Senior Care Center - Brunswick

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that the dumpster area was free of debris and maintained in sanitary conditions. In addition, the facility failed to ensure the dumpsters lids for three of the four dumpsters had a secure fit and closed properly. The deficient practice had the potential to promote the harboring of pests, insects, and other organisms and create the potential for disease transmission by pest and rodents. The census was 126 residents.

Inspectors wroteBased on observations, staff interviews, record reviews and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to follow professional standards of quality care for two of six residents (R) (R89 and R51). Specifically, the facility failed to ensure all medications ordered were administered and documented according to professional standards of clinical practice.

Inspectors wroteBased on observations, residents and staff interviews, record review, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to ensure the medication error rate was less than five percent. There were nine errors with 56 opportunities for three of six residents (R) (R51, R89 and R92) observed for a medication administration with an error rate of 16.07 percent. This deficient practice had the potential to place all residents at risk of avoidable medical complications due to not receiving medications or receiving an incorrect dose of medication other than that prescribed by the physician.

Inspectors wroteBased on observations, staff interviews and review of the facility's policy titled, Medication Storage in the Healthcare Center, the facility failed to ensure that all drugs and biologicals were discarded prior to the expiration date on one of nine medication carts (Harbor Side) and two of six medication rooms (Central Supply and Ocean Breeze). This deficient practice had the potential to place residents at risk for medical complications and delayed treatment. The facility census was 126 residents.

Inspectors wroteBased on staff and residents' representative interviews, record review, and review of the facility's policy titled, Resident Trust Funds, the facility failed to ensure two out of three residents (R) (R135 and R139) accounts reviewed, that the resident or residents' representative received a final refund within 30 days of expiration or discharge.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to ensure a safe, clean, comfortable, home-like environment for one out of 29 rooms (room [ROOM NUMBER] B) located on the 200 hall. Specifically, clean bed linens were not provided for the resident in room [ROOM NUMBER] B.

Inspectors wroteBased on observations, staff interviews, record review and review of the facility's policies Care Plans and Smoke Free Policy, the facility failed to develop and implement care plan interventions for four out of 49 sampled residents (R) (R120, R10, R16, and R26). Specifically, care plans addressing the following were not developed and implemented for R10 and R120 related to elopement, R16 related to smoking, and R26 related to diet orders. This failure had the potential to cause the residents not to receive treatment and/or care according to their needs.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, resident and staff interviews, record reviews, and reviews of the facility's policy titled, Medication Administration: General Guidelines the facility failed to follow the physician's orders as recommended for one resident (R) (R94) of 49 sampled residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Occurrences and Smoke Free Policy, the facility failed to ensure the environment was free of accident hazards for one of 15 sampled residents (R) (120) reviewed for elopement and one of two residents (R16) reviewed for smoking. Specifically, the facility failed to complete an elopement assessment for R120 after an occurrence and failed to complete a smoking assessment for R16 with known tobacco use. The deficient practice created a potential risk to the safety and well-being of R120 and R16.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure mechanical soft - chopped meats were prepared properly for one out of 36 residents resident (R) (R26) reviewed on a mechanical soft diet.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Standard Precautions, the facility failed to ensure resident personal care items were stored in a manner to prevent cross-contamination in three of 12 bathrooms shared between rooms (216 and 218, 215 and 217, 205 and 207) on the 200 Hall. The deficient practice had the potential to expose residents to infections due to cross-contamination.

Inspectors wroteBased on observations, interviews, and review of the facility's policy titled Patient/Resident Rights, Accommodation of Needs, the facility failed to ensure privacy for two out of 29 resident rooms observed (room [ROOM NUMBER] A and 218 B) had privacy curtains.

Inspectors wroteBased on record review and staff interviews, the facility failed to protect one of three residents (R) (R4) sampled for falls during transfer. Harm was identified to have occurred on 2/19/2025 when R4 fell while being transferred from a chair to the bed by staff, resulting in a mid-shaft radius fracture.

Inspectors wroteBased on record review, resident, family, and staff interviews, and review of facility document titled, Facility Assessment , the facility failed to ensure there was sufficient staffing to provide the assistance residents needed with activities of daily living (ADLs). This deficient practice had the potential to affect the care provided to the 118 residents that resided in the facility.

Inspectors wroteBased on observation, record review and staff and resident interviews, the facility failed to ensure three residents (R2, R3, and R 6) were given showers as scheduled from a sample of six residents.

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility policy titled Abuse Prohibition, the facility failed to protect the resident's right to be free from sexual abuse by a resident and physical and verbal abuse by staff. Specifically, R84 was sexually abused by R41, and R14 was physically and verbally abused by a Certified Nursing Assistant (CNA) AA. There were five residents reviewed for abuse. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. [...]

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled, Abuse Prohibition, the facility failed to complete a thorough investigation for two of five sampled Residents (R) (R84 and R41) reviewed for abuse. Specifically, there was no evidence the facility interviewed R84 the victim, other staff, or residents regarding the allegations of potential sexual abuse as a part of the facility's investigations. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. [...]

Inspectors wroteBased on staff interviews, record review, and the facility policy titled Nursing Care Plan, the facility failed to develop a care plan for two residents, R84 for sexual abuse from another resident and R14 for verbal and physical abuse by staff. In addition, the facility failed to ensure a care plan was created for elopement and safety concerns for R115. There were 52 residents sampled. This deficient practice had the potential to have an adverse effect for the residents. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. [...]

Inspectors wroteBased on interviews, record reviews, and review of the job summaries for the Administrator and Director of Nursing (DON), the facility Administration failed to effectively oversee an abuse prevention program to promote, foster, and maintain an abuse-free environment. The facility census was 149. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility's policies titled Abuse Prohibition and General Medication Preparation and Administration, the facility failed to ensure that two residents (R) (R136 and R302) of 52 sampled residents were given medication without having a physician's order. Actual harm was identified on 1/23/2024 when LPN I2 administered her personal Melatonin to R136 and R302, which resulted in the residents becoming lethargic.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure infection control standard practices were performed to prevent cross contamination of linens and to prevent cross-contamination of resident equipment for resident (R43). The deficient practice had the potential to increase the probability of the spread of infection on two of four halls.

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility policy titled Self-Administration Program, the facility failed to ensure that one of 34 residents (R115) did not have unsecured unauthorized medications stored at the bedside in the facility's secure Memory Care Unit. This deficient practice had the potential to allow unauthorized access to medications to other residents and visitors in the facility.

Inspectors wroteBased on interview, record review, and review of the facility policy titled Abuse Prohibition, the facility failed to ensure that allegations of abuse were reported to the State Agency (SA) in a timely manner for one resident (R14) from a total sample of five residents.

Inspectors wroteBased on record reviews, staff interviews, and the facility polices titled Discharge Planning Policy and Nursing Care Planning, the facility failed to develop a discharge plan of care for seven residents (R78, R81, R84, R98, R115, R104, and R454) 52 sampled residents.

Inspectors wroteBased on record review and staff interview the facility failed to provide a completed discharge summary with a recapitulation of the resident's stay for one of one discharged resident (R) 454.

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to ensure one of 52 sampled residents (R) R78 reviewed for limited range of motion (ROM) received passive range of motion (PROM) treatment as needed to address limited ROM in his right upper extremity (right hand). This failure had the potential to decrease the residents' quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Non-invasive long-term Ventilation Support, and Cleaning and Disinfecting Respiratory Therapy Equipment, the facility failed to ensure respiratory equipment was properly stored while not in use for two of five Residents (R)30 and (R49) receiving respiratory treatment. The facility also failed to ensure that nebulizer equipment was dated and properly stored for one of 21 residents, R49. The deficient practice had the potential to increase the probability of respiratory complications for the residents receiving respiratory care and treatment.

Inspectors wroteBased on record review, interviews, and the facility's policy's titled Automatic Stop orders and Psychoactive Medications, the facility failed to ensure an antipsychotic medication was not ordered as needed (PRN) beyond 14 days and failed to document the rationale in the resident's medical record and indicate the duration for the PRN order for one of six sampled residents (R) R111.

Inspectors wroteBased on staff interview, record review, review of Administrator, Assistant Administrator, and Director of Nursing job descriptions, the facility administration failed to ensure timely Minimum Data Set (MDS) coding and transmissions, the development of policies and procedures for the care and services for dialysis residents according to the Census and condition that were receiving dialysis treatment, and adequate management and monitoring of Quality Assurance Improvement (QAPI). The facility census was 146 residents.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Quality Assurance/Risk/Performance Improvement, the facility failed to implement corrective action plans that effectively addressed concerns with the monitoring and documenting residents monthly and weekly weights and Minimum Data Set (MDS) transmission. The facility also failed to ensure policies and procedures were implemented for residents receiving dialysis services. The facility census was 146 residents.

Inspectors wroteBased on staff interview and record review, the facility failed to obtain a physician's order for two of four resident(s) ((R) R# 46 and R#14), receiving hospice services.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for five residents (R) R#1, R#2, R#3, R#4, R#5. The facility census was 146.

Inspectors wroteBased on observation, interviews, and clinical record reviews, it was determined that the facility failed to coordinate Preadmission Screening, and Resident Review (PASRR) Level II services for one resident (R) #93 to address known behaviors of 54 sampled residents.

Inspectors wroteBased on record review, staff interview, and the facility policy 'Person-Centered Care Planning', the facility failed to develop a care plan for two residents ((R) #14 related to hospice and R#46 related to code status), failed to implement care plan interventions for one resident (R#93) related to behavioral health and one resident (R#129) related to nutrition/hydration and dialysis needs. The sample size was 54.

Inspectors wroteBased on staff interview, review of documentation, and review of the policy titled, Person-Centered Care Planning, the facility failed to update the care plan for one resident (R) R # 7 related to a fall with major injury. The sample size was 54 residents.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure quality care and services in accordance with professional standards for one resident ((R) R # 404) for the provision of care related to an insulin pump. The sample size was 54 residents.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy titled Special needs: Tracheostomy Care and Suctioning. the facility failed to ensure that an emergency trach kit was available at the nedside for use for one resident (R) R#153, the facility also failed to ensure that orders were written for oxygen use for R#153. The deficit practice had the potential to affect one of one resident in the facility that had a tracheostomy.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to have orders for dialysis treatment and services and failed to maintain consistent communication with completed forms with the dialysis center to coordinate care for one resident (R) #129 of seven residents receiving dialysis.