Based on review of the Facility Reported Incident (FRI), 5-day incident follow-up, facility's abuse prohibition policy, and investigative report, the facility failed to ensure that 1 of 6 sampled residents was free from verbal abuse. (#1) Finding: On 6/13/2025 the Division of Licensing and Certification (DLC) received a facility reported incident (FRI) reporting that on 6/12/25 two CNAs were alleged to have verbally abuse a resident [Resident #1], the incident was reported to the facility by [non-facility member] who overhead what was said while using a video and audio communication app. On 6/17/25 the DLC received the facility 5-day follow-up to the 6/13/25 incident the follow-up stated that the two CNAs involved were interview and admitted to saying to Resident #1 I hope you are not saying inappropriate things to my peers, you will be in big trouble. And if you touch me, I will bite you. The two CNAs also admitted to saying things such as when Resident #1 asked the year they stated 2022 and told Resident #1 your [spouse] is dead. When Resident #1 asked to go the bathroom Resident #1 was told to go in your pants. Additionally, the follow-up states that Resident#1 did not recall any of the interactions with the CNAs, and the two CNAs involved were terminated from employment. A review of the facility investigation states that Resident #1 has a history of being sexually inappropriate and has dementia-severe with psychotic disturbance diagnosis and does exhibit behaviors at times. The facility investigation confirms that the two CNAs admitted to making the statements to Resident #1. The investigation concluded that the CNAs violated: professional behavior, dignity of a resident, resident right to feel safe in environment, and compassionate care. A review of the facility's Abuse Prohibition Policy with a last review date of 3/6/25 states The resident has the right to be free from abuse and the policy/procedure includes information regarding verbal abuse. Resident #1 was not able to be interviewed, however; a clinical record review does not reveal any negative outcome because of the above interactions with the two CNAs. On 7/1/25 at approximately 9:00 a.m., in an interview with the Director of Nursing, the surveyor discussed that Resident #1 was verbally abused by two CNAs employed at the facility. At the time of the survey, the facility presented the surveyor with corrective action taken to address this incident. The facility was determined to be in past non-compliance after the review and verification of the implemented corrective actions. The facility conducted a facility wide education on Compassionate Dementia Care and Abuse Training. Completed a review of staff hired during the month of June to ensure that all staff have received abuse training during their orientation process. The CNAs involved were terminated from duty. Observations of Resident #1 find that [he/she] is well-groomed and interactions with staff are courteous and professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 2 of 28 sampled residents (#10 and #19). Findings: 1. On 3/27/23 at 11:12 a.m., during an interview, Resident #10 stated he/she is supposed to have a team meeting, it's been a long time since I've had one and only one as far as I can remember. During a review of Resident 10's medical record, the surveyor noted the Minimum Data Set (MDS) Significant Change in Status assessment dated [DATE]. The clinical record lacked evidence that a care plan meeting was held by the IDT for the 1/12/23 assessment. 2. During a review of Resident 19's medical record, the surveyor noted the Minimum Data Set (MDS) Quarterly Review assessments, dated 5/10/22 and 9/27/22. The clinical record lacked evidence that a care plan meeting was held by the IDT for the above assessments. On 3/29/23 at 9:38 a.m., during an interview with the Licensed Social Worker Conditional the above findings were confirmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that the resident's environment was free of accident hazards relating to patient lift and a hallway bumper guard for 1 of 1 facility tour, for 1 of 3 units(Cottage) on 1 of 3 days of survey. (3/27/23) In addition, the facility failed to ensure that the resident's environment was free of accident hazards relating to a string of lights in a resident's room (Windsor 2 Unit) for 1 of 3 days of survey (Resident #20). Findings: 1. On 3/27/23 at 11:59 a.m., a surveyor and the Nurse Manager observed a Reliant 450 patient lift which was missing one of the safety clips on the sling arm. Additionally, a surveyor and the Nurse Manager observed an approximately 7 foot long bumper guard, in the hallway by resident room [ROOM NUMBER], that was missing the cover and both edge caps exposing sharp metal edges. At this time, in an interview, the Nurse Manager confirmed that these two issues were accident hazards to the residents. On 3/27/23 at 2:30 p.m., in an interview, a surveyor discussed the findings with the Administrator. 2. On 3/27/23 at approximately 3:09 p,m., a surveyor an the Director of Nursing observed a string of decorative battery operated lights in Resident # 20s room, the string of lights were tucked under the metal rail for the privacy curtain at the ceiling level, the lights ran in the air across the residents bed in a downward manner (at a height the resident could have reached) and then were fastened to the wall the length of the bed (the bed was pushed against the wall). The other end of the string of lights was hanging from the ceiling to the floor. These string lights presented a potential accident hazard. The Director of Nursing immediately removed the string lights, and confirmed the potential for an accident hazard.

2. On 3/27/23 at 1:35 p.m., a surveyor observed an unlocked unattended treatment cart int the hallway of Windsor 1 unit. There were two residents sitting in the hallway next to the cart. The cart contained insulin, heparin with needles, various prescription creams, and dressing supplies. On top of the cart was a tupperware type container with a cover that contained lancets. On 3/27/23 at 1:35 p.m., this finding was confirmed with the Nurse Manager. Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 2 units, (Windsor 1 unit) and failed to ensure that medications were stored properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications, on 1 of 3 days of survey. (Windsor 1 unit) Findings: 1. On 3/27/23 at 9:42 a.m., during observation of the Windsor 1 unit treatment cart with the Licensed Practical Nurse (LPN), the following was observed: - Novolog insulin labeled with an open date of 2/4/23 with manufacturer instructions to Use within 28 days after opening. - Levemir insulin flex pen opened and not labeled with a date of opened or expiration. Manufactures instructions for unused Levemir should be thrown away after 42 days. - 3 Semglee insulin pens, one opened and not labeled with a date of opened or expiration and 2 pens not opened but stored in the cart. Manufactures instructions to store unused pens between 36°F and 46°F until first use, once opened use within 28 days. On 3/27/23 at 11:18 a.m., during an interview, the Registered Nurse manager confirmed the above findings.

Based on observations, interviews, the facility's Dish Machine Use - Policy Interpretation and Implementation, the facility's Refrigerators and Freezers - Policy Interpretation and Implementation, the facility's Main Kitchen Refrigerator/Freezer Temperature Logs and the facility's Sanitation Compliance- Dish Machine policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors, an exhaust vent, air intake vents, a blender, a slicer, and a floor mixer. The facility also failed to ensure products in the reach-in refrigerator, the walk-in refrigerator, the walk-in freezer, and a unit refrigerator(Cottage) were labeled and dated, and failed to label whipped topping with a thaw date. Additionally, the facility failed to monitor temperatures of the milk walk-in refrigerator, cook reach-in refrigerator, meat walk-in refrigerator, walk-in freezer, ice cream freezer. Further, the facility failed to monitor the dishwasher wash and rinse cycle temperatures for certain dates. This occurred for 2 of 2 tours on 1 of 1 survey days (3/27/23) in the kitchen and on 1 of 3 units(Cottage). Findings: Review of the facility's Dish Machine Use - Policy Interpretation and Implementation noted under: 7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. Review of the facility's Refrigerators and Freezers - Policy Interpretation and Implementation noted under: 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. Monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable. 4. Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates, dates of delivery, will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and used by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring foods items in pantry, refrigerators, and freezes are not expired or pass perish dates. On 3/27/23 from 9:15 a.m. to 9:55 a.m., a kitchen tour was conducted with the Food Service Director in which the following findings were observed: 1. > There was food debris and trash on the floor in the dish room around all the floor edges. > There was food debris and trash on the kitchen floor around all the edges and under equipment and shelves. > The exhaust vent in the dish room had chipped/missing paint and was rusty. > There were 8 air vents in the kitchen that were dusty/dirty and had rust on them. > The blender had dried food particles and dried liquid residue on it. > The slicer had dried food particles on the blade and blade shroud/cover. > The floor mixer had dried food particles on the mix arm and the base. > The reach-in refrigerator had two, 16 ounce bags of whipped topping that had no thaw date of them. The label noted that the product was only good for 14 days after thaw date. > The walk-in refrigerator had thirteen, 16 ounce bags of whipped topping that had no thaw date of them. The label noted that the product was only good for 14 days after thaw date. > The walk-in freezer had one, open to the air, package of fish patties that was not dated or labeled and one large bag of opened scallops that was not dated and labeled. Additionally, there was a large chunk of ice built up on a large bucket of ice cream and a large one inch thick slab of ice built up on a box of cookie dough. On 3/27/23 at 9:55 a.m., in an interview, the Food Service Director confirmed the findings. 2. > The Cottage Unit refrigerator had one open16 ounce whipped topping package with no thaw date on it. The label noted that the product was only good for 14 days after thaw date. On 3/27/23 at 12:17 p.m., in an interview, the Nurse Manager confirmed this finding. 3. Main Kitchen Refrigerator/Freezer Temperature Logs-- reviewed by a surveyor on 3/27/23 at 2:04 PM January 2023 was missing temperatures for the 28th, 29th, 30th and 31st for the evening check of the milk walk-in refrigerator, the cook reach-in refrigerator, the meat walk-in refrigerator, the walk-in freezer, and the ice cream freezer. March 2023 was missing temperatures for the 25th and 26th for the morning and evening checks for the milk walk-in refrigerator, the cook reach-in refrigerator, the meat walk-in refrigerator, the walk-in freezer, and the ice cream freezer. > Sanitation Compliance- Dish Machine temperatures reviewed by a surveyor on 3/27/23 at 2:04 PM The wash temperature was not monitored on 3/12/23 for morning shift. The wash and rinse temperatures were not monitored on 3/26/23 for the morning and evening shifts. The wash and rinse temperatures were not monitored on the morning shift for 1/28/23, 1/29/23 and 1/30/23. The wash and rinse temperatures were not monitored on the morning shift and the evening shift for 2/25/23 to 2/28/23. On 3/28/23 at 8:34 a.m., in an interview, the Administrator confirmed the findings. On 3/28/23 at 8:50 a.m., in an interview, the Food Service Director confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on 3 of 3 units (Windsor I, Windsor II and Cottage) for 1 of 1 environmental tour. Findings: On 3/29/23 from 8:40 a.m. to 9:30 a.m., a facility tour was conducted with the Maintenance Director in which the following were observed: Windsor I Unit: > Resident room [ROOM NUMBER]-1 - A commode bucket was on the floor in the bathroom. > Resident room [ROOM NUMBER]-1 - The room had dried liquid residue on the floor between the bed and the bathroom door. > Resident room [ROOM NUMBER]- A commode bucket was on the floor in the bathroom. > Resident room [ROOM NUMBER] - A commode bucket was on the floor in the bathroom. > Resident room [ROOM NUMBER]- The wall was gouged, with sheet rock exposed, next to the recliner on the left side of the room. > Resident room [ROOM NUMBER] - A bed pan, only half covered with a plastic bag, was stored on the back of the toilet. Windsor II Unit > Resident room [ROOM NUMBER] - The nightstand had chipped/missing laminate creating an uncleanable surface. > Resident room [ROOM NUMBER]- The nightstand and the foot board for bed 1 had chipped/missing laminate creating uncleanable surfaces. > Resident room [ROOM NUMBER]- The commode chair had brown fecal like substances on the front of the seat area. > Resident room [ROOM NUMBER] - The armoire near the door entrance had chipped/missing laminate on the bottom two drawers. The base board heating unit had chipped/missing paint creating uncleanable surfaces. > Resident room [ROOM NUMBER] - The right and left wheelchair arm rests were ripped/cracked. Cottage Unit > Resident room [ROOM NUMBER] - The bathroom baseboard heater had chipped/missing paint and was rusty. > Resident room [ROOM NUMBER] - The room door and door frame had chipped/missing paint. There were holes in wall with unpainted areas over Bed 1. The bathroom base board heating unit was rusty. > Resident room [ROOM NUMBER] - The bathroom base board heating unit was rusty. > The whirlpool room wheelchair scale had a ripped/missing section of non-skid surface, creating an uncleanable surface. On 3/29/23 at 9:30 a.m., in an interview, the Maintenance Director confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record review, observations, and interviews, the facility failed to follow their own policy and failed to provide an environment to help prevent the development and transmission of disease and infection related to organisms colonized in urine. In addition, the facility failed to implement Infection Control Contact Precautions for a 2 of 2 residents (Resident #10 and #43) diagnosed with Extended Spectrum Beta-Lactamase (ESBL- a Multidrug-Resistant Organism) for 2 of 3 days of survey. (3/27/23 and 3/28/23). This has the potential to affect all 16 residents on the Windsor 1 unit. Findings: Review of the facilities policy Multidrug-Resistant Organisms (MDROs) dated 8/2019 states, Enhanced infection control precautions: use of contact precautions. Implement contact precautions routinely for all residents colonized or infected with a target MDRO . modify contact precautions to allow MDRO colonized/infected residents whose site of colonization or infection can be appropriately contained and who can observe good hygiene practices to enter common areas and participate in Group activities. When active surveillance cultures are obtained as part of the intensified MDRO control program, implement contact precautions until the surveillance culture is reported negative for the target MDRO. On 3/27/23 at approx. 9:30 a.m., upon entrance to Windsor 1 unit, 2 surveyors observed Transmission Based Precautions (TBP), Contact Precautions posted on room [ROOM NUMBER]-1 (Resident #45) and 107-1 (Resident #43) with available Personal Protective Equipment (PPE) near the entrance. On 3/28/23 at 9:16 a.m., observation of medication pass on Windsor 1 unit with the Certified Medication Technician (CNA-M) for room [ROOM NUMBER]-1 (Resident #10). At this time, Resident #10's room did not display any contact precautions posted or PPE available for staff. On 3/28/23 during review of Resident #10's care plan, it indicated the resident has an MDRO which was colonized stating, The resident has ESBL - colonization of urine Date Initiated: 03/28/23 Revision on: 03/28/23. The resident will be free from no s/sx of acute infection in spite of colonization of (SPECIFY SITE). Date Initiated: 03/28/23 Target Date: 10/18/22. CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. Date Initiated: 03/28/23 o Educate the resident/family/caregivers regarding the importance of hand washing. Use antibacterial soap and disposable towels. Wash hands immediately after ADLs, care tasks and activities. Date Initiated: 03/28/23. Additional review of lab results indicated Resident #10 had urine cultures on both 2/4/23 and 3/3/23 with microbiology results of ESBL present. On 3/28/23 at 1:42 p.m., observation of Resident #10's room door frame to now have a small 3x5 magnet stating, stop see nurse before entering. At this time Surveyor asked the Certified Nurses Aid (CNA) what the sign is for. The CNA stated, I'm not sure. I think it's for oxygen, but they have signs for oxygen. I don't know. She then walked into nurse's station and asked the Licensed Practical Nurse (LPN) what the stop sign was for. The LPN stated [Resident #10] had an infection. The CNA then asked the LPN, is it the urine thingy? The LPN responded with yes, she then looked into the medical record and stated to both the surveyor and the CNA that [Resident #10] has ESBL in his/her urine. Surveyor asked the CNA if she was aware that Resident #10 had ESBL in the urine. CNA shrugged her shoulders then stated, Well, I don't usually work down here. Surveyor asked if she had worked with Resident #10 today. CNA stated, yes, but I didn't do anything with her urine. At this time both the surveyor and the LPN walked into hallway. The LPN stated only Resident #10 and Resident #43 (room [ROOM NUMBER]-1) have ESBL in the urine. Both the surveyor and LPN observed Resident #43's room [ROOM NUMBER]-1, and Resident #10's room with no Contact precautions posted or PPE available for staff at the door. The LPN stated, there should be a cart there containing PPE. On 3/28/23 at 1:50 p.m., the surveyor, the Registered Nurse (RN) Manager and the Director of Nursing (DON) observed both Resident #10 and #43's rooms with no contact precautions posted or PPE available at the door. The RN stated that both residents have colonized ESBL in their urine, they both should have precautions posted and PPE outside the door. She then stated, they did, not sure why it's not there now. Surveyor discussed neither resident had these precautions in place yesterday and the CNA was unaware of the precautions. Both the DON and the RN stated they will immediatley post contact precautions and place a PPE cart for both rooms. The RN then stated, the CNA's have a report sheet that says these 2 residents have ESBL. Review of the CNA reports sheet indicated both residents have ESBL however, the site of the ESBL or precautions needed was not available on the CNA report. The RN stated, she will update the CNA report immediately. On 3/28/23 at 2:14 p.m., in an additional interview with the RN Manager, surveyor asked what precautions would be in place for any resident who has colonized MDRO's. RN stated, basically contact precautions, on my floor, I want contact precautions for anyone regardless and because you never know, what if they have another UTI (urinary tract infection). On 3/28/23 at 2:17 p.m., in an interview with the CNA-M, she stated she wasn't aware of Resident #10 being on precautions stating, he/she was on precautions for VRE (vancomycin-resistant enterococcus, another type of MDRO) a couple of weeks ago, and he/she is not currently on precautions. On 3/28/23 at 2:25 p.m., in an additional interview, the CNA stated, she feels like she knew something was in [Resident #10's] urine, but she hasn't worked on the unit for a couple of weeks. The CNA stated, the resident did at one point had precautions in place, but they weren't there today. The CNA confirmed she does get a report sheet however, she did not look at it. On 3/28/23 at approx. 2:30 p.m., review of Residents #43's care plan, indicated the resident has an MDRO which was colonized stating, The resident has ESBL colonization of urine Date Initiated: 03/28/23 Revision on: 03/28/23. The resident will be free from no s/sx of acute infection in spite of colonization of urinary tract Date Initiated: 03/28/23. Addition review of the lab results indicated he/she had a urine culture on 1/21/23 with microbiology result of ESBL present. On 3/28/23 at 3:34 p.m., during an interview, the DON stated, both residents had ESBL but with the absence of symptoms, it is colonized however, still requires contact precautions when working directly with area of concern, confirming the above concerns with lack of contact precautions posted and PPE available.

Based on observation and interview, the facility failed to adequately store medication (insulin pens) in a locked compartment of the treatment administration cart on 1 of 4 days of survey and on 1 of 3 units in the facility (Windsor 1). Finding: On 03/10/20, at approximately 7:28 a. m., a surveyor observed the Windsor 1 unit's treatment administration cart to have the locking tab pulled out, sitting mid hallway between resident rooms and down the hall from the nursing station, with no staff present in the area. The surveyor intervened at approximately 7:30 a.m., to alert the Registered Nurse (R. N.) who was down the hallway inside the nursing station and out of view of the treatment cart. The R. N. immediately returned with the surveyor to the treatment cart, confirmed it was unattended by staff and left in an unlocked state, then observed to contain the following stored medications and needles for administration: One (1) Lantus insulin pen and one (1) Novolog insulin pen for Resident #47. One (1) Basaglar Kwik insulin pen and one (1) Novolog insulin pen for Resident #1. On 3/11/20, at 2:30 p.m., in an interview with the Administrator, and the Director of Nursing, the surveyor confirmed the medication (insulin) was stored in an unlocked cart.

Based on clinical record review and interviews, the facility failed to ensure that dental services were scheduled and provided as ordered on 1 of 33 residents selected for further investigation. (Resident #16.) Finding: On 03/09/20, at approximately 1:09 p. m., during interview with the surveyor, Resident #16 indicated occasional pain from a broken front tooth, confirmed the facility had been made aware of the issue, but he/she was not clear if an appointment had been made to address the dental issue. A review of the clinical record indicated that on 6/15/19 an order was issued for the resident to be seen by the dental hygienist on the next visit to the facility for tooth pain. The clinical record lacked documentation indicating the visit with the dental hygienist had been completed as was ordered on 6/15/19. On 03/10/20, at 2:22 p. m., the surveyor discussed the lack of documentation in the clinical record for the dental services ordered on 6/5/19 with the Director of Nursing (DON) who indicated he/she would call the dental hygienist to inquire about documentation and the services provided for Resident #16, the hygienist is in the facility frequently with a room set up for resident visits. On 3/11/20, at 10:30 a. m., the DON indicated that Resident #16 was not seen by the dental services provider as was ordered on 6/15/19 but now has an appointment for 03/26/20 to be seen. In an interview with the surveyor, the administrator, and the DON on 3/11/20, at 2:30 p. m., the finding was discussed. The surveyor confirmed the finding for dental services not provided. On 3/18/20, at 2:52 p. m., the DON indicated the dental hygienist is in almost monthly, was in the facility in August, September, and November of 2019, then again in January, February, and March of 2020 with the resident seen on 3/12/20 by the hygienist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed for 1 of 2 sampled residents reviewed for PASARR (#47). Finding: On 4/09/19 at 11:30 a.m., Resident #47's medical record was reviewed. The resident was admitted to the facility on [DATE] with a diagnosis of history of Delusional Disorders and Auditory Hallucinations, and other specified Depressive Disorders. The medical record lacked evidence that a PASARR Level I was completed upon admission to determine if the resident met the State of Maine's definition of a serious mental health disorder. On 4/09/19 at 12:05 p.m., in an interview with the Administrator and the Social Worker, the surveyor confirmed the medical record lacked evidence of the PASARR Level I.

Based on clinical record review and interviews, the facility failed to revise a care plan related to pressure ulcers to meet 1 of 17 sampled residents needs (Resident #9). Finding: A review of Resident #9's clincial record reveals on 1/25/19, a right buttock pressure ulcer was noted. The resident's wound was most recently noted on 4/7/19 in a Weekly Wound Note as a Stage 2 pressure ulcer. However; the Resident #2's care plan was not revised to reflect the Stage 2 pressure ulcer. On 4/9/19 at 11:28 a.m., in an interview with the Minimum Data Set (MDS) Coordinator, he/she confirmed the care plan had not been timely revised when the pressure ulcer was first noted in January 2019. On 4/9/19 at 11:35 a.m., in an interview with Director of Nursing (DON) and Director of Clinical Operations, the surveyor discussed and confirmed the finding.

Based on observations and interviews the facility failed to adequately store controlled substances in a separately locked, permanently affixed compartment in 3 of 3 observations of medication storage rooms. Findings: 1. On 4/8/19 at 1:33 p.m., the surveyor and a Registered Nurse (RN), Unit Manager observed on Windsor II in the locked Medication Storage Room, the refrigeration unit contained one (1) 30 ml bottle of lorazepam concentrated liquid, a Schedule IV controlled medication, in an open plastic container on the shelf of the refrigerator. On 4/8/19 at,1:33p.m., in an interview with the Unit Manager, the surveyor confirmed the finding. 2. On 4/8/19 at 2:19p.m., the surveyor and an RN observed in a Medication Storage Room on Windsor I, in the storage refrigeration unit, one (1) 30 ml bottle of lorazepam concentrated liquid, a Schedule IV controlled medication, unopened on the shelf of the refrigerator. On 4/8/19 at 2:19 p.m., in an interview with the RN, the surveyor confirmed the finding. 3. On 4/10/19 at 7:48 a.m., the surveyor and a Certified Nursing Assistant - Medications (CNA-M), observed in a Medication Storage Room at Cottage House, in a storage refrigeration unit, one (1) 30 ml bottle of Lorazepam concentrated liquid, a Schedule IV controlled medication on the shelf of the door. On 4/10/19 at 7:50 a.m., in an interview with the Unit Manager, the surveyor confirmed the finding.