**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident reviewed who is positive for Methicillin Resistant Staphylococcus Aureus (MRSA), Resident ID #316. Findings are as follows: Record review of a document titled, Guidelines for the Management of Methicillin Resistant Staphylococcus aureus [MRSA, an antibiotic resistive infection, Multidrug-Resistant Organism, MDRO] in Rhode Island Long Term Care Facilities states in part, .Contact precautions [gown and gloves when entering the resident's room] are indicated for all residents infected with MRSA and those colonized residents who are more likely to shed MRSA into the environment . Review of a facility policy titled, Categories of Transmission-Based Precautions Isolations states in part, .Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable disease or infections that can be transmitted to others .Gown .Wear a gown to protect the skin and prevent soiling or contamination of clothing during procedures and care when contact with blood, bodily fluids, excretions, or secretions is anticipated . Record review revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, osteomyelitis (infection in the bone) and surgical removal of the left second toe. Record review of a document titled, Continuity of Care-Post-Acute Facility [COC] dated 1/26/2024 revealed, the resident's left 2nd toe surgical cultures were positive for MRSA. The resident was started on an oral antibiotic for 3 weeks with instructions to follow up with infectious disease. Further review of the COC revealed the resident was to be placed on infection control precautions of isolation related to his/her diagnosis of MRSA. Review of the admission Minimum Data Set assessment dated [DATE] failed to indicate that the resident had an MDRO. It further revealed that s/he was receiving surgical wound care with an application of a dressing to his/her foot. Review of the comprehensive care plan dated 2/8/2024 failed to reveal evidence of documentation that the resident had MRSA in his/her surgical site or that the facility implemented contact precautions related to the positive MRSA cultures, in order to mitigate the risk of transmission of this infectious disease to others in the facility. Surveyor observations on 2/14/2024 and 2/15/2024, failed to reveal evidence that the resident was on contact precautions for MRSA. During a surveyor observation on 2/15/2024 at 10:00 AM of the dressing change with Licensed Practical Nurse, Staff A, she was observed to perform wound care to the MRSA positive surgical site without donning a gown, as required per the facility policy, and the Guidelines for the Management of Methicillin Resistant Staphylococcus aureus [MRSA, an antibiotic resistive infection, Multidrug-Resistant Organism, MDRO] in Rhode Island Long Term Care Facilities. During a surveyor interview on 2/15/2024 at 10:59 AM with Staff A, she indicated that she was unaware that the resident was positive for MRSA in his/her left second toe until it was brought to her attention by the surveyor. Additionally, she acknowledged that the resident was not currently on isolation precautions. During a surveyor interview on 2/15/2024 at 11:52 AM with the Infection Preventionist, she was unable to provide evidence that the facility placed the resident on contact precautions for MRSA when s/he was admitted to the facility to prevent the transmission of his/her infectious disease to staff, residents, and visitors. Further review of the care plan revealed that it was updated on 2/15/2024 to indicate that the resident was admitted with MRSA to his/her left second toe surgical site and was to be placed on standard/contact precautions.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status for 1 of 9 residents reviewed, Resident ID #53. Findings are as follows: Review of the resident's record revealed that s/he was admitted to the facility in April of 2022 with a diagnosis including, but not limited to, celiac disease (an immune reaction to eating gluten, a protein found in wheat, barley, and rye). Review of the weight documentation revealed that s/he weighed 132.4 pounds (lbs.) on 4/18/2022. Further review of the weights from August 2022 through January 2023 revealed the following: - 8/4/2022: 129.0 lbs - 9/2/2022: 122.2 lbs., loss of 6.8 lbs. in 1 month - 10/10/2022: 117.4 lbs, loss of 4.8 lbs. in approximately 1 month - 10/20/2022: 113.2 lbs., loss of 4.2 lbs. in 10 days - 11/4/2022: 111.2 lbs., loss of 3 lbs. in 11 days - 11/25/2022: 110.2 lbs. - 12/1/2022: 108.8 lbs. - 12/17/2022: 106.4 lbs. - 12/23/2022: 104.0 lbs. - 12/31/2022: 104.3 lbs., loss of 5.9 lbs. in approximately 1 month - 1/5/2023: 103.8 lbs. Review of a Dietitian note, dated 12/27/2022 at 5:47 PM, revealed that the resident continues to lose weight and an intervention of gluten free milkshakes was added to his/her meals the previous week. Review of the daily dietary meal ticket for this resident for all days of the survey, 1/3/2023 through 1/6/2023, revealed that s/he is to be provided two 4 fluid ounce lactaid milkshakes (8-ounce gluten free, lactose free milkshake) on his/her meal tray for all meals. Surveyor observations of the following meals failed to reveal evidence the that above mentioned gluten free milkshakes were provided to the resident: - 1/4/2023, approximately 9:00 AM at breakfast - 1/5/2023, approximately 1:00 PM at lunch - 1/6/2023, approximately 9:00 AM at breakfast During an additional surveyor observation of the resident's meal tray in the presence of Certified Nursing Assistant, Staff A, and subsequent interview on 1/6/2023 at 9:17 AM, it was revealed that she did not administer the gluten free milkshake to the resident and it was not provided on the resident's breakfast tray. During an interview with the Dietitian on 1/5/2023 at approximately 5:00 PM, and an additional interview on 1/6/2023 at approximately 9:30 AM, she indicated that goal for the resident is to gain weight and the weights are measured to see if the facility interventions are working. She could not provide evidence that the gluten free milkshakes were provided to the resident as indicated on the meal ticket on the above-mentioned dates and mealtimes.

Based on record review and staff interview it has been determined that the facility failed to have a tracking mechanism that identified each staff 's role, assigned work area, and how they interact with residents for individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Findings are as follows: Review of the facility's COVID-19 document titled HOSPICE updated 1/6/2023, failed to reveal evidence of COVID-19 vaccination tracking documentation for the following individuals who provided care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement, including, but not limited to the following individuals: 1. Hospice Nurse Practitioner, Staff E documented in the building on 10/11/2022 2. Hospice Music Therapist, Staff F documented in the building on 11/15/2022 3. Hospice Spiritual Counselor, Staff G documented in the building on 11/10/2022 4. Hospice Nursing Assistant, Staff H documented in the building on 11/18/2022 5. Palliative Provider, Staff I documented in the building on 10/26/2022 During an interview with the Director of Nursing Service on 1/6/2023 at approximately 2:00 PM, she was unable to provide a tracking document with the above-mentioned vendors listed.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is served and distributed in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 4-501.114, states in part, .a chemical sanitizer for a manual or mechanical operation at contact times .shall be used as follows: (A) A chlorine solution shall have a minimum concentration range 50-99 MG/L . During the initial tour of the main kitchen on 1/3/2023 at approximately 8:45 AM the sanitizing test strip registered 10 MG/L (milligrams per liter) on dinnerware that was being washed and sanitized. Immediately following this observation the surveyor interviewed the [NAME] President of Operations and he indicated that he would contact the service representative for the dishwasher. Record review revealed that the service representative repaired the dishwasher on 1/3/2023. During an additional surveyor observation on 1/5/2023 at approximately 9:50 AM the chlorine test strip read 10 MG/L on dinnerware that was being washed and sanitized. Immediately following this observation the surveyor interviewed the [NAME] President of Operations and he indicated that he would contact the service representative for the dishwasher. Record review revealed that the service representative repaired the dishwasher on 1/5/2023. An additional surveyor observation on 1/6/2022 at approximately 10:15 AM the chlorine test strip read 10 MG/L. Immediately following this observation the surveyor interviewed the [NAME] President of Operations and he acknowledged the above findings and indicated at this time the dishwasher would not be utilized for warewashing. 2. The Rhode Island Food Code 2018 Edition 4-501.110 states in part, .The temperature of the wash solution in a spray type ware washer that use chemicals to sanitize may not be less than 49 degrees Celsius (120 degrees F) . During a surveyor observation on 1/4/2023 at approximately 1:20 PM the wash cycle gauge was not registering a wash temperature. During a surveyor interview with the Administrator and the [NAME] President of Operations on 1/4/2023 at approximately 1:30 PM they acknowledged that the wash cycle gauge was not registering a temperature and they indicated that they would contact the service representative for the dishwasher. 3. The Rhode Island Food Code 2018 Edition 2-402.11, states in part, Food Employees shall wear hair restraints such as hats, hair covering, beard restraints that covers body hair . During surveyor observations of Dietary Aide, Staff B, on 1/3/2023 at approximately 12:30 PM and 1/4/2023 at 1:25 PM and 3:30 PM revealed he was not wearing a beard restraint while delivering residents lunch meal trays and washing dishes. An additional surveyor observation on 1/5/2023 at 8:45 AM revealed Dietary Aide, Staff D without a beard restraint while on the breakfast serving line. 4) The Rhode Island Food Code 2018 Edition 3-501.19 Time as a Public Health Control reveals in part; .the food shall have an initial temperature of 5 degrees Celsius (41 degrees Fahrenheit) or less when removed from cold holding temperature control . During a surveyor observation on 1/4/2023 at approximately 12:20 PM revealed super pudding, a product made on premise with whole milk for resident meal consumption, had a serving temperature of 61 degrees Fahrenheit at the serving line. During a surveyor interview on 1/5/2023 at approximately 2:00 PM with the Food Service Director she acknowledged the serving temperature of the super pudding was not within the acceptable temperature parameter and the two dietary staff members were not wearing beard restraints.