How many inspection deficiencies does BREAKWATER COMMONS have?

BREAKWATER COMMONS has 49 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at BREAKWATER COMMONS?

BREAKWATER COMMONS has a four-star staffing rating from CMS with 0.79 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is BREAKWATER COMMONS located?

BREAKWATER COMMONS is located in ROCKLAND, ME. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does BREAKWATER COMMONS have?

BREAKWATER COMMONS has 96 certified beds.

Who owns BREAKWATER COMMONS?

BREAKWATER COMMONS is a for profit - limited liability company facility and operates independently (not part of a chain).

What questions should families ask when visiting BREAKWATER COMMONS?

Families visiting BREAKWATER COMMONS 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 BREAKWATER COMMONS compare to other nursing homes?

BREAKWATER COMMONS has a 1-star overall rating, which is below average compared to other nursing homes in ME. Families should carefully review inspection findings and consider alternatives.

BREAKWATER COMMONS

Name: BREAKWATER COMMONS
Address: 100 COMMONS DRIVE, ROCKLAND, ME, 04841, US
Telephone: (207) 301-6810
Rating: 1.0

100 COMMONS DRIVE, ROCKLAND, ME 04841 · (207) 301-6810

For profit - Limited Liability company 96 Beds Independent Data: November 2025

Trust Grade

23/100

#62 of 77 in ME

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BREAKWATER COMMONS nursing home in ROCKLAND, ME - Photo 1 of 4

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Last Inspection: January 2025

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

Overview

Breakwater Commons in Rockland, Maine, has received a Trust Grade of F, indicating significant concerns and a poor quality of care. It ranks #62 out of 77 nursing homes in Maine, placing it in the bottom half of facilities in the state, although it is the only option in Knox County. The facility's performance is worsening, with issues increasing from 14 in 2024 to 21 in 2025. Staffing is a relative strength, earning a rating of 4 out of 5 stars, but the turnover rate is concerning at 73%, much higher than the state average of 49%. The nursing home has incurred fines totaling $11,998, which is average for the state, but specific incidents of concern include a resident who fell and suffered a hip fracture because their call bell was out of reach, highlighting serious safety lapses.

Trust Score: F
In Maine: #62/77
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: 73% turnover. Very high, 25 points above average. Constant new faces learning your loved one's needs.
Penalties: $11,998 in fines. Higher than 64% of Maine facilities. Some compliance issues.
Skilled Nurses: Each resident gets 47 minutes of Registered Nurse (RN) attention daily — more than average for Maine. RNs are trained to catch health problems early.
Violations: 49 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 14 issues

2025: 21 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

1-Star Overall Rating

Below Maine average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 73%

27pts above Maine avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $11,998

Below median ($33,413)

Minor penalties assessed

Staff turnover is very high (73%)

25 points above Maine average of 48%

The Ugly 49 deficiencies on record

1 actual harm

May 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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to obtain a physician order to change an indwelling urinary catheter (Foley catheter) for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #1). Finding: Resident #1 has diagnoses to include benign prostatic hyperplasia (enlarged prostate), retention of urine, urinary tract infection, and Foley catheter. Review of Resident #1's clinical record revealed a nursing progress note, dated 4/29/25, stating, Resident complained of pain with [his/her] foley catheter. Foley was not flowing. This nurse flushed foley with no relief. Foley catheter 16 french was changed out. Balloon filled with 10 cc [cubic cenimeters]. Resident stated relief from pain. No issues with the foley change. Resident tolerated well. 750 urine output. Further review of Resident #1's clinical record lacked evidence of a provider order for an as-needed (PRN) Foley catheter change. On 5/28/25 at 1:51 p.m., during an interview, Nurse Practitioner (NP) #1 stated she was unaware of the above Foley catheter change on 4/29/25. On 5/28/25 at 4:28 p.m. during a telephone interview, NP #2 stated a nurse should have an order to change a foley catheter and that he was not made aware of the above concerns with Resident #1's Foley catheter, did not give an order for a PRN Foley catheter change on 4/29/25, and was not contacted about it until the next day when the Director of Nursing called him. On 5/28/25 at 5:04 p.m. during a telephone interview, Licensed Practical Nurse (LPN) # 1 stated Resident #1's catheter slipped out and there was no liquid in the balloon, so she used a PRN order to change the Foley catheter and stated she did not check Resident #1's orders to ensure there was a PRN order prior to changing the Foley catheter.

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

Medical Records (Tag F0842)

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 ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #1). Findings: 1. Resident #1 has diagnoses to include benign prostatic hyperplasia (enlarged prostate), retention of urine, urinary tract infection, and indwelling urinary catheter (Foley catheter). Review of Resident #1's active physician orders revealed an order with a start date of 1/13/25 for, Intake and Output (I & O) 2 Times Daily . Review of the April and May 2025 Treatment Administration Records (TAR) revealed I & O is scheduled daily at 5:00 a.m. and 6:00 p.m. Further review of the April 2025 and May 2025 TAR lacked documentation of intake and lacked evidence that output was recorded on the following dates: -4/1/25 at 5:00 a.m. -4/6/25 at 5:00 a.m. -4/8/25 at 5:00 a.m. -4/11/25 at 5:00 a.m. -4/27/25 at 6:00 p.m. -5/7/25 at 6:00 p.m. On 5/28/25 at 11:15 a.m., during an interview with 2 surveyors, the above finding was discussed with the Regional Quality Improvement Specialist. At this time, the Regional Quality Improvement Specialist stated I&O should be entered on the TAR by the nurse and should include any I&O documented by the Certified Nursing Assistant (CNA) because the provider reviews the TAR, not CNA documentation to determine urinary output. 2. Review of Resident #1's clinical record revealed the following nursing progress note, dated 5/8/25 by the East Unit Manager ([NAME]): Resident advised this RN that [he/she] 'felt like [he/she] had to urinate.' This RN assessed resident's catheter bag to see if there was urine draining into the bag. Bag contained very little urine . Unable to flush tubing. This RN removed catheter .Following sterile procedure for insertion of catheter, this RN inserted a 16 Fr [French] into resident's bladder .Secured tubing to left leg .Urine flowing freely into catheter bag. Further review of the clinical record revealed the progress note did not specify a late entry and was not entered until 5/13/25 at 11:23 a.m. On 5/28/25 at 11:15 a.m., during an interview, the Regional Quality Improvement Specialist stated the above progress note was entered late because during the facility's investigation of an incident concerning Resident #1, the facility discovered the [NAME] had not documented the above concern on 5/8/25 when it occurred. On 5/28/25 at 1:47 p.m., during an interview, the [NAME] stated she had a really busy day and did not document the progress note until 5/13/25. 3. Review of Resident #1's active physician orders revealed an order with a start date of 3/26/25 for, Insert indwelling catheter (16 french) Every Twenty-Eight Days starting 3/26/25 . Review of Resident #1's April 2025 TAR revealed his/her indwelling catheter was changed, according to the above order, on 4/23/25. Review of Resident #1's clinical record revealed a nursing progress note, by the East Unit Manager ([NAME]), dated 5/8/25 stating, Resident advised this RN that [he/she] 'felt like [he/she] had to urinate.' This RN assessed resident's catheter . Unable to flush tubing. This RN removed catheter . Following sterile procedure for insertion of catheter, this RN inserted a 16 Fr into resident's bladder . Further review of the clinical record lacked evidence of a provider order for the indwelling catheter insertion on 5/8/25. On 5/28/25 at 1:47 p.m., during an interview with 2 surveyors, and in the presence of the Regional Quality Improvement Specialist, the [NAME] stated she had received a verbal order from NP #1 for the catheter change and didn't enter the order and should have.

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 F0865 (Tag F0865)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to implement its Quality Assurance and Performance Improvement (QAPI) program to ensure compliance with its Plan of Correction (POC) for F-842, related to intake and output (I & O) documentation resulting in inaccurate and incomplete documentation.During the revisit survey on 7/16/25, F-842 was recited related to incomplete intake and output (I & O) documentation. The facility POC indicated a date of correction date of 7/10/25 that included the following corrective actions: A house audit was performed by the unit managers of resident charts for residents with an order for I & O tracking. Educate nurse managers on documenting the facility order protocol inclusive of entering verbal provider orders into the clinical chart. Nurse managers/designee will conduct weekly audits for 60 days. Audit results will be reviewed in QAPI. On 7/16/25 a.m. at 2:00 pm during an interview with a surveyor, the above finding was confirmed with the Regional Quality Improvement Specialist.

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 F0940 (Tag F0940)

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 implement and maintain an effective training program for nursing staff in the areas of urinary catheter care, as part of the facility's follow-up to their facility reported incident dated 5/12/25. Additionally, the facility failed to implement and maintain an effective training program for nursing staff contracted through a staffing agency, in the areas of urinary catheter care and infection prevention, for 2 of 2 staff reviewed during an investigation of a facility-reported incident (Licensed Practical Nurse [LPN] #2, #3). Findings: 1. The facility's 5-day follow-up, submitted to the state agency on 5/19/25, states, .The clinical coordinator will educate licensed staff on foley catheter policies and procedures . Upon entrance to the facility, the survey team requested evidence of the above education. A folder, containing educational materials titled, Flushing Urinary Catheters, Catheter Care Competency, Urinary Catheter or Urinary Tract Infection Critical Element Pathway, and Urinary Catheter Care Education for RNs [Registered Nurses]; and facility Policy, Urinary Catheters Insertion and Maintenance, was provided by the Director of Nursing Services (DNS). Scheduled Friday 5/30 2pm was written on a Post-It note on the cover of the folder. On 5/28/25 at 9:52 a.m., during an interview, the East Unit Manager ([NAME]) stated she conducted a debriefing with her staff following the incident, but staff has not received any education and that the Educator is responsible for conducting education. On 5/28/25 at 10:18 a.m., during an interview, RN #2 stated that she has not received education following the incident and that the Educator is responsible for staff education. On 5/28/25 at 1:47 p.m., during an interview, the Regional Quality Specialist stated that skills checklists for nurses and Certified Nursing Assistants (CNA) were established but have not been implemented. On 5/28/25 at 3:43 p.m, during an interview, the DNS stated the Educator gathered information and gave it to the unit managers to provide education. At this time, the DNS confirmed education had not been implemented prior to the survey team entrance today. 2. Review of Reportable Incident Form, dated 5/12/25, indicates LPN #1 was a witness to the incident dated 5/11/25. Review of LPN #1's Core Mandatory Clinical Assessment competency, completed 2/23/25 by the staffing agency lacked evidence of education on urinary catheter care. Review of LPN #2's Core Mandatory Clinical Assessment competency, completed 2/23/25 by the staffing agency lacked evidence of education on urinary catheter care. During an interview on 5/28/25 at 2:32 p.m., Nurse Educator stated at the time of the incident she was asked to find education for foley care, which she did. She made 4 folders that included all the education resources she gathered. She was never directed to start education, just to gather the information. Confirmed only facility staff receive new hire orientation. On 5/28/25 at 3:32 p.m. during an interview, the DNS and the IP stated agency staff do not receive an orientation or education, other than a handbook emailed to them, and the facility relies on competencies provided by the staffing agency. On 5/28/25 at 4:03 p.m., during a telephone interview, LPN #2 stated she has the option for education through her staffing agency but has not been offered any training by the facility. On 5/28/25 at 4:21 p.m., during a telephone interview, LPN #1 stated she was the dayshift nurse on the day the facility-reported incident occurred, and that she has not had any training on urinary catheter care, transmission-based precautions (TBP), or enhanced barrier precautions (EBP). LPN #1 then stated that she wears gloves to provide catheter care but does not wear a gown unless a resident is on TBP. When a surveyor asked what Enhanced Barrier Precautions require, LPN #1 stated she knows EBP are regarding skin tearing and skin health and means residents are at an increased risk of friction, shearing, and pressure ulcers, so staff need to keep an extra eye on the resident's bottom and provide good incontinence and perineal care.

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

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** 2 Review of Center for Disease Control: Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated July 12, 2022 states Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Make PPE, including gowns and gloves, available immediately outside of the resident room. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. Review of facility provided Foley Catheter list revealed Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 had indwelling foley catheters. During an observation of above resident rooms on 5/28/25 between 12:00 and 12:20 p.m., with two surveyors and Quality Improvement Specialist (QIP) revealed the following: East Wing -room [ROOM NUMBER]B, belonging to Resident #2, lacked signage at the door, no PPE available for use. -room [ROOM NUMBER]A, belonging to Resident # 3, lacked signage at the door, no PPE available for use. -room [ROOM NUMBER]-1, belonging to Resident #1, lacked signage at the door, no PPE available for use. -room [ROOM NUMBER] belonging to Resident #6, lacked signage at the door, no PPE available for use. room [ROOM NUMBER] belonging to Resident #8 revealed a sign on the footboard of the bed stating Enhanced Barrier Precautions. There is no signage at the door and no PPE available for use. South Wing -room [ROOM NUMBER]-A belonging to Resident #5 revealed a sign attached to footboard stating Enhanced Barrier Precautions. There is no signage at the door and a bag hanging over the back of the door that is empty. There is no PPE available for use. -room [ROOM NUMBER]-1 belonging to Resident #4 revealed an Enhanced Barrier Sign face down on the floor behind the door. There is no PPE available for use. -room [ROOM NUMBER] belonging to Resident #9 revealed no sign on door, and no PPE available for use. At this time QIP confirmed above findings. During an interview on 5/28/25 at 11:28 a.m., QIP stated facility follows Lipincott for Enhanced Barrier Precautions. At this time provided surveyor with Clinical & Nursing Services Policy (Not otherwise Specified) dated 10/18 states The Lippincott Manual of Nursing Practice will be utilizes as a reference guide for standard clinical information and procedures. The Lippincott Manual of Nursing will be updated annually or when new additions are published. North Country Associates will utilize the Maine CDC website for infection control issues . During in interview on 5/28/25 at 1:30 p.m., The Director of Nursing (DON) was asked to the facilitys Lippincott Manual. At the time DON stated that she did not know where it was as the had been looking for it the other day. Based on record review, observations, interviews, facility policy, and Center for Disease Control (CDC) guidance the facility failed to maintain and implement an infection control program to help prevent the development and transmission of infectious disease for 9 of 9 residents reviewed for foley catheters. (Residents #1, #2, and #3, #4, and #5, #6, #7, #8, and #9). Findings: Review of facility policy Infection Control: Multi-Resistant Organism (MDROs) Policy dated 4/18/24 states Enhanced Barrier Protection (EBP): Gowns and gloves are worn during high-contact resident care activity. Examples of high-contact activity are: Providing device care Device care would include, . Catheters . Residents being treated for an active MDRO infection will be placed on Contact Precautions. EBP is indicated for anyone with chronic wounds and indwelling medical devices regardless of MDRO status 1. Resident #1 has diagnoses to include urinary tract infection requiring an indwelling urinary catheter. Review of Resident #1's care plan, most recently updated on 5/13/25, revealed, .has an Infection related to Urinary tract infection .Contact precautions . Review of Resident #1's hospital Discharge summary, dated [DATE], revealed, Urine positive for klebsiella and e. Coli [Escherichia coli] . On 5/28/25 at approximately 12:00 p.m., an observation of Resident #1's room lacked signage/Personal protective equipment (PPE) for transmission-based precautions (TBP). On 5/28/25 at 11:55 a.m., during an interview, Registered Nurse #1 stated there are no residents on the East Wing on any precautions. On 5/28/25 at 1:43 p.m., during an interview, a surveyor discussed the above finding with the Regional Quality Improvement Specialist, and she stated Resident #1 should be on contact TBP. On 5/28/25 at 2:45 p.m. during an interview, the Infection Preventionist (IP) stated that the facility currently does not have any residents on TBP. At this time, a surveyor reviewed the above finding with the IP, and the IP stated Resident #1 should be on contact TBP. During an interview on 5/28/25 at 4:05 p.m., Certified Nursing Assistant (CNA)1 stated she was never made aware that Resident #1 was on contact precautions.

Jan 2025 16 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 ensure that a medical provider and the resident's representative were notified of a significant change in medical condition for 1 of 2 residents reviewed for death (Resident #243). Finding: Upon review of Resident #243's clinical record, a hospice Discharge Summary dated 10/16/24 stated during a telephone call, the resident's representative reports anger with the facility that she was not notified of [Resident #243's] change in status from transitioning to active and was not given the opportunity to be present when [Resident #243] died. Review of all the Nursing notes from 10/2/24 through 10/5/24 included all of the following: Nursing note on 10/2/24 at 1:37 p.m. stated, Alert but not swallowing well and pocketing of food noted at lunch. [Doctor] notified. New orders received and noted to downgrade to puree texture diet. Notified [resident representative] of new order. Nursing note on 10/2/24 at 6:11 p.m. stated, Had eaten all of (his/her) mashed potatoes for lunch today, however at dinner resident has been holding puree food and fluids in (his/her) mouth and not swallowing. Lots of encouragement required for resident to swallow. Also groaning and yelling out during dinner, PRN morphine administered. Nursing note on 10/2/24 at 8:20 p.m. stated, HS meds held due to lethargy and not awake enough to swallow medications. Resident had difficulty swallowing at supper this evening and was holding (his/her) food and drinks in (his/her) mouth. Charge nurse notified. Hospice was in this evening and nurse notified her of the above and resident's difficulty swallowing. Nursing note on 10/5/24 at 10:27 a.m. stated, Writer was called to assess patient, upon exam death was noted to be at 1007 on 10/05/2024. Exam: upon auscultation there were no heart sounds and breath sounds were noted after 1 minute. Eyes were fixed and dilated without pupillary light reflex, no palpable central pulse was noted, no response to painful stimuli noted. Provider notified . Family notified by phone and is traveling here to see [Resident #243], staff was notified postmortem care was provided. Hospice was called . On 1/23/25 at 10:09 a.m., during an interview, Registered Nurse #3 (RN#3) stated she was working on a different unit the day Resident #243 passed. She was asked by the Licensed Practical Nurse to come over to pronounce the death. The surveyor asked if Resident #243 had family present. RN#3 stated, Nobody, I had to call the daughter myself to have her come. On 1/23/25 at 10:55 a.m. the lack of nursing documentation of the resident decline with medical provider and family representative being notified from 10/2/24 through 10/5/24 was discussed with the [NAME] President of Quality Improvement and Nursing Services.

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 F0637 (Tag F0637)

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 Minimum Data Set, Version 3.0 (MDS) Significant Change in Status Assessment was completed within 14 days from the effective date of the Hospice election, for 1 of 2 sampled residents reviewed for hospice (Resident#243). Finding: The Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, page 2-23 reads that a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Assessment Reference date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. Resident #243's clinical record indicated the resident was receiving hospice services, with the admission date into hospice as 6/19/24. Further review showed a Significant Change in Status Assessment completed on 9/17/24, 76 days later than required. On 1/23/25 at 10:55 a.m. the above was discussed with the [NAME] President of Quality Improvement and Nursing Services.

CONCERN (D)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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Based on the review of annual evaluations and interviews, the facility failed to complete a annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 1 of 5 CNA's reviewed with employment greater than 1 year. (CNA#4) Finding: CNA #4 was hired on 2/8/21. The employee lacked evidance of a annual preformance evaluaion being completed for 2024. On 1/23/25 at 11:32 a.m , during an interview, the [NAME] President of Clinical Services and Qaulity Improvement confirmed CNA #4 did not have a preformace evaluation on file for the year of 2024.

CONCERN (D)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

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Based on an interview and review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan, meeting attendance sheet and Power Points provided, the facility failed to present evidence that the required members attended 3 of 4 quarters provided. Finding: The facilities QAPI Plan under Governance and leadership states, The Administrator is responsible for the successful implementation of the QAPI Program through enforcement of scheduling and education to participants. On 1/22/25 at 11:37 a.m., during an interview with 3 surveyors present, the Administrator was only able to provide an attendance sheet for the 12/19/23 QAPI meeting stating, the previous Director of Nursing put the power point presentations together, and he thought she was taking attendance. He then stated the Medical Director at the time was not at the 3rd quarter QAPI. Review of the QAPI power points from Quarter 1 (4/23/24), Quarter 2 (7/23/24) and Quarter 3 (11/26/24) lacked evidence of the required member's attendance. In addition, the QAPI failed to include the infection preventionists for 4 of 4 quarterly QAPI meetings reviewed.

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 observation, interview and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development of infections related to Subcutaneous injected medication for 1 of 1 resident observed for subcutaneous medication administration (Resident #60). Finding: The facilities Injectable Medication Administration policy revised 1/2018, states under Purpose: To administer medications via subcutaneous .routes in a safe, accurate and effective manner and Equipment Required .Examination gloves The facilities Medication Administration - General Guidelines policy revised 1/2018, states under Administration . Hands are washed before putting on examination gloves and upon removal for administration of . injectable medications. On 1/22/25 at 7:20 a.m. during observation of Resident #60's medication administration with a Register Nurse #1(RN#1). The RN#1 prepared the Novolog Insulin for a subcutaneous injection and entered the resident's room, without performing hand hygiene and donning gloves, he immediately cleansed the residents right lower abdomen with the alcohol prep and administered the NovoLog insulin subcutaneously. At this time, the RN#1 confirmed he should have performed hand hygiene and donned gloves prior to the medication administration. On 1/22/25 at 7:40 a.m., the above was discussed with the [NAME] President of Quality Improvement and Nursing Services.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on immunization record review, review of the facility's immunization policy and interview, the facility failed to implement their Influenza, Pneumococcal, COVID policy for 1 of 5 residents whose immunization records were reviewed (#16) Finding: The facility's Immunization Policy indicated in Procedure I: Before offering the Influenza or Pneumococcal vaccine or COVID vaccine, each resident, and/or resident's legal representative will receive the appropriate Vaccine Information Statement (VIS) produced by the Maine and/or Federal Centers for Disease Control regarding the benefits and potential side effects of the vaccines for the current year. The resident's clinical record will include the following documentation: Signature of the person receiving the educational material, designating receipt and understanding of the material. Verbal consent may also be obtained if communication is done via a telephone conversation. Proof the resident either received the Influenza, COVID and/or the Pneumococcal vaccine, the vaccine(s) was contraindicated for medical reasons, or the resident refused the vaccine(s). ImmPact website can be utilized to see if these vaccines have been administered. Each resident will be offered an Influenza Vaccine October 1 through March 31 annually, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period. Each resident will be offered a COVID Vaccine, upon admission unless the immunization is medically contraindicated, or the resident has already been immunized. VIS will also be provided to educate on risk vs benefit. Each resident will be offered a Pneumococcal Vaccine, upon admission unless the immunization is medically contraindicated, or the resident has already been immunized. Vaccines will be given in accordance with the Maine Center for Disease Control. For Immunocompromised adults aged 65 years or older. A single dose of PCV 20 may be administered or administered 1 dose of PCV 15, if not previously administered, followed by 1 dose of 23 valent pneumococcal polysaccharide vaccine (PPSV23) at a minimum interval of 8 weeks between both doses. The vaccine administration will be documented on the vaccine record in the medication administration record. Resident #16's clinical record indicated that the resident was admitted to the facility on [DATE]. Resident #16's immunization records lacked evidence that the resident's PCV 20 and Influenza immunization was current or offered and administered as directed by the facility's Immunization - Influenza, Pneumococcal, COVID Policy. On 1/23/25 at 10:27 a.m., a surveyor confirmed the above findings in an interview with the Quality Improvement Specialist.

CONCERN (D)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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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** 3. Resident #16 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 4. Resident #84 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 5. Resident #17 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 6. Resident #83 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 7. Resident #86 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. Based on facility policy review, record reviews, and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 11 of 13 residents reviewed for advanced directives. (Resident #13, #79, #16, #84, #17, #83, #86, #54, #85, #37, #33). Findings: Review of facility policy Advanced Directives dated 10/18 states .The resident has the right and the facility will assist the resident to formulate an advanced directive at their option. Upon admission, the facility will inform and provide the resident and/or resident's representative with information about advance directives. Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advanced directive. a resident has the option to execute an advance directive but will not be required to do so. 1.Resident #13 was admitted on [DATE]. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 2. Resident #79 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 8. Resident #54 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 9. Resident #85 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 10. Resident #37 was admitted on [DATE]. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representative, or that the resident and/or resident representative were provided, written information concerning the right to formulate an advanced directive. 11. Resident #33 was admitted on [DATE]. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representative, or that the resident and/or resident representatives were provided, written information concerning the right to formulate an advanced directive. During an interview on 1/22/25 at 9:54 a.m., the Quality Improvement Specialist confirmed that the above residents and/or resident representatives were not offered/reviewed or provided with written information concerning the right to formulate an advanced directive.

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 environment on 2 of 3 units (East and South) for 3 of 3 days of survey. Findings: East Unit: 1. On 1/21/25 at 11:28 a.m., observations of room [ROOM NUMBER]'s, shared bathroom with 2 basins stored on the floor under the sink. One of the basins had a commode bucket stored in it. room [ROOM NUMBER]'s bathroom had a wash basin on the floor with commode bucket stored inside of it. 2. On 1/22/25 at 8:41 a.m., observations of room [ROOM NUMBER]'s bathroom had a commode bucket on the floor with the basin stored inside of it. room [ROOM NUMBER]'s bathroom had a commode bucket stored on the floor. 3. On 1/23/25 from 8:13 a.m. to 8:21 a.m., the Surveyor and the Director of Nursing discussed the above observations and observed both rooms [ROOM NUMBERS]'s bathrooms with commode buckets stored on the floor. South Unit: 4. On 1/21/25 at 9:23 a.m., and on 1/22/25 at 7:31 a.m., observations of room [ROOM NUMBER]'s bathroom with an uncovered bed pan stored on shelf in between 2 wash basins. 5. On 1/21/25 at 9:37 a.m., and on 1/22/25 at 7:35 a.m., observations of room [ROOM NUMBER]'s bathroom with an uncovered bed pan on shower shelf with 3 briefs stored inside it. On 1/23/25 at 9:20 a.m., during an interview with 4 surveyors, the Director of Nursing confirmed the bed pans were not stored properly.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #16's physician orders indicates that he/she has been recieving oxygen since 11/11/24 with the diagnosis of an Upper Respiratory Infection. Resident #16's medical record lacks evidence of a care plan for oxygen usage. On 1/23/25 at 9:30 a m., the above information was confirmed with the Director of Nursing. 6. Resident #71's Minimum Data Set (MDS) 3.0 admission assessment dated [DATE], under Care Area Assessment Summary, noted Resident #71 would be care planned for Psychotropic Drug use. As of 1/23/25, Resident #71's medical record lacked evidence of a comprehensive care plan in the area of psychotropic drug use. On 1/23/25 at 1:45 p.m., in an interview, the [NAME] President of Quality Improvement and Nursing Services confirmed the above finding. Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of cardiac pacemaker (Resident #86, #83), hospice services (#243), respiratory needs (#54, #16) and psychoactive medications (#71) for 6 of 26 sampled residents reviewed for comprehensive care plans. Findings: 1. On 1/21/25 at 9:56 a.m., during an interview, Resident #86 stated he/she had a pacemaker placed about 1 year ago and is followed by cardiology. Review of Resident #86's medical record states he/she was admitted on [DATE] with a diagnosis of sick sinus syndrome, chronic atrial fibrillation and nonrheumatic aortic insufficiency with the presence of cardiac pacemaker. The medical record lacked evidence that a comprehensive care plan had been developed in the area of a cardiac pacemaker. On 1/22/25 at 11:32 a.m., during an interview, the [NAME] President of Quality Improvement and Nursing Services the care plan lacks pacemaker. 2. Resident #83 was admitted on [DATE] with diagnosis of Atrial fibrillation with the presence of cardiac pacemaker. The medical record lacked evidence that a comprehensive care plan had been developed in the area of a cardiac pacemaker. On 1/22/25 at 2:29 p.m., during an interview, the above was confirmed with the [NAME] President of Quality Improvement and Nursing Services and the Quality Improvement Specialists. 3. Resident #243 was admitted to Hospice services on 6/19/24 for primary diagnosis of senile degeneration of brain and passed away on 10/5/24. The medical record lacked evidence that a comprehensive care plan had been developed in the area of hospice/end of life care. On 1/23/25 at 10:00 a.m., the above was discussed with the Director of Nursing and the [NAME] President of Quality Improvement and Nursing Services. 4. Resident #54 was admitted to the facility on [DATE]. Review of the residents physican orders indicates that he/she has been recieving oxygen since 11/20/24 with the diagnosis of Hypoxia. Further review of the his/her medical record lacks evidence of a care plan for oxygen usage. On 1/22/25 at 1:50 p.m., the above information was confirmed with the Quality Improvement Specialist.

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Resident #71's medical record, surveyor noted two MDS Significant change assessments, dated 2/15/24 and 5/1/24 and two MDS Quarterly assessments dated 7/1/24 and 9/4/24. The clinical record lacked evidence that a care plan meeting was held by the IDT for the 2/15/24, 5/1/24, 7/1/24 and 9/4/24 assessments. On 1/23/25 at 1:41 p.m., the above finding was confirmed with the [NAME] President of Quality Improvement and Nursing Services 3. On 1/21/25 at 9:07 a.m., during an interview, Resident #90 stated he/she was not sure if he/she had an IDT meeting. Resident #90 was admitted on [DATE] and had an admission MDS completed on 1/1/25. The medical record lacks evidence that an IDT meeting, which included the participation of the resident and resident's representative, was held within 7 days of this assessment. On 1/21/25 at 2:29 p.m., during an interview, the [NAME] President of Quality Improvement and Nursing Services stated social services believes they had one on either the 7th or the 14th but they failed to have anyone sign for attendance or document their meeting. Based on interviews, record reviews, and facility policy, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessments, for 10 of 26 residents whose care plans were reviewed (#73, #79, #90, #28, #51, #54, #67, #71, #37, #40). Findings: Review of policy Comprehensive Person Centered Care Planning. Dated 119 states The comprehensive person-centered care plan must be consistent with resident rights, developed with the resident/representative input; Include resident goals and desired discharge plans; The facility must develop and implement a comprehensive person centered care plan for each resident, which includes measurable objectives and time frames to meet a residence medical, nursing, and mental/ psychosocial needs identified in the comprehensive assessment/evaluation. A comprehensive care plan must be: Developed within seven days after completion of the comprehensive assessment . 1. Resident #73 was admitted on [DATE] and has diagnoses to include Parkinson's Disease. Review of Resident #73's clinical record revealed he/she had a Brief Interview for Mental Status of 15 of 15 indicating he/she is cognitively intact. Further review of Resident #73's clinical record revealed that an Interdisciplinary Team Meeting (IDT) was held on 1/20/2025. The clinical record lacked evidence that Resident #73 was invited to attend the IDT meeting. During an interview on 1/23/25 Resident #73 stated he/she was not invited to the IDT meeting but would have gone if invited. 2. Review of Resident #79 clinical record revealed quarterly MDS dated [DATE]. Further review of Resident #79's clinical record lacked evidence that an IDT meeting was held within 7 days of this assessment. During an interview on 1/23/25 at 1:35 p.m., [NAME] President of Quality Improvement and Nursing Services confirmed she reviewed clinical record and there was no evidence that and IDT meeting was held after MDS 11/28/24. During an interview on 1/23/25 at 12:00 p.m. Social Worker Trainee stated IDT meetings should be held withing 1 week of comprehensive assessments and residents and their representatives are supposed to be invited, and all invitations should be documented in the clinical record. At this time confirmed IDT meetings were not held on time, and residents have not been invited to attend. 4. Review of Resident #28 medical record indicates that he/she was admitted to the facility on [DATE]. The quarterly MDS dated [DATE] with an IDT meeting taking place on 12/30/24, indicated the IDT meeting was not completed within 7 days of the MDS. On 1/23/25 at 12:00 p.m., the above information was confirmed with the Social Worker. 5. Review of Resident #51's medical record shows he/she was admitted to the facility on [DATE] with the diagnosis of Post Operative Left Femur Fracture. On 1/13/25 an admission MDS revealed Resident had a BIMS of 13 of 15, indicating he/she is cognitively intact. During an interview on 1/21/25 at 9:16 a.m., the resident states he/she did not think his/her care plan meeting occurred. Further review of the resident's medical record showed a care plan meeting took place on 1/14/25 however, lacked evidence that the resident was invited and/or attended the care plan meetng. 6. Review of Resident #54's medical record indicates that he/she was admitted to the facility on [DATE] with the diagnosis of Chronic Respiratory Failure. On 1/7/25 Resident #54 had a BIMS of 15 of 15, indicating he/she is cognitively intact. Further review shows the resident had a MDS completed on 1/3/25 and an IDT meeting held on 1/24/25, indicating the IDT meeting was not completed within 7 days of the MDS. On 1/23/25 at 12:00 p.m., the above information was confirmed with the Social Worker. 7. Review of Resident #67's medical record shows he/she was admitted to the facility on [DATE] with the diagnosis of Dementia. On 1/7/25 Resident #67 had a BIMS of 13 of 15, indicating he/she is cognitively intact. During an interview on 1/21/25 at 1:00 p.m., the resident stated he/she is unsure if he/she was invited to the care plan meetings. Further review of the residents medical record shows that a care plan meeting took place on 1/7/25 however, lacked evidence that the resident was invited and/or attended the care plan meetng On 1/23/25 at 8:37 a.m., during an interview with 3 surveyors present, the Administrator stated, he was not sure if residents were being invited to their meetings but he created a form to make sure residents are being invited. 9. Review of Resident #37's clinical record revealed a Minimimum Data Set (MDS) Significant Change Assessment was completed on 7/26/24. Further review of the clinical record lacked evidence that an interdisciplinary team (IDT) meeting was held following the assessment. During an interview on 1/23/25 at 3:27 p.m., the [NAME] President of Clinical Services and Quality Assurance confirmed that she reviewed Resident #37's clinical record and that there was no evidence an IDT meeting was held after the 7/26/24 MDS assessment. 10. Review of Resident #40's clinical record revealed a Comprehensive MDS Assessment was completed on 8/23/24 and an MDS Quarterly Assessment was completed on 12/5/24. Further review of the clinical record lacked evidence that an IDT meeting was held within 7 days of the assessments. During an interview on 1/23/25 at 3:27 p.m., the [NAME] President of Clinical Services and Quality Assurance confirmed that she reviewed Resident #40's clinical record and that there was no evidence an IDT meeting was held after the 8/23/24 or 12/5/24 MDS assessments.

CONCERN (E)

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 observations, interviews, record reviews, facility policy, and manufacturer directions, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice in the area of nutrition for 1 of 2 residents reviewed (Resident #60) and in the area of falls for 2 of 3 residents reviewed (Residents #79, #37). Additionally, the facility failed to obtain physician orders for medications located at a resident's bedside, for 2 of 2 sampled residents (Residents #40, #70). Findings: 1. Review of manufacturer directions dated November 2024 states NovoLog® is a rapid-acting insulin that helps lower mealtime blood sugar spikes in adults . with diabetes .NovoLog® starts acting fast. Eat a meal within 5 to 10 minutes after taking it . Resident #60 was admitted on [DATE] and has diagnosis to Diabetes Mellitus II. Review of Resident #60 active orders dated January 2025 reveled order with state date of 11/30/24 for Novolog U-100 Insulin; Aspart 100 unit/mL subcutaneous solution Before Meals for Type II diabetes mellitus; Sliding Scale Insulin: Insulin Units <70 or > 400 Notify MD; MD; 151-200, 2Units; 201-250, 4Units; 251-300, 6Units; 301-350, 8Units; 351-400, 10Units; 401-450, 12 units. During a medication observation pass on 1/22/25 at 7:20 a.m., a surveyor observed Registered Nure #1 (RN#1) administering 4 units of Novolog to Resident #30 for blood sugar of 206, per provider order. Observation of breakfast meal on 1/22/25 revealed Resident #60 did not receive his/her breakfast tray until 8:45 a.m., which is 1 hour and 25 minutes after receiving Novolog. During an interview on 1/22/25 at 9:15 a.m., RN #1stated he administered sliding scale insulin to Resident #30 earlier this morning but could not specifically remember what time it was as he did not write it down. RN#1 further stated he did not know how to look back in the Electronic Medical Record to see what it was, but was aware that Resident #30 had not received his/her breakfast until 8:45 a.m. During an interview with 4 surveyors on 1/22/25 at 10:08 a.m., Quality Improvement Specialists stated that Residents that received short acting insulin before a meal should eat as soon as possible after insulin was administered. At this time a surveyor discussed the above findings. 2. Review of provided Side Rails/Grab Bars Policy dated 11/18 states .Whenever side rails or grab bars are considered .A physician's order will be obtained to include the reason for use.The nurse will provide and review A Guide to Bed Rail Safety for Patients with resident/resident representative; Informed consent for Use of Side Rails/Grab Bars will be obtained. Side rail and grab bar use will be screened quarterly and with any significant change in the resident's condition or behavior. Resident #79 was admitted on [DATE] and had diagnoses to include hemiplegia, dementia, and history of falls. Observations of Resident #79 on 1/22/25 at 7:15 a.m., he/she was observed lying in bed with bilateral side rails in use. Review of Resident #79's care plan updated 9/20/24 states enablers to promote independent bed mobility. Falls: I am at risk for falls r/t impaired mobility, poor safety awareness, impulse control, secondary to a stroke and dementia Fall without injury 8/12/24 . Review of Resident #79's clinical record revealed a Fall Risk Assessment completed 11/24/24, and Side Rail Screen dated 11/24/24. Further review of Resident #79's clinical record lacked evidence that side rail assessments/screens were conducted prior to 11/24/24. Review of Resident #79's clinical record lacked evidence that a provider order was obtained for bed rail use, that the resident/representative was presented with copy of A Guide to Bed Rail Safety for Patients, a signed consent for bed rail use was obtained and quarterly side rail screenings were completed. During an interview on 1/23/25 at 12:31 p.m. the Director of Nursing reviewed Resident #79's entire clinical record and confirmed the above findings. On 1/22/25 at 8:30 a.m. and on 1/23/25 at 9:15 a.m., observation of an Albuterol Sulfate HFA 90 mcg aerosol inhaler on the resident's bedside table. On 1/22/25 at 8:30 a.m., during an interview, Resident #70 states that he/she uses the inhaler often as needed. In an additional interview on 1/23/25 at 9:15 a.m., Resident #70 states that he/she and their power of attorney requested to keep the inhaler at bedside. During this interview resident proceeded to take 2 puffs of the inhaler for shortness of breath. Review of Resident #70 medical record shows the medication being Albuterol Sulfate HFA 90 mcg aerosol inhaler with instructions to use every 6 hours as needed. Further review of the resident's medical record lacks evidence of an order to keep the medication at bedside. Review of the Medication Administration Record lacks evidence that the resident has received/administered the medication for the month of January. On 1/22/25 at 9:25 a.m., during an interview with the [NAME] President of Clinical Services and Quality Improvement the above information was confirmed. 3. Resident #37 was admitted on [DATE] and has diagnoses to include dementia and repeated falls. On 1/21/25 at 10:51 a.m. and 1/22/25 at 11:04 a.m., Resident #37 was observed lying in bed, with bilateral side rails in use. Review of Resident #37's care plan, updated 11/4/24, revealed, ADL [Activities of Daily Living] .Side rails as enablers to promote independent bed mobility . and Falls: I am at risk for falls r/t [related to] impaired mobility . Review of Resident #37's clinical record revealed a Fall Risk Screen was completed on 10/21/24 and 1/20/25, and a Side Rail Screen was completed on 10/21/24. Further review of Resident #37's clinical record lacked evidence of a physician's order for side rail use and lacked evidence that informed consent for use of side rails was obtained. During an interview on 1/23/25 at 3:27 p.m., the [NAME] President of Clinical Services and Quality Assurance reviewed Resident #37's entire clinical record and confirmed the above finding. 4. Review of Facility Policy Self-Administration of Medications Policy, revealed, Procedure: A. If the resident has an order to keep a medication at bedside, the facility must complete a Self-Administration of medications screen. B. If outcome .indicates resident is able to self-administer his/her medications, obtain a physician order to self-administer . F. If the resident has an order to keep medications at bedside, the medication must be secured in a locked box, to maintain the safety of other residents . During observations of room [ROOM NUMBER] on 01/21/25 at 10:41 a.m. and 1/22/25 at 8:58 a.m., a 0.38 ounce (72 sprays) Flonase 50mcg/spray nasal spray medication device and a 30-pad box of Ocu Soft Lid Scrub eyelid pads were observed on Resident #40's bedside table. Review of Resident #40's clinical record lacked evidence of a physician order for the Flonase and Ocu Soft Lid Scrub and lacked evidence of a physician order to self-administer. Further review of the clinical record lacked evidence of a Self-Administration screen. During an interview on 1/22/25, between 9:14 a.m. and 9:22 a.m., Registered Nurse (RN) #2 stated that if a resident or resident's family brings a medication in from home, there should be a physician order for the medication and an order that the resident may keep the medication at bedside. At this time, RN #2 reviewed Resident #40's clinical record and confirmed that there was no order for the Flonase, the Ocu Soft Lid Scrub, or for resident to keep medications at bedside. During an interview on 1/22/25 at 9:27 a.m., the South Unit Manager stated it was her expectation that if a resident had medication at the bedside, there would be a physician order for the medication(s) and the order must state it is ok for the medication to be at bedside and for the resident to self-administer. At this time, the above finding was reviewed with the South Unit Manager. On 1/22/25 at 11:10 a.m., the above finding was reviewed with the Quality Improvement Specialist.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/21/25 at 9:15 a.m., 1/22/25 at 8:41 a.m., and on 1/23/25 at 8:21 a.m., observations of Resident #17's oxygen nasal cannula tubing dated 1/13 and an undated nebulizer pipe stored on the back of the nebulizer machine and the bedside dresser. Review of resident #17's medical record had providers orders dated 1/9/25 to Change Tubing 1 Time Weekly, Clean/Store oxygen tubing not in use 1 Time Weekly and provider orders dated 1/4/25 for ipratropium 0.5 mg (milligram)-albuterol 3 mg (2.5 mg base)/3 mL (milliliter) nebulization solution .Inhalation Three Times Daily. The most recent care plan for Impaired Respiratory secondary to Acute on Chronic Respiratory Failure, RLL (right lower lobe) Pneumonia, COPD AEB (chronic obstructive pulmonary disease acute exacerbation) need for hospitalization, respiratory medications/treatments and supplemental Oxygen with interventions of Change oxygen tubing weekly; label and date. Review of the January treatment administration records states the oxygen tubing was changed on the 12th and the 19th and lacked evidence of the nebulizer tubing being changed. On 1/23/25 from 8:13 a.m. to 8:21 a.m., both the surveyor and the Director of Nursing conducted a tour of the East unit and observed the above nebulizer tubing and pipe storage, the oxygen tubing dates and discussed the inaccurate documentation in the residents TAR relating to changing the tubing. 4. Observations of room [ROOM NUMBER] on 1/21/25 at 9:18 a.m., 1/22/25 at 7:27 a.m., and 1/23/25 at 1:17 p.m., revealed nebulizer located on top of Resident #13's side table with tubing attached with/to facemask/reservoir which is resting/stored on top of the side table without a barrier between the nebulizer mask and the machine allowing potential cross contamination. During an interview with 4 surveyors on 1/23/25 at 9:20 a.m., the Director of Nursing confirmed Resident #13's nebulizer tubing was not stored appropriately when not in use. Based on observations and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to oxygen and nebulizer use for 5 of 6 residents reviewed for respiratory care. (Resident #54, #70, #17, #13 and #42) Findings: Review of provided Oxygen Use & Storage Policy dated 10/24 states: .when nebulizer parts are not in use; after being air dried, the mask and/or hand held devices should be stored in a plastic bag to the risk of it being contaminated. 1. On 1/21/25 at 8:40 a.m. and on 1/22/25 at 8:50 a.m., observation of Resident #54's oxygen nasal cannula tubing on the floor by his/her bed labeled with the date of 1/6/25. Review of Resident #54 medical record reveals a physician order to change oxygen weekly. Review of the Treatment Administration Record (TAR) stated the tubing was changed on 1/12/25 and on 1/19/25. 2. On 1/21/25 at 9:01 a.m. and on 1/22/25 at 8:30 a.m., observation of Resident #70's unlabeled nebulizer pipe and tubing stored on the nebulizer machine. 5. Resident #42 was admitted on [DATE] and has diagnoses to include obstructive sleep apnea. During an observation of room [ROOM NUMBER] on 1/21/25 at 10:44 a.m., Resident #42's unbagged nasal cannula and oxygen tubing, dated 1/17, was lying on the floor by Resident #42's bed and was connected to an oxygen concentrator, located next to the bed, with an empty black antimicrobial bag, dated 1/8/24, stored on top of the concentrator. During a follow-up observation of room [ROOM NUMBER] on 1/22/25 at 9:00 a.m., the oxygen tubing was observed in the black antimicrobial bag, dated 1/8/24, located on top of the oxygen concentrator. Review of Resident #42's care plan revealed, Respiratory .I use O2 [oxygen] at 2L [liters] HS [hour of sleep] r/t [related to] SOB [shortness of breath] .Change oxygen tubing and antimicrobial bag weekly; label and date . Review of Resident #42's active January Treatment Administration Record (TAR) revealed an order, with a start date of 10/9/24, to Change O2 tubing and antimicrobial bag Q [every] Sunday night and date both . Review of the TAR indicated the tubing and antimicrobial bag were changed on Wednesday, 1/15/24. During an interview on 1/23/25 at 8:53 a.m., in the presence of 5 surveyors, the above finding was reviewed with the Director of Nursing.

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, the facility failed to ensure expired medications were removed from the supply available for use and failed to ensure that medications were stored properly as per manufacturers' recommendations for 3 of 5 medication/treatment carts reviewed for medication storage. Findings: 1. On 1/22/25 at 7:30 a.m., observation of the South unit nurse treatment cart #2 with the Registered Nurse #2 (RN#2), the cart contained an opened and undated vail of Tuberculin Purified Protein Derivative with manufactures instructions of Store between 36 degrees - 46 degrees F and Once entered vial should be discarded after 30 days. At this time, RN#2 confirmed the Tuberculin vial was not labeled or stored correctly and immediately wasted the vial. 2. On 1/22/25 at 7:36 a.m., observation of the South unit medication cart with the Certified Medication Technician #1 (CNA-M #1), the cart contained an opened bottle of Acidophilus w/Pectin with the manufactures instructions to refrigerate after opening, one opened bottle of Famotidine 10mg (milligram) with an expiration date of 12/24 and one opened bottle of Loratadine 10mg with an expiration date of 11/24. At this time, the CNA-M#1 removed the expired bottle and acidophilus. On 1/22/25 at 7:40 a.m., the above was discussed with the [NAME] President of Quality Improvement and Nursing Services. 3. On 1/22/25 at 9:57 a.m., observation of the [NAME] unit medication cart with the CNA-M #2, the cart contained an opened bottle of Acidophilus probiotic with the manufacturer's instructions of refrigerate after opening. At this time, the CNA-M#2 removed the acidophilus. On 1/22/25 at approx. 10:15 a.m., the above was discussed with the [NAME] President of Quality Improvement and Nursing Services.

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 policy review the facility failed to ensure foods were dated and labeled in, stand up freezer, dry storage room and the walk in freezer. In addition, the facility failed to discard obvious freezer burned food on 1 of 3 survey days. Additionally, the facility failed to ensure a sanitary environment during 1of 2 dining observations of meal service on 1 of 3 units. Findings: Review of policy Food Storage undated states . All containers must be legible and accurately labeled and dated .Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days (4 days or 96 hours per Maine regs) or discarded. During an initial kitchen tour with 2 surveyors and the Dietary Manger on 1/21/25 between 8:22 a.m. and 8:45 a.m., the following was observed: -Dry storage area: A rolled up unlabeled clear bag containing unknown brown crumbly substance with open date of 11/12 available for use. -Stand up freezer: Small undated blue squeezable bag of chocolate icing opened with frosting coming out of it and 3 gallon size bags of bananas with obvious freezer burn. -Walk in refrigerator: Undated and unlabeled, unknown brown substance rolled up with plastic wrap, the Dietary Manger stated it was crumbled bacon, 1 large metal tray with multiple small metal containers containing green and red peppers, one containing pork chops, one containing a sandwich, 1 containing unidentifiable small round brown balls, and 2 small containers of unidentifiable substances, all undated and unlabeled. During an interview with 2 surveyors on 1/21/25 at 8:45 a.m., the Dietary Manger confirmed above findings. 2. Facility policy, Director of Food and Nutrition Services Responsibilities, states, Procedure .6 .Staff will follow proper sanitation and food handling practices . and facility policy, Hazard Analysis Critical Control Points and Food Safety, states, Procedure: 1. Staff will be aware of the following sources of food borne organisms in food service: a. Humans (nose and throat, hands .clothing) .poor hand washing practices . During an observation of the lunch dining service for the South Kitchen on 1/22/25 between 12:06 p.m., and 12:25 p.m., Dietary Aide #1 walked up to refrigerator and placed his left hand on the freezer door handle and then opened the refrigerator door with right hand. Dietary Aide #1 then removed a container of chocolate milk from the refrigerator and using his right hand, poured chocolate milk into a cup, drank the chocolate milk, proceeded to put the cup into the trash can and then donned (put on) gloves. Dietary Aide #1 then removed the serving spoons from the container on the top of the food truck, removed the plastic wrap from the metal food trays in the food service area, and placed a serving spoon in each tray. Dietary Aide #1 then rested his right hand on the counter and placed his gloved left hand on his left hip and then doffed (took off) the gloves and proceeded to don a new pair of gloves. Dietary Aide then spooned pasta onto a plate and with his gloved right hand, picked up a piece of garlic bread from a metal tray on the counter and placed it on a meal plate. At this time, a surveyor intervened, and Dietary Aide #1 stated he has worked here since November and has not received education on hand hygiene. At this time, Dietary Aide #1 doffed gloves, sanitized his hands and donned new gloves before continuing to plate food. Review of Dietary Aide #1's Orientation Acknowledgement Checklist, dated 12/2/24, included receipt of facility policy, Infection Control/Exposure Control Plan but lacked evidence that Dietary Aide #1 received education on hand hygiene or safe food handling practices. On 1/22/25 at 12:38 p.m., the above finding was reviewed with the Quality Improvement Specialist. On 1/22/25 at 12:53 p.m., the finding was reviewed with the Dietary Manager, who stated new-hire training was conducted but that Dietary Aide #1 has not received formal hand hygiene or safe food handling training.

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 Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 5 of 5 randomly selected CNAs employed greater than 1 year (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5). Findings On 1/22/25, a surveyor reviewed the following employee education files: 1. CNA #1 was hired 12/5/1994. Review of CNA #1 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. 2. CNA #2 was hired 8/31/2020. Review of CNA #2 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. 3. CNA #3 was hired 3/18/2013. Review of CNA #3 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. 4. CNA #4 was hired 2/8/2021. Review of CNA #4 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. 5. CNA #5 was hired 6/8/2020. Review of CNA #5 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. On 1/22/25 at 1:34 p.m., during an interview with 4 surveyors present, the Administrator confirmed the above findings.

Nov 2024 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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation and interviews, the facility failed to serve food in accordance with professional standards for food service safety by not delivering food in a sanitary manner for 1 of 1 units observed during the noon meal service. (East unit) Finding: On 11/12/24 at 12:10 p.m., a surveyor observed the noon meal service on the East unit. A CNA (Certified Nursing Assistant) was observed carrying a tray with an uncovered plate of pot pie and an uncovered dessert down a hallway to a resident's room. The CNA returned to the serving line with the tray and stated the resident wanted a salad instead. The surveyor asked if meals were always delivered to residents in their rooms in this manner. The dietary aide stated meals were always delivered on trays this way. At this time, the surveyor observed several CNAs were present at the serving line. The surveyor asked if they knew the correct way the trays should be delivered. One CNA picked up a plate cover and placed it over the next meal tray's plate. The CNA who had delivered the uncovered tray asked the surveyor if all items were supposed to always be covered. The surveyor confirmed that food items should be covered. On 11/12/24 at 12:30 p.m., the surveyor discussed the observation with the Administrator, who acknowledged the concerns with delivering uncovered meals down the hallways.

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 F0557 (Tag F0557)

Could have caused harm · This affected multiple residents

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Based on interviews and review of the facility internal investigation reports, the facility failed to ensure that 2 of 5 residents reviewed were treated with dignity and respect (#1, #4) . Findings: 1. On 10/21/24, the Division of Licensing and Certification received a facility reported incident. The report noted that a Resident #1 complained to his/her family member that there was a bar under him/her. The family member moved the bed linens and saw that a bedpan had been left underneath the resident. A review of the clinical record for Resident #1 revealed diagnoses that included Alzheimer's Disease and recent fractures of the left hip and humerus. A review of the Minimum Data Set (MDS) 3.0, admission Assessment, dated 10/17/24, noted in Section C0500, Cognitive Patterns, a BIMS (Brief Interview of Mental Status) score of 3, indicating severe cognitive impairment. Section GG0130, Self Care, Resident #1 was dependent on staff for toileting, lying to sitting, and sitting to standing for bed mobility. A review of the facility's internal investigation noted staff had failed to effectively communicate that Resident #1 was placed on a bedpan resulting in Resident #1 being left on the bedpan for approximately one and one half hours. Written statements obtained from the CNA (Certified Nursing Assistant) who had placed Resident #1 on the bedpan noted he/she assumed that others had removed the bedpan. On 11/12/24 at 10:30 a.m., in an interview with a surveyor, the Director of Nursing (DON) confirmed that on 10/21/24, Resident #1 had been placed on the bedpan between 6:15-6:30 a.m. The family member reported finding Resident #1 on the bedpan at 7:50 a.m., and stated staff immediately removed the bedpan and assessed the resident's skin. The DON stated on 10/21/24 at 8:18 a.m., she assessed Resident #1 and noted a red line on the skin where the bedpan had been. In follow-up, the facility terminated the contract with the agency CNA. 2. On 10/31/24, the Division of Licensing and Certification received a facility reported incident. The report noted that a licensed nurse heard a CNA state to Resident #4, Stop being an asshole. You always make up stuff to hit your call light. A review of Resident #4's clinical record noted diagnoses including spinal stenosis with bilateral foot drop, osteoarthritis, osteoporosis, diabetes mellitus with polyneuropathy and chronic pain. No recent BIMS assessment was located in the record. A nursing progress note, dated 10/30/24 at 5:18 p.m., stated Resident #4's daughter was called regarding an allegation of verbal abuse and that it was being reported and investigated. On 11/12/24 at 12:40 p.m., in an interview with a surveyor, the DON discussed the facility's investigation. She stated when Resident #4 was interviewed, he/she did not remember being called a name. The CNA, who was employed by a travel staffing agency, denied the allegations. The CNA's agency contract had ended and the facility notified the agency of the allegations. On 11/12/24 at 4:00 p.m., in the exit interview with the facility's Administrator and DON, the surveyor discussed that residents had not been treated with dignity and respect when CNA staff left Resident #1 on the bedpan for an hour and a half, and when swearing at Resident #4. On 11/21/24 at 8:58 a.m., in a telephone interview with a surveyor, the licensed nurse stated I was sitting at my desk and (Resident #4's) room is right by the nurses station. I can hear just about anything. I heard her (CNA) say 'you're acting like an asshole. Why do you keep ringing? You're being an asshole. The nurse stated I walked in and talked to (Resident #4) and apologized for the way the CNA acted.

Oct 2024 1 deficiency

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

Deficiency F0655 (Tag F0655)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, 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 properly care for 1 of 3 residents reviewed during a complaint investigation (Resident #3). Findings: Review of facility policy 48 Hour Baseline Care Plan dated 10/18 states A baseline care plan will be created within 48 hours of admission .Based on the admission assessment, physician orders and resident preferences a care plan will be created to facilitate a smooth transition of care and provide effective, person centered care. The Care Plan will contain the following 6 key elements: initial goals based on admission orders; all physician orders, including medications and administration schedule; dietary orders; therapy services to be provided; Social Service needs; PASRR recommendations (if any). Resident #3 was admitted on [DATE] and has diagnoses to include Diabetes Mellitus, chronic kidney disease, history of falls, pulmonary hypertension, respiratory failure, atrial fibrillation, benign prostatic hyperplasia (BPH) Review of Resident #3's active orders for October 2024 revealed: -Order with start date of 10/10/24 for Trulicity 3 mg/0.5 mL subcutaneous pen injector (0.5ml) pen injector (ML) Subcutaneous One Time Weekly for Type II Diabetes mellitus -Order with start date of 10/28/24 for Jardiance 25 mg tablet 1 Time Daily for type II diabetes with chronic kidney disease. Review of Resident #3's baseline care plan initiated 10/10/24 lacked evidence that goals and interventions were put into place in areas to include diabetes and nutrition. During an interview with 2 surveyors on 10/30/24 at 3:17 p.m., the Director of Nursing reviewed Resident #3's care plan and confirmed it lacked goals and interventions in the areas of diabetes and nutrition.

Sept 2024 6 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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on policy review, record reviews, and interviews the facility failed to establish/implement their own grievance policy reviewed for 1 of 4 records reviewed during a complaint investigation (Resident #3). Findings: On 7/29/24 at 9:24 a.m., the Department of Licensing received a complaint indicating they filed a grievance on behalf of their family member (Resident #3) on 7/25/24 and did not receive a response for 30 days, even though [complainant] kept inquiring. Complainant further indicated [he/she] was informed the Grievance Officer was the Director of Nursing (DON) and the facility provided [him/her] with 2 different grievance policies, one policy states a response will be received in 15 days, and the other says they will respond in a reasonable amount of time, but they never told [him/her] what a reasonable amount of time was. Review of facility provided Grievance Policy dated 10/18 states The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed through the investigation and resolution process. The facility grievance process will be overseen by a Grievance Official who will be responsible for receiving and tracking grievances through their conclusion . Resident and Resident Representative Notification: The notice shall include. Reasonable time frame for completing the review of a complaint . Upon receipt of a grievance or concerns, the Grievance Official will initiate the appropriate notification and investigation processes per indicial and facility policies. Resolution: The facility will strive for a prompt resolution outcome for grievances or complaints rendered. A reasonable time frame will be agreed upon with involved parties. Review of Resident admission Packet revealed Notice of Resident Grievance Procedure undated, states . The Administrator will respond to a written grievance within 15 days. The response will include actions taken . Review of facility provided Grievance packet dated 7/29/24 states: Care being provide by [cna] [staff member], UTI concern, decline and hospice needing to do a sternal rub; getting out of bed; drinks. Further review of Grievance packet revealed response was dated 8/26/24. During an interview with 2 surveyors on 9/25/24 at 1:16 p.m., Social Worker (SW) indicated she used to be the Grievance Officer, but the responsibility was transferred to the Director of Nursing in April (2024). SW indicated she does encourage residents and families to try to settle things without a grievance, but when that's not possible they are encouraged to file a grievance with the Director of Nursing and the facility has 15 days to get back to the person that filed it. At this time SW confirmed Resident #3's family member filed the grievance on 7/25/24. During an interview on 9/26/24 at 2:26 p.m., DON indicated that the SW was the Grievance Officer, but it was the responsibility of whatever department to investigate the grievance. When asked how long it takes to respond to a grievance, the DON replied 30 days and that she felt that was a reasonable time frame. At this time DON confirmed she received complainants' grievance on 7/25/24 but DON didn't file it until the 26 because she had a few questions she needed answered first.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that an injury of unknown origin was reported to the State Agency after a resident was found on the floor and bleeding from a head laceration for 1 of 4 complaint investigations reviewed (Resident #1). Findings: On 9/11/24 at 8:00 a.m., the Department of Licensing received a compliant indicating on 9/8/24 at 10:30 a.m., Resident #1, who is a high fall risk was left in his/her room unattended in a Broda chair and was found face down on the floor, sustaining head and right hand laceration requiring transfer to and acute care hospital for evaluation and treatment. Resident #1 has diagnoses to include dementia, anxiety, depression, is dependent on staff for all Activities of Daily Living (ADL)'s and is receiving Hospice services for end of life care. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 1 had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Review of facility Resident Incident Reporting Form dated 9/7/23 states .This nurse was notified that resident was on the floor in [his/her] room and the broad chair was lying on its side . Upon entering residents' room this nurse noted resident lying face down but more on [his/her] right side . noticed there was blood on the floor by [his/her] head. Upon checking resident over[he/she] had a laceration to [his/her] outer eye at the end of her eyebrow . During an interview on 9/26/24 at 7:52 a.m., Administrator confirmed the facility did not report this injury of unknown origin to the state. In front of 2 surveyors.

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

Investigate Abuse (Tag F0610)

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 investigate an injury of unknown origin after a resident was found on the floor, bleeding from a head laceration for 1 of 4 complaint investigations reviewed (Resident #1). Findings: On 9/11/24 at 8:00 a.m., the Department of Licensing received a compliant indicating on 9/8/24 at 10:30 a.m., Resident #1 who is a high fall risk was left in his/her room unattended in a Broda chair and was found face down on the floor, sustaining head and right hand laceration requiring transfer to and acute care hospital for evaluation and treatment. Resident #1 has diagnoses to include dementia, anxiety, depression, and is receiving Hospice services for end of life care. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 1 had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Review of Resident 1's clinical record revealed that he/she is dependent on staff for Activities of Daily Living (ADL)'s and has had multiple falls since admission. Review of facility Resident Incident Reporting Form dated 9/7/23 states .This nurse was notified that resident was on the floor in [his/her] room and the broad chair was lying on its side . Upon entering residents' room this nurse noted resident lying face down but more on [his/her] right side . noticed there was blood on the floor by [his/her] head. Upon checking resident over[he/she] had a laceration to [his/her] outer eye at the end of her eyebrow . Further review of Resident 1's clinical record lacked evidence that an investigation was conducted after this incident. During an interview with 2 surveyors on 9/26/24 at 7:52 a.m., Administrator confirmed the facility did not investigate this injury of unknown origin.

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

Medical Records (Tag F0842)

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 ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for incontinent care (Resident #1). Findings: Resident #3 was originally admitted on [DATE] and has diagnoses to include neurogenic bladder. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Further review of MDS revealed he/she is dependent on staff for all Activities of Daily Living (ADL). Review of Resident #3 Care plan initiated on 6/18/24 revealed Urinary Continence: I am incontinent of urine. I require your total assist for incontinence care.Check for incontinence at times such as before or after meals, HS, and prn; change if wet/soiled [minimum of 6 times daily]. Review of ADL Verification Worksheet dated July 2024 revealed Resident #3 received incontinent 1 (one) time on 7/10/24, 7/18/24, 7/24/24, 7/25/24, 7/26/24, 7/27/24, 7/28/24, and 7/31/24. 2 (two) times on 7/1/24, 7/2/24, 7/3/24, 7/4/24, 7/8/24, 7/9/24, 7/12/24, 7/15/24, 7/16/24, 7/17/24, 7/19/24, 7/20/24, 7/22/24, 7/23/24, and 7/30/24, and 3 (three times) on 7/5/24, 7/6/24, 7/7/24, 7/11/24, 7/13/24, 7/14/24, and 7/29/24. During a review of Resident #3's clinical record with 2 surveyors on 9/26/24 at 2:55 p.m., the Director of Nursing (DON) indicated that at the time of documents reviewed, residents should have been toileted/changed at each meal time, first thing in the morning, before bed and any other time necessary in between. At this time DON confirmed 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 interviews, the facility failed to maintain a comfortable homelike environment for 1 of 2 units reviewed during a complaint investigation (Memory). Findings: On 9/11/24 at 8:00 a.m., the Department of Licensing received an anonymous compliant indicating on 9/8/24 at 10:30 a.m., indicating on multiple times when [family member] has visited her mother/father in the morning, his/her room has been very cold. Resident #1 was admitted on [DATE] and has diagnoses to include dementia, anxiety, depression, and is receiving Hospice services for end of life care and resided on the Memory Care unit. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 1 had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. During an interview with 2 surveyors on 9/26/24 at 10:30 a.m., Memory Care Unit Manager (UM) indicated a couple of weeks ago he/she came to work in the am and observed a resident coming out of his/ her room and they looked cold, UM went over to see if he/she wanted a sweater and brought resident back into their room and noted it was very cold. UM looked at the thermostat and the air conditioning (AC) was on and set to 68F. UM turned the heat on and went around to check other rooms and found that there were multiple other rooms that also had their AC on at 68F as well. During a confidential interview with 2 surveyors on 9/26/24 at 10:45 a.m. a SM #2 indicated that some CNA's on the overnight shift have been turning the AC on in the Memory Unit at night to try to keep the residents in bed, so they don't wander. Has come in multiple times to AC on in rooms, very cold. (most recently 2-3 days ago [9/23/24]). not comfortable giving names, but it continues to happen. During an interview with 2 surveyors on 9/26/24 at 2:26 p.m., Director of Nursing confirmed she was aware that staff were turning ac on at night and addressed it in a CNA meeting on 9/17/24 and is not sure if it is still happening or not.

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

Comprehensive Care Plan (Tag F0656)

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, observations, and facility policy, the facility failed to update and include goals and interventions on the resident's current comprehensive care plan for the areas of falls for 1 of 3 residents reviewed (Resident #2), incontinent care for 1 of 3 residents (Resident #3), and psychotropic medication use for 3 of 3 residents reviewed during a complaint investigation. Findings: Review of facility policy Psychoactive Medication Use Policy dated 9/18 states Psychoactive medications will only be used in conjunction with the Individual Care Plan . 1. Resident #1 has diagnoses to include hypertension (HTN), kidney disease, dementia, anxiety, and depression and is receiving Hospice for end of life care. Review of active medication orders dated September 2024 revealed Resident #1 was taking anti-anxiety medications Ativan and Lorazepam, antidepressant Sertraline, and antipsychotic Risperdal. Review of Resident #1 Care plan most recently reviewed on 9/24/24 revealed Mood: I have Depression, Anxiety and Dementia. I use psychoactive medications for management of symptoms of striking out physically, paranoid thoughts, depression, trying to stand on my own. I will have no adverse drug reactions from psychotropic medications over the next 90 days. Monitor, report, and document changes in mentation: Anti- anxiety: sedation, drowsiness, ataxia, dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash . Further review of Resident #1's clinical record lacked documented evidence that he/she was being monitored for the above medication side effects. During an interview with 2 surveyors on 9/26/24 at 3:09 p.m., the Director of Nursing reviewed the entire clinical record and confirmed Resident #1 was not being monitored for side effects of the above medications. 2. Resident #2 was admitted on [DATE] and has diagnoses to include heart failure, Alzheimer's disease, anxiety, depression and is receiving Hospice for end of life care. Review of active orders dated September 2024 revealed Resident #2 was taking antidepressant medication Sertraline, and Lorazepam for anxiety. Observations of Resident #2 on 9/25/24 at 2:38 p.m., and 9/26/24 at 1:02 p.m., revealed Resident #2 in bed, bed was located against the wall, with fall mat at bedside. Review of Resident #2's care plan, most recently reviewed 8/5/24 revealed: FALL: I have a potential for falls r/t poor safety awareness. I will not have any falls over the next 90 days. anticipate and meet needs. keep personal space clutter free. Unable to use call bell due to cognitive impairment. Mobility: extensive assistance required with mobility; Hoyer lift for transferring; COGNITION: Cognition: [Resident #2] has an alteration in mood state related to Alzheimer's dementia with anxiety: Goal: Medications and treatments per physician orders. Monitor for side effects and effectiveness, Medications and treatments per physician orders. Monitor for side effects and effectiveness. Further review of Resident #2's clinical record lacked documented evidence he/she was being monitored for side effects of psychotropic medication use. Further review of Resident #2's care plan lacked evidence of goals and interventions for locating the bed against the wall or fall mat use. In addition, Resident #2's clinical record laced documented evidence he/she was being monitored for side effects of psychotropic medication use. During an interview with 2 surveyors on 9/26/24 at 3:10 p.m., Director of Nursing (DON) reviewed Resident #2's entire clinical record and confirmed it lacked evidence Resident #2 was being monitored for signs and symptoms for psychotropic medication use, and the care plan was not updated with goals and interventions to have the bed against the wall or fall mat use. 3. Resident #3 was originally admitted on [DATE] and has diagnoses to include neurogenic bladder, arthritis, heart failure, dementia, anxiety, depression and is receiving Hospice services for end of life care. Review of Resident #3 Care plan initiated on 6/18/24 revealed Urinary Continence: I am incontinent of urine. I require your total assist for incontinence care.Check for incontinence at times such as before or after meals, HS, and prn; change if wet/soiled [minimum of 6 times daily]; Mood and Behavior: .I take medication for my moods/behaviors . will have no adverse drug reactions from psychotropic medications over the next 90 days. Monitor Anti- anxiety: sedation, drowsiness, ataxia, dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash. Antidepressant: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity, excessive weight gain. Antipsychotics: sedation, drowsiness, dry mouth, constipation, blurred vision, EPS, weight gain, edema, postural hypotension, seizures, glaucoma, jaundice. Hypnotic/Sedative: Sedation, drowsiness, ataxia . Review of entire clinical record laced evidence lacked documented evidence Resident #3 received/refused incontinent care per care plan and lacked evidence he/she was being monitored for side effects of psychotropic medication use. During an interview with 2 surveyors on 9/26/24 at 2:50 p.m., the Director of Nursing reviewed the entire clinical record and confirmed Resident #3 is not being monitored for side effects of psychotropic medication, and was not receiving incontinent care per care plan interventions.

Apr 2024 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 F0558 (Tag F0558)

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 and interviews, the facility failed to ensure that a call bell was accessible to 1 of 3 sampled residents observed for accommodation of needs. (Resident #3). Findings: Review of Facility assessment dated (4/5/24 currently under revision) states .Typed of Disease and Conditions: .Below is a list of common diseases, conditions, physical and cognitive disabilities .that require complex medical care and management that we commonly provide care .Vision: Cataracts, Glaucoma, Macular Degeneration, Blindness . Review of facility email dated 8/10/23 at 6:36 p.m. states .Subject: division for blind FYI: Finally made contact with Division of the blind for our visually impaired resident that has fallen outside and has ADA complaints The person is out next week for training but will be in the following week to map the building and outside . The facility did not provide any further information for this visit. Resident 3 was originally admitted to facility on 3/1/22 with diagnoses to include blindness, history of stroke and left sided hemiplegia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 3 had a Brief Interview for Mental Status (BIMS) of 7 of 15 indicating he/she is not cognitively intact. Further review of MDS revealed he/she needs partial to moderate assistance with Activities of Daily Living and has a severe visual impairment. Review of Resident 3's clinical record revealed the following: Review of Resident 3's care plan, updated 3/16/24 states, Goal: [Resident 3] is at risk for falls r/t low vision, impaired mobility, poor safety awareness, impulse control; Goals: . call bell in reach at all times . Progress note dated 4/04/2024 states During patient checks resident was observed with call bell clipped to [his/her] shirt and the cord looped around [his/her] neck one time loosely. Call bell removed from around [his/her] neck and clipped to his bottom sheet near [his/her] hand for safety. During an observation on 4/9/24 at 11:00 a.m., Resident 3 was observed in bed in a 90 degree position. At this time this writer asked if he/she could demonstrate how he/she would use the call bell. Resident 3 indicated his/her call bell is usually on the right side of his/her bed where he/she can reach it and was then observed using his/her right hand to pat around his/her right side and was unable to locate the call bell . Call bell noted to be affixed to the right-side rail, behind residents elevated mattress and not in reach. Resident 3 then states that he/she sometimes will wrap the cord around his/her neck so he/she has easy access to it. States that staff tell him/her that it isn't safe, but he/she does it anyway. When asked what he/she would do if he/she wasn't able to reach the call bell, Resident #1 indicated that he/she would just scream really loud and they come eventually. During an interview on 4/9/24 at 12:34 p.m., Licensed Practical Nurse (LPN) indicated that if Resident 3 feels that they aren't attending to his/her needs fast enough he/she will yell really loud. At 10:59 a.m. This writer and LPN entered Resident 3's room and LPN confirmed his/her call bell was affixed to side rail, behind residents' right side and not in reach. LPN indicated that Resident 3 is often found with the cord around his/her neck as that is where he/she puts it so it can be reached. LPN indicated that there are other residents in the building that use hand bells. During an interview on 4/9/24 at 1:24 p.m., Certified Nursing Assistant (CNA1) indicated that Resident 3 has been found with call bell hanging around his/her neck and had to remove it on multiple occasions. During an interview on 4/9/24 at 1:34 p.m., CNA2 indicated that Resident 3 needs his/her call bell placed on the right side as he/she has left side weakness from a stroke and he/she puts the call bell around his/her neck loosely, and they will remove it and remind him/her that it's not safe to do that. CNA2 further indicated that management staff are aware. During an interview on 4/9/24 at 2:28 p.m., Facility Nurse Practitioner (FNP) indicated that Resident 3 is able to use his/her call bell and the expectation that it is reach. Has had increased cognitive deficit since last stroke and has no Insite to his/her limitations and tends to wrap the call bell cord around his/her neck. FNP states he/she was opened to Division for the Blind for services but daughter canceled them. FNP further indicated that the facility should make accommodations for blindness. During an interview on 4/10/24 at 12:08 p.m., Unit manager Long Term care (LTCUM) indicated that she is new to the Unit Manager role as of 10/2/23 and was aware Resident 3 liked to wrap the call bell around his/her neck so he/she could easily find it. They did have the call bell affixed to his/her right-side rail but was unaware that he/she could not reach it when he/she was sitting straight up. States she is aware of other residents in building that use hand bells for assistance. During an interview on 4/9/24 at 10:05 a.m., Social Worker (SW) indicated that the Division of the Blind (DOB) was just in for Resident 3, and his/her daughter actually canceled any services on 3/18/24. SW then indicated that she was not in the facility when the DOB came in and was not sure if any recommendations were made as they have not called her back. When asked if there is a call bell alternative for Resident 3 that would be safer for him/her and could stay in his/her reach, SW indicated that there are some residents in the facility that use hand bells and that may work for Resident 3. During an interview on 4/10/ on 4/10/23 at 1:02 p.m., with Administrator and Director of Nursing (DNS), DNS confirmed that she was aware that Resident 3 was putting the call bell around his neck, and were trying to find something that would work with their current call system and haven't found anything yet so they decided to affix his/her call bell to the right side rail in order for him/her to find it. DNS indicated that a staff member just told her that he/she was unable to reach the call bell if he/her was sitting up in bed. DNS indicated that Division of the Blind came to see Resident 3 and was not aware if any recommendations were made for accommodations. At this time DNS confirmed 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, the facility failed to notify the State Agency after two (2) falls that resulted in head injury. (Resident 1, and Resident 2.) Findings: 1. Resident 1 was originally admitted on [DATE] with diagnoses to include diabetes myelitis, Heart failure, hypertension, aphasia, dementia, hemiplegia, and seizure disorder. On 11/2/24 Resident 1 was found on the floor in his/her room after an unwitnessed fall. Resident 1 was sent to the emergency room and subsequently admitted with a brain bleed. Review of quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident 1 has a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Further review of MDS revealed Resident 1 had a history of falls and needs substantial assistance with Activities of Daily Living. Review of Resident #1's clinical record revealed the following progress note dated 11/2/23 stating Resident was found face down on the floor by writer. Resident stated [he/she] fell off the bed. [He/she] was A&0 [alert and orientated] x2. [He/she] was covered in blood that came from the top of [his/her] head. Resident also has a cut above the R [right] eye and bleeding out of [his/her] mouth . Resident sent to ED [emergency department] via ambulance for evaluation. Progress Note dated 11/3/23 at 7:52 p.m., Spoke to ER nurse, pt is admitted and was transferred to Maine Health for brain bleed. 2. Resident 2 was admitted on [DATE] with diagnoses to include Alzheimer disease, depression, and is open to hospice for end-of-life care. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Further review of MDS revealed he/she is nonverbal and is dependent for all Activities of Daily Living [ADL]. Review of Resident 2's clinical record revealed progress note dated 10/30/23 20:42 At approximately 1630, CNA called for this nurse to see Resident on the floor with blood beside [him/her] head. Per CNA in room, Resident fell from a lift during transfer. Resident noted to have blood from an abrasion on [his/her] right side of head. During an interview on 4/10/24 at 3:26 p.m. with the Director of Nursing (DNS) and Administrator, the DNS confirmed that the facility did not report the events as she did not think they were reportable.

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

Investigate Abuse (Tag F0610)

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 and facility policy, the facility failed to thoroughly investigate two falls with head injury (Resident 1 and Resident 2). Findings: Review of facility policy Accidents/Incidents Involving Residents dated 12/14/21 states, Each incident or accident must be detailed in the medical record. This includes happening or experience which may be traumatic or inflict bodily injury to a resident . Each incident, accident . must be investigated immediately for determination of root cause. The DNS (or designee) will audit the system for completion/compliance . 1. Resident 1 was originally admitted on [DATE] with diagnoses to include diabetes myelitis, Heart failure, hypertension, aphasia, dementia, hemiplegia, and seizure disorder. On 11/2/24 Resident 1 was found on the floor in his/her room after an unwitnessed fall. Resident 1 was sent to the emergency room and subsequently admitted with a brain bleed. Review of quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident 1 has a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Further review of MDS revealed Resident 1 had a history of falls and needs substantial assistance with Activities of Daily Living. Review of Resident #1's clinical record revealed the following progress note dated 11/2/23 stating Resident was found face down on the floor by writer. Resident stated [he/she] fell off the bed. [He/she] was A&0 [alert and orientated] x2. [He/she] was covered in blood that came from the top of [his/her] head. Resident also has a cut above the R [right] eye and bleeding out of [his/her] mouth. VS [vital signs] taken .Pressure was applied to top of the head and EMS [emergency medical services] was called [power of attorney] was notified and [provider]. Resident sent to ED [emergency department] via ambulance for evaluation. Progress Note dated 11/3/23 at 7:52 p.m., Spoke to ER nurse, pt is admitted and was transferred to Maine Health for brain bleed. Further review of Resident 1's clinical record lacked evidence that an incident report was completed for this fall. 2. Resident 2 was admitted on [DATE] with diagnoses to include Alzheimer disease, depression, and is open to hospice for end-of-life care. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Further review of MDS revealed he/she is dependent for all Activities of Daily Living [ADL]. Review of Resident 2's clinical record revealed progress note dated 10/30/23 20:42 At approximately 1630, CNA called for this nurse to see Resident on the floor with blood beside [him/her] head. Per CNA in room, Resident fell from a lift during transfer. Resident noted to have blood from an abrasion on [his/her] right side of head. Further investigation of Resident 2's clinical record lacked evidence that an incident report was completed for this fall. During a telephone interview on 4/10/24 at 11:50 a.m., Certified Nursing Assistant (CNA3) indicated that on 10/30/23 around 4:20 p.m. she and a coworker were preparing to get Resident 2 out of bed using a Hoyer lift. CNA3 further indicated that as she was lifting Resident 2 out of bed with the Hoyer, her coworker left the room indicating they were going to get someone else up. It wasn't until Resident 2 slid out of the Hoyer pad and fell on the floor, striking his/her head that she realized she had not crossed the pad under his/her legs. During an interview on 4/10/24 at 12:08 p.m. Unit manager Long Term care (LTCUM) indicated that she is new to the role as of 10/2/23 but is now aware that if there is an accident a nurse would go into the to do list and fill out an incident report, as a unit manager it is her responsibility to go in and ensure that it was completed. On 4/9/24 between 9:00 a.m. and 3:26 p.m., Director of Nursing (DNS) indicated that a complete investigation with root cause was completed for Resident #1 and Resident #2's falls and would provide it to this writer. After multiple attempts to obtain the facility investigations, on 2/9/23 at 2:59 p.m., DNS indicated I'm working on it, at 3:26 p.m., DNS provided this writer with copies of progress notes written by the nurse regarding the falls but did not provide this writer with copies of investigation notes. When asked if she had anything in writing regarding the incidents, DNS replied I did them at that moment in time. When asked if she had any notes/documents at all, DNS indicated that she did and would go get them. As of 4:00 p.m. on 4/9/24 nothing had been received. On 4/10/24 this writer was provided with a copy of Review of Toileting Sling Education dated 12/12/23. During an interview on 4/10/24 at 3:26 p.m., with Administrator and DNS, DNS indicated that when she spoke with CNA3, she was told that CNA3 was using the Hoyer alone, and CNA3 had told her a different story other than what this writer was told. This writer again asked if she had any documentation to support this and DNS was unable to provide any information. At this time DNS confirmed that the facility did not thoroughly investigate 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

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 interviews, record review and policy review the facility failed to update/implement care plans in the area of falls for 2 of 3 residents reviewed for falls (Resident's 1 & 2) and in the area of psychotropic medication use for 1 of 3 residents reviewed for medications (Resident 3). Findings: Review of facility policy Falls Management Policy dated 7/19 states .DNS or designee will review fall incident reports regularly and identify potential patterns or trends. Resident's care plan will be updated with all new interventions. Review of facility policy Psychoactive Medication Use Policy dated 9/18 states .A psychoactive drug is any medication affecting brain activity associated with mental processes and behavior . Psychoactive medications will only be used in conjunction with the Individual Care Plan. 1. Resident 1 was originally admitted on [DATE] with diagnoses including dementia, left sided hemiplegia, and seizure disorder. On 11/2/24 had an unwitnessed fall and was transferred to the emergency room and subsequently admitted with a brain bleed. Review of Resident 1's physician orders effective April 2024 revealed: -Order with start date of 11/27/24 for Potassium chloride ER 20 Meq tablet. Oral. One tab daily for stage 3 chronic kidney disease (CKD). -Order with start date of 3/27/24 for Tradjenta 5mg tablet orally one time daily for type 2 dm with CKD. -Order with start date of 11/27/24 for Timolol maleate 0.5% eye drops (1drop) Drops both eyes One time daily for glaucoma. Review of Resident 1's care plan most recently updated 3/31/24 lacked evidence that his/her care plan was updated to reflect goals and interventions for brain bleed, hemiparesis, vision and chronic kidney disease. 2. Resident 2 was admitted on [DATE] with diagnoses to include Alzheimer disease, depression, and is open to hospice for end-of-life care. Review of Resident 2's clinical record revealed progress note dated 10/30/23 states At approximately 1630, CNA called for this nurse to see Resident on the floor with blood beside [him/her] head. Per CNA in room, Resident fell from a lift during transfer. Resident noted to have blood from an abrasion on [his/her] right side of head. Review of Resident 2's Care plan initiated on 7/14/20, most recently reviewed on 3/26/24 revealed Resident 2 is a dependent of staff for all ADL needs. Further review of care plan revealed Falls: [Resident] is at risk for falls r/t impaired mobility, poor safety awareness .Interventions: keep environment free from clutter, and pathways clear of obstacles; encourage [resident 2] to ask for assist with transfers. Further review of Resident 2's care plan lacked evidence that Resident 2's care plan was updated with goals and interventions after the fall and failed to update care plan with his/her current transfer and communication status. During an interview on 4/9/24 at 12:40 p.m., Licensed Practical Nurse (LPN) indicated that Resident #2 is totally dependent on staff to meet his/her needs and is nonverbal. Unable to walk for some time and is a Hoyer lift for all transfers. LPN further states that she believes the Unit Manger is responsible to update care plans and they should reflect the residents current care needs. During an interview on 4/9/24 at 1:26 p.m. Certified Nursing Assistant (CNA1) indicated that Resident #2 is nonverbal, but can make noises for yes and no. Unable to use his/her call bell and is a Hoyer lift for all transfers. 3. Resident 3 was originally admitted to facility on 3/1/22 with diagnoses to include blindness, history of stroke and left sided hemiplegia. Review of Resident 3's April 2024 orders reveled the following: -Order with start date of 2/27/24 for donepezil 10 mg tablet (1 tab) Tablet oral one time daily for major depressive disorder. -Order with start date of 3/28/24 for sertraline 50 mg tablet (1) tablet oral one time daily for anxiety disorder. Progress note dated 4/04/2024 states During patient checks resident was observed with call bell clipped to [his/her] shirt and the cord looped around [his/her] neck one time loosely. Call bell removed from around [his/her] neck and clipped to his bottom sheet near [his/her] hand for safety. Review of Resident 3's care plan, updated 3/16/24 states, Goal: [Resident 3] is at risk for falls r/t low vision, impaired mobility, poor safety awareness, impulse control . call bell in reach at all times. During an observation on 4/9/24 at 11:00 p.m. Resident 3 was observed in bed in a 90 position. At this time this writer asked if he/she could demonstrate how he/she would use the call bell. Resident 3 indicated his/her call bell is usually on the right side of his/her bed where he/she can reach it. At this time Resident 3 was observed using his/her right hand to pat around his/her right side and was unable to locate the call bell . Call bell noted to be affixed to the right-side rail, behind his/her elevated mattress and not in reach. At this time Resident #3 indicated that he/she sometimes will wrap the cord around his/her neck so he/she has easy access to it. States that staff tell him/her that it isn't safe, but he/she does it anyway. When asked what he/she would do if he/she wasn't able to reach the call bell, Resident #1 indicated that he/she would just scream really loud, and they come eventually. During an interview on 4/9/24 at 1:24 pm., Certified Nursing Assistant (CNA1) indicated that Resident 3 has a habit of throwing him/herself on the floor when he/she doesn't get his/her way. CNA1 further indicated that he/she has been found with call bell hanging around his/her neck and remove it/ and provide education for safety. CNA1 indicated this has happened multiple times. During an interview on 4/9/24 at1:34 p.m., CNA2 indicated that Resident 3 puts the call bell around his/her neck loosely, and they will remove it and remind him/her that it's not safe to do that and indicates that management staff are aware. During an interview on 4/10/24 at 12:08 p.m., Unit Manager, Long Term care (LTCUM) indicated that she is new to the role as of 10/2/23 and states it is her responsibility to update resident care plans. LTCUM further indicated that care plans should be updated within 7 days of any incident and should reflect residents' current care needs. At this time LTCUM confirmed care plans were not updated with goals and interventions to reflect current needs of Resident 1 in the area of brain bleed, hemiparesis, vision and chronic kidney disease, Resident 2 to reflect transfer and ambulation, and Resident 3 to reflect psychotropic medication use and behaviors. During an interview on 4/10/24 at 3:26 p.m., with Administrator and Director of Nursing (DNS), DNS indicated that the Unit Manger is responsible to update care plans. At this time DNS confirmed care plans were not updated to reflect residents' current care needs.

Mar 2024 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

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 and the resident representative of significant changes in the resident's condition in a timely manner for 1 of 1 sampled residents. (1#) Finding: On 3/13/24, a review of Resident #1's clinical record was completed. Resident #1's clinical record indicates he/she was hospitalized on [DATE] and diagnosed with a Hemorrhagic stroke. A Physician/Nurse Communication Tool dated 2/19/24 at 10:08 a.m. indicates Resident #1 had left sided weakness, slurring speech and drooping on the right side of his/her face. The blood sugar was noted to be 65 and Blood Pressure 196/90. Nursing progress notes on 2/19/24 at 10:57 a.m. indicate that Resident #1 had a low blood sugar of 65 before breakfast and was given juice, also noticed left sided weakness, slurry speech and facial drooping as well as incontinence of bladder, leaning to the left side, lethargy and confusion noted. Resident #1's blood pressure was noted to be 196/90. Resident #1 was given the medication Hydralazine and a recheck of the blood pressure was 130/65. Resident #1 is still symptomatic. The physician assessed Resident #1 and ordered to send the resident to the emergency department for an evaluation and treatment. Emergency transport came and transported Resident #1 to the emergency department. On 3/13/24 at 1:10 p.m. during an interview with Registered Nurse #1 (RN), he/she stated that Resident #1's blood sugar was taken between 7:30 a.m. and 8:00 a.m. and at that time the resident looked funny. Resident #1 was given the medication Hydralazine for a high blood pressure. On 3/13/24 at 1:00 p.m. during an interview with the physician, he stated that he believed he was notified of Resident #1's change in condition about 9:00 a.m. but feels he should have received a call sooner. On 3/14/24 at 1:16 p.m., certified Nurses Aid #1 (CNA) stated that he/she was asked by RN #1 and RN #2 to assist Resident #1 with repositioning at approximately 8:10 a.m. CNA #1 states that he/she observed Resident #1 leaning to one side, facial drooping, left sided weakness, garbled speech and not making sense. At that time, CNA #1 expressed concern that Resident #1 may be having a stroke. CNA #1 states that he/she was told that Resident #1's symptoms were due to a low blood sugar and Resident #1 was just drooling. CNA #1 states that he/she entered the room of Resident #1 again at 9:00 a.m. to retrieve his/her breakfast tray. Resident #1 was found alone with facial drooping, left sided weakness and garbled speech. CNA #1 expressed concern again to RN #1 and RN #2 that Resident #1 may be having a stroke. CNA #1 recalls being told that Resident #1's vital signs and blood sugar were normal. Emergency Medical Services (EMS) documentation indicates that the call from the facility to transfer the resident to the emergency department was 10:21 a.m. EMS arrival time to the facility was 10:29 a.m. Additionally, the clinical record lacked documentation that the physician and resident representative were notified of a significant change in Resident #1's medical condition in a timely manner. On 3/13/24 at 2:30 p.m., a surveyor discussed the finding that the physician and resident representative were not notified of a significant change in Resident #1' medical condition in a timely manner.

Nov 2023 7 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

Accident Prevention (Tag F0689)

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, interview and review of the Safety Data Sheets, the facility failed to ensure that the resident environment remained free from the potential risk of accidents when they failed to ensure that two chemicals were properly secured during 1 of 3 days of survey (10/30/23). Findings: 1. On 10/21/23 at 9:30 a.m., a surveyor observed a 19-ounce spray can of Lysol Disinfectant Spray and a jar of pumpkin spice scent crystal beads sitting on Resident #20's bedside table. The Safety Data Sheet for the Lysol Disinfectant Spray noted: Section 2. Hazards identification: Keep out of reach of children. Section 4. First Aid Measures: Eye Contact: Immediately flush 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 if irritation occurs. 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 trained personnel. 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 [NAME] attention immediately. Maintain an open airway. Loosen tight clothing such as a collar, tie, belt, or waistband. Skin Contact: Flush contaminated skin with plenty of water. Remove contaminated clothing and shoes. Get medical attention if symptoms occur. Wash clothing before reuse. Clean shoes thoroughly before reuse. 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 feels sick as vomiting maybe 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 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 the jar of pumpkin spice scent crystal beads noted: Section 4. First aid measures: Eye Contact: Rinse thoroughly with plenty of water, also under the eyelids. If symptoms persist, call a physician. Skin Contact: Wash with soap and water. Inhalation: Remove to fresh air/ Ingestion: Rinse mouth immediately and drink plenty of water. Never give anything by mouth to an unconscious person. Self-protection of the first aider: Remove all sources of ignition. Ensure that medical personnel are aware of the material(s) involved, take precautions to protect themselves and prevent sprea of contamination. Use personal protective equipment as required. Wear personal protective equipment. On 10/20/23 at 2:53 p.m., a surveyor confirmed with the Administrator that a bottle of Lysol and jar of scented beads were stored incorrectly on the resident's bed side table and should not have been stored there.

CONCERN (D)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility's Quality Assurance Committee failed to ensure that the plan of correction for an identified deficiency from the Annual Long Term Care Recertification survey dated 11/1/23 was followed and effective. The Federal citation F584 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 12/7/23. Findings: During the annual Long Term Care Recertification survey, dated 10/30/23 through 11/1/23, a deficiency was cited at F584 for the failure to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition. The facility's POC, dated 11/18/23, indicated that the facility would be cleaned and repairs made to ensure that the building and equipment would be in good repair and in a sanitary condition, with plan of POC completion date of 12/1/23. On 12/7/23 at 11:55 a.m., in an exit interview with the Director of Nursing, she confirmed that the environment had not been brought into compliance as stated in the facility's Plan of Correction.

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 good repair and in a sanitary condition for 2 of 3 units(East Wing-100s and South Wing-200s) for 1 of 1 environmental tour. Findings: On 11/1/23 from 1:20 p.m. to 2:10 p.m., during a tour of the facility/resident rooms with the Environmental Services Director and the Maintenance Assistant, the following findings were observed: East Wing-100s > Resident room [ROOM NUMBER] - There was a bedpan on the floor in the bathroom. > Resident room [ROOM NUMBER] - There were two (2) commode buckets on the floor in the bathroom. > Resident room [ROOM NUMBER] - There was a wash basin on the floor under the sink in the bathroom. > The sit-to-stand patient lift, in the hallway by room [ROOM NUMBER], had debris and dirt in the base area and the arm pads and frame were dusty/dirty. > Resident room [ROOM NUMBER] - There were two (2) commode buckets on the floor in the bathroom. > Resident room [ROOM NUMBER] - There was a wash basin and commode bucket on the floor under the sink in the bathroom. South Wing-200s > The patient lift, in the hallway between rooms [ROOM NUMBERS], had hair wrapped around wheels and had chipped/missing paint on the frame creating an uncleanable surface. > The two(2) sit-to-stand patient lifts, located in the hallway, had dirt/debris in the foot base area and had chipped/missing paint on the base and legs creating uncleanable surfaces. On 11/01/23 at 2:10 p.m., in an interview, the Environmental Services Director and the Maintenance Assistant confirmed the findings.

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, interview, and the facility's Food Storage and Leftover Food Storage policy, Daily High-Temp Ware Wash checklist Policy, Daily High-Temp Ware Wash checklist Policy, and Refrigerator and Freezer Temperatures checklist Policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a food slicer and ceiling vents; failed to ensure all staff were wearing facial hair protectors; failed to ensure foods were labeled and/or in the dry storage room, reach-in refrigerator, the reach-in freezer, the walk-in refrigerator and the walk-in freezer for 1of 1 kitchen tour on 1 of 3 days of survey. (10/30/23). Additionally, the facility failed to ensure temperatures were monitored for the dish machine and the refrigerators/freezers for dates in August, September and October 2023. Findings: The facility's Food Storage and Leftover Food Storage policy noted: Procedure: 4. All containers must be legible and accurately labeled and dated. 7. c. Food should be dated as it is placed on the shelves if required by state regulation. d. Date marking to indicate the date or day by which a ready to eat, time/temperature control for safety food should be consumed, sold, or discarded will be visible on all high risk food. 13. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. 14. b. Foods must be maintained at or below 41 degrees Fahrenheit unless otherwise specified by law periodic law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees Fahrenheit thermometer should be checked at least two times each day. Quotation C sample freezer and refrigerator temperature forms quotation. d. Each nursing unit with a refrigerator/freezer unit will be supplied with thermometers and monitored for appropriate temperatures. 15. c. All frozen foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe used by dates or discarded. Leftover food policy procedure: a period leftovers will be securely covered, labeled and clearly dated with the date the item was prepared and the use by date. The facility's Daily High-Temp Ware Wash checklist Policy noted at the bottom of the page: Notify food service director if there are any standards that are out of compliance (i.e. Wash temperatures that are less than 150 degrees or rinse temperatures that are less than 180 degrees. Follow manufacturers recommendations for temps) The facility's refrigerator and freezer temperatures checklist Policy noted at the bottom of the page: Please record the temperatures twice a day. If two consecutive readings for the refrigerator ever exceeds 42 degrees, and if two consecutive readings for the freezer ever exceeds 5 degrees, notify the highest ranking person in the kitchen. On 10/30/23 from 9:15 a.m. to 10:00 a.m., a kitchen tour was conducted with the with Food Service Director in which the following findings were observed: 1. > One(1) male worker with facial hair was cooking at the stove and was not wearing facial hair protection. > The food slicer had dried food particles on the blade, the blade shroud and the base. > There were two(2) ceiling vents that were heavily soiled with dust/dirt. > The dry storage room had one(1) large package of prunes that was unlabeled and undated, four(4) unlabeled and undated bags of cereal with one of the bags ripped open, and three(3) bags of chips that were unlabeled and undated. > The reach-in milk cooler had a one gallon container of chocolate milk that had an expiration date of 10/28/23. > The reach-in refrigerator had one(1) unlabeled bag of bacon, three(3) unlabeled packages of cheese, one(1) undated and unlabeled package of baked cookies, and two(2) undated and unlabeled metal containers of sauces. > The reach-in freezer had one(1) unlabeled package of steaks, one(1) unlabeled package of chicken tenders, one(1) unlabeled package of veggie burgers, and two(2) unlabeled packages of chicken nuggets. > The walk-in refrigerator had three(3) undated and unlabeled plates of cakes, and one(1) unlabeled package of cut up meat. > The walk-in freezer had two(2) undated and unlabeled metal containers of cupcakes, and three(3) undated and unlabeled pies. 0n 10/30/23 at 10:00 a.m., in an interview, the Food Service Direct confirmed the findings. 2. The facility's high temperature dish washing machines did not have the temperatures monitored on the following dates: August 2023 Main Kitchen: Lunch - 8/6/23, 8/16/23, 8/19/23, 8/30/23 Supper - 8/1/23, 8/2/23, 8/4/23, 8/8/23, 8/9/23, 8/11/23-8/16/23, 8/19/23, 8/21/23, 8/23/23, 8/25/23, 8/27/23- 8/29/23, and 8/31/23. East Wing-100s: Lunch - 8/6/23, 8/7/23, 8/21/23, and 8/27/23 Supper - 8/1/23, 8/4/23, 8/8/23, 8/11/23, 8/13/23, 8/20/23-8/23/23, 8/25/23, 8/26/23, and 8/30/23. South Wing- 200s: Breakfast - 8/12/23 Lunch - 8/4/23, 8/5/23, 8/12/23 and 8/16/23 Supper - 8/2/23, 8/3/23, 8/5/23, 8/7/23, 8/9/23, 8/12/23, 8/15/23-8/19/23, 8/21/23, 8/23/23, 8/25/23-8/28/23, 8/30/23 and 8/31/23. West Wing-300s: Breakfast - 8/1/23, 8/13/23 and 8/27/23 Lunch - 8/1/23, 8/13/23, 8/26/23, 8/27/23 and 8/30/23 Supper - 8/1/23, 8/2/23, 8/5/23- 8/7/23, 8/13/23, 8/14/23, 8/18/23, 8/21/23, 8/23/23, 8/25/23, 8/27/23, 8/28/23 and 8/30/23. September 2023 Main Kitchen: Breakfast - 9/13/23, 9/23/23 and 9/24/23 Lunch - 9/13/23, 9/23/23, 9/24/23, 9/26/23 and 9/27/23 Supper - 9/1/23, 9/8/23, 9/9/23, 9/11/23-9/13/23, 9/18/23, 9/22/23-9/26/23, 9/28/23 and 9/29/23 East Wing-100s: Breakfast - 9/7/23, 9/13/23, 9/14/23, 9/16/23, 9/20/23, 9/22/23 and 9/27/23 Lunch - 9/7/23, 9/9/23, 9/13/23, 9/16/23, 9/20/23, 9/22/23 and 9/27/23 Supper - 9/5/23, 9/9/23, 9/10/23, 9/16/23, 9/18/23, 9/22/23-9/24/23 and 9/28/23 South Wing- 200s: Breakfast - 9/15/23, 9/20/23 and 9/23/23 Lunch - 9/11/23, 9/20/23, 9/21/23 and 9/23/23 Supper - 9/1/23, 9/4/23-9/6/23, 9/9/23, 9/11/23, 9/13/23-9/15/23, 9/18/23-9/20/23, 9/23/23, 9/24/23 and 9/27/23-9/29/23 West Wing-300s: Breakfast - 9/6/23 and 9/29/23 Lunch - 9/6/23, 9/9/23, 9/16/23, 9/17/23 and 9/29/23 Supper - 9/3/23, 9/4/23, 9/6/23, 9/8/23, 9/10/23, 9/11/23, 9/17/23, 9/25/23- 9/27/23, 9/20/23, 9/23/23, 9/24/23 and 9/27/23-9/29/23 October 2023: Main Kitchen: 10/1/23-10/31/23 no documentation provided for breakfast, lunch or supper. East Wing-100s: Breakfast - 10/21/23 and 10/29/23- 10/31/23 Lunch - 10/3/23, 10/11/23-10/13/23, 10/21/23 and 10/28/23-10/31/23 Supper - 10/7/23-10/10/23, 10/12/23, 10/21/23, 10/22/23, 10/30/23 and 10/31/23 South Wing- 200s: Breakfast - 10/16/23, 10/26/23 and 10/31/23 Lunch - 10/3/23, 10/6/23, 10/7/23, 10/11/23-10/13/23, 10/16/23-10/26/23 and 10/28/23-10/31/23 Supper - 10/2/23-10/4/23, 10/6/23-10/8/23, 10/11/23-10/13/23, 10/15/23-10/26/23 and 10/28/23-10/31/23 West Wing-300s: Breakfast - 10/8/23, 10/9/23, 10/22/23, 10/23/23 and 10/31/23 Lunch - 10/7/23-10/9/23, 10/22/23, 10/23/23, 10/30/23 and 10/31/23 Supper - 10/11/23, 10/17/23, 10/18/23, 10/22/23-10/25/23, 10/27/23, 10/28/23, 10/30/23 and 10/31/23 3. The facility's refrigerators/freezers did not have the temperatures monitored on the following dates: August 2023 Main Kitchen: 8/1/23-8/31/23 - No documentation provided for walk-in refrigerator, walk-in freezer, reach-in refrigerator, reach-in freezer, and reach-in dairy juice cooler. East Wing-100s: Reach-in refrigerator- 8/1/23(pm), 8/2/23(pm), 8/13/23(pm), 8/21/23(pm) and 8/22/23(pm), Reach-in freezer - 8/1/23(pm), 8/2/23(pm), 8/13/23(pm), 8/21/23-8/23/23(pm) and 8/26/23(pm) South Wing-200s: Reach-in refrigerator- 8/4/23(pm), 8/12/23(am), 8/23/23(pm) and 8/28/23(pm) Reach-in freezer - 8/4/23(pm), 8/11/23(pm), 8/15/23(pm) and 8/28/23(pm) West Wing-300s: Reach-in refrigerator- 8/5/23(pm), 8/6/23(pm), 8/8/23(pm), 8/18/23(pm), 8/27/23(am), 8/28/23(pm) and 8/27/23(pm) Reach-in freezer - 8/5/23(pm), 8/6/23(pm), 8/8/23(pm), 8/18/23(pm), 8/27/23(am), 8/28/23(pm) and 8/27/23(pm) September 2023 Main Kitchen: Walk-in refrigerator- 9/1/23(pm), 9/2/23(pm), 9/4/23-9/7/23(pm), 9/9/23-9/13/23(pm), 9/16/23(pm), 9/17/23(pm), 9/19/23-9/21/23(pm) and 9/24/23(pm) Walk-in freezer- 9/1/23(pm), 9/2/23(pm), 9/4/23-9/7/23(pm), 9/9/23-9/13/23(pm), 9/16/23(pm), 9/17/23(pm), 9/19/23-9/21/23(pm), 9/24/23(pm) and 9/25/23(pm) Reach-in refrigerator- 9/1/23(pm), 9/2/23(pm), 9/4/23(pm), 9/6/23(pm), 9/7/23(pm), 9/9/23-9/13/23(pm), 9/16/23(pm), 9/17/23(pm), 9/19/23-9/21/23(pm), 9/24/23(pm) and 9/25/23(pm) Reach-in freezer - 9/1/23(pm), 9/2/23(pm), 9/4/23(pm), 9/6/23(pm), 9/7/23(pm), 9/9/23-9/13/23(pm), 9/16/23(pm), 9/17/23(pm), 9/19/23-9/21/23(pm), 9/24/23(pm) and 9/25/23(pm) Reach-in dairy juice cooler- 9/1/23(pm), 9/2/23(pm), 9/4/23(pm), 9/6/23(pm), 9/7/23(pm), 9/9/23-9/13/23(pm), 9/16/23(pm), 9/17/23(pm), 9/19/23-9/21/23(pm), 9/24/23(pm) and 9/25/23(pm) East Wing-100s: Reach-in refrigerator- 9/7/23(am), 9/13/23(pm), 9/14/23(pm), 9/20/23(am), 9/22/23(am/pm), 9/23/23(pm), 9/24/23(pm), 9/27/23(am) and 9/28/23(pm) Reach-in freezer - 9/14/23(pm), 9/20/23(am), 9/22/23(am/pm), 9/23/23(pm) and 9/27/23(am) South Wing-200s: Reach-in refrigerator- 9/1/23(pm), 9/21/23(am), 9/22/23(pm), 9/23/23(pm), 9/25/23(pm), 9/28/23(pm) and 9/29/23(pm) Reach-in freezer - 9/1/23(pm), 9/21/23(am), 9/22/23(pm), 9/23/23(pm), 9/28/23(pm) and 9/29/23(pm) West Wing-300s: Reach-in refrigerator- 9/3/23(pm), 9/10/23(pm), 9/20/23(pm), Reach-in freezer - 9/3/23(pm), 9/10/23(pm), 9/20/23(pm), October 2023: Main Kitchen: Walk-in refrigerator- 10/6/23(pm), 10/9/23(pm), 10/13/23-10/15/23(pm), 10/20/23(pm), 10/22/23(pm), 10/23/23(pm), 10/28/23-10/30/23(pm) and 10/31/23(am/pm) Walk-in freezer- 10/6/23(pm), 10/9/23(pm), 10/13/23-10/15/23(pm), 10/20/23(pm), 10/22/23(pm), 10/23/23(pm), 10/28/23-10/30/23(pm) and 10/31/23(am/pm) Reach-in refrigerator- 10/6/23(pm), 10/9/23(pm), 10/13/23-10/15/23(pm), 10/20/23(pm), 10/22/23(pm), 10/23/23(pm), 10/28/23-10/30/23(pm) and 10/31/23(am/pm) Reach-in freezer - 10/6/23(pm), 10/9/23(pm), 10/13/23-10/15/23(pm), 10/20/23(pm), 10/22/23(pm), 10/23/23(pm), 10/28/23-10/30/23(pm) and 10/31/23(am/pm) Reach-in dairy juice cooler- 10/6/23(pm), 10/9/23(pm), 10/13/23(pm), 10/22/23(pm), 10/23/23(pm), 10/28/23-10/30/23(pm) and 10/31/23(am/pm) East Wing-100s: Reach-in refrigerator- 10/1/23(am), 10/4/23(am), 10/7/23-10/10/23(pm), 10/11/23(am), 10/12/23(am), 10/15/23(am), 10/17/23(am), 10/21/23(am/pm), 10/29/23(am), 10/30/23(am/pm) and 10/31/23(am/pm) Reach-in freezer- 10/1/23(am), 10/3/23(pm), 10/7/23-10/10/23(pm), 10/11/23(am), 10/12/23(am), 10/15/23(am), 10/17/23(am), 10/19/23(am), 10/21/23(pm), 10/29/23(am), 10/30/23(am/pm) and 10/31/23(am/pm) South Wing-200s: Reach-in refrigerator- 10/6/23(am), 10/24/23(pm), 10/28/23-10/30/23(pm), 10/31/23(am/pm) Reach-in freezer- 10/6/23(am), 10/24/23(pm), 10/28/23-10/30/23(pm), 10/31/23(am/pm) West Wing-300s: Reach-in refrigerator- 10/8/23(am), 10/9/23(am), 10/17/23(pm), 10/22/23(pm), 10/23/23(am/pm), 10/24/23(pm), 10/27/23(pm), 10/28/23(pm), 10/30/23(pm), 10/30/23(pm) and 10/31/23(am/pm) Reach-in freezer- 10/8/23(am), 10/9/23(am), 10/17/23(pm), 10/22/23(pm), 10/23/23(am/pm), 10/24/23(pm), 10/27/23(pm), 10/28/23(pm), 10/30/23(pm), 10/30/23(pm) and 10/31/23(am/pm) 0n 10/30/23 at 3:00 p.m., the surveyor discussed the findings with the facility Administrator.

MINOR (B)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected multiple residents

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Based on interviews and record reviews, the facility failed to issue a written transfer/discharge notice, which included information regarding appeal rights and the name and address of the Office of the State Long-Term Care Ombudsman, to residents or their representatives for 2 of 3 sampled residents transferred/discharged by the facility to an acute care hospital (Residents #99 and #256). Findings: 1. Documentation in Resident 99's clinical record indicated that the resident was transferred was transferred to an acute care facility on 9/25/23 and 10/6/23. The clinical record lacked evidence that the facility had provided a transfer/discharge notices to the resident and his/her representative. On 11/1/23 at 11:25 a.m., in an interview with a surveyor, the facility's Social Worker confirmed that a Transfer/Discharge Notice was not given to the resident or resident representative upon transfer to an acute care facility for either transfer. 2. Documentation in Resident 256's clinical record indicated that the resident was transferred to an acute care facility on 10/3/23. The clinical record lacked evidence that the facility had provided a transfer/discharge notice to the resident and his/her representative. On 11/1/23 at 9:25 a.m., in an interview with a surveyor, the facility's Social Worker confirmed that a Transfer/Discharge Notice was not given to the resident or resident representative upon transfer to an acute care facility. In addition, it was confirmed that the facility was not providing notice of resident transfers/discharges to the Office of the State Long-Term Care Ombudsman.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0625 (Tag F0625)

Minor procedural issue · This affected multiple residents

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Based on record reviews and interviews, the facility failed to issue a bed hold notice in writing, or within 24 hours, to residents or their legal representatives, for 3 of 3 residents transferred to an acute care facility (#99, #202 and #256). Findings: 1. Documentation in Resident 99's clinical record indicated that the resident was transferred to an acute care facility on 9/25/23 and 10/6/23. The clinical record lacked evidence that the facility had provided a bed hold notices to the resident or his/her representative. On 11/01/23 at 2:15 p.m., in an interview with the surveyor, the social worker confirmed that bed hold notices were not provided for Resident #99's transfer to the hospital on 9/26/23 and 10/06/23. 2. Documentation in Resident 202's clinical record indicated that the resident was transferred to an acute care facility on 10/16/23. The clinical record contained a progress note indicating the bed hold notice was provided on 10/23/23 to Resident #202's representative. On 10/31/23 at 3:31 p.m., in an interview with a surveyor, the social worker confirmed that the bed hold notice was not provided until 7 days after Resident #202's hospital admission. The social worker stated there is no process to ensure a resident's transfer to a hospital is communicated by nursing staff to social services staff. On 10/31/23 at 3:45 p.m., the surveyor discussed with the Administrator that nursing and social services staff do not have a process to ensure residents and family representatives receive bed hold notices within 24 hours of transfer to a hospital. 3. Documentation in Resident 256's clinical record indicated that the resident was transferred to an acute care facility on 10/3/23. The clinical record lacked evidence that the facility had provided a bed hold notice to the resident or his/her representative. On 11/1/23 at 9:25 a.m., in an interview with a surveyor, the facility's Social Worker confirmed that a bed hold notice was not given to the resident or resident representative in writing upon transfer to an acute care facility.

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 current daily nurse staffing information that includes the facility name, and a breakdown of the number of hours of registered and unlicensed nursing staff responsible for direct resident care in a prominent place readily accessible to residents and visitors for 3 of 3 survey days. (10/30/23, 10/31/23 & 11/1/23) Findings: On 10/30/23 at 10:00 a.m., during a facility tour, a surveyor observed that the nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. On 10/31/23 at 9:30 a.m., during a facility tour, a surveyor observed that the nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. On 10/31/23 at 10:41 a.m., in an interview, with the Administrator stated that the daily nurse staffing hours are not posted in the building since the facility opened on 7/19/23. On 11/1/23 at 4:45 p.m., during an exit interview, the above findings were discussed with the Administrator.

Sept 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observations, interviews and record review the facility failed to ensure that a resident's care plan was implemented, for 1 of 1 sampled resident reviewed for a hearing aids (#1). Findings: On 9/26/23 the surveyor reviewed Resident #1's current care plan. dated 9/5/23. under cognitive loss interventions noted: Attempt to remove hearing aid at night x1 and put on charger. If he/she refuses/resists, notify nurse to call [resident representative] Attempt to put hearing aid in x1 in morning. If [he/she] refuses/resists notify nurse to call [resident representative]. On 9/26/23 at 9:35 a.m., a surveyor observed Resident #1 dressed for the day and resting in his/her bed. The resident was having a hard time hearing the surveyor. The surveyor observed a clear locked box secured to the night stand which contained a cell phone and a hearing aid charger with a hearing aid in the charger. On 9/26/23 at 10:00 a.m., in an interview, CNA #1 confirmed that she had not put the hearing aid in the Resident #1's ear or attempted to this morning. CNA #1 stated, I thought the night shift, who gets the resident up, cleaned up and dressed, would have done this. I probably should have tried because the resident has been up and out of his/her room walking with his/her walker around the unit. On 9/26/23 at 10:15 a.m., in an interview, Licensed Practical Nurse #1 [LPN] stated, I haven't received any report from any CNA that the resident was not wearing his/her hearing aid. I have seen Resident #1 up walking around the unit and was not aware that he/she did not have his/her hearing aid in as the CNA's usually put it in. On 9/26/23 at 2:15 p.m., the surveyor observed Resident #1 sitting in common area next to the dining room with a group of other residents. Resident #1 was not wearing his/her hearing aid. A certified nursing assistant/medication technician[CNA/M #2] confirmed that Resident #1 did not have his/her hearing aid in. At this time, the surveyor went to Resident #1's room and observed Resident #1's hearing aid on the charger inside the lock box. A review of Resident #1's clinical record lacked evidence that Resident #1 was offered and refused to wear his/her hearing aid. On 9/26/23 at 2:40 p.m., in an interview, the Director of Nursing confirmed that Resident #1's care plan was not being followed and that Resident #1's clinical record lacked documentation of evidence of success or failure in putting in resident number ones hearing aid and the notification to family if it did not occur.

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 F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure a treatment cart containing multiple medicated creams, powders, ointments and syringes was locked on 1 of 3 units. (Memory Care Unit) Finding: On 9/26/23 at 12:27 p.m., a surveyor observed an unlocked, unattended treatment cart for 3 minutes outside the Memory Care unit nurses station. There was no staff in sight. During this time, the surveyor was able to open all 3 of the treatment cart draws, all which contained multiple medicated creams, powders, ointments and syringes. At approximately 12:30 p.m., a Certified Nurses Assistant - Medication Technician (CNA-Med tech) returned to her locked medication cart. The surveyor asked the CNA-Med tech if the treatment cart should be locked? The CNA-Med tech stated It should be locked. It's the nurses cart today, and walked away from the treatment cart leaving it unlocked. At approximately 12:33 p.m. LPN #1 returned to the treatment cart and locked it. LPN #1 acknowledged that the treatment cart should have been locked. On 9/26/23 at approximately 3:10 p.m., a surveyor discussed this finding with the Administrator.

Jan 2022 5 deficiencies 1 Harm

SERIOUS (G)

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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Based on record review and interviews, the facility failed to provide accessible call bell assistance devices necessary to prevent an avoidable accident from occurring for 1 of 3 sampled residents who experienced a fall (Resident #21) . Finding: Resident #21 was admitted to the facility from an acute hospital early in February of 2020, with a diagnosis of lack of coordination, unsteadiness on feet, history of falling and abnormalities of gait and mobility. A review of the care plan, initiated on 2/4/20, noted that the resident was a Moderate risk for falls r/t (related to) deconditioning and included the intervention to Be sure call light is within reach and encourage use for assistance as needed. On 10/10/21 Resident #21 had an unwitnessed fall resulting in lower back pain. A nurse's Fall Note dated 10/10/21 stated, [Resident] got up from [his/her] chair to get [his/her] call bell. On 10/18/21 Resident #21 had another unwitnessed fall which resulted in a left hip fracture requiring surgical repair on 10/19/21. A nurse's Fall Note dated 10/18/21 stated, Pt (patient) injury is likely due to the fact that Pt was placed on the commode without a call bell within reach. It was assumed [resident] was attempting to reach [his/her] call bell by self ambulating to it. And details of the event stated, Pt fall likely due to call bell not placed within reach. On 1/4/22 at 9:30 a.m., during an interview, Resident #21 confirmed the call bell was not within reach prior to falling stating, no, that's the problem, that's what I was trying to reach. On 1/4/22 at 1:43 p.m., during an interview with the Director of Nursing and Clinical House Coordinator, they confirmed both falls and the major injury of a hip fracture were avoidable if the resident had had access to the call bell.

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 for 1 of 23 sampled residents whose assessments were reviewed (Resident #13). Finding: On review of Resident #13's clinical record, a surveyor noted the resident was receiving hospice services, initiated on 11/28/21. On further review, the surveyor noted the most recent comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment was completed on 10/11/21 and no comprehensive MDS 3.0 assessment was completed within 14 days of the initiation of hospice services. On 1/4/22 at 11:50 a.m., the former MDS Coordinator stated the facility had hired another company to assume the role of completing MDS assessments and confirmed there is no system in place to trigger significant change events which would require a new MDS assessment. On 1/4/22 at 2:15 p.m., the Director of Nursing confirmed a significant change assessment should have been completed when the resident began hospice services, and that there was no process in place by which the consultant company was made aware of significant changes requiring completion of comprehensive assessments.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observations and interviews, the facility failed to ensure proper storage of medications during 1 of 3 survey days (1/4/22). The unattended cart allowed access to medicated creams and ointments by residents and unauthorized persons. Finding: On 1/4/22 at 12:43 p.m., a surveyor observed the 1st floor treatment cart, unlocked and unattended, in the hallway near the nurses' station. The cart contained multiple topical prescription ointments and creams. No staff noted the surveyor open and close the cart drawers. The surveyor alerted the Clinical House Coordinator to the unlocked/unattended cart, who confirmed the finding at this time.

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 1 of 7 meal observations. Finding: On 1/3/22 at 12:07 p.m. during lunch in the first floor dining room, a surveyor noted the food server readjust her face mask, with gloved hands, three times during food service to 2 residents, then pick up a ready-to-eat whoopie pie with gloved hands to cut and serve to another resident. The surveyor intervened and discussed the observation with the food server who acknowledged the handling of ready-to-eat foods with unclean gloves. On 1/5/22 at 7:15 a.m., the surveyor discussed the observation with the Director of Nursing who acknowledged the whoopie pie was not handled in a sanitary manner.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

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 implement its Pneumococcal Immunization policy for 1 of 5 residents whose immunization records were reviewed (Resident #40). Finding: The facility's Pneumococcal Immunization policy, with a review date of 4/2018, indicated On admission to the [NAME] Center each resident is offered pneumococcal immunization, in accordance with CDC guidelines unless medically contraindicated or the resident has previously been immunized within the CDC recommended time frames. On review of Resident #40's clinical record, the surveyor noted an admission date of 5/3/19 and no evidence a pneumococcal immunization was offered or a history of pneumococcal immunization. On 1/5/22 at 10:17 a.m. during an interview with the Director of Nursing, the surveyor confirmed that there was no evidence that a pneumococcal immunization was offered.

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

• 49 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• $11,998 in fines. Above average for Maine. Some compliance problems on record.
• Grade F (23/100). Below average facility with significant concerns.
• 73% turnover. Very high, 25 points above average. Constant new faces learning your loved one's needs.

Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Breakwater Commons's CMS Rating?

CMS assigns BREAKWATER COMMONS an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Maine, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Breakwater Commons Staffed?

CMS rates BREAKWATER COMMONS's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 73%, 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 68%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Breakwater Commons?

State health inspectors documented 49 deficiencies at BREAKWATER COMMONS during 2022 to 2025. These included: 1 that caused actual resident harm, 44 with potential for harm, and 4 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Breakwater Commons?

BREAKWATER COMMONS is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 96 certified beds and approximately 90 residents (about 94% occupancy), it is a smaller facility located in ROCKLAND, Maine.

How Does Breakwater Commons Compare to Other Maine Nursing Homes?

Compared to the 100 nursing homes in Maine, BREAKWATER COMMONS's overall rating (1 stars) is below the state average of 3.0, staff turnover (73%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Breakwater Commons?

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 Breakwater Commons Safe?

Based on CMS inspection data, BREAKWATER COMMONS has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Maine. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Breakwater Commons Stick Around?

Staff turnover at BREAKWATER COMMONS is high. At 73%, the facility is 27 percentage points above the Maine average of 46%. Registered Nurse turnover is particularly concerning at 68%. 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 Breakwater Commons Ever Fined?

BREAKWATER COMMONS has been fined $11,998 across 2 penalty actions. This is below the Maine average of $33,199. 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 Breakwater Commons on Any Federal Watch List?

BREAKWATER COMMONS is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 96
Avg. Residents: 90
Occupancy: 93.8%
Ownership: For profit - Limited Liability company
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -10
1 Actual Harm citation: -5
49 Deficiencies: -10
Fines ($11,998): -2
Final Score: 23/100

Nearby Alternatives

No other facilities found in this area.

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 205124