Dexter Health Care

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

calmed down after being outside for a bit. RN1 stated that after the Housekeeper brought Resident R1 back inside and took him/her to their room to be washed up that Resident R1 wanted to go back out but RN1 didn't have anybody that could go out with Resident R1 at that moment. RN1 stated, I mean I don't know if you ever worked with demented people, you can't really reason with them so it was like we were trying to explain to him/her, alright give us a few minutes we'll find somebody to go out with you and you can go back out but Resident R1 didn't want to hear that. The surveyor asked RN1 if she ever held Resident R1's hands down and RN1 stated, I didn't hold his/her hands down, I tried to pick them up so that I could wheel the chair but that was it, I didn't try to hold them, I just tried to get them out of the way of the wheels. On 8/29/25 at 12:47 p.m., the surveyor asked CNA2 to explain the observation on 8/16/25 in more detail on how RN1 held Resident R1's arms down. CNA2 stated that Resident R1 was flailing his/her arms up trying to hit RN1 and then RN1 reached over his/her shoulders, to hold them down and then CNA2 heard RN1 say OW but CNA2 did not see the action of biting. CNA2 stated, It was dragged out and that after RN1 was bitten by Resident R1, RN1 took him/her outside and when Resident R1 came back inside, he/she was better for a bit. On 8/29/25 at 1:50 p.m., during an interview with a surveyor, CNA4 stated RN1 just kept saying to Resident R1, you need to stop, you need to stop, you can't go outside. CNA4 further stated that RN1 was speaking in a frustrating manner and Resident R1's hands were kind of moving. CNA4 stated, I am not sure that Resident R1 could have moved his/her arms because of the way that RN1 had her arms positioned because she had her arms crossed around Resident R1's upper shoulder. I'm not sure Resident R1 would have been able to lift his/her arms up. CNA4 continued to say that she did try to redirect Resident R1 and the behaviors that Resident R1 was showing were normal behaviors for the weekends which she sees this regularly and is good at deescalating Resident R1. CNA4 stated that she was trying not to let the situation progress but was told by RN1, no you are not helping the situation. CNA4 stated that she was personally yelled at and told to remove herself from the situation by RN1. CNA4 stated that RN1's actions towards Resident R1, repeatedly stating to Resident R1, you can't go outside, you can't go outside and just kept taking Resident R1 back to his/her room made Resident R1 worse and that the situation was escalated by RN1.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dexter Health Care

64 Park Street Dexter, ME 04930

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0603

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Level of Harm - Minimal harm or potential for actual harm

Based on review of the facility's Nursing Facility Reportable Incident Form and investigation, facility policy review, employee file review, and interviews, the facility failed to ensure a resident was free from involuntary seclusion for 1 of 1 facility reported incidents reviewed (8/16/25).Finding:The facility's policy, Use of Restraints, revised 3/2025, indicated that seclusion, which is defined as the placement of the resident alone

in a room, shall not be employed. On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that staff reported that Resident #1 (Resident R1) was exit seeking and escalating and saw Registered Nurse #1 (RN1) bring Resident R1 back to his/her room and closed and held the door for a few seconds, up to a maybe a minute.On 8/26/25, RN1's employee file was reviewed and included a Performance Correction Notice, dated 8/18/25 that indicated RN1 was on leave, pending investigation, because of an incident with an allegation of abuse that included details that RN1 was outside Resident R1's door, holding the door shut for an amount of time while Resident R1 was in his/her room, attempting to get out. On 8/26/25, the surveyor reviewed the written statements gathered by the facility as part of their investigation for the 8/16/25 incident. On 8/16/25, Certified Nursing Assistant #2 (CNA2)'s written statement indicated that on around 8:15 a.m., Resident R1 was at the front door angry, yelling and screaming, kicking the door, and was trying to get out. Multiple staff tried to redirect Resident R1 from this behavior but Resident R1 kept getting louder. RN1 told Resident R1 to stop it, that he/she was not going out and to stop kicking the door. RN1 then grabbed Resident R1's wheelchair to move it away from the door when Resident R1 grabbed the wheels to stop it. Resident R1 yelled I'm not moving you son of a . RN1's response was oh yes you are! CNA2 assisted RN1 to help move Resident R1 from in front of the door and to the hallway. Resident R1 was taken to his/her room by RN1. CNA2 heard loud banging, turned around, and saw RN1 holding Resident R1's door closed. Resident R1 was kicking the door from the inside. RN1 eventually let the door go and went into the nurse's station. On 8/18/25, CNA1's written statement indicated that around 8:30 a.m. that morning (8/16/25), she saw RN1 put Resident R1 in their room, shut the door and held it shut but was not sure how long it was shut because she was in the middle of passing medications. On 8/18/25, CNA3 wrote that on 8/16/25, she had observed RN1 push Resident R1 in his/her wheelchair and then proceeded to hold the door shut not letting Resident R1 out. On 8/26/25 at 12:15 p.m.,

during an interview with a surveyor, CNA1 stated that Resident R1 had been acting out after breakfast, around 8:30 a.m. on 8/16. CNA1 was passing medications and looked up and saw RN1 put Resident R1 in his/her room and closed the door and held it, but she wasn't sure how long.On 8/26/25 at 1:05 p.m., during an interview with

the Administrator and Director of Nursing, the surveyor confirmed that written statements/interviews indicated that RN1 was observed holding Resident R1's door, with Resident R1 kicking the door wanting to get out. On 8/26/25 at 2:04 p.m., during an interview with a surveyor, CNA2 stated that Resident R1 was out front at the door kicking it and yelling. We all tried to redirect Resident R1 but he/she wouldn't stop yelling and kicking and trying to get out the door. CNA2 was able to help RN1 remove Resident R1 from the front entrance area and to the hallway. CNA2 stated that as she was walking away, she saw RN1 hold Resident R1's door closed, and Resident R1 was inside, kicking the door.

Once RN1 let go, Resident R1 opened the door and came out. CNA2 stated she didn't know how long she held the door shut.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dexter Health Care

64 Park Street Dexter, ME 04930

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or potential for actual harm

Based on review of the facility's investigation/written statements and interviews, the facility failed ensure that a resident was free from restraint when a Registered Nurse used body contact as a method of physical restraint to limit a resident's voluntary movement for 1 of 1 facility reported incidents reviewed (8/16/25).

Finding

The facility's policy, Use of Restraints, revised 3/2025, indicated Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. On 8/26/25, RN1's employee file was reviewed and included a Performance Correction Notice, dated 8/18/25 that indicated RN1 was on leave, pending investigation, because of an incident with an allegation of abuse that was considered restraining a resident that included details that RN1 held a resident's arms/hands down while resident was trying to hit staff. On 8/26/25, the surveyor reviewed the written statements and interviews provided as part of the facility's investigation for the 8/16/25 incident. On 8/16/25, Certified Nursing Assistant #2 (CNA2)'s written statement indicated that she heard super loud banging on the door because Resident #1 (Resident R1) was trying to get out and that she ran to the area. Registered Nurse #1 (RN1) came around and yelled at Resident R1, saying I told you to stop it, you're not going out! RN1 proceeded to drag Resident R1's (wheel)chair when Resident R1 threw a cup of coffee at RN1. RN1 was trying to hold Resident R1's hands down because after he/she threw the coffee, Resident R1 tried to hit her (RN1), so she (RN1) kept trying to hold Resident R1's hands down. RN1 stated to Resident R1 that you're not going to hit me. RN1 and Resident R1 argued back and forth and the next thing RN1 screamed, OW, Resident R1 friggen bit me! On 8/18/25, CNA4's written statement for the 8/16/25 incident indicated, RN1 removed Resident R1 away from the front door repeatedly as the situation escalated, CNA4 saw RN1 put her arms around Resident R1's upper chest as she wheeled him away from

the door, both of them yelling at each other. On 8/26/25 at 2:04 p.m., during an interview with a surveyor, CNA2 stated at one-point, RN1 held Resident R1's arms down, RN1 was standing from behind the chair because Resident R1 was kicking the door and RN1 didn't want to get hit. She tried to wheel Resident R1 around, she was behind Resident R1, she tried to hold his/her arms down while standing behind, and Resident R1 bit her. On 8/29/25 at 12:47 p.m., during an

interview with a surveyor, CNA2 stated that Resident R1 was flailing his/her arms up trying to hit her and then RN1 reached over his/her shoulders, to hold them down and then she heard RN1 say OW but she did not see

the action of Resident R1 biting RN1.On 8/29/25 at 1:50 p.m., during an interview with a surveyor, CNA4 stated RN1 just kept saying to Resident R1, you need to stop, you need to stop you can't go outside as RN1 was speaking in a frustrated manner. Resident R1's hands were kind of moving but CNA4 stated that she didn't think Resident R1 could have moved his/her arms because of the way that RN1 had her arms crossed around Resident R1's upper shoulder.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dexter Health Care

64 Park Street Dexter, ME 04930

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

Based on facility policy review, the Nursing Facility Reportable Incident Form and investigation review, timecard review, and interviews, the facility failed to protect residents after staff notification of concern of behavior by a Registered Nurse towards a Resident for 1 of 1 facility reported incident reviewed (8/16/25).Finding:The facility's Identifying types of Abuse, revised 3/2025, indicated the following: Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that on 8/16/25, staff reported to the Director of Nursing (DON) that Resident #1 (Resident R1) was agitated and Registered Nurse #1 (RN1) escalated resident's behavior to the point that Resident R1 bit RN1's hand. Review of the facility's investigation with written statements and facility interviews that were provided to the surveyor on 8/26/25 indicated the following:On 8/16/25 at 8:41 a.m., Licensed Practical Nurse #1 (LPN1) sent the DON a text message that indicated that RN1 was bit by a resident which broke the skin on RN1's right hand. On 8/16/25 at 8:41 a.m.,

the DON responded to this message from LPN1, asking RN1 to complete an incident report and follow up with Work Health on Monday. At 11:04 a.m., Certified Nursing Assistant #1 (CNA1) reported to the DON via text messages that Resident R1 was swinging at RN1 and RN1 was flapping her arms right back at the resident and telling the resident to go ahead and hit her; the DON responded back to CNA1 at 11:11 a.m. At 11:09 a.m., CNA3 texted the DON that she had concerns regarding RN1's behavior towards Resident R1; at 11:12 a.m., the DON spoke with CNA3 via telephone and asked if she needed to come in, to which CNA3 responded that Resident R1 was being sent to the hospital. The CNAs were asked to complete written statements regarding what

they had seen.On 8/18/25, the DON again asked for written statements from CNA1 and CNA3, which started the facility's investigation. The statements obtained included additional information that RN1 and put her hands on Resident R1 and that RN1 had put Resident R1 in his/her room and closed the door and held it shut.On 8/26/25,

a review of RN1's timecard indicated that she worked on 8/16/25 from 6:27 a.m. thru 6:57 p.m., and on 8/17/25 from 6:28 a.m. thru 6:57 p.m.On 8/26/25 at 1:35 p.m., during an interview with the Administrator and DON, the DON stated that we called the staff on 8/16/25 but no one mentioned anything physical. The DON stated that she spoke with Licensed Practical Nurse #1 (LPN1) and asked her to assume care of Resident R1 when he/she returned from the hospital. The surveyor confirmed that RN1's interaction with Resident R1 that was texted on 8/16/25 by staff at 11:04 a.m. was an allegation of a form of abuse but RN1 was allowed to remain at the facility providing patient care throughout the weekend.On 8/27/25 at 2:10 p.m., during an

interview with a surveyor, LPN1 stated that the DON asked her to assume care of Resident R1 but RN1 told her no, because Resident R1 was RN1's patient. LPN1 stated that when Resident R1 returned from the hospital, there were no further behaviors. On 8/28/25 at 9:41 a.m., during an interview with a surveyor, RN1 stated that she took care of Resident R1 both Saturday and Sunday because Resident R1 was her patient.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dexter Health Care

64 Park Street Dexter, ME 04930

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on Nursing Facility Reportable Incident Form review and interview, the facility failed to notify the State Agency (Division of Licensing and Certification [DLC]) timely for an allegation of abuse for 1 of 1 facility reported incidents reviewed (8/16/25).Finding:On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that on 8/16/25, staff reported to the Director of Nursing (DON) that Resident #1 (Resident R1) was agitated and Registered Nurse #1 (RN1) escalated resident's behavior to the point that Resident R1 bit RN1's hand.

Per documentation on this incident form, on 8/18/25, staff came to further report additional information to

the events that occurred on 8/16/25 between RN1 and Resident R1 that occurred when Resident R1's behaviors were escalating and Resident R1 was exit seeking, which included RN1 putting Resident R1 in his/her room, closed the door and held the door for several seconds up to one minute. In addition, on 8/16/25 at 11:04 a.m., Certified Nursing Assistant #1 (CNA1) reported to the DON via text message that Resident R1 was swinging at RN1 and RN1 was flapping her arms right back at the resident and telling the resident to go ahead and hit her. On 8/16/25 at 11:09 a.m., CNA3 texted the DON that she had concerns regarding RN1's behavior towards Resident R1. The facility started an investigation on 8/18/25 for the employee to resident interactions that occurred on 8/16/25. On 8/26/25 at 1:35 p.m., during an interview with the Administrator and DON, the surveyor confirmed that the interactions between RN1 and Resident R1 were allegations of abuse, and the State Agency was not notified timely.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dexter Health Care

64 Park Street Dexter, ME 04930

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on record review, facility investigation with written statements, and interviews, the facility failed to fully develop and implement a care plan for a resident who was agitated and trying to leave the facility for 1 of 1 facility reported incidents reviewed (8/16/25) when staff observed a Registered Nurse yelling at the resident instead of approaching/speaking in a calm manner and for the intervention to distract the resident from eloping, the resident preferences was BLANK. Finding:On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25.

The report indicated that staff reported that Resident #1 (Resident R1) was exit seeking and escalating.On 8/26/25, Resident R1's care plan was reviewed and included the following:Focus: The resident is an elopement risk/wanderer related to (r/t) safety awareness, dementia with interventions that included distract resident from wandering by offering pleasant diversions, structure activities, food, conversation, television, book. Resident prefers: IS BLANK. This care area was initiated on 12/8/24 and revised on 6/13/25. Focus: The resident has a behavior problem .r/t dementia with interventions that included minimize potential for the resident's disruptive behaviors by offering tasks which divert attention and to intervene as necessary approach/speak in a calm manner. This care area was initiated and revised on 12/8/24. On 8/26/25, a surveyor reviewed the facility's investigation with written statements from staff regarding the incident that occurred 8/16/25Certified Nursing Assistant #4 (CNA4) wrote that she observed Registered Nurse #1 (RN1) remove Resident R1 from the front door numerous times and take him/her back to their room. At one point, RN1 and Resident R1 were yelling at each other. On 8/26/25 at 12:22 p.m., during an interview with a surveyor, CNA1 stated Resident R1 gets in his/her moods but can be easy to calm down but not like that Saturday, CNA1 stated that she thought Resident R1 was provoked with RN1 adding to his/her being aggressive. This all started around 8:30 a.m., when Resident R1 returned from breakfast. CNA1 stated that around 10:30 a.m., she intervened between Resident R1 and RN1 and took Resident R1 back to his/her room after she observed RN1 mimicking Resident R1's flapping arms and telling Resident R1 to go ahead and hit her.

On 2:04 p.m., during an interview with a surveyor, CNA2 stated that Resident R1 has dementia, and he/she was triggered on that day (8/16/25) . Resident R1 gets triggered easily and you have to let him/her be. If someone is wound up, you got to leave them alone for a bit. Resident R1 wanted to go outside. and kept yelling and saying this is

a prison and he/she has the right to go out.yelling it loudly, disruptive to the other residents. At one point, RN1 was mimicking Resident R1 with the arms and both were yelling. With all of us wanting to defuse it, all you had to do was take him outside, but it was a busy time for us. As a result of this incident and facility investigation, the following corrective actions were initiated:-On 8/17/25, Resident R1's care plan had a new care area developed the resident is/has potential to be physically aggressive strike out related to dementia with

an intervention that included staff take turns taking resident outside one on one. -RN1's last day worked was 8/17/25 and was terminated for 8/28/25.-Education to staff on challenging behaviors in dementia care and aggressive or violent behavior was started on 8/19/25 with completion due by 8/29/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dexter Health Care

64 Park Street Dexter, ME 04930

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information which included documentation of Resident Representative notification of hospital transfer, charge nurse documentation of resident behaviors as directed per Treatment Administration Record (TAR), and documentation to indicate that a resident returned from the hospital for 1 of 1 facility reported incidents reviewed (8/16/25). On 8/26/25, the surveyor reviewed Resident #1's (Resident R1) clinical record after an incident that occurred on 8/16/25 which resulted in Resident R1 being transferred to the hospital for evaluation of increased behaviors. The clinical record lacked evidence of documentation on 8/16/25 of Resident Representative notification or an attempt to notify, notes from Registered Nurse #1 (RN1) who had signed of the treatment sheet that behaviors were monitored, or information regarding when Resident R1 returned to the facility after being transferred from the hospital. On 8/26/25 at 1:35 p.m., during an

interview with the Administrator and the Director of Nursing, the surveyor confirmed RN1 did not document behaviors in the clinical record as directed by a treatment on the TAR, dated 4/5/25, which directed licensed staff to monitor for the following behaviors and to document behaviors in the nurses/progress notes. On 8/16/25, RN1 documented on Resident R1's TAR that behaviors were monitored but lacked evidence of RN1 documenting the behaviors in the nurses/progress notes. In addition, the clinical record lacked evidence of Resident R1 returning to the facility after a hospital transfer. On 8/27/25 at 2:10 p.m., during an interview with a surveyor, Licensed Practical Nurse #1 (LPN1) stated that she did call Resident R1's Resident Representative and left

a message; she thought she documented the information in Resident R1's clinical record. The surveyor confirmed with LPN1 that she had not documented this information in the clinical record. On 8/28/25 at 9:41 a.m.,

during an interview with a surveyor, RN1 stated that (on 8/16/25) she documented on the TAR earlier in the shift on the behavior monitoring treatment but forgot to go back and update the clinical record when Resident R1 started behaviors around 8:30 a.m. In addition, RN1 stated that she was supposed to document information

on Resident R1's return from the hospital forgot to document Resident R1's return to the facility from the hospital in the clinical

record but forgot to.

Event ID:

Facility ID:

If continuation sheet