Acadia Nursing and Rehab Center

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly label and date food products, failed to properly maintain the dishwater temperature logs, failed to maintain kitchen equipment in a sanitary condition, failed to properly store chemicals, and failed to properly restrain hair creating the potential for cross contamination in the Main Kitchen of the facility and the facility failed to ensure food was stored and maintained in accordance with professional standards for food safety for one of two resident refrigerators (Conference Room - Resident Refrigerator).

Inspectors wroteBased on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (R5, R17, and R45).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility provider failed to notify a resident of planned changes to resident's medications and failed to allow the resident to be able to participate in the decision-making process regarding resident's care for one of three residents (Resident R68).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain a confidential personal medical record for one of two residents (Resident R20).

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to conduct a Significant Change Minimum Data Set assessment for one of four sampled residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Resident R8, and R58).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R11).

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift for one of three observed days (6/7/26).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of two medication storage rooms (Front Hall Medication Room) and two of three medication carts (Zone 2 Medication Cart and Zone 3 Medication Cart).

Inspectors wroteBased on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of three observed meals (lunch meal 6/7/26) and failed to have the registered dietitian review and approve the menu and nutritional substitutes prior to implementation for one out three meals served (lunch meal 6/7/26).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to dispose of garbage into the dumpster properly for one dumpster observed outside of the building.

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions (EBP) for one of three residents (Resident R58) with enteral feeding tubes (G- Tube, a tube inserted in the stomach through the abdomen), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for two of 12 months (July 2025, and April 2026).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for two of twelve months (July 2025, and April 2026) and failed to provide a complete antibiotic order for one of four residents (Resident R33).

Inspectors wroteBased on review of facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for two periods during the time frame from June 2025, through May 2026 (11/12/25 - 11/24/25, and 4/26/26 - 5/20/26).

Inspectors wroteBased on review of facility policy, observations, resident and staff interviews, it was determined that the facility failed to make certain resident funds were accessible on holidays and weekends for two of four residents reviewed (Residents R1 and R2).

Inspectors wroteBased on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of three observed meals on 5/27/25, (Dinner Meal).

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly monitor food expiration dates in the Main Kitchen, failed to maintain food equipment in a clean, sanitary condition, failed to properly restrain beards, failed to maintain sanitary conditions during tray line which created the potential for cross contamination, and failed to verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness.

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 12 of 12 months (April 2024, - April 2025).

Inspectors wroteBased on facility policy, pest control log, observations, and staff interviews it was determined the facility failed to maintain an effective pest control program related to gnats in the kitchen (Main Kitchen).

Inspectors wroteBased on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain timely documentation of the admission agreement for four of four residents (Resident R2, Resident R12, R33, and R56) and failed to ensure residents had the capacity to understand the terms of the admission agreement for three of four residents (Residents R12, R33, and R56).

Inspectors wroteBased on review of facility policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of three nurse aide personnel records (Nurse Aides (NA) Employee E10, NA Employee E11, and NA Employee E12).

Inspectors wroteBased on review of facility policy, facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for three of five residents (Resident R12, R33, and R56).

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (Front and Back hallways).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for four of five employees (Nurse Aide (NA) Employees E10, E11, E12, and Licensed Practical Nurse (LPN) Employee E8).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide compliance and ethics training for four of five staff members (Nurse Aide (NA) Employees E10, E11, E12, and Licensed Practical Nurse (LPN) Employee E8).

Inspectors wroteBased on review of the Code of Federal Regulations, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain residents were free from mental abuse, including abuse facilitated or enabled through the use of technology for two of four residents reviewed (Residents R13 and R21).

Inspectors wroteBased on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for two of four residents (Resident R17, and R45).

Inspectors wroteBased on review of the Code of Federal Regulations, personnel records and staff interview, it was determined that the facility failed to conduct a criminal background check prior to working on the nursing unit for one out of five personnel records (Nurse Aide (NA) Employee E7).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of three residents (Resident R3 and R42).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed and documented by the consultant pharmacist for one of four residents (Resident R44).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (back hall medication room).

Inspectors wroteBased on review of resident clinical records, facility policy, and staff interviews, it was determined the facility failed to obtain a physician order for hospice services and failed to ensure the coordination of hospice services (supportive services for end stage terminal illness) with facility services to meet the needs of each resident for end-of-life care for two of four residents (Resident R22, and R31).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for two of five staff members (Nurse Aide (NA) Employees NA E11, and NA E12).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide behavioral health training as determined by the Facility Assessment for two of five staff members (Employees E8, and E10).

Inspectors wroteBased on observations, resident, and staff interviews, it was determined that the facility failed to obtain physician orders and failed to care plan interventions for medication self-administration for one of three residents (Residents R1).

Inspectors wroteBased on review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the facility failed to implement infection prevention and control monitoring policies for COVID-19 for ten out of ten residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9 and Resident R10), and failed to use Personal Protective Equipment (PPE) appropriately, which created the potential for the cross-contamination and the spread of diseases and infections on 3 out of 10 COVID-19 positive rooms.

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to complete influenza vaccination consent for one of five residents (Resident R4), failed to make certain that influenza vaccination was administered in a timely fashion for one of five residents (Resident R5), and failed to complete pneumococcal vaccine consent for two of five residents (Resident R4 and R5).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and providing education for two of five residents reviewed for immunizations (Resident R1 and R5), and failed to offer staff COVID-19 vaccines for 7 of 7 employees interviewed. (E4, E5, E6, E7, E8, E9, and E10)

Inspectors wroteBased on review of facility policies, closed resident records and staff interview, it was determined that the facility failed to acquire and document a physician's discharge order and acquire and document physician orders for medications for one out of two closed resident records (Closed Resident Record CR1).

Inspectors wroteBased on review of facility policies, clinical record reviews and staff interviews it was determined that the facility failed to provide written notice, including reason for the change, prior to moving a resident to another room, for two of four residents reviewed (Residents R1, and R2).

Inspectors wroteBased on review of facility policy, resident records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one of four sampled records (Resident R3).

Inspectors wroteBased on review of facility documents, interviews with residents, and staff, it was determined that the facility failed to pay staff in a timely manner as scheduled. This resulted in kitchen staff and multiple nurse aides not reporting to work, which created a situation that placed 50 out of 50 residents in immediate jeopardy in which health and safety were impacted due to a potential interruption of proper food, supplies and services.

Inspectors wroteBased on review of facility policy, clinical records, facility documents, resident interview, and staff interview, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge). This failure created an immediate jeopardy situation for one of 50 residents (Resident R48).

Inspectors wroteBased on manufacturer's instructions, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death), and placed one resident (Resident R37) in immediate jeopardy in which health and safety were impacted.

Inspectors wroteBased on resident observations, resident interviews, staff interviews, clinical record review, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of three of ten residents (Resident R35, R46, and R104). Findings Include: Review of a resident grievance dated 10/25/23, Resident R 35 stated concern over response time to call bells being answered. During an interview on 2/28/24, at 12:01 p.m. MDS (minimum data set- periodic assessment of resident care needs) Coordinator Employee E13 stated Lately we've had no agency (nursing staff). I think it ' s because they weren't being paid. We were pretty good there for a while until we didn ' t get paid the second time. During a group interview on 2/28/24 at 1:31 p.m. [...]

Inspectors wroteBased on a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for five months for five out of five sampled residents (Resident R3, R8, R11, R17, and R49).

Inspectors wroteBased on observation and staff interview it was determined that the facility failed to maintain sanitary conditions in the main kitchen and dining room creating the potential for unsafe condition and cross contamination.

Inspectors wroteBased on review of facility policy, resident council documents, resident council group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from resident council and failed to respond to concerns in a timely manner for three out of nine months (December 2023, January 2024, and February 2024).

Inspectors wroteBased on review of facility policy, tour of the facility, and staff interview it was determined that the facility failed to make certain that a posted grievance policy and procedure was met federal guidelines for two out of two nursing units (Front hall nursing unit and back hall nursing unit).

Inspectors wroteBased on review of personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for four out of five nurse aides (NA Employee E4, E19, E20, and E21).

Inspectors wroteBased on staff interviews it was determined that the facility failed to employ a qualified Dietary Manager and Registered Dietitian since October 2023.

Inspectors wroteBased on menu, resident council group interview and staff interviews, it was determined that the facility failed to follow the menu for two of two meals (Breakfast and Lunch meal Saturday 2/24/24).

Inspectors wroteBased on review of facility documents, and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of three quarters reviewed (second quarter April-June 2023, and third quarter July-September 2023).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R10) and the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for three of nine months (October 2023, November 2023, and December 2023).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for three of nine months (October 2023, November 2023, and December 2023).

Inspectors wroteBased on review of facility policy, resident clinical record, resident interview and staff interview it was determined that the facility failed to provide goods and services resulting in neglect for one of two residents (Resident R104).

Inspectors wroteBased on review of facility policy, resident clinical record, reports submitted to the State, resident interview and staff interview it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R104).

Inspectors wroteBased on a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was implemented to meet resident care needs for one of six residents reviewed (Resident R37) to address care needs related to a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death).

Inspectors wroteBased on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings and monitoring of Food Service operations

Inspectors wroteBased on policy and clinical record review and resident, family, and staff interviews, it was determined that the facility failed to make certain that showers and assistance for activities of daily living were consistently provided for one of five residents (Resident R46).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services for one of three residents (Resident R37) to address care needs related to Life Vest (wearable defibrillator designed to protect residents from sudden cardiac death).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening for one of three residents (Resident R10).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide a resident with necessary behavioral non-pharmacological interventions to maintain the highest practicable mental and psychosocial well-being for one out of four sampled resident records (Resident R3).

Inspectors wroteBased on facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary medications for two of four residents (Resident R3 and R8).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly and safely store medications under appropriate temperatures in one of two medication rooms (Front medication room).

Inspectors wroteBased on clinical record review, staff interviews and a review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.

Inspectors wroteBased on a review of facility policy, observations, and staff interview, it was determined the facility failed to store food items in accordance with professional standards for food service safety in one of two food service areas (Main Kitchen.)

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label, date and store medications in two of three medication carts. (Med Cart 1-9, and Med Cart Long Hall)