**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with edema (swelling due to excess fluid trapped in the body's tissues), Resident ID #51. Findings are as follows: Review of an undated facility policy titled, WHEN THERE IS A CHANGE OF CONDITION states in part, .The resident's attending physician or on-call physician must be notified when a change of condition has occurred .resident responsible party must be notified. Changes in condition include but are not limited to .A need to alter resident's medical treatment . Record review revealed the resident was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, Alzheimer's disease, acute kidney failure, hypertensive heart (a condition caused by chronic high blood pressure) and chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 4 out of 15, indicating the resident has severe cognitive impairment. Record review revealed the resident was seen by the physician on 6/1/2025 with no acute issues present. Record review revealed the following progress notes: -6/5/2025 at 4:31 PM, Resident had a non-productive cough this shift, lung sounds assessed, s/he has bilateral wheezing on exertion. -6/5/2025 at 2:50 PM, Resident continues on the respiratory protocol. -6/6/2025 at 5:02 AM, Resident was noted with a coughing episode from 1:30 AM until 1:45 AM and lung sounds diminished (a condition when the lungs do not fully inflate). -6/8/2025 at 5:33 PM, Resident has diminished lung sounds with a faint expiratory wheeze (a noise heard on exhaling) and an occasional cough was noted. During a surveyor observations of the resident on 6/9/2025 at approximately 10:30 AM and again at 3:36 PM, the resident was observed to have swelling to his/her lower legs and had a congested, non-productive cough. Record review revealed the following physician's orders: 3/28/2025 - Diuretic (a medication used to treat fluid retention and high blood pressure) use, monitor for edema, congestion and weight changes every shift. 5/3/2025 - Furosemide (Lasix-a diuretic medication) 40 milligrams (mg) twice a day. 6/5/2025 - Monitor respiratory status, include lung sounds and document in nursing notes every shift for three days. Further record review failed to reveal evidence that the resident's respiratory status was assessed per the above-mentioned orders on the following dates and shifts: -6/5/2025 3:00 PM - 11:00 PM -6/6/2025 7:00 AM - 3:00 PM -6/6/2025 3:00 PM - 11:00 PM -6/6/2025 11:00 PM - 7:00 AM -6/7/2025 7:00 AM - 3:00 PM -6/7/2025 3:00 PM - 11:00 PM -6/7/2025 11:00 PM - 7:00 AM During an additional surveyor observation on 6/11/2025 at approximately 9:00 AM through 9:45 AM, the resident was observed seated in his/her wheelchair with an occasional non-productive cough and swelling to both of his/her lower extremities. During a surveyor interview on 6/11/2025 at 10:03 AM with Certified Medication Technician, Staff D, he revealed that he observed the resident coughing on 6/10/2025 and 6/11/2025. He indicated that he wanted to give the resident a medication for his/her cough on 6/10/2025 but the resident did not have a physician's order. Additionally, he was unable to recall if he notified the nurse. During a surveyor interview on 6/11/2025 at 9:53 AM with Licensed Practical Nurse, Staff A, she acknowledged that she observed the resident coughing on 6/11/2025. She revealed that she had not assessed the resident's respiratory status. Record review of the June 2025 Treatment Administration Record (TAR) revealed Staff A signed off the physician's order to monitor the resident for edema and congestion on 6/9/2025 during the 7:00 AM to 3:00 PM shift as completed. During a surveyor interview with Staff A on 6/11/2025 at 12:49 PM, she revealed she did not assess the resident for the presence of edema on 6/9/2025 even though she had documented that the assessment was completed. Additionally, she indicated that the resident was experiencing crackles at the bases of both of his/her lungs on 6/9/2025. During a surveyor observation immediately following the above interview with Staff A, she began to assess the resident for the presence of edema in his/her bilateral extremities. Staff A indicated that the resident presented with 4+ pitting edema (when the edema is pressed it leaves a dimple this is called pitting edema. A 4+ pitting edema indicates severe edema that can take up to 2-5 minutes to rebound) in his/her right lower extremity and 3+ pitting edema(this indicates severe edema and can take up to 30 seconds or more to rebound) in his/her left lower extremity, after this concern was brought to her attention by the surveyor. Further review failed to reveal evidence that the physician was notified of the resident's change in condition until 6/11/2025, after it was brought to the facility's attention by the surveyor, 6 days after initially being assessed by a nurse on 6/5/2025. Record review revealed the following physician's orders were obtained after the surveyor brought the resident's change in condition to the facility's attention: -The order for Lasix was increased from 40 mg twice a day to 60 mg twice daily for 4 days - A chest x-ray was to be obtained - A basic metabolic panel (a blood test that measures eight different substances in your blood, providing information about your body's metabolism, fluid balance, and kidney function) was to be obtained - A Pro BNP (a blood test used to measure heart failure) was to be obtained Additional record review revealed the Pro BNP was obtained on 6/12/2025 with a result of 827.0 picograms/milLiliter (pg/mL), which indicates an elevated value (a normal reference range is 0-300.0 pg/mL). During a surveyor interview on 6/11/2025 at approximately 3:10 PM with the Nurse Practitioner, she revealed that she was not made aware of the resident's change in condition on 6/5/2025. She further indicated that she would have expected to have been notified. During a surveyor interview on 6/11/2025 at 1:12 PM, with the Director of Nursing Services, he indicated that he would expect the provider to be notified of the resident's change in condition when it was identified on 6/5/2025, that the resident would have been assessed every shift for three days as ordered, and the findings to be reported to the provider. Additionally, he indicated that he would expect that the nurses would monitor the resident for the presence of edema and congestion every shift per the physician's order.

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 to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE) for 1 of 1 resident observed for wound care and transfers, Resident ID #21. Findings are as follows: Review of a facility policy titled, .Policy for Enhanced Barrier Precautions [EBP] (infection control measures which require donning gown and gloves during high-contact residents' care activities) states in part, .the [facility name redacted] home is committed to ensuring the highest quality of care for our residents. It is to that end that this policy will follow CMS [Centers for Medicare and Medicaid Services] for guidance and or regulations of the RIDOH [Rhode Island Department of Health] and the Centers for Disease Control and Prevention associated with infection control practices related to Enhanced Barrier Precautions .Enhanced Barrier Precautions are indicated for nursing home residents with any of the follow[ing] .EBP is primarily intended to where high-contact care activities occurs, in the residents room, including transfers that are bundled together with other high contact activity such as morning or evening care . Signage must be present outside residents' rooms to signal individuals entering a room the specific actions they should take to protect themselves and the residents . Record review revealed the resident was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, muscle weakness and difficulty in walking. During a surveyor observation on 6/9/2025 at approximately 10:00 AM, there was an EBP sign observed outside of the resident's door which stated in part, .wear gloves and gown for this following High-Contact Resident Care Activities .Transferring . Record review of a physician's order revealed the following: - 3/5/2020 - the resident is to be assisted with a Hoyer lift by 2 staff for all transfers. - 5/5/2025 - Maintain Enhanced Barrier Precautions related to a wound. - 5/5/2025 - Cleanse the wound to the left ischium (a paired bone located within the pelvis which forms the lower and the back portion of the hip) with normal saline, pat dry with gauze, apply Medihoney (a medical-grade honey that aids in wound healing) follow by plain calcium alginate then cover with a dressing. Review of a document titled, Weekly Wound Assessment dated 6/2/2025 revealed a stage two pressure ulcer (a partial-thickness skin loss involving the the second layer of the skin) on the left ischium measuring 0.8 centimeters (cm) x 0.5 cm x 0.1 cm. 1. During a surveyor observation on 6/12/2025 at 7:50 AM, Registered Nurse (RN), Staff C, was observed entering the resident's room for a dressing change without wearing a gown as ordered. After removing the resident's soiled dressing with gloves, she entered the resident's bathroom to perform hand hygiene. However, when she exited the bathroom she indicated that she had forgotten to put on a gown before starting the wound dressing change. She exited the room, put on a gown and gloves then resumed the resident's wound dressing change. During the wound dressing change, Staff C was observed cleansing the wound with a gauze previously soaked with normal saline, she then placed the soiled gauze directly on the bedside table. Further, Staff C was observed placing the dirty cotton swabs used to spread the Medihoney and the calcium alginate to the wound bed, on the bedside table. Staff C failed to disinfect the bedside table after the wound dressing was completed. Furthermore, Staff C was observed exiting the resident's room to the hallway without taking off her gown. When she realized she still had the gown on, she went back to the room to take it off. During a surveyor interview immediately following the wound dressing observation, Staff C acknowledged she did not wear a gown as required prior to starting the resident's wound dressing change and failed to remove the gown prior to exiting the resident's room. Additionally, she acknowledged that she placed the soiled dressing items directly on the bedside table and did not disinfect it afterwards. 2. During a surveyor observation on 6/12/2025 at 8:16 AM two Nursing Assistants (NAs), Staff F and G, were observed entering the resident's room without wearing a gown or gloves. Additionally, Staff F and G were observed rolling the resident onto his/her side in attempts to place a Hoyer pad underneath him/her. Further, Staff F and G were observed transferring the resident from the bed to a wheelchair without wearing a gown or gloves. During a surveyor interview immediately following the above observation, both Staff F and G acknowledged that they failed to follow the EBP protocol as ordered and acknowledged that they should have when they transferred the resident. During a surveyor interview on 6/12/2025 at 10:54 AM with the Staff Educator, he indicated that he would expect the staff to follow the infection control protocol when required. Additionally, he indicated that he would expect the staff to wear the appropriate PPE before providing care to the residents who are on EBP, as ordered, and/or per the signage on the doors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident was offered or received the indicated pneumococcal vaccination or did not receive the vaccination due to medical contraindications or a refusal for 2 of 5 residents reviewed, Resident ID #s 88 and 111. Additionally, the facility failed to have updated policies regarding pneumococcal immunizations. Findings are follows: According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for adults 65 years or older who have received PCV13 (a type of pneumococcal conjugate vaccination) at any age and the PPSV23 at [AGE] years of age or older, are recommended to receive a single dose of the PCV20 or PCV21 vaccine after 5 or more years from the date of the last pneumococcal vaccine. 1a. Record review revealed Resident ID #88 was readmitted to the facility in March of 2025. Review of the resident's immunization records revealed that the resident received his/her PCV13 vaccine in November of 2015 (at age [AGE]) and his/her PPSV23 vaccine in September of 2019 (at age [AGE]). Record review failed to reveal evidence that the resident was offered, received, or declined the PCV20 or PCV21 vaccine. 1b. Record review revealed Resident ID #111 was readmitted to the facility in November of 2024. Review of the resident's immunization records revealed that the resident received his/her PPSV23 vaccine in December of 2013 (at age [AGE]) and his/her PCV13 vaccine in June of 2018 (at age [AGE]). Record review failed to reveal evidence that the resident was offered, received, or declined the PCV20 or PCV21 vaccine. During a surveyor interview on 6/12/2025 at 11:29 AM with the Infection Preventionist, she revealed that she follows the CDC guidance relative to pneumococcal vaccinations. Additionally, she was unable to provide evidence that Resident ID #s 88 and 111's medical records included documentation that indicates, at a minimum, if the residents were either offered, received, or refused the PCV20 or PCV21 pneumococcal vaccine. 2. Review of a facility policy titled, Resident Vaccination (Flu and pneumonia) dated 3/2020 states in part, .Vaccinations are to be provided in accordance with the most recent ACIP (Advisory Council on Immunization Practices) guidelines for these vaccinations. As of 2019, ACIP has recommended the following pneumonia vaccination schedule (Also follow CDC Vaccination for Elders guidelines): ACIP recommends a routine single dose of PPSV23 for adults aged greater than or equal to 65 years .and who have not previously received PCV13. If a decision to administer PCV13 is made, PCV13 should be administered first followed by PPSV23 at least 1 year later . During a surveyor interview on 6/12/2025 at 12:20 PM with the Director of Nursing Services, he acknowledged that the policy that the facility is currently using is not up to date and does not include the current guidelines for pneumococcal vaccinations.

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment relative to 1 of 3 kitchenettes and the main kitchen. Findings are as follows: 1. During the initial tour of the kitchen on 6/9/2025 at 9:54 AM, in the presence of the Food Service Director (FSD), the walk-in freezer was noted to have an accumulation of ice buildup on the sprinkler head and on the left fan, located near the ceiling of the freezer. During a surveyor interview, immediately following the above observation, the FSD acknowledged the ice buildup and indicated it should be cleaned. 2. During a surveyor observation on 6/9/2025 at approximately 10:30 AM, of the Jamestown Unit Kitchenette, in the presence of the FSD, revealed one microwave, mounted above the counter, which was noted to be severely cracked with peeling paint on the exterior of the microwave. During a surveyor interview, immediately following the above observation, the FSD acknowledged the cracks and peeling paint on the exterior of the microwave and indicated that the microwave would be removed.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 4 of 8 residents reviewed with an air mattress, Resident ID #s 86, 91, 111, and 135, 1 of 3 residents reviewed for oxygen administration, Resident ID #70, and for 1 of 1 resident reviewed with an order for daily weights, Resident ID #93. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1a. Record review revealed Resident ID #86 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, Parkinson's disease and adult failure to thrive. Record review revealed a physician's order dated 2/26/2024 which states in part, Air mattress to bed for comfort and pressure reduction. Check Setting according to resident weight. Special Instructions: Check settings every shift . Record review revealed the resident weighed 119.6 pounds (lbs.) on 6/5/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 300 lbs.: - 6/10/2025 at 8:57 AM - 6/11/2025 at 3:19 PM During a surveyor interview with Licensed Practical Nurse (LPN), Staff A on 6/11/2025 at 3:19 PM, she acknowledged the above observation. Additionally, she revealed that she was unaware of what the mattress should be set to. 1b. Record review revealed Resident ID #91 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, Ankylosing hyperostosis (a condition where ligaments and tendons become hard and calcified, often leading to bone spurs and stiffness) and osteoarthritis. Record review revealed a physician's order dated 3/24/2025 which states in part, Air mattress to bed for comfort and pressure reduction. Special Instructions: Check settings every shift . Record review revealed the resident weighed 141 lbs. on 10/1/2024. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 350 lbs.: - 6/9/2025 at 12:58 PM - 6/10/2025 at 3:27 PM - 6/11/2025 at 9:00 AM During a surveyor interview with Staff A on 6/11/2025 at 3:19 PM, she acknowledged the air mattress was set to 350 lbs. Additionally, she revealed that she was unaware of what the mattress should be set to. 1c. Record review revealed Resident ID #111 was admitted to the facility in September of 2022 with a diagnosis including, but not limited to, cerebral infarction (stroke). Record review revealed a physician's order dated 11/24/2024 which states in part, Air mattress to bed for comfort and pressure reduction set to 250 lb. Special Instructions: Check settings every shift . Record review revealed the resident weighed 212 lbs. on 6/9/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 325 lbs.: - 6/9/2025 at 10:30 AM - 6/10/2025 at 12:54 PM - 6/11/2025 at 1:35 PM During a surveyor interview with LPN, Staff B on 6/11/2025 at 2:38 PM, she acknowledged that the resident's air mattress was set to 325 lbs. and not to 250 lbs., per the physician's order. 1d. Record review revealed Resident ID #135 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, sepsis, the need for assistance with personal care, and sciatica. Record review revealed a physician's order dated 5/8/2025 which states in part, Air mattress to bed for comfort and pressure reduction. Special Instructions: Check settings every shift . Record review revealed the resident weighed 175.8 lbs. on 6/9/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 100 lbs.: - 6/9/2025 at 9:10 AM - 6/11/2025 at 3:23 PM During a surveyor interview with Staff A on 6/11/2025 at 3:23 PM, she acknowledged the resident's bed was set to 100 lbs. Additionally, she revealed the resident does not weigh 100 lbs. and the air mattress setting should be readjusted to be closer to the resident's weight. During surveyor interviews with the Director of Nursing Services (DNS) on 6/12/2025 at 11:27 AM and 11:35 AM, he revealed that he would expect Resident ID #111's air mattress to be set to 250 lbs. per the physician's order. Additionally, he revealed his expectation would be for Resident ID #s 86, 91, and 135's air mattresses to be set to the residents' weights and for the physician's orders to be clarified to include the residents' weights. 2. Record review revealed Resident ID #70 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, heart failure, edema (the accumulation of fluid in extremities), and an acute cough. Record review revealed a physician's order dated 3/15/2025 for oxygen at 2 Liters (L) per minute via nasal cannula (a medical device used to provide supplemental oxygen therapy) continuously. During surveyor observations the resident was observed receiving oxygen at 4 L per minute via nasal cannula on the following dates and times: - 6/9/2025 at 12:52 PM - 6/10/2025 at 9:01 AM, 12:35 PM, and at approximately 3:30 PM - 6/11/2025 at 8:45 AM During a surveyor interview on 6/11/2025 at 3:19 PM with Staff A, she acknowledged that the resident was not receiving oxygen at 2 L continuously, per the physician's order. During a surveyor interview with the DNS on 6/12/2025 at 11:35 AM, he indicated that he would expect the physician's order would be followed relative to the oxygen liter flow. 3. Record review revealed Resident ID #93 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, Alzheimer's disease, edema (swelling caused by too much fluid trapped in the body), and congestive heart failure. Record review revealed a physician's order dated 1/29/2025 to obtain daily weights three times per week on Monday, Wednesday, and Friday prior to the morning meal. Special Instructions indicate to notify the physician if there is a weight gain greater than 3 lbs. in a day or greater than 5 lbs. in a week. Record review of the June 2025 Treatment Administration Record revealed the resident weighed 145.8 lbs. on 6/2/2025 and 151.2 lbs. on 6/9/2025, indicating a weight gain of 5.4 lbs. Further record review failed to reveal evidence that the physician was notified of the above-mentioned weight gain. During a surveyor interview with Registered Nurse, Staff C, on 6/11/2025 at 2:57 PM, she revealed that the 3rd shift (11:00 PM - 7:00 AM) nurse obtained the resident's weight on the morning of 6/9/2025 and did not notify her of the weight discrepancy. Additionally, she revealed that she did not notify the physician of the resident's 5.4 lbs. weight gain. During a surveyor interview with the Nurse Practitioner on 6/11/2025 at 3:03 PM, she indicated that she would have expected to have been notified of the resident's weight gain, per the physician's order. During a surveyor interview with the DNS on 6/11/2025 at 3:06 PM, he acknowledged that the resident experienced a weight gain of over 5 lbs. in a week and would have expected the physician to be notified as ordered. Cross Reference F-842

Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices relative to 3 of 8 residents reviewed with an mattress, Resident ID #s 86, 91, and 135, 1 of 3 residents reviewed for oxygen administration, Resident ID #70, and for 1 of 1 resident reviewed for the use of an incentive spirometer (a handheld medical device used to help patients improve the functioning of their lungs, by training patients to take slow and deep breaths), Resident ID #66. Findings are as follows: 1a. Record review revealed Resident ID #86 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, Parkinson's disease and adult failure to thrive. Record review revealed a physician's order dated 2/26/2024 which states in part, Air mattress to bed for comfort and pressure reduction. Check Setting according to resident weight. Special Instructions: Check settings every shift . Record review revealed the resident weighed 119.6 pounds (lbs.) on 6/5/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 300 lbs.: - 6/10/2025 at 8:57 AM - 6/11/2025 at 3:19 PM Record review of the June 2025 Treatment Administration Record (TAR) revealed that the order was signed off as completed during first shift on 6/10 and 6/11/2025. During a surveyor interview with Licensed Practical Nurse (LPN), Staff A, on 6/11/2025 at 3:19 PM, she acknowledged that the air mattress was set to 300 lbs and that the air mattress was not set to the resident's weight. During a surveyor interview with Staff A on 6/11/2025 at 3:19 PM, she acknowledged the air mattress was set to 350 lbs. and that it was not set to the resident's weight. Additionally, she revealed that she had documented the order as completed 6/11/2025 without checking what weight the air mattress was set to. 1b. Record review revealed Resident ID #91 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, Ankylosing hyperostosis (a condition where ligaments and tendons become hard and calcified, often leading to bone spurs and stiffness) and osteoarthritis. Record review revealed a physician's order dated 3/24/2025 which states in part, Air mattress to bed for comfort and pressure reduction. Special Instructions: Check settings every shift . During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 350 lbs.: - 6/9/2025 at 12:58 PM - 6/10/2025 at 3:27 PM - 6/11/2025 at 9:00 AM Record review of the June 2025 TAR revealed that the order was signed off as completed during first shift on 6/9, 6/10, and 6/11/2025. During a surveyor interview with Staff A on 6/11/2025 at 3:19 PM, she acknowledged the air mattress was set to 350 lbs. and that it was not set to the resident's weight. Additionally, she revealed that she had documented the order as completed on 6/9 and 6/11/2025 without checking what the air mattress was set to. 1c. Record review revealed Resident ID #135 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, sepsis, the need for assistance with personal care, and sciatica. Record review revealed a physician's order dated 5/8/2025 which states in part, Air mattress to bed for comfort and pressure reduction. Special Instructions: Check settings every shift . Record review revealed the resident weighed 175.8 lbs. on 6/9/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 100 lbs.: - 6/9/2025 at 9:10 AM - 6/11/2025 at 3:23 PM Record review of the June 2025 TAR revealed that the order was signed off as completed during first shift on 6/9 and 6/11/2025. During a surveyor interview with Staff A on 6/11/2025 at 3:23 PM, she acknowledged the resident's bed was set to 100 lbs. and that it was not set to the resident's weight. Additionally, she revealed that she had documented the order as completed on 6/9 and 6/11/2025 without checking what the air mattress was set to. During a surveyor interview with the Director of Nursing Services (DNS) on 6/12/2025 at 11:35 AM, he revealed that he would expect Resident ID #s 86, 91, and 135's air mattresses to be set to their weights. Additionally, he would expect nurses to sign off the orders as completed in the TAR after the air mattress settings are checked. 2. Record review revealed Resident ID #70 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, heart failure, edema (fluid accumulation in extremities), and an acute cough. Record review revealed a physician's order dated 3/15/2025 for oxygen at 2 Liters (L) per minute via nasal cannula (a medical device used to provide supplemental oxygen therapy) continuously. During surveyor observations, the resident was observed receiving oxygen at 4L per minute via nasal cannula on the following dates and times: - 6/9/2025 at 12:52 PM - 6/10/2025 at 9:01 AM, 12:35 PM, and at approximately 3:30 PM - 6/11/2025 at 8:45 AM Record review of the June 2025 Medication Administration Record (MAR) revealed that the resident was documented as receiving oxygen at 2L per minute on the above-mentioned dates and times, although the resident was observed by the surveyor receiving approximately 4L of oxygen. During a surveyor interview on 6/11/2025 at 3:19 PM with Staff A, she acknowledged that she signed off the resident's MAR on 6/9 and 6/11/2025 without checking the liter flow of oxygen. During a surveyor interview with the DNS on 6/12/2025 at 11:35 AM, he indicated that he would expect the physician's order would be followed relative to oxygen liter flow and that nurses would ensure the resident is receiving the correct liter flow of oxygen before documenting the order as completed. 3. Record review revealed Resident ID #66 was re-admitted to the facility in June of 2025 with diagnoses including, but not limited to, myocardial infarction (heart attack), chronic obstructive pulmonary disease, and acute/chronic respiratory failure with hypoxia (low oxygen levels). Record review revealed a physician's order dated 6/4/2025 to encourage the use of an incentive spirometer every shift. During surveyor observations on the following dates and times, there was no incentive spirometer located in the resident's room: - 6/9/2025 at approximately 10:30 AM - 6/12/2025 at approximately 10:00 AM Record review of the June 2025 TAR revealed the resident was documented as having been encouraged to use the incentive spirometer during first shift on 6/9 and 6/11 by Staff A and on 6/12 by LPN, Staff E. During a surveyor interview and observation with Staff E on 6/11/2025 at 10:00 AM, he indicated that he could not find the incentive spirometer in the resident's room and would need to order one. During a surveyor interview with Staff A on 6/12/2025 at 11:00 AM, she acknowledged that she documented the order as completed on 6/9 and 6/11 without encouraging the use of or checking to see if the resident used the incentive spirometer. During a surveyor interview with the DNS on 6/12/2025 at 11:35 AM, he indicated he would expect the nurses to complete the order before documenting it as completed in the resident's record. Cross Reference F-658

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 3 of 5 residents reviewed for antibiotic use, Resident ID #s 69, 85, and 135. Findings are as follows: According to a Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Perform antibiotic 'time outs.' .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions: - Does this resident have a bacterial infection that will respond to antibiotics - If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration? - Can the spectrum of the antibiotic be narrowed or the duration of therapy shortened (i.e., de-escalation)? - Would the resident benefit from additional infectious disease/antibiotic expertise to ensure optimal treatment of the suspected or confirmed infection . 1. Record review revealed that Resident ID #69 was admitted to the facility in January of 2020 with a diagnosis including, but not limited to, Parkinson's disease. Record review revealed the resident received doxycycline (an antibiotic) 100 milligrams (mg) twice daily from 6/3/2025 through 6/10/2025, for an infection of the great toe. Record review failed to reveal evidence that an antibiotic time out or a review was conducted. 2. Record review revealed that Resident ID #85 was readmitted to the facility in March of 2024 with a diagnosis including, but not limited to, type II diabetes. Record review revealed the resident received cephalexin (an antibiotic) 500 mg twice daily from 6/5/2025 through 6/12/2025 as a preventative measure related to a surgical incision. Record review failed to reveal evidence that an antibiotic time out or a review was conducted. 3. Record review revealed that Resident ID #135 was readmitted to the facility in May of 2025 with a diagnosis including, but not limited to, heart failure. Record review revealed the resident received doxycycline 100 mg twice daily from 6/6/2025 through 6/12/2025 for pneumonia. Record review failed to reveal evidence that an antibiotic time out or a review was conducted. During a surveyor telephone interview on 6/11/2025 at 9:15 AM with the Infection Preventionist, she acknowledged that there were no antibiotic timeouts completed for Resident ID #s 69, 85, and 135. Additionally, she revealed that she would expect antibiotic timeouts to be completed within 48 to 72 hours following the initiation of an antibiotic. Further, she revealed that she is on a leave of absence and indicated that there is not a designated staff member to complete the antibiotic timeouts.

Based on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented relative to skin assessments for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled, Skin Care Program states in part, .Weekly skin assessments will be done and documented appropriately . Review of a community reported complaint received by the Rhode Island Department of Health on 8/14/2024 alleged that the resident was treated at the hospital on 8/4/2024 for multiple wounds to his/her feet that contained maggots. Review of photographs taken at the hospital dated 8/4/2024 revealed the resident had wounds between multiple toes with visible black tissue and white maggots. Review of hospital admission paperwork for Resident ID #1 dated 8/4/2024 states in part, .Upon removing a kerlix dressing to [the resident's] rt [right] foot noted to have old blood, black colored tissue with maggots in between toes, top of right foot with redness. Pedal pulse weak .Seen by house resident, and supervisor, cleansed extensively with wound cleanser to partially remove many maggots and left open to air . Further review of the hospital admission paperwork revealed the resident was admitted with cellulitis to the right lower extremity and was started on intravenous antibiotics. Review of a skin assessment completed by, Registered Nurse (RN), Staff A dated 8/3/2024, the day prior to the resident's hospitalization, revealed that the resident had dry skin to his/her bilateral lower extremity and foot wounds were not identified. During a surveyor interview on 8/19/2024 at 9:40 AM with RN, Staff A, she revealed that she completed the skin assessment on 8/3/2024 and did not note any wounds to the resident's feet. Additionally, she revealed that she did not look in between the resident's toes to assess that skin in those areas. During a surveyor interview on 8/19/2024 at 1:40 PM with the Director of Nursing Services he revealed that he would expect the nursing staff to assess the skin between a resident's toes during a skin assessment. Additionally, he was unable to provide evidence that the skin assessment was completed accurately for Resident ID #1.

Based on record review, and staff and resident interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed for the utilization of a Freestyle Libre sensor (a continuous glucose monitoring system that is designed to replace finger sticks and lessen the need for test strips for persons with diabetes), Resident ID #2. Findings are as follows: Review of the Freestyle Libre 2 User Manual revealed that the sensor is to be changed every 14 days. Record review revealed that the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, diabetes and chronic obstructive pulmonary disease. During a surveyor interview with the resident on 5/14/2024 at 11:04 AM, s/he revealed that s/he has a Freestyle Libre sensor. Additionally, s/he revealed that the Freestyle Libre sensor needs to be changed every 14 days. Record review failed to reveal evidence of a physician order for a Freestyle Libre sensor. Record review failed to reveal evidence of documentation indicating when to change the resident's Freestyle Libre sensor or the last time it had been changed. During a surveyor interview with the Director of Nursing Services on 5/15/2024 at 11:38 AM, he was unable to provide evidence of documentation indicating that the resident had a Freestyle Libre sensor, when to change the Freestyle Libre sensor, or the last time it was changed. Additionally, he revealed that there should be a physician's order for the Freestyle Libre sensor and an order to change it.

Based on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 1 of 3 residents reviewed for insulin, Resident ID #2. Findings are as follows: Record review revealed that the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, diabetes and chronic obstructive pulmonary disease. Review of a physician's order dated 4/19/2024 revealed Humalog Mix 75-25 insulin once a day with special instructions to, GIVE 25 UNITS IF BLOOD SUGAR IS LESS THAN 150 or GIVE 35 UNITS IF BLOOD SUGAR ABOVE 150. Review of the April and May 2024 Medication Administration Record revealed the following dates when the resident's blood sugar was greater than 150 and the resident received 25 units of insulin when s/he should have received 35 units of insulin per the physician's order: -4/21/2024 with a blood sugar of 155 -4/22/2024 with a blood sugar of 206 -4/26/2024 with a blood sugar of 189 -4/29/2024 with a blood sugar of 159 -5/2/2024 with a blood sugar of 178 -5/4/2024 with a blood sugar of 189 -5/5/2024 with a blood sugar of 212 -5/6/2024 with a blood sugar of 167 -5/9/2024 with a blood sugar of 158 During a surveyor interview with the Director of Nursing Services on 5/15/2024 at 11:38 AM, he acknowledged that the resident received the incorrect amount of insulin on the above-mentioned dates. Additionally, he revealed that he would have expected that the resident received the correct amount of insulin as per the physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 3 residents reviewed for staff to resident abuse, Resident ID #1. Findings are as follows: On 12/1/2023 the Rhode Island Department of Health received a facility reported incident that states in part .Reported to this writer on 12/1/2023 via statements, resident did not want a shower. When approached by CNA [Nursing Assistant], according to witnesses CNA then got resident out of recliner, put his arms around [him/her] and pushed [him/her] down in the wheelchair. He proceeded to give [him/her] a shower . Record review of a facility policy revised on October 31, 2022, titled POLICY/PROCEDURE .Abuse Prohibition states in part, .It is the policy of this facility to ensure that all resident are treated with respect and dignity and that all resident are free from abuse, mistreatment, neglect .Abuse: Willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish includes but is not limited to the following .physical: hitting, punching, pinching, kicking, corporal punishment .A. Personnel Screen Any person seeking employment at this facility .shall be subject to a criminal background check .If the facility receives notice of disqualifying information regarding the employee, said employee will be disqualified from employment .D. Identification and Reporting Any instance of actual or suspected abuse .must be reported immediately to the DNS [Director of Nursing Services] The Department of Health .will be contacted .as soon as possible but not to exceed 2 hours after the discovery by the facility . Record review revealed that the resident was admitted to the facility in June of 2021 with diagnoses including, but not limited to, Alzheimer's disease, dementia, mood disorder, and major depressive disorder. Review of a Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 10 out of 15, indicating that the resident has moderate cognitive impairment. Additionally, the resident requires extensive assistance of 1 staff member for transfers, walking, personal hygiene, and bathing. Review of the resident's care plan dated 7/3/2023 revealed a self-care deficit related to his/her impaired balance, vision and cognition with interventions including, but not limited to, approach resident in a calm friendly manner for care, encourage daily decisions regarding care and schedule, explain all care procedures prior to initiating tasks. Record review of a witness statement dated 11/30/2023 authored by NA, Staff B, who was in the room at the time of the incident, states in part, .On Tuesday 11/28 while out in the [unit]sitting area I witnessed [Staff A] interact with [Resident ID #1] in an abusive way .He asked [him/her] to get up out of the recliner and sit in the wheelchair .[s/he] was confused and was refusing saying, 'wait a minute' he then lifted [him/her] up in a rough manner, [s/he] kept resisting, he then proceeded to put his arms around [his/her] waist and slammed [him/her] into the chair . During a surveyor interview on 12/5/2023 at 11:34 AM with Staff B, she indicated that Staff A pushed Resident ID #1 down in his/her wheelchair forcefully. She indicated that the resident was saying 'what are you doing'. She further revealed that she did not report the incident until 11/30/2023, two days after the incident occurred. Record review of a second witness statement dated 11/30/2023 authored by NA, Staff C, who was in the room at the time of the incident, states in part, .On Tuesday 11/28/23 .I was then standing at the lockers behind the desk when I heard a commotion, I turn to witness him and [resident] he told [him/her] lets go were going to the shower room. [S/he] stood up but was saying no to sitting in the wheelchair. He kept saying I told you to sit down. Now sit down and when [s/he] would not sit he put his arm across [his/her] chest and forced [him/her] to sit . During a surveyor interview on 12/5/2023 at 11:58 AM with Staff C, she indicated that Staff A had Resident ID #1 by the arm and was trying to push him/her in the chair. Staff A then put his arm across the resident, pushing him/her down in the chair. Staff C further revealed she did not report the incident until 11/30/2023, two days after the incident occurred. Review of a third witness statement authored by NA, Staff D, who was in the room at the time of the incident, states in part, .On Tuesday November 28, 2023 I witnessed [Staff A] being aggressive with [Resident ID #1] .[Resident ID #1] was saying no that [s/he] didn't want a shower. [Staff A] then got [Resident ID #1] up from the recliner while saying no. [Staff A] then proceeded to put his arm around [Resident ID #1] and pushed [him/her] down into the wheelchair . During a surveyor interview on 12/5/2023 at 11:19 AM with NA, Staff D, she did not report the incident after it occurred. She further revealed that she reported the incident to the nurse, Staff F on 11/29/2023, one day after the incident occurred. Review of a fourth witness statement authored by NA, Staff E, who was in the room at the time of the incident, states in part, .On Tuesday [Staff A] was trying to transfer [Resident ID #1] from the recliner .He was pushing [him/her] down into the unlocked wheelchair with his arm .He was talking with [him/her] in a rough way . During a surveyor interview on 12/5/2023 at 1:17 PM with the first shift supervisor, Registered Nurse, Staff F, she revealed that on 11/30/2023 at approximately 3:30 PM, Staff B, C, D and E came into her office. She further revealed the staff stated that they didn't like the way Staff A transferred Resident ID #1 into his/her wheelchair. Record review of Resident ID #1's N.A. documentation reveals that Staff A provided personal care to Resident ID #1 on the following dates and times: 11/28/2023 8:34 PM 11/29/2023 8:15 PM 11/30/2023 8:38 PM Record review of a criminal background check dated 9/15/2022 completed for Staff A, revealed that the record contained disqualifying information. During a surveyor interview on 12/6/2023 at approximately 12:00 PM with the Director of Clinical Services, he acknowledged that Staff A was hired with disqualifying information on his Criminal Background Check. Additionally, he revealed he was not made aware of the incident until three days after the incident occurred. Further, he revealed his expectation would be that staff would report all allegations of abuse. Additionally, he was unable to provide evidence that the facility kept Resident ID #1 free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed with 15-minute checks for behaviors, Resident ID #1. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Review of two facility reported incidents, received by the [NAME] Department of Health on 11/20/2023, revealed allegations of inappropriate behaviors against Resident ID #1 towards other residents at the facility. Review of the record revealed the resident was admitted to the facility in July of 2022 with diagnoses, including but not limited to, Alzheimer's disease and anxiety. Review of the care plan, last revised on 11/20/2023, revealed s/he had interventions in place for checks every 15 minutes and to remove him/her from other resident rooms when s/he wanders on the unit. Review of a document titled, Physician's Order Report, revealed a 9/2/2023 order for 15-minute checks to be completed each shift: night from 11:00 PM to 7:00 AM, day from 7:00 AM to 3:00 PM, and evening 3:00 PM to 11:00 PM. Review of the Treatment Administration Records (TAR) from 9/2/2023 through 11/20/2023, revealed that the 15-minute checks were documented as completed. Review of the September 2023 15-minute check documentation failed to reveal evidence that the checks were completed on the following dates and times: - 9/5/2023: day shift from 1:15 PM-2:45 PM - 9/6/2023: day shift from 12:30 PM-2:45 PM - 9/7/2023: day shift from 1:15 PM-2:45 PM - 9/8/2023: night shift from 5:30 AM-6:45 AM and evening shift from 6:15 PM-10:45 PM - 9/9/2023: day shift from 2:15 PM-2:45 PM - 9/10/2023: day shift from 7:00 AM-2:45 PM - 9/11/2023: day shift from 9:15 AM-3:00 PM and evening shift from 3:15 PM-10:45 PM - 9/12/2023: day shift from 7:00 AM-3:00 PM and evening shift from 3:15 PM-10:45 PM - 9/13/2023: day shift from 7:00 AM-2:45 PM - 9/14/2023: evening shift from 3:15 PM-10:45 PM - 9/15/2023: day shift from 1:00 PM-3:00 PM and the evening shift from 3:15 PM-10:45 PM - 9/16/2023: night shift from 5:15 AM-6:45 AM - 9/17/2023: evening shift from 6:30 PM-10:45 PM - 9/18/2023: night shift from 6:15 AM-6:45 AM and the evening shift from 3:15 PM-10:45 PM - 9/19/2023: evening shift from 3:15 PM-10:45 PM - 9/20/2023: day shift from 8:45 AM-2:45 PM - 9/21/2023: day shift from 2:00 PM-2:45 PM - 9/22/2023: night shift 12:00 AM-7:00 AM and day shift from 7:15 AM-11:45 AM - 9/23/2023: day shift from 8:45 AM-3:00 PM and evening shift from 3:15 PM-10:45 PM - 9/25/2023: day shift from 2:15 PM-2:45 PM - 9/26/2023: day shift from 7:00 AM-10:45 AM and 11:45 AM- 3:00 PM, the evening shift from 3:15 PM-10:45 PM - 9/28/2023: day shift from 10:15 AM-2:45 PM - 9/29/2023: day shift from 1:15 PM-3:00 PM and the evening shift from 3:15 PM-10:45 PM - 9/30/2023: day shift from 9:45 AM-2:45 PM Review of the October 2023 15-minute check documentation failed to reveal evidence that the checks were completed on the following dates and times: - 10/3/2023: evening shift from 3:00 PM-10:45 PM - 10/4/2023: night shift from 5:45 AM- 6:45 AM - 10/5/2023: day shift and evening shifts - 10/6/2023: day shift from 11:15 AM-2:45 PM and evening shift from 7:15 PM-10:45 PM - 10/7/2023, 10/9/2023-10/10/2023: day and evening shifts - 10/11/2023: day shift 7:00 AM-3:00 PM and the evening shift from 3:00 PM-10:15 PM - 10/12/2023: day shift 2:15 PM-3:00 PM and evening shift - 10/13/2023: evening shift from 7:30 PM-10:45 PM - 10/14/2023: day shift from 7:00 AM-2:45 PM and the evening shift 3:45-4:15 PM, 5:15-6:15 PM, 7:15-8:15 PM, and 9:15-10:15 PM - 10/15/2023: evening shift from 3:15 PM-8:45 PM - 10/16/2023: night shift from 6:15-6:45 AM and the evening shift from 7:15-10:45 PM - 10/17/2023: day shift from 1:15-3:00 PM and evening shift - 10/18/2023: day shift from 2:00-2:45 PM - 10/19/2023: night shift from 11:00-11:45 PM and 6:15-7:00 AM, and the day and evening shifts - 10/20/2023: day shift from 9:15 AM-12:45 PM - 10/21/2023: night shift from 12:00 AM-7:00 AM, and the day and evening shifts - 10/22/2023 and 10/23/2023: day and evening shifts - 10/24/2023: day shift from 7:00 AM-2:45 PM, and the evening shift from 4:15-4:45 PM, 6:15-6:45 PM, and 8:15-10:45 PM - 10/25/2023: day shift and evening shifts - 10/26/2023: night shift from 12:15-7:00 AM, and the day and evening shifts - 10/29/2023: night shift from 12:00-6:45 AM - 10/30/2023: day shift from 7:15 AM-2:45 PM Further review of the record failed to reveal evidence of any documented checks for the night, day, or evening shifts on 10/8/2023, 10/27/2023, 10/28/2023, and 10/31/2023. Review of the 15-minute check documentation, from 11/1/2023 through 11/20/2023, failed to reveal evidence that the checks were completed on the following dates and times: - 11/1/2023: night shift 2:15-7:00 AM, day shift 7:15 AM-2:45 PM, and evening shift 5:45-10:45 PM - 11/2/2023: day shift 11:15 AM-2:45 PM - 11/3/2023: evening shift 11:15-11:45 PM - 11/4/2023: night shift 12:00-7:00 AM, day shift 7:15 AM-2:45 PM - 11/5/2023 and 11/6/2023: day shifts 7:00 AM-2:45 PM - 11/7/2023: day shift 7:15 AM-2:45 PM - 11/8/2023: day shift 2:15-3:00 PM, and evening shift 3:15-10:45 PM - 11/9/2023: day shift 12:30-2:45 PM - 11/10/2023: day shift 12:00-3:00 PM, evening shift 3:15-10:45 PM - 11/11/2023: day shift 7:15 AM-2:45 PM - 11/13/2023: night shift 5:15-7:00 AM, day shift 7:15 AM-2:45 PM - 11/14/2023: day shift 7:00 AM-2:45 PM - 11/15/2023: day shift 7:00 AM-2:45 PM, and evening shift 10:15-10:45 PM - 11/17/2023: day shift 9:00 AM-2:45 PM - 11/18/2023: day shift 7:15 AM-2:45 PM - 11/19/2023: day shift 12:15 PM-2:45 PM - 11/20/2023: day shift 10:00 AM-2:00 PM Review of a 11/20/2023 note, authored by Licensed Practical Nurse (LPN), Staff A, revealed the resident was sent from the facility to an acute care hospital for an evaluation at approximately 2:10 PM due to the facility reported allegations of abuse. During a surveyor interview on 11/22/2023 at 10:51 AM with LPN, Staff A, she acknowledged that the above mentioned 15-minute check documentation on 11/20/2023 was not complete and that she documented in the TAR that the checks were done without verifying. Additionally, she indicated that the nurses are responsible for ensuring that the checks are completed each shift and that the 15-minute checks and TAR documentation should match. During a surveyor interview on 11/22/2023 at approximately 12:00 PM with LPN, Staff B, she acknowledged documenting in the TAR that the 15-minute checks were completed from 11/17/2023 through 11/19/2023 for the above-mentioned times. Additionally, she indicated that the nurses are responsible for ensuring that the checks are completed each shift and that she did not verify that the 15-minute checks were done for those dates and times. During a surveyor interview on 11/22/2023 at approximately 1:00 PM with the Assistant Director of Nursing, she indicated her expectation would be that the 15-minute checks would be done, and the nurse working each shift would verify that the documentation is complete. She further indicated that both the checks and TAR documentation should match.

**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 ensure that each resident receives adequate supervision to prevent elopements, for 1 of 1 residents reviewed for a successful elopement, Resident ID #52. Findings are as follows: Review of a facility policy titled Elopement Assessments, dated 11/1/2022, states in part, .PROCEDURE .An elopement assessment is to be performed whenever a resident exhibits a change in behaviors which signals an increase in risk, such as verbalizing a wish to leave the building, wandering with intent to leave, wandering unsafely and actually attempting to leave the building .If the resident is assessed to be a risk for elopement, then the necessary and appropriate intervention must be put in place immediately to keep the resident safe (i.e., wander guard bracelet [a device made for the purpose of keeping people with dementia from wandering, where the devices alert the caregiver whenever the resident breaches a perimeter or strays too far], frequent checks, etc.) and a care plan instituted . Record review revealed the resident was admitted to the facility in March of 2020 with diagnoses including, but not limited to, Alzheimer's disease and unspecified dementia with behavioral disturbances. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 11 out of 15, which indicates the resident has a moderately impaired cognition. Review of the resident's progress notes revealed the resident had a successful elopement attempt in October of 2022, where s/he was found walking down the main road by the Assistant Director of Nursing Services (ADNS) around 7:00 PM. Upon his/her arrival back to the facility, s/he was placed on 15-minute checks for 3 days and a wanderguard was implemented. Review of an Elopement Assessment dated 10/7/2022, revealed the resident was alert, confused, and forgetful, independent with ambulation, had an elopement success in the past, verbalized statements about leaving, is verbally abusive and was found to be at risk for elopement. Additional review of the resident's progress notes revealed a note from 2/13/2023 which revealed the resident was crying and requesting to have the wanderguard removed, and verbalized, on many occasions, that it was a mistake to leave the facility and s/he would not do it again. Further review of the progress notes revealed an elopement assessment was completed and the wanderguard was discontinued. Review of an Elopement Assessment dated 2/13/2023, revealed the resident was alert and oriented, independent with ambulation, had an elopement success in the past, had a history of leaving the facility, but was found not to be at risk for elopement. Record review failed to reveal evidence that an alternative intervention was implemented to ensure that the resident receives adequate supervision to prevent future elopements. During the following surveyor observations, the resident was observed sitting in a chair, in the main lobby, with his/her rolling walker and was looking out the window: -3/28/2023 at 12:57 PM, 1:04 PM, and 3:15 PM -3/29/2023 at 9:20 AM, 11:00 AM, and 1:40 PM -3/30/2023 at 12:55 PM During a surveyor interview on 3/29/2023 at 8:57 AM, with Registered Nurse, Staff A, she acknowledged that she completed the resident's Elopement Assessment on 2/13/2023 and indicated that administration told her to complete the assessment and document the resident was not at risk for elopement, so the wanderguard could be discontinued and removed. She acknowledged that no additional intervention were put in place after the wanderguard was discontinued. During a surveyor interview on 3/29/2023 at 10:16 AM, with the Director of Nursing Services, he was unable to provide evidence of an alternative intervention was put in place following the removal of the wanderguard. Additional record review revealed the resident was placed on 15-minute checks and a care plan, relative to the resident being an elopement risk, was implemented on 3/30/2023, after the concerns were identified by the surveyor and brought to the facility's attention.

Based on record review and staff interview it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for Narcan (a medication used for the emergency treatment of known or suspected opioid overdose) use, Resident ID #131. Findings are as follows: Review of a facility policy titled, Narcan Administration dated 10/27/2022 states in part, .The administration of Narcan is to be by a Registered Nurse, LPN [Licensed Practical Nurse] or MD/NP/PA [Medical Doctor/Nurse Practitioner/Physician Assistant] in the case of a clinical overdose .Clinical Overdose is classified as having a respiration rate of 8-10 or lower per minute, inability to arouse/unconscious, pin point pupils . Record review revealed that the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, type 2 diabetes mellitus and dementia. Review of a progress note dated 3/28/2023 at 11:51 AM, revealed the resident was unable to be fully aroused. Additionally, it was revealed the resident was administered Narcan 0.4 milligrams (MG) IM (intramuscularly) with minimal effect and the resident was transferred to the hospital for evaluation. Review of a progress note dated 3/28/2023 at 1:41 PM revealed the resident's vital signs at the time of the Narcan administration were: temperature 97.2 degrees, blood pressure 133/66, pulse 64 and respiration rate 24 per minute. Further record review failed to reveal evidence of a clinical overdose as defined by the facility policy. During a surveyor interview on 3/28/2023 at 2:17 PM with LPN, Staff B, she revealed that the resident had a change in mental status at breakfast and was unable to follow directions due to increased lethargy but that his/her respiration rate were 24. Additionally, she revealed that the facility did have a Narcan administration policy, but she was unsure what it said. Staff B further revealed that the resident had received Oxycodone (opioid medication used to treat pain) 5 MG at midnight, approximately 10 hours prior to the Narcan administration. She also revealed that the resident did not have a history of drug use. Review of the March Medication Administration Record revealed the following: - oxycodone 5 mg; Amount to Administer: one tablet oral, signed as administered on 3/28/2023 at 12 AM. - Narcan injection 0.4 mg/ml (milliliter); Administer intramuscular signed as administered on 3/28/2023 at 10:51 AM. During a surveyor interview on 3/29/2023 at approximately 9:30 AM with the NP, Staff C she revealed that she was unaware of the resident's vital signs when she gave the order for Narcan to be administered. Additionally, she revealed that if she had been made aware that the resident's respiration rate was 24 she would not have given the order for Narcan because it did not meet the clinical definition of an overdose. She also revealed that the resident did not have a history of drug use that she was aware of. During a surveyor interview on 3/29/2023 at 9:52 AM with LPN, Staff D she revealed that she was the nurse that administered the Narcan. Additionally, she revealed that the resident presented with an altered mental status and had changes in his/her respiratory pattern. Staff D further acknowledged that a resident with a respiration rate of 24 does not meet the definition of a clinical overdose per the facility policy. During a surveyor interview on 3/29/2023 at approximately 10:20 AM with the Director of Nursing Services, he was unable to provide evidence that the facility followed its policy for administration of Narcan based on the classification of a clinical overdose. Additionally, he was unable to provide evidence that the facility kept Resident ID #131 free of unnecessary drugs.

**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 to help prevent the transmission of communicable diseases and infections for 1 of 1 resident's reviewed for Methicillin-resistant Staphylococcus aureus (MRSA, an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics) and for 1 of 1 resident's reviewed for Extended spectrum beta-lactamases (ESBL, an infection that is resistant to specific types of antibiotics), Resident ID #s 3 and 89. Additionally, the facility failed to have a completed water management plan. Findings are as follows: 1a. Record review of the facility provided policy titled Guidelines for Management of MDRO's [Multidrug Resistant Organism] revealed that MRSA is transmitted primarily by contact with a person who either has a purulent site, a clinical infection of the urinary tract, or who is colonized (the resident has no symptoms of the illness. MDRO colonization may persist for long period of time which contributed to the silent spread of MDROs to other residents according to the Centers for Disease Control and Prevention, CDC). The most likely mode of patient transmission is via the hands of the healthcare worker. Additionally, contact precautions (use of gown and gloves when providing care) are indicated for residents who have an indwelling urinary catheter associated with MRSA or other MDRO, urinary tract infection or colonization, or resident who have other body sites heavily colonized or infected with MRSA or other MDRO. Record review revealed that Resident ID #3 was readmitted to the facility in December of 2022 with diagnoses including, but not limited to, carrier or suspected carrier of MRSA, Alzheimer's disease, and urinary tract infection. Record review revealed a lab dated 3/12/2023 for a urine culture and a culture of the right and left nephrostomy (an indwelling catheter that's inserted through your skin and into your kidney, a tube that drains urine from your body) tube sites that resulted positive for MRSA. Record review of the resident's progress notes revealed the following: 3/12/2023 at 9:57 PM revealed that during a dressing change the residents left nephrostomy tube had increased drainage with redness and inflammation with foul odor. Further review revealed the resident complained of an increased burning sensation in the surrounding area. Additionally, the right nephrostomy tube had a small amount of drainage and redness to the area. 3/18/2023 at 2:15 PM the resident's left nephrostomy tube had a moderate amount of tan drainage and the right nephrostomy tube had a small amount of tan drainage around the sites. Additionally, the resident had dark pink colored urine draining from the right-side nephrostomy tube. Further review of the progress notes from 3/18/2023 revealed the resident was started on an antibiotic. 3/19/2023 11:53 AM the resident had a moderate amount of tan drainage from the left nephrostomy tube and the left side nephrostomy tube site was red and puffy. Additionally, the right nephrostomy tube had a scant amount of tan drainage. 3/22/2023 2:12 PM the facility received a call from the resident's urologist to change the current antibiotics to Bactrim DS. Record review of the physician's order revealed an order dated 3/22/2023 for Bactrim DS (an antibiotic) for 10 days. Further record review failed to reveal evidence that the resident was on contact precautions, per the facility policy. During multiple surveyor observation on 3/27/2023 through 3/30/2023 failed to reveal signage or an isolation cart outside of the resident's room indicating that s/he was on contact precautions. During a surveyor interview 3/29/2023 at 2:18 PM with Registered Nurses (RN), Staff E and RN Staff F, they revealed they only have one resident on droplet precautions for Covid-19. During a surveyor interview on 3/30/2023 at 7:53 AM with RN Staff F, she revealed that the resident's nephrostomy dressings were changed on 3/29/2023 due to being soiled. Additionally, she revealed that the resident was not on any type of precautions so only gloves are required to change the dressings. Furthermore, she revealed that at times the resident attempts to empty his/her own nephrostomy bags and will dispose of the urine in the trash, urinal, or the toilet. During a surveyor interview on 3/30/2023 at 10:23 AM with the Infection Preventionist, she revealed that she was unaware that the resident was emptying his/her urine from the nephrostomy tubes into the trash. Additionally, she acknowledged that the resident was positive for MRSA at both nephrotomy sites and in his/her urine. Furthermore, she was unable to provide evidence the resident was on contact precaution to prevent the spread of infection per the policy. 1b. Review of the CDC's document titled, Multidrug-resistant organisms (MDRO) management states in part, .For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living .) .use Contact Precautions in addition to Standard Precautions .For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on their risk to other patients and on the ability of the colonized or infected patients . Review of a facility provided policy titled, Guidelines for Management of MDRO revealed contact precautions are used with a specific person known or suspected to be infected or colonized with a microorganism that can be transmitted by direct contact with the person or indirect contact with environmental surfaces or equipment. Additionally, contact precautions are used for those residents who are infected and totally dependent upon healthcare workers for activities of daily living. Record review revealed that Resident ID #89 was admitted to the facility in August of 2022 with diagnoses including, but not limited to, dementia and hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side (stroke). Record review revealed a urine culture obtained on 2/21/2023 which resulted as positive for ESBL. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is an extensive assist for toileting, personal hygiene, and dressing. Record review revealed the resident received antibiotic treatment from 2/23/2023 through 3/1/2023 related to ESBL. Additional record review revealed the resident had a repeat urine culture on 3/6/2023 which resulted positive for ESBL. Further record review revealed the resident was removed from contact precaution due to colonization on 3/9/2023. Additionally, record review failed to reveal evidence that the resident was on contact precautions per the facility policy. During a surveyor interview on 3/30/2023 at 10:23 AM with the Infection Preventionist, she acknowledged that the resident tested positive for ESBL and was considered colonized at this time. Additionally, she was unable to provide evidence that the resident who is colonized with ESBL and depended on healthcare workers, was on contact precautions to prevent the spread of ESBL, per the policy. During a surveyor interview on 3/30/2023 at 10:56 AM with the Director of Nursing Services, he revealed that when a resident completes their dose of antibiotics the facility removes the resident from precautions. Additionally, he acknowledged that Resident ID #3 and Resident ID #89 tested positive for MDRO's in March of 2023 and ID #3 was receiving antibiotics currently for MRSA. Furthermore, he was unable to provide evidence that the facility followed their own policy related to contact precautions to prevent the spread and transmission of MDRO's. 2. During a surveyor interview on 3/28/2023 at approximately 11:00 AM with the Director of Maintenance he indicated that the facility utilizes the CDC toolkit for their water management program. Record review of the CDC toolkit titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings indicates that the facility must establish a water management program team, describe the building water systems using text and flow diagrams, identify areas where Legionalla could grow and spread, decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, make sure the program is running as designed and is effective and document and communicate all activities. Record review of a facility document titled Water Management Program failed to reveal evidence that the facility established ways to intervene when control limits are not met, evaluated the effectiveness of the program or specify testing protocols and acceptable ranges for control measures and that corrective actions must be taken when control limits are not maintained. During a surveyor interview on 3/28/2023 at approximately 1:00 PM with the Administrator and the Director of Maintenance they were unable to provide evidence that their Water Management Program included the required components listed above.