficial effects similar to those produced by a mild toilet soap. Oral injection may result in gastro intestinal irritation with nausea, vomiting, or diarrhea. Eye contact: flush eyes with water. Oral ingestion: dilute with fluids and treat symptomatically. Skin contact: rinse exposed skin. Remove contaminated clothing and launder before reuse. The Safety Data Sheet for Woolite Damage Defense Laundry Detergent noted the following: 4. First Aid Measures Eye contact: immediately flush eyes with plenty of water, occasionally lifting the upper and lower eyelids. Check for and remove any contact lenses. Continue to rinse for at least 10 minutes. Get medical attention. Inhalation: remove victim to fresh air and keep at rest in a position comfortable for breathing period if not breathing, if breathing is irregular or if respiratory arrest occurs, provide artificial respiration or oxygen by trained professional. It may be dangerous to the person providing aid to give mouth to mouth resuscitation. Get medical attention if adverse health effects persist or are severe. If unconscious, place in recovery position and get medical attention immediately. Maintain an open airway. Loosen tight clothing such as a collar, tie, belt or waistband. In case of inhalation of decomposition products in a fire, symptoms may be delayed. The exposed person may need to be kept under medical surveillance for 48 hours. Skin contact: wash with plenty of soap and water. Remove contaminated clothing and shoes. Wash contaminated clothing thoroughly with water before removing it, or wear gloves. Continue to rinse for at least 10 minutes. Get medical attention. In the event of any complaints or symptoms, avoid further exposure. Wash clothing before reuse. Clean shoes thoroughly before reuse. Ingestion: wash out mouth with water. Remove dentures if any period remove victim to fresh air and keep at rest in a position comfortable for breathing period if material has been swallowed and the exposed person is conscious, gives small quantities of water to drink. Stop if the exposed person feels sick as vomiting may be dangerous period do not induce vomiting unless directed to do so by medical personnel. If vomiting occurs, the head should be kept low so that the vomit does not enter the lungs. Get medical attention if adverse health effects persist or are severe. Never give anything by mouth to an unconscious person. If unconscious, place in recovery position and get medical attention immediately. Maintain an open airway. Loosen tight clothing such as collar, tie, belt or waistband. On 4/22/24 at 12:50 p.m., in an interview, the Administrator confirmed the above findings.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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Based on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to oxygen and nebulizer mask/tubing for 2 of 2 residents reviewed for respiratory care (Residents #19 and #49) for 2 of 2 observations (4/22/24 and 4/23/24). Findings: 1. On 4/22/24 at 12:15 p.m., and on 4/23/24 at 8:50 a.m., a surveyor observed the unlabeled oxygen tubing for Resident #19. A review of the Resident #19's clinical record revealed that there was no order to change the tubing and no documentation showing that the tubing had been changed weekly. On 4/24/24 at 2:15 p.m., in an interview, the Senior Director of Nursing confirmed that Resident #19's oxygen tubing had not been changed weekly and that Resident #19's clinical record lacked evidence showing that the tubing had been changed weekly. 2. On 4/22/24 at approx. 10:03 a.m., and on 4/23/24 at 8:00 a.m., observations of Resident #49's nebulizer mask stored on the nightstand labeled with a dated of 4/1/24. In a brief interview Resident #49 stated, he/she uses the nebulizer twice daily. Review of Resident #49's medical record lacked evidence of an order or documentation of the nebulizer mask and tubing changed weekly. On 4/24/24 at 8:42 a.m., the above was discussed with the Senior Director of Nursing who stated, the nebulizer masks should be rinsed and air dried after use then placed in plastic bag for storage and all oxygen related tubing should be changed every Sunday.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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Based on performance evaluation review and interview, the facility failed to complete annual performance evaluations at least every 12 months for 5 of 5 sampled employees (Certified Nursing Assistant [CNA]). Findings: 1. CNA #1 was hired on 2/4/2019. The last annual performance evaluation was completed in 2021. The facility was unable to provide evidence of a completed annual performance evaluations for 2022 and 2023. 2. CNA #2 was hired on 2/4/2020. The last annual performance evaluation was completed in 2021. The facility was unable to provide evidence of a completed annual performance evaluations for 2022 and 2023. 3. CNA #3 was hired on 4/5/2021. The facility was unable to provide evidence of a completed annual performance evaluations for 2022 and 2023. 4. CNA #4 was hired on 10/12/2021. The facility was unable to provide evidence of a completed annual performance evaluations for 2022 and 2023. 5. CNA #5 was hired on 7/2/2018. The last annual performance evaluation was completed in 2021. The facility was unable to provide evidence of a completed annual performance evaluations for 2022 and 2023. On 4/25/24 at 9:30 a.m., in an interview, the Market Clinical Advisor confirmed there was no facility documentation of annual performance evaluations for the CNAs since 2021.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, record reviews, facility policy, and Centers for Disease Control (CDC) guidance, the facility failed to ensure proper vaccine storage temperatures for 2 of 2 medication storage room refrigerators (Spring Harbor and Penobscot House). Findings: Review of facility policy titled Medication Storage Guidance .influenza vaccine dated 2023 states, Store in the refrigerator at 36 degrees to 46 degrees Fahrenheit. Review of CDC guidance Vaccine Storage and Handling Toolkit dated 1/23 states .Refrigerators should maintain temperatures between 2° C and 8° C (36° F and 46° F) .Every vaccine storage unit must have a Temperature Monitoring Device (TMD). An accurate temperature history that reflects actual vaccine recommended temperature range. 1.On 4/23/24 at 7:15 a.m., two surveyors and Director of Nursing (DON) observed Spring Garden medication room refrigerator containing 3 vials of influenza vaccine available for use. Further observation of the medication room lacked evidence of monitoring refrigerator temperatures. At this time, the DON indicated that refrigerator temperatures should be monitored on a daily basis. 2. On 4/23/24 at 12:40 p.m., during observation of Penobscot House medication room with the Registered Nurse (RN#1), a surveyor noted the Temperature Log for Medication/Vaccine Refrigerators - Fahrenheit dated April 2024 which stated, Record temps twice each day lacked evidence that refrigerator temperatures were taken from 4/1/24 through 4/15/24 (15 days). RN#1 indicated that she had been at the facility for eight months and was not aware they needed to be documented. On 4/23/24 at 3:13 p.m., the Senior Director of Nursing was unable to provide refrigerator temperature logs from 1/1/24 through 4/15/24, confirming the facility did not start monitoring temperature for vaccine storage until 4/16/24.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and the facility's policies, the facility failed to ensure products in the walk-in refrigerator and freezer were labeled and/or dated and failed to remove expired foods available for use for 1 of 1 kitchen tours. Further, the facility failed to ensure that the freezers were monitored, and temperatures documented accurately and that the dish machine was maintaining proper temperature ranges for proper washing/cleaning. This has the potential to affect all residents. Findings: Facilities Cold food policy and procedure revised 4/2018 states, All Time/Temperature Control for Safety (TSC) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. 4. An accurate thermometer will be kept in each refrigerator and freezer a written record of daily temperatures will be recorded. 5. All foods will be wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Facilities Machine Warewashing and Sanitizing policy effective 5/2023 states: To ensure all dishware is cleaned and sanitized after use' and For high temperature machine, the wash cycle temperatures ranges between 150-165 degrees Fahrenheit for a sanitary rack, single temperature machine. 1. On 4/22/24 at 9:20 a.m., during a kitchen tour with the Dietary manager, the following was observed, Walk-in refrigerator contained: One opened bottle of Horseradish 32 oz with expiration date of 10/19/22 One opened container of Lobster base with expiration date of 4/5/2024 One opened container of Gochujang Red pepper paste with expiration date of 8/22/23 One bottle of Kiwi Lime Flavored Dessert Sauce with expiration date of 2/23/24. Walk-in Freezer contained: 2 bags of patties not labeled or dated 1 bag of pizza dough crust not labeled or dated On 4/22/24 at approx. 9:30 a.m., the Dietary Manger confirmed the above and removed the expired foods and unlabeled/dated products. 2. Review of the facilities Temperature logs from November 2023 to the current April 2024 revealed the freezer temperatures for November 2023, February 2024, March 2024 (except for 4 days in March) and April 2024 are all documented temperatures of 0 degrees twice daily. On 4/25/24 at 10:14 a.m., during an interview, the Dietary Manager stated the freezer was out of order from [DATE] through April 2024 and recently was fixed approx. 2 weeks ago. In the meantime, the facility had an outside refrigerator/freezer they were utilizing. The surveyor asked how all the freezer temperatures for 4 months are documented as 0 degrees. The Dietary Manager confirmed that the freezer temperatures fluctuates and it's very unlikely the temperatures would all be at 0 degrees, confirming accurate temperatures were not documented properly. 3. On 4/25/24 at approx. 10:20 a.m., both the surveyor and the Dietary Manager observed the dish machine wash and rinse cycles x2 which failed to reach the wash cycle temperatures ranges between 150-165 degrees. - wash temperature - 140 degrees, rinse temperature 188 degrees - wash temperature - 140 degrees, rinse temperature 192 degrees At this time, the Dietary Manager notified maintenance. Review of the facilities Dish Machine Temperature logs from January 2024 through the current April 2024 revealed the dish wash temperature was 155 degrees and the rinse temperatures were 180 degrees for breakfast, lunch and dinner daily. At this time, the dietary Manager could not explain why all the temperatures for the wash and rinse cycle were exactly the same, several times a day and for 4 months in a row. On 4/25/24 at 10:21 a.m., during an interview with the Market Clinical Advisor, the above concerns for both the freezer temperatures and dish wash/rinse temperatures all being the same temperature multiple times daily were discussed. On 4/25/24 at 10:34 a.m., the Senior Maintenance Director met with the surveyor and observed dish washer temperatures once again. He stated the screen in the dishwasher was out and being rinsed when the previous temperatures were being observed, so the water would go right down the drain during the wash, not holding proper temperature. Additional observations of wash temperatures: Wash temperature - 154 degrees, Rinse temperature - 194 degrees Wash temperature - 148 degrees, Rinse temperature - 194 degrees Wash temperature - 148 degrees, Rinse temperature - 196 degrees Wash temperature - 150 degrees, Rinse temperature - 196 degrees Once again at 10:44 a.m., additional wash cycle temperature was observed to reach 150 degrees On 4/25/24 at 10:47 a.m., a surveyor confirmed the above with the Administrator and the Market Clinical Advisor

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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Based on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 3 residents reviewed for medication administration (Resident #10 and #219). Findings: 1. Resident #10 was admitted to facility on 11/17/22 and has diagnoses to include dementia, and major depressive disorder. Review of Resident #10's active orders effective April 2024 revealed: -Order with start date of 2/29/24 for antipsychotic Risperdal oral tablet (Risperidone). Give 0.125 mg by mouth two times a day for mood stabilizer, agitation. Review of Resident #10's entire clinical record lacked evidence of behavior monitoring for side effects. - Order with start date of 11/3/23 for antidepressant Zoloft Oral Tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth in the morning for major depression . Review of Resident #10s clinical record lacked evidence of behavior monitoring for side effects. On 4/23/24 at 2:50 p.m., review of Resident 10's entire clinical record with the Senior Director of Nursing confirming the above findings. 2. On 4/24/24 during a record review for Resident #219, it was noted that he/she had an order for Lorazepam Oral Tablet 0.5 MG (milligram)(Lorazepam) Give 0.5 mg by mouth two times a day for anxiety Pharmacy Start date 4/11/2024 16:00.(4:00 p.m.) On 4/21/24 at 20:04 (8:04 p.m.), a nursing note was written that noted Not enough ativan to get [resident] through weekend until providers arrive on Monday. [Resident] has BID dosing. On 4/22/24 at 00:28(12:28 a.m.), a nursing note was written that noted Note Text: Lorazepam Oral Tablet 0.5 MG Give 0.5 mg by mouth two times a day for anxiety not available when scheduled-delivered on midnight run resident sleeping On 4/24/24, review of the North Wind Medication Control Book #2 noted on page #23 that on 4/19/24 at 1645(4:45 p.m.), the last tablet was administered to the resident making the count zero. A new page, #27, was started for the resident and noted that on 4/21/24 at 2230(10:30 p.m.), 6 tablets were received and signed in from pharmacy. Medication was not given to the resident until 4/22/24 at 8:30 a.m Review of the resident's Medication Administration Record (MAR) showed documentation of Resident #219 receiving the medication, signed off by a nurse on the morning of 4/20/24 and not again until 4/22/24. On 4/24/24 at 12:05 p.m., in an interview, the Senior Director of Nursing stated that the facility has an emergency kit for medications and the nurse could have called the pharmacy to get override code and get the medication for the resident. She further stated that it would be documented in the back of the North Wind Medication Control Book #2 that the emergency kit was used. The pharmacy would have documentation of the facility call and authorization to access the emergency kit. Upon review, she could not find documentation showing the emergency kit was accessed. She also called the pharmacy and found they were never called for access to the emergency kit. At this time, after reviewing Resident #219's clinical record with the surveyor, the Senior Director of Nursing confirmed that the MAR documentation was not accurate and that Resident #219 did not receive the medication on 4/20/24 and 4/21/24.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related to personal toileting items, wash basins, medical supplies and linen for 2 of 4 days of survey on 3 of 4 units (Windward Gardens Penobscot and Spring Gardens). Findings: 1. On 4/22/24 and 4/23/24, a surveyor observed on Windward Gardens unit a bedpan and a wash basin located in a shared bathroom on the floor under the sink in room [ROOM NUMBER]. On 4/23/24 at approximately 9:45 a.m., in an interview with a surveyor, the Administrator confirmed the above observations did not support good infection control practice. 2. On 4/22/24 at 10:54 a.m. to 11:06 a.m., observation of Penobscot to have the following: - room [ROOM NUMBER] had bariatric bed pan stored on the floor next to the toilet and a wash basin on shower floor. - room [ROOM NUMBER] had a bed pan stored upside down on the toilet seat. - room [ROOM NUMBER] had a bed pan stored on the shower room floor On 4/23/24 at 8:12 a.m., observation of Penobscot room [ROOM NUMBER] with a bariatric bed pan stored on the floor with another bed pan stored inside of it. On 4/23/24 at 9:33 a.m., during an interview, the above was discussed with the Senior Director of Nursing 3. On 4/22/24 and 4/23/24 the following was observed on Spring Gardens by two surveyors: - room [ROOM NUMBER]-108 shared bathroom contained a soiled hospital gown and a used glove on the floor. - room [ROOM NUMBER]-102 shared bathroom contained an empty sealed specimen cup in a biohazard bag and an unlabeled urinal hanging on grab bar next to sink. - room [ROOM NUMBER] contained a bariatric commode stored over the toilet which contained urine and a bed pan was stored on floor with the emergency call bell string resting on the inside of the bed pan. On 4/23/24 at 9:20 a.m., the above findings were confirmed during a tour of Spring Gardens with 2 surveyors and the Corporate Nurse Educator (CNE).

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, resident rights and dementia management by failing to ensure that 4 of 5 Certified Nursing Assistant's (CNAs) employed, completed the required annual training (CNA #1, CNA #2, CNA #4 and CNA #5). Findings: On 4/25/24, during a review of employee personnel records, the following was noted: 1. CNA #1 was hired on 2/4/2019. CNA #1's employee personnel record lacked evidence of mandatory resident rights education and dementia training within the last twelve months. 2. CNA #2 was hired on 2/4/2020. CNA #2's employee personnel record lacked evidence of mandatory abuse education, resident rights education and dementia training within the last twelve months. 3. CNA #4 was hired on 10/12/2021. CNA #4's employee personnel record lacked evidence of mandatory resident rights education within the last twelve months. 4. CNA #5 was hired on 7/2/2018. CNA #5's employee personnel record lacked evidence of mandatory abuse education, resident rights education and dementia training within the last twelve months. On 4/25/24 a 9:30 a.m., in an interview, the Market Clinical Advisor confirmed that CNA #1, CNA #2, CNA #4 and CNA #5 did not receive all required mandatory education and training within the last twelve months.

MINOR (B)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident, family and/or the resident's representative in writing of the transfers/discharge to an acute care hospital for 2 of 6 residents sampled for hospitalizations (Residents #5 and #49). Findings: 1. Documentation in Resident #5's clinical record indicated that the resident was transferred to the hospital on [DATE] and 11/24/23 and subsequently admitted . The clinical record lacked evidence that Resident #5 and/or the resident representative were provided with written transfer/discharge notices upon either transfer. On 4/24/24 at 9:45 a.m., during an interview, the Licensed Social Worker stated he/she could not locate the transfer/discharge for the dates of 11/22/23 and 11/24/23. 2. Documentation in Resident #49's clinical record indicated that the resident was transferred to the hospital on 4/17/24 and subsequently admitted . The clinical record lacked evidence that Resident #49 and/or the resident representative were provided with a written transfer/discharge notice upon transfer. On 4/24/24 at approximately 10:15 a.m., the surveyor confirmed these findings with the Senior Director of Nurses.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0625 (Tag F0625)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member and/or legal representative for 2 of 6 sampled residents who had been transferred to the hospital (Residents #5 and #49). Findings: 1.Resident #5's clinical record revealed the resident was transferred to an acute care hospital on [DATE] and 11/24/23 and subsequently admitted . The clinical record lacked evidence that Resident #5 and/or the resident representative were provided with a written bed hold notice for the dates of 11/22/23 and 11/24/23. On 4/24/24 at 9:45 a.m., during an interview, the Licensed Social Worker stated he/she could not locate the bed hold notice for the dates of 11/22/23 and 11/24/23. 2. Resident #49's clinical record revealed the resident was transferred to an acute care hospital on 4/17/24 and subsequently admitted . The clinical record lacked evidence that Resident #49 and/or the resident representative were provided with a written bed hold notice. On 4/24/24 at approximately 10:15 a.m., the surveyor confirmed these findings with the Senior Director of Nurses.

Jan 2024 10 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interviews and facility policy review, the facility failed to implement their Abuse Prohibition policy to ensure an alleged violation involving verbal abuse was reported within 2 hours to the Division of Licensing and Certification (State Agency) for 1 of 29 residents reviewed. (#5) Finding: The facility's Abuse Prohibition, revised 10/24/22 on Page 6 reads Report allegations involving abuse (physical, verbal, sexual, mental) no later than two hours after the allegation is made and Notify local law enforcement, licensing board and registries and other agencies as required. On 4/20/23, the Division of Licensing and Certification received from the facility a reportable incident form which indicated an allegation of verbal abuse towards Resident #5 by a Licensed Practical Nurse (LPN) who was witnessed raising his/her voice, in a derogatory manner and using profanity while working with the resident. Further review of the Nursing Facility Reportable Incident Form, reveals the date of the alleged incident to have occurred on the evening of 4/15/23. On 1/9/24 at 3:00 p.m. in an interview with a surveyor, the Director of Nursing and Marketing Clinical Advisor confirmed the facility did not notify the Division of Licensing and Certification of the allegation of alleged verbal abuse until 4/20/23, 5 days after the initial alleged incident.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of the transfers/discharges to an acute care hospital for 1 of 7 residents sampled for hospitalizations. (#22) Finding: Documentation in Resident #22's clinical record indicated that the resident was transferred to the hospital on 4/23/23 and subsequently admitted . The clinical record lacked evidence that Resident #22 and/or the resident representative were provided with a written transfer/discharge notice upon transfer. On 1/9/24 at approx. 11:00 a.m., during an interview, the Director of Nursing confirmed the above finding.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member or legal representative for 1 of 7 residents sampled for hospitalizations. (#22) Finding Resident #22's clinical record revealed the resident was transferred to an acute care hospital on 4/23/23 and subsequently admitted . The clinical record lacked evidence that Resident #22 and/or the resident representative were provided with a written bed hold notice. On 1/9/24 at approx. 11:00 a.m., during an interview, the Director of Nursing confirmed the above finding.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 6 residents that were reviewed for baseline care plans. (#21) Finding: Resident #21 was admitted to the facility on [DATE]. The discharge summary from the hospital included information that the resident had a diagnosis of diabetes, peripheral neuropathy, bilateral foot drop which requires braces for ambulating, spinal stenosis and frequent falls. Review of the clinical record revealed that it lacked evidence of a baseline care plan completed within 48 hours to include the instructions necessary to properly care for Resident #21's immediate health and safety needs for the above concerns. The care plan was initiated on 8/18/23, 7 days after admission. In addition, the care plan lacked information on Resident #21's bilateral foot drop which required braces for ambulating. On 1/9/24 at 8:52 a.m., the above finding was confirmed during an interview with the Director of Nursing.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to review/revise and update care plan interventions for the problem area of Activities of Daily Living (ADL) care for 1 of 2 residents reviewed for falls. #21 Findings: Review of Resident #21's care plan initiated on 8/18/23 in the area of ADL's states, provide resident/patient with extensive assist of 2 for transfers using a lift to wheelchair and Provide resident/patient with extensive assist of 2 for toileting. admission Minimum Data Set (MDS) 3.0 comprehensive assessment, dated 8/17/23, was coded on section GG Mobility, that Resident required partial moderate assist and, helper does less than half of the effort, for sit to stand and chair/bed to chair transfer. The Certified Nursing Assistant (CNA) documentation reviewed for 8/12/23 - 8/25/23 revealed Resident #21 required limited to extensive assist of 1 staff for transfers/walking in room and supervision/limited assist of 1 staff for toileting. Interviews conducted with staff during the complaint survey revealed that Resident #21 required limited assistance of 1 staff for transfers/toileting. On 1/9/24 at 9:54 a.m., the above finding was confirmed during an interview with the Director of Nursing.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to identify a resident's care needs and provide timely treatment to manage pain for 1 of 2 residents reviewed for falls with injury (#13). Findings: A review of the facility's Falls Management policy, with a revision date of 8/7/23, stated Purpose: To evaluate the patient for injury post-fall and provide appropriate and timely care. Section 5, Post-Fall Management: 5.2.2. If the extent of injuries cannot be determined, the nurse will notify emergency medical services (EMS) for evaluation and transport to the hospital. A review of the clinical record of Resident #13, noted a [AGE] year old, admitted to the facility on [DATE] following repair of a right hip fracture. Additional diagnoses included Dementia and Parkinsonism. The admission Minimum Data Set (MDS) 3.0, completed 10/24/23, identified Resident #13's need for maximum to moderate assistance with activities of daily living (ADL's) including dressing, transfers, toileting, and bed mobility. The MDS also noted Resident #13 exhibited wandering behaviors on most days. The care plan, last revised 11/30/23, includes Resident #13 is dependent on staff for assistance with ADL's. On 11/10/23 at 5:45 p.m., nursing documentation noted Resident #13 had no complaints of pain. On 11/11/23 at 7:40 a.m., documentation noted Resident #13 was found on floor in room, lying on [his/her] back. An on-call provider advised staff to observe patient and call with any change. On 11/12/23 at 1:07 p.m., staff noted apparent pain right leg greater than left. On-call (provider) gave orders for STAT (urgent) xray hip tomorrow on Monday. On 11/13/23 at 1:15 a.m., staff noted Resident #13 was showing signs of being anxious, complaints of pain in [his/her] right hip. It was reported to me in shift change that an x-ray has been ordered for tomorrow, but is also scheduled for discharge Monday. On 11/13/23 at 5:36 p.m., a note stated Resident sent to (Emergency Department) for eval after a fall over the weekend. Resident report 7/10 pain to right hip. Xray shows new right hip fracture. A review of hospital documentation, dated 11/13/23, stated here for evaluation 2 days after recurrent fall and right-sided hip pain. Imaging shows periprosthetic fracture. On 11/15/23, the facility's provider evaluated the resident and ordered an xray. A review of the provider orders for Resident #13 revealed this was the only order for an xray. On 11/16/23, Resident #13 was transferred to the hospital for increased pain. A review of hospital documentation noted Resident #13 now had a dislocated right hip, which was temporarily reduced under sedation. The hospital noted the prognosis for this form of injury was poor and recommended palliative/hospice care. The provider note stated the guardian and friend is very clear to say that after the hip injury patient has really not had good quality of life. He/she has been bedbound certainly for the past 1 week since injury, and this is a patient who takes joy in moving around and walking, so this has been very difficult as the patient has been in pain. On 11/17/23, Resident #13 was returned to the facility with orders for comfort care/hospice. On 1/8/24 at 2:15 p.m., in a discussion with a surveyor, the facility's Interim Director of Nursing (DON) confirmed there was no evidence of a facility investigation regarding Resident #13's fall. On 1/9/24 at 10:00 a.m., in an interview with a surveyor, an RN stated Resident #13 was ambulatory prior to the fall. After the fall, he/she had lots of pain. The RN stated an order was obtained for an xray, and the resident went to the hospital and had the xray. The RN stated They sent [him/her] back. My question was why it took so long? On 1/9/24 at 11:00 a.m., in a discussion with the Interim DON, the corporate Marketing Clinical Advisor, and an Administrator from a sister facility, the surveyor discussed that no order for a stat xray was found in Resident #13's physician orders. Resident #13 demonstrated pain the day after the fall, but was not evaluated until 2 days later, at which time he/she was found to have a new fracture of the right hip.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the residents environment was free from the potential risk of accident relating to moving dollies, a floor heater unit, and exit doors and exit pathways for 2 of 2 observations for 2 of 2 days of survey. (1/8/24 and 1/9/24) In addition, the facility failed to provide adequate supervision and complete an assessment of resident capabilities and deficits to determine resident safety for 2 of 2 residents reviewed for smoking (#24, #26). Findings: 1. 0n 1/8/24 at 10:35 a.m., during a facility tour with the Administrator, the following findings of accident hazards were observed: Spring Gardens Unit: > There were 2 rolling moving dollies sitting on the floor in the television/sitting room. > The floor heater unit in the dining room was missing an access panel exposing wiring, hot water pipes and sharp metal. > The exit doors and exit pathways were not cleared of snow, ice and open for use as exits to a public way after a recent snow storm on the Spring Gardens Unit, the North Wind Unit and the Therapy Room. 0n 1/8/24 at 10:35 a.m., in an interview, the Administrator confirmed that there are confused and vulnerable ambulating residents on the unit and the findings are accident hazards. 2. On 1/9/24 from 11:10 a.m. to 11:40 a.m., an environmental tour was conducted with a Maintenance Director and the Marketing Clinical Advisor in which the following accident hazard was observed: > There was a broken outlet in the Spring Gardens Unit hallway by resident room [ROOM NUMBER] exposing wires. On 1/9/24 at 11:40 a.m., in an interview, the Maintenance Director and the Marketing Clinical Advisor confirmed that the broken outlet was an accident hazard and the unit has vulnerable ambulating residents on it. 3. On 1/8/24 at 10:55 a.m., a surveyor observed no staff present in the dining area of the Spring Gardens Unit. The surveyor observed two residents outside of the locked and alarmed door of the dining room. Both residents were observed smoking a cigarette and neither wore a coat. One resident was using a rolling walker. The surveyor went to find a staff person and located a Certified Nursing Assistant (CNA). The surveyor asked if the residents were allowed outside to smoke. The CNA stated he/she was a new employee and only knew one of the residents, and did not know if they were allowed outside to smoke. The residents attempted to re-enter the building and the door alarm sounded. The CNA opened the door but could not silence the alarm. The CNA stated I don't know how to make it stop, and Resident #24 stated, star 812, which was the door code. On 1/8/24 at 11:00 a.m., a surveyor discussed observing Resident #26 smoking with a charge nurse on the Northwind unit. The nurse confirmed the resident did not have permission to smoke. On 1/8/24 at 11:05 a.m., the surveyor discussed the observations with the Interim Director of Nursing (DON), who stated the facility was a no smoking facility and no one had permission to smoke. The Interim DON did not know that the residents had been smoking. A review of Resident #24's clinical record noted an admission date of 9/19/23, and diagnoses including: right-sided hemiplegia, multiple sclerosis, foot drop, muscle weakness, a history of falls and right hip fracture, and nicotine dependence. The Minimum Data Set (MDS) 3.0, admission Assessment, completed 9/23/23, noted the Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident's care plan, last revised 12/27/23, did not include smoking. The clinical record did not include a smoking assessment. The facility's Smoke-Free Center Acknowledgement Form with the admission agreement was not signed. A review of Resident #26's clinical record noted an admission date of 10/25/23, and a diagnosis of a previous fall. The MDS, admission Assessment, completed on 10/29/23, indicated a BIMS score of 15. The resident's care plan initiated on 10/26/23, included: Patient may not smoke per smoking evaluation and non-smoking facility. The facility's Smoke-Free Center Acknowledgement Form with the admission agreement was signed on 10/27/23. Review of the facility's Smoking policy, with a revision date of 8/7/23, stated Process. 1.4.1. The admissions designee will explain the smoke-free policy to new patients and their representative(s). 1.5. The patient/patient representative will sign the Smoke-Free Center Acknowledgement Form. 1.5.1. The Acknowledgement Form will be placed with the admissions paperwork.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observations and interviews, the facility failed to ensure that foods in the kitchenette refrigerators and cupboards we're labeled and securely closed for 1 of 4 kitchenettes (Spring Gardens Unit) for 1 of 2 survey days (1/8/24). Additionally the facility failed to ensure that staff working in the kitchen we're wearing hair protectors and/or facial hair protectors for 1 of 1 kitchen tour on 1 of 2 survey days (1/9/24). Findings: 1. 0n 1/8/24 at 10:30 a.m., a surveyor observed the following in the refrigerator and a cupboard on the Spring Gardens Unit: > The refrigerator had an open pudding cup that was not sealed or labeled with a name. > The bread cupboard had a previously opened unsealed loaf of bread. 0n 1/8/24 at 10:30 a.m., in an interview, a certified nursing assistant (CNA) confirmed the findings. 2. 0n 1/9/24 at 9:40 a.m., a surveyor observed a male kitchen worker with a full beard not wearing a facial hair protector and a female kitchen worker with long hair not wearing a hair protector. 0n 1/9/24 at 9:40 a.m., in an interview, the Food Service Director confirmed the findings. 0n 1/9/24 a 9:45 a.m., in an interview, a surveyor discussed the findings with the Director of Nursing and the Marketing Clinical Advisor.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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Based on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 7 of 7 residents reviewed for activities of daily living (#11, #12, #13, #14, #15, #20, #21). Findings: 1. A review of Resident #11's Certified Nursing Assistant (CNA) documentation of activities of daily living (ADLs) for November 1-30, 2023, revealed multiple days lacking documentation on multiple shifts as follows: Bed Mobility: 22 out of 30 days Behavior Monitoring and Interventions: 21 out of 30 days Eating: 21 out of 30 days Bathing: 23 out of 30 days Dressing: 23 out of 30 days Drinks/snacks other than meals: 23 out of 30 days Hygiene: 23 out of 30 days Toileting: 21 out of 30 days Transfers: 22 out of 30 days Wheelchair mobility - 24 out of 30 days Walking - 24 out of 30 days Mouth care - 21 out of 30 days 2. A review of Resident #12's CNA documentation of ADL's for August 1-31, 2023, revealed multiple days lacking documentation on multiple shifts as follows: Bed Mobility: 23 out of 31 days Behavior Monitoring and Interventions: 24 out of 31 days Eating: 14 out of 31 days Bathing: 26 out of 31 days Dressing: 27 out of 31 days Drinks/snacks other than meals: 25 out of 31 days Hygiene: 25 out of 31 days Toileting: 22 out of 31 days Transfers: 25 out of 31 days Walking - 24 out of 30 days Mouth care - 25 out of 31 days Locomotion on/off unit - 26 out of 31 days Additional review of Resident #12's CNA documentation of ADL's for October 1-31, 2023, revealed multiple days lacking documentation on multiple shifts as follows: Bed Mobility: 18 out of 31 days Behavior Monitoring and Interventions: 20 out of 31 days Eating: 14 out of 31 days Bathing: 18 out of 31 days Dressing: 15 out of 31 days Drinks/snacks other than meals: 17 out of 31 days Hygiene: 18 out of 31 days Toileting: 17 out of 31 days Transfers: 17 out of 31 days Walking - 18 out of 30 days Mouth care - 16 out of 31 days Locomotion on/off unit - 26 out of 31 days Wheelchair mobility - 18 out of 31 days 3. A review of Resident #13's CNA documentation of ADL's for October 20-31, 2023, revealed multiple days lacking documentation on multiple shifts as follows: Bed Mobility: 10 out of 12 days Behavior Monitoring and Interventions: 8 out of 12 days Eating: 6 out of 12 days Bathing: 11 out of 12 days Dressing: 12 out of 12 days Drinks/snacks other than meals: 11 out of 12 days Hygiene: 11 out of 12 days Toileting: 10 out of 12 days Transfers: 11 out of 12 days Walking - 11 out of 12 days Mouth care - 10 out of 12 days Locomotion on/off unit - 26 out of 31 days Wheelchair mobility - 11 out of 12 days 4. A review of Resident #14's CNA documentation of ADL's for October 1-31, 2023, revealed multiple days lacking documentation on multiple shifts as follows: Bed Mobility: 22 out of 31 days Eating: 18 out of 31 days Bathing: 25 out of 31 days Dressing: 26 out of 31 days Drinks/snacks other than meals: 26 out of 31 days Hygiene: 26 out of 31 days Toileting: 26 out of 31 days Transfers: 26 out of 31 days Walking - 26 out of 31 days Mouth care - 21 out of 31 days Wheelchair mobility - 24 out of 31 days 5. A review of Resident #15's CNA documentation of ADL's for October 4-31, 2023, revealed multiple days lacking documentation on multiple shifts as follows: Bed Mobility: 22 out of 28 days Eating: 18 out of 28 days Bathing: 24 out of 28 days Dressing: 24 out of 28 days Drinks/snacks other than meals: 17 out of 28 days Hygiene: 22 out of 28 days Toileting: 23 out of 28 days Transfers: 22 out of 28 days Mouth care - 18 out of 28 days Wheelchair mobility - 23 out of 28 days 6. A review of Resident #20's CNA documentation of ADLs for December 12-13, 2023 revealed a lack of documentation for Bed Mobility, Eating, Bathing, Dressing, Drinks/snacks other thana with meals, Hygiene, Toileting, Transfers, Walking and Wheelchair mobility, for 1 of 2 days the resident resided in the facility. 7. A review of Resident #21's CNA documentation of ADLs for August 12-31, 2023, revealed multiple days lacking documentation on multiple shifts for Bed Mobility, Eating, Bathing, Dressing, Drinks/snacks other thana with meals, Hygiene, Toileting, Transfers, Walking and Wheelchair mobility, each with a total of 12 out of 20 days. In addition, Mouth care lacked documentation for 9 out of 20 days. On 1/9/24 at 1:35 p.m., in an interview with the Marketing Clinical Advisor, the surveyor discussed that CNA documentation reviewed for Residents #11, 12, 13, 14, 15 and #21 contained multiple days and shifts with incomplete ADL documentation. The Marketing Clinical Advisor stated we always strive to be 100% complete, and stated education had been provided regarding recent MDS changes, but it has been hard for the CNA's to complete.

Sept 2023 2 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to ensure a treatment cart containing multiple medicated creams, powders, ointments, syringes, insulin and inhalation treatment medications was locked on 2 of 7 units. (Penobscot House & Spring Gardens) Findings: 1. On 9/6/23 at 10:55 a.m., a surveyor observed an unattended, unlocked treatment cart in the hallway across from the Penobscot House nurses station. The treatment cart contained multiple medicated creams, powders, ointments and syringes. Resident residents and unauthorized personnel were observed crossing through area. A surveyor confirmed the above finding, at the time of the observation with Registered Nurse #1 (RN) at 11:00 a.m., who immediately locked the cart and confirmed that the treatment cart should be locked. 2. On 9/6/23 at 11:48 a.m to 11:56 a.m , a surveyor observed an unattended, unlocked treatment cart in the hallway across from the Spring Gardens nurses station. The cart contained multiple medicated creams, powders, ointments, inhalation treatments, needles, and syringes. There were four residents obsrved in the area during the eight minutes that the treatment cart was unlocked. A surveyor confirmed the above finding, at the time of the observation with LPN #1 who immediately locked the cart and confirmed that the treatment cart should be locked. On 9/6/23 at 2:20 p.m., a surveyor discussed the above findings with the Administrator.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

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Based on observation and interview, the facility failed to post the current daily nurse staffing information between 8/31/23 and 9/6/23. Finding: On 9/6/23 at 7:45 a.m., a surveyor observed that the nurse staffing information was posted on the first floor entrance door. The date on the nurse staffing information was 8/31/23; staffing for 6 days earlier. On 9/6/23 at 11:31 a.m. in an interview with a surveyor, the Regional Administrator confirmed that the nurse staffing had not been posted since 8/31/23.

Jul 2023 3 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure there was sufficient staff available to provide needs for residents receiving Long Term Care in the areas of Activities of Daily Living (showers) for 3 of 7 residents reviewed. (Resident #1, Resident #4, and Resident #5) Findings: On 7/26/23 at 10:06 a.m. during an interview with Resident #10. Surveyor asked if the staff answered his/her call bell in a timely manner? Resident #10 stated Not all the time. They are short changed, especially on the day shift. Surveyor asked are you receiving your weekly bath? No, my bath day is Saturday. Surveyor asked Do staff help you get washed and dressed in the morning? Resident #10 stated No they don't. On 7/26/23 at 10:39 a.m., during an interview with Resident #1, he/she stated they had only had two showers since being there. Stated he/she had not refused a shower or bath but did refuse a hair wash because of a clogged ear. He/She stated that PA (Physicians Assistant) was notified and the wax was removed. Resident #1 stated he/she cannot always get out of bed because it takes two people for the lift. He/She stated they are supposed to have two people (for the lift), You do the math, these people are being asked to do the impossible. He/She stated that sometimes there is only one person for this floor and one upstairs. When asked if there is a long wait time when he/she rang the call bell, he/she stated he/she recently waited over an hour, and it hurts holding in urine and recently had a urinary tract infection. He/she stated that they are a morning person and would prefer care in the morning, however, care often isn't started until 11:00 a.m. and lunch is at 12:00 p.m. On 7/26/23 at 12:05 p.m., during an interview with a staff member #1 she stated We can't always get our baths done with only 1 Certified Nursing Assistants (CNA's) on the floor and 16 residents. We have 7 hoyers/sit stand lifts that requires 2 people. That requires the nurse to help. This floor is not safe with just 1 RN and 1 CNA. On 7/26/23 at 1:15 p.m. during an interview with staff member #2 she stated I'm not able to get residents baths done every week. I would need the nurse to help me especially if they were a hoyer lift. There is only 1 nurse and 1 CNA for 16 residents. I'm still doing my charting for yesterday. The CNA [NAME] indicates that Resident #1s scheduled shower/tub day is every Thursday. The Certified Nursing Assistant (CNA) documentation reviewed from June 2023 to July 2023 indicated that Resident #1 did not receive scheduled showers on 6/1/23, 6/8/23, 6/15/23 and 7/6/23. CNA documentation indicates resident refused his/her scheduled shower on 6/29/23 and 7/27/23. Resident #1 received showers on 6/22/23, 7/13/23 and 7/20/23. The CNA [NAME] indicates that Resident #4s scheduled shower/tub day is every Wednesday. The CNA documentation reviewed from June 2023 to July 2023 indicated that Resident #4 did not receive scheduled showers on 6/7/23, 6/14/23, 6/28/23, 7/5/23 and 7/21/23. CNA documentation indicates resident refused his/her scheduled shower on 7/11/23 and 7/18/23. Resident #1 received showers on 6/20/23 and 7/16/23. The CNA [NAME] indicates that Resident #5s scheduled shower/tub day is every Tuesday. The CNA documentation reviewed from June 2023 to July 2023 indicated that Resident #5 did not receive scheduled showers 7/4/23, 7/11/23 and 7/18/23. Resident #5 received showers on 6/7/23, 6/13/23, 6/20/23, 6/28/23 and 7/25/23. On 7/26/23 at 4:00 p.m. the above findings were discussed with the Administrator, Director of Nursing and Clinical Lead.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Safe Environment (Tag F0584)

Minor procedural issue · This affected multiple residents

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Based on observations and interviews, the facility failed to create a homelike dining experience for residents dining in the dining room by serving their lunch meals on a tray for 1 of 1 meals observed (Spring Gardens Unit). Findings: On 7/26/23, at 12:12 p.m., a surveyor observed 11(eleven) residents eating lunch meals in the dining room/common area. 10 (ten) of the 11 (eleven) resident meals were served on trays. On 7/26/23 at 4:00 p.m., the above findings were discussed with the Administrator, Director of Nursing, and the Clinical lead.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Respiratory Care (Tag F0695)

Minor procedural issue · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to maintain respiratory equipment consistent with the facility's oxygen equipment policy for 1 of 1 Residents reviewed that was receiving oxygen therapy (Resident #1). Finding: On 7/26/23 at 9:57 a.m., Resident #1 was observed to be receiving oxygen via nasal cannula. The oxygen cannula tubing was labeled as changed 7/15/23 at 1:27 p.m. Review of the facility's Oxygen Nasal Cannula Procedure effective 1/1/04, revised 6/15/22 stated, 22. Replace disposable set-up every seven days. Date and store cannula in treatment bag when not in use. On 7/26/23 at 10:30 a.m., the above finding was confirmed with Registered Nurse #1. On 7/26/23 at 4:00 p.m. the above findings were discussed with the Administrator, Director of Nursing and Clinical Lead.

Apr 2023 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a two-person, mechanical lift assist was provided during a transfer for 1 of 5 sampled residents (Resident #1) reviewed for incidents with injuries. The failure resulted in Resident #1 falling during an improper transfer from the bed to the wheelchair. The injury sustained from the fall led to Resident #1's death 7 days later. Findings: On 3/14/23 at 12:56 p.m., a Report of Facility Incident was received from the facility. The facility reported a resident presenting with unexplained bruising, pain, and swelling of the right thigh. On 3/16/23 at 4:24 p.m., the facility submitted a 5 Day Follow Up investigation, dated 3/16/23, in which it stated Investigation found a fall from 3/ 11/23, that was not adequately documented. Fall was identified as the cause of injuries sustained in the original report. [Resident #1] was sent to the hospital upon identification of injury. Hospital sent [Resident #1] back without new orders or further recommendations. No x-rays were obtained during this visit. Due to continuous pain, a physician order was placed by our in-house provider to have the injured area x-rayed. X-ray identified a right femur fracture. Provider was notified of results, and an order was obtained to send to the emergency room for further evaluation. Resident returned from hospital with a hospice referral and orders for morphine. The Follow Up also included a written statement from the CNA #1, who stated he/she worked at another facility and was asked to work the overnight shift. The CNA stated Upon coming in I had never been on that unit, never worked with any of the residents. In the report I was told that [Resident #1] was a 1 (person) assist. I was asked to have people dressed in the morning. I thought that when I was getting [Resident #1] dressed I should try to get him/her up as well as he/she was only 1-assist. So I tried doing a stand pivot from bed to the wheelchair. It was almost a successful transfer, I just needed to scoot him/her back in the wheelchair. He/she started going forward too much so I lowered resident to the floor. When I made sure he/she seemed ok, I called down to the nurse that was covering both my unit and the one downstairs. I relayed exactly what happened, (the nurse) looked him/her over and we got a Hoyer to get him/her up and back into bed. Resident #1's clinical record revealed diagnoses that included: Dementia, Spinal Stenosis, Osteoarthritis, and obesity. A Lift Transfer Reposition Assessment, dated 1/28/23, determined staff were to use a sit to stand lift for transferring [Resident #1]. Resident #1's Minimum Data Set (MDS) 3.0, quarterly review, dated 2/20/23, under section G. Functional Status, G0110, Activities of Daily Living (ADLs) Assistance, B. Transfer: Self Performance is coded 3 - Extensive assistance, resident involved in activity, staff provide weight-bearing support, and 2. Support Provided is coded 3 - Two+ persons physical assist. Resident #1's Care Plan, last revised 6/24/22, indicated under Focus: At risk for decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting. Interventions included: If resident is unable to bear weight, sit to stand is to be used. Certified Nursing Assistant (CNA) [NAME] for Resident #1, section Ambulation/Mobility/Transfers stated Provide resident/patient non ambulatory. Provide resident/patient with 2 assist for bed mobility. CNA documentation of interventions and tasks provided to Resident #1 during March 2023, indicated that Resident #1 received extensive to total assistance with 2-person support provided for transfers. Nursing documentation on 3/13/23 at 1:36 p.m., stated [Resident #1's] representative was notified of the right leg bruising and pain, and with the plan to transfer to the hospital for evaluation. On 3/14/23 at 1:30 a.m., nursing staff noted there were no changes to [Resident #1's] leg since going to the hospital. On 3/15/23 at 11:09 a.m., the record stated stat (urgent) x-rays of right knee and femur this shift. X-ray tech in to do imaging spoke with provider. Order to send to hospital for orthopedic consult. A telehealth provider's note, dated 3/13/23, stated The nurse states that she was trying to do some therapy with the patient when she noticed that [resident] had some swelling of the right thigh area with some bruises that she had not noticed before. There is no documented injury. Unfortunately, the patient is somewhat confused and was unable to determine or knowledge (of) any injury had occurred. The patient would cry and pain with any manipulation of the right leg. The provider ordered transfer to the emergency room for evaluation. Provider's visit note, dated 3/15/23, stated Patient was evaluated in emergency room on Sunday (3/12/23) and x-rays not taken and patient transferred back to facility. Given increased pain and decreased range of motion, stat x-ray obtained at facility and concerns for displaced femur. Discussed with [representative] and will send to emergency room for orthopedic consult. On 3/15/23 at 6:53 p.m., nursing documentation stated X-ray done by (mobile x-ray) this morning, results showed fracture of right femur and malalignment of knee replacement joint. Seen by provider. Order to send to (emergency department) for evaluation by Orthopedics. Returned at 4:30 p.m., resident is on comfort measures, Hospice referral pending. Scheduled Morphine 15 mg (milligram) tablet every 4 hours as needed. On 3/30/23 at 11:00 a.m., in an interview, the surveyor asked the Director of Nursing (DON) if the transfer of Resident #1 had been performed correctly. The DON stated it was her understanding the transfer was completed and the resident slid out of the wheelchair after the transfer was done. The CNA reported to the RN on duty what had happened, and the RN assessed Resident #1 and there had been no complaints. The DON stated CNA #1 had received report from the previous CNA and was told Resident #1 was a 1-person, pivot-transfer assist. The DON stated the RN had not reported the incident. It was not reported until bruising was discovered by another nurse. On 4/6/23 at 12:56 p.m., in a telephone interview with a surveyor, CNA #1 stated he/she was told Resident #1 was a 1-assist. I had one other resident like him/her who was a stand-pivot transfer so I thought ok, I can do this. I almost had him/her in the chair and he/she scooted out a little bit. I lowered him/her down to the floor with his/her pants and at that point, he/she was fine. His/her legs were out in front of him/her. On 4/10/23 at 11:20 a.m., in a telephone interview with a surveyor, the RN on duty at the time of Resident #1's fall stated CNA #1 had notified him/her for help after the fall. The RN stated he/she assessed Resident #1 and did not see signs of injury and there were no complaints of pain. Resident #1 was then assisted back to bed using a Hoyer lift. The RN confirmed the fall had not been reported until the next day when Resident #1 began to demonstrate pain. A review of Resident #1's Certificate of Death, dated 3/20/23, noted the cause of death as Complications of femur fracture due to blunt force injury. The facility's Safe Resident Handling/Transfer Equipment Policy, with a revision date of 10/1/21, stated The Sit to Stand Lift will be used for those patients who meet the following criteria: Can follow simple instructions; Cannot be transferred from sitting to standing comfortably and safely by other transfer techniques; and have some weight bearing ability and head/trunk control.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure resident care needs were correctly communicated and accessible to direct care staff on 3 of 3 units. In addition, the facility failed to ensure licensed nursing staff received training regarding it's Falls Management policy for 1 of 3 staff records reviewed. Findings: 1. On 3/30/23 at 12:30 p.m., the surveyor asked the Director of Nursing (DON) how Certified Nursing Assistants (CNA) who are new to the facility obtain information regarding a resident's care needs. The DON stated CNAs do have the [NAME]. On 3/30/23 at 2:25 p.m., in an interview with a surveyor, CNA #3 was asked how he/she learns about a resident's care needs. CNA #3 stated the information is obtained from the nurse or another CNA when I come in. On 3/30/23 at 2:35 p.m., a surveyor asked CNAs #5 and #6 if they were able to access a resident's care plans or [NAME] from the electronic record at the CNA documentation kiosk. The staff stated they were unable to access this information. On 3/30/23 at 2:50 p.m., in an interview, the surveyor notified the DON that CNA staff were unable to access resident care plans or the [NAME] in the electronic record system. The DON stated she was not aware of this. On 4/6/23 at 12:56 p.m., in a telephone interview with a surveyor, CNA #1 stated he/she was informed by the outgoing shift's CNA that Resident #1 was to be transferred with a sit to stand lift. The surveyor asked CNA #1 if he/she could access Resident #1's care plan or [NAME] in the electronic medical record. CNA #1 stated I wasn't able to get into their system to chart. I couldn't get into their computer to verify and I wasn't able to see what (Resident #1) needed. The surveyor asked if, when the system is opened, can the CNA see the [NAME]? CNA #1 stated It only asks for what you did, and does not provide information from the plan of care when the program is opened. On 4/18/23 at 10:10 a.m., in an interview with a surveyor observed CNA #2 demonstrate accessing a resident's care plan or [NAME] in the electronic medical record. CNA #2 opened the electronic records using an IPad. Several different residents were viewed. There were no care plans or [NAME] information available to view. CNA #2 stated staff rely on paper resident assignment sheets, but they are not regularly updated. CNA #2 then noted 3 residents on the assignment sheet with inaccurate information concerning the amount of assistance required from staff. On 4/18/23 at 10:20 a.m., in an interview with a surveyor, CNA #7 was asked to access a resident's care plan or [NAME] using the IPad. CNA #7 stated he/she was able to do this, however when attempted, there was no care plan or [NAME] information available. This was noted with several attempts to view different residents. On 4/18/23 at 10:40 a.m., in an interview with a surveyor, CNA #8 was asked how staff learn what a resident's care needs are. The CNA stated We find out on our own. Therapy comes and assesses them and will tell us what we need to do, then we will pass it on and it's communicated shift to shift. On 4/18/23 at 11:55 a.m., in an interview with a surveyor, CNA #4 was asked to access a resident's care plan or [NAME] on a desk top computer. CNA #4 attempted to do this but was not successful and stated I don't know how to pull it up. On 4/18/23 at 12:00 p.m., in an interview with a surveyor, CNA #11 was asked to access a resident's care plan or [NAME]. CNA #11 stated he/she knew how to do this, but when two different residents' information was accessed, the tabs would not open. CNA #11 stated staff rely on communication with other staff for resident care information. CNA #11 stated the information could also be added to the paper CNA assignment sheets, though they're never updated. On 4/18/23 at 2:10 p.m., a surveyor discussed with the Administrator, concerns with CNA staff lacking access to resident care plans and [NAME] information required to provide care. 2. On 3/30/23 at 11:00 a.m., in an interview with a surveyor, the Director of Nursing (DON) discussed an incident involving a resident falling and sustaining a fracture. The DON stated the CNA reported the incident to Registered Nurse (RN) #1. RN #1 assessed the resident and found no obvious injuries or complaints of pain. The incident was not reported to the oncoming shift, the provider or family, and was not documented as per the facility's policy. On 4/10/23 at 11:10 a.m., in a telephone interview with a surveyor, RN #1 confirmed it had been an error to not report the incident involving a resident falling. The RN stated he/she had assessed the resident and did not find any obvious injury. The surveyor asked if the nurse had received training regarding the facility's fall management policy. RN #1 stated he/she had not received training regarding the policy and did not learn the facility had a policy until after the incident. A review of the facility's Fall Management Policy, with a revision date of 6/15/22, stated on page 2, section 5. Post-Fall Management: 5.4: The patient's representative will be notified of the fall and any follow-up treatment needed. 5.5: Document circumstances of the fall, post-fall assessment, and patient outcome: 5.5.1: As a new event in the PointClickCare Risk Management portal; 5.5.2: Change of Condition UDA; 5.5.3: on the 24 hour report. On 4/18/23 at 12:50 p.m., a surveyor reviewed the employee file for RN #1 and could not locate evidence of training regarding the facility's fall management policy. The Director of Nursing confirmed the finding at this time.

Feb 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to review and revise the care plan to reflect the current needs of 1 of 2 residents reviewed for falls sustaining fractures. (#2) Finding: Resident #2 was admitted to the facility on [DATE] with diagnosis of Cardiovascular accident with right side hemiparesis requiring assistance for transfers. On 1/19/23 Resident #2 sustained an unwitnessed fall while attempting to self transfer resulting in a right clavicle shaft fracture with malalignment. Physician order dated 1/24/23 directed staff to, No ROM (range of motion) out from body RIGHT. OK internal/external rotation RIGHT, OK elbow wrist finger ROM. Ice to shoulder and sling to R arm x4-6 weeks. An additional physician order dated 2/9/23 states, Ortho F/U at PBMC: RT arm can come up to 90 degrees. Active assistive ROM, Abduction, forward flexion. Full internal and external rotation of RT arm at side. No progressive resistive exercises. On 2/21/23 review of Resident #2's care plan, did not include interventions to address the limitations and/or restrictions for the fractured clavicle. On 2/21/23 at 11:00 a.m., during an interview, the above concern was discussed with the Director of Nursing.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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Based on record reviews, interview and policy and procedure review the facility failed to follow their 'Neurological Evaluation policy and procedure for completing neurological checks for 2 of 2 residents reviewed for falls (#1 and #2). Findings: Facilities Policy for Fall Management, revised on 6/15/22 states, Post-Fall management: 5.3 Any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neuro check per policy. Facilities Policy for Neurological Evaluation, revised on 6/1/21 states, Neurological evaluation will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluations will be performed: every 15 minutes x two hours, then every 30 minutes x two hours, then every 60 minutes x four hours, then every 8 hours until at least 72 hours has elapsed. 1. Resident #1's electronic clinical record, under progress notes, documents that on 1/11/22, 1/24/22, 1/25/22, 1/29/23, 1/31/23 and 2/2/23 Resident #1 had unwitnessed falls. Further review of the clinical record was completed and there was no evidence of completed neuro checks per the Fall Management and Neurological Evaluation policy and procedure in the electronic clinical record or the paper record for the above dated unwitnessed falls. In addition, Resident #1 had 2 other unwitnessed falls on 1/8/23 and 1/17/23, review of the Neurological evaluation flow sheets, started on 1/8/23 at 7:45 p.m., and 1/17/23 at 4:30 p.m., both lacked evidence of neuro checks every 8 hours until at least 72 hours has elapsed. 2. Resident #2's electronic clinical record, under progress notes, documents that on 1/19/23 at 7:35 a.m., Resident #2 Fall on floor next to bed, attempted self transfer to commode at the foot of the bed. Didn't call staff for assistance to stand and pivot .Crying out in pain to RT(right) shoulder, arm and rib cage areas, guarding observed. Bruise to RT elbow observed, ice applied to area with some relief. Review of the Neurological evaluation flow sheet, started on 1/19/23 at 7:35 a.m., lacked evidence of nursing staff evaluating resident #2 every 8 hours from 1/19/23 at 2330 through 1/20/23 at 2330. On 2/21/23 at 2:14 p.m., the above concerns were discussed with the Director of Nursing.

Jan 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to issue written bed hold notices to include cost of care to the resident and /or legal representative for 1 of 3 sampled resident reviewed for transfer to an acute care hospital. (Resident #1). Findings: Resident #1 was originally admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus II, and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score or 9 of 15 indicating moderate cognitive impairment. Review of Resident #1's complete clinical record revealed he/she was transported to an acute care hospital and subsequently admitted on [DATE], 11/30/22 and 12/22/22. Further review of Resident #1's clinical record lacked evidence that the resident representative received a written copy of facility's bed hold notice. During an interview on 1/31/23 at 3:36 p.m., Corporate Director of Nursing confirmed that Resident #1's resident representative was not provided a written copy of bed hold notice for the above-named dates.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, and facility policy, the facility failed to update and include interventions on the resident's current comprehensive care plan for the areas of falls and diabetes for 1 of 3 residents observed for care plans (Resident #3). Findings: Review of facility policy Person-Centered Care Plan revised 10/24/22 states The Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident. That includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Resident #1 was originally admitted to the facility on [DATE] with diagnoses to include uncontrolled Diabetes Mellitus II, and dementia. Review of Resident #1's entire clinical record revealed he/she had falls on 11/22/22 and 1/17/23 and was transferred to an acute care hospital for hypoglycemia on 1/17/23 and on 1/24/23 for hyperglycemia. Review of Resident #1's care plan initiated on 8/31/22, most recently updated on 1/28/23 lacked evidence that his/her care plan was updated with new goals and interventions in the area of falls and hyper/hypoglycemic events. During an interview on 1/31/23 at 3:36 p.m. the Corporate Director of Nursing (CDON) indicated that care plans should be updated with new goals and interventions after a fall or diabetic event. At this time CDON confirmed that Resident #'1's care plan was not updated with new goals and interventions for the above concerns.

Mar 2022 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility's interdisciplinary team (IDT) failed to determine if it was clinically appropriate for a resident to keep medications at bedside and self-administer medications for 1 of 18 Residents reviewed during the final stage of the survey process (Resident #32). Finding: On 2/28/22 at approximately 2:00 p.m., during the initial interview with Resident #32, the surveyor observed on the resident's bedside table 3 bottles of eye drops, (2.5 Latanoprost, Timolol Maleate 0.5%, and Dorzolamide 2%) with a pharmacy label on the bottle and a bottle of Aleve pain reliever. Resident #32 stated [he/she] has been putting [his/her] own eye drops in their eyes since [he/she] has been here (admitted on [DATE]). During review of his/her clinical record, the surveyor could not find evidence that the facility's interdisciplinary team determined it was clinically appropriate for Resident #32 to keep medications at bedside and self-administer the medication. On 3/1/22 at 8:30 a.m. during an interview with the Center Nurse Executive (CNE), she stated that Resident #32 had a Medication Self-Administration evaluation completed on 2/28/22 at 3:03 p.m. The CNE and the surveyor confirmed that Resident #32 had the three bottles of eye drops and a bottle pain reliever on his/her bedside table. On 3/2/22 at approximately 12:00 p.m. the surveyor confirmed the above finding during an interview with the Clinical Lead for corporate. Resident #32 did not have a Medication Self-Administration evaluation and the IDT team did not determine if it was clinically appropriate for Resident #32 to keep medications at bedside and self-administer the medications when he/she was admitted to the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to conduct a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days after a resident experienced a significant change of condition and hospice services were initiated for 1 of 1 sampled residents receiving hospice services (Resident #24). Finding: On 3/2/22, during a review of Resident #24's clinical record, a surveyor noted the resident received hospice services, initiated on 1/31/22. On further review, the surveyor noted the most recent Minimum Data Set 3.0 (MDS 3.0) assessment was a quarterly assessment completed on 1/4/22. The most recent comprehensive MDS was dated 10/4/21 and no comprehensive MDS 3.0 assessment was completed with 14 days of the initiation of hospice services. On 3/2/22 at 12:17 p.m., in an interview with the Clinical Lead for Genesis Maine, the surveyor confirmed a significant change of condition MDS 3.0 was not completed in a timely manner.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on observations, interviews and review of the facility menu, the facility failed to insure that the menu plan provided sufficient vegetables to meet the minimum daily food requirements for adults on 1 of 4 days of survey (2/28/22). Finding: On 2/28/22 at 12:05 p.m., a surveyor observed the lunch meal service. During this meal service it was noted the lunch did not provide a vegetable. Review of the facility menu and during an interview with the Food Service Director (FSD) it was determined the regular house diet was based on a 2000 calorie diet which required 2 ½ cups of vegetables per day as required by the National Dietary Guidelines. The menu for the week of 2/27/22 was reviewed and indicated that the facility failed to provide vegetables for lunch. On 2/28/22 at 12:05 p.m. the surveyor confirmed during an interview with the FSD that the menu did not have the required vegetables per day as required and the residents were not served any vegetables with their lunch meal on 2/28/22.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observations and interviews the facility failed to serve food in a sanitary manner during meal service and a meal preparation observation on 1 of 4 days of survey (2/28/22). Finding: On 2/28/22 at 12:05 p.m. during the lunch meal tray service observation, a surveyor observed the cook plating the lunch meal with ungloved hands. As he was plating the meal he turned around and opened the oven door, he wiped his hands on his shirt and grabbed the meal slips. After plating the meal, using his ungloved contaminated hand he then reached in a bowl of a green garnish and sprinkled it on the potatoes and meat. The surveyor asked the cook to stop and explained the observation of using bare hands to handle the garnish, that plate of food was discarded. On 2/28/22 at 12:05 p.m. a surveyor confirmed the above finding with the cook at the time of the observation. On 3/1/22 at 7:30 a.m., the surveyor discussed the observation with the Food Service Director who acknowledged the garnish was not handled in a sanitary manner.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on review of the facility Infection Prevention and Control Program (IPCP) policies and procedures and interviews, the facility failed to conduct an annual review of their IPCP. Finding: On 3/2/22 at 2:00 p.m., a review of the facility's Infection Prevention and Control Program (IPCP) was completed and discussed with the Infection Preventionist (IP). There was no evidence that the IPCP had been reviewed annually. On 3/2/22 at 2:30 p.m., in an interview with the IP, she stated she was unable to find evidence of the IPCP being reviewed. On 3/3/22 at 10:00 a.m., in an interview with the Center Nurse Executive, she confirmed with the surveyor that she was unable to find evidence that an annual review of the facility's IPCP done.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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2. On 2/28/22 at 12:51 p.m., a surveyor observed the lunch meal service in the Windward Center dining room and noted a Licensed Practical Nurse standing beside Resident #13 to assist with feeding. The surveyor observed this practice for approximately 5 minutes and intervened. Also observed during this meal observation was Resident #9 seated at a dining room table, wearing street clothes covered by a full length nightgown. A Certified Nursing Assistant stated to the surveyor that she couldn't find an available clothing protector and used the nightgown instead. On 3/1/22 at 10:49 a.m., the surveyor discussed the findings with the Center Nurse Executive, who confirmed that feeding residents while standing and using a nightgown as a clothing protector was not treating residents in a dignified manner. Based on observation and interview, the facility failed to promote care for a resident in a manner that maintained the residents' dignity and/or respect when staff failed to cover a urinary drainage bag that was visible to other residents and visitors during 1 of 1 days of survey (Resident #34). Additionally, the facility failed to ensure residents received feeding assistance and provided appropriate clothing protection in a dignified manner for 2 residents during 1 of 6 dining observations (Residents #9 and #13). Findings: 1. On 2/28/22 at 12:00 p.m., a surveyor observed Resident #34 sitting in the Spring Garden dining room, having lunch and talking to a resident and staff member at his table. Observed that Resident #34's had an uncovered urinary drainage bag, which contained urine and was hanging on a rung of his chair. On 12/28/22 at 12:05 p.m., in an interview with the Spring Garden Charge Nurse, she confirmed with the surveyor that the drainage bag was uncovered. On 2/28/22 at 12:10 p.m., observed the Spring Garden Charge Nurse cover the drainage bag as Resident #34 was leaving the dining room.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observations, and interviews, and instructions for storage of lorazepam oral concentrate solution, the facility failed to adequately store controlled substances in separately locked, permanently affixed compartments in 2 of 3 medication room refrigerators (Spring Garden Unit, and North Wind Unit) for 1 of 2 days of medication storage observations (3/1/22). Findings: 1. On 3/1/22 at 12:23 p.m., in the medication room unlocked refrigerator on North Wind Unit, the following observation was made: A 30 milliliter (ml.) bottle of lorazepam oral concentrate solution, a schedule IV controlled substance, 2 milligram (mg.)/ml. dosage, was available for use in a locked box that was removable in an unlocked refrigerator. The lorazepam oral concentrate solution, a schedule IV controlled substance, was not in a permanently affixed compartment in the refrigerator. On 3/1/2022 at 12:23 p.m., the medication storage finding for North Wind Unit was confirmed with a surveyor in an interview with the Licensed Practical Nurse on North Wind Unit. 2. On 3/1/22 at 2:09 p.m., in the medication room unlocked refrigerator on Spring Garden Unit, the following observation was made: A 30 ml. bottle of lorazepam oral concentrate solution, a schedule IV controlled substance, 2 mg./ml. dosage, was available for use in a locked box that was removable in an unlocked refrigerator. The lorazepam oral concentrate solution, a schedule IV controlled substance, was not in a permanently affixed compartment in the refrigerator. On 3/1/22 at 12:23 p.m., the medication storage finding for the Spring Garden Unit was confirmed with a surveyor in an interview with the Registered Nurse on the Spring Garden Unit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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4. On 2/28/22 at 1:06 p.m., in Resident #248's room on the North Wind Unit, the following lunch meal observation was made. Resident #248 received the main meal served on a white plate, with a slice of white bread, covered with white turkey and off white colored gravy with a side of white mashed potatoes with off white gravy. There was a scant sprinkle of parsley on the plates. Based on observations and interview the facility failed to provide attractive meals, during 1 of 4 days of survey (2/28/22), by serving foods that were all the same color. Findings: 1. On 2/28/22 at 12:05 p.m. during initial tour of the kitchen the meal distribution tray service was observed. The meal being served for lunch was an open-faced hot turkey sandwich. The cook plated a slice of white bread; he then placed a piece of white turkey meat on each piece of bread, a scoop of mashed potatoes in each plate and then ladled off-white gravy over the open-faced hot turkey sandwich and the mashed potatoes. On 2/28/22 at 12:10 shortly after the initial observation the surveyor confirmed with the Food Service Director at this time that the meal was all white placed on a white dinner plate. 3. During a dining observation on Windward Center on 2/28/22 at 12:51 p.m., a surveyor noted the lunch meal consisted of a slice of turkey served on a slice of white bread with a white gravy on top and mashed potatoes with a white gravy, all on a white plate). There was a small garnish of parsley on each plate. Those residents requiring pureed food also received a meal with no color variation except with small specks of the garnish pureed in with the food. 2. On 2/28/22 at 12:20 p.m., in the main dining room on the Spring Garden Unit, the following lunch meal observations were made. The Residents that received the main meal were served on a white plate, with a slice of white bread, covered with white turkey and off white colored gravy with a side of white mashed potatoes with off white gravy. There was a scant sprinkle of parsley on the plates.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Special Focus Facility, 1 harm violation(s). Review inspection reports carefully.
• 76 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade F (3/100). Below average facility with significant concerns.
• 74% turnover. Very high, 26 points above average. Constant new faces learning your loved one's needs.

Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.

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About This Facility

What is Windward Gardens's CMS Rating?

WINDWARD GARDENS does not currently have a CMS star rating on record.

How is Windward Gardens Staffed?

Staff turnover is 74%, which is 27 percentage points above the Maine average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 73%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Windward Gardens?

State health inspectors documented 76 deficiencies at WINDWARD GARDENS during 2022 to 2025. These included: 1 that caused actual resident harm, 69 with potential for harm, and 6 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Windward Gardens?

WINDWARD GARDENS is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 58 certified beds and approximately 63 residents (about 109% occupancy), it is a smaller facility located in CAMDEN, Maine.

How Does Windward Gardens Compare to Other Maine Nursing Homes?

Compared to the 100 nursing homes in Maine, WINDWARD GARDENS's staff turnover (74%) is significantly higher than the state average of 46%.

What Should Families Ask When Visiting Windward Gardens?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.

Is Windward Gardens Safe?

Based on CMS inspection data, WINDWARD GARDENS has documented safety concerns. The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 0-star overall rating and ranks #100 of 100 nursing homes in Maine. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Windward Gardens Stick Around?

Staff turnover at WINDWARD GARDENS is high. At 74%, the facility is 27 percentage points above the Maine average of 46%. Registered Nurse turnover is particularly concerning at 73%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Windward Gardens Ever Fined?

WINDWARD GARDENS has been fined $7,901 across 1 penalty action. This is below the Maine average of $33,158. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Windward Gardens on Any Federal Watch List?

WINDWARD GARDENS is currently on the Special Focus Facility (SFF) watch list. This federal program identifies the roughly 1% of nursing homes nationally with the most serious and persistent quality problems. SFF facilities receive inspections roughly twice as often as typical nursing homes. Facilities that fail to improve face escalating consequences, potentially including termination from Medicare and Medicaid. Families considering this facility should ask for documentation of recent improvements and what specific changes have been made since the designation.

Facility Details

Beds: 58
Avg. Residents: 63
Occupancy: 109.7%
Ownership: For profit - Limited Liability company
Chain: GENESIS HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
High Turnover: -10
1 Actual Harm citation: -5
76 Deficiencies: -10
Fines ($7,901): -2
Special Focus Facility: -20
Final Score: 3/100

Nearby Alternatives

BREAKWATER COMMONS 1-star

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 205180