Based on record review and staff interview, it has been determined that the facility failed to develop and implement individualized care plans that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment relative to Activities of Daily Living (ADL's, e.g. eating, oral hygiene, toileting hygiene, showering and bathing, personal hygiene, dressing, rolling to the left and right, all transfers and mobility) for 5 of 5 residents reviewed, Resident ID #s 1, 4, 5, 6, and 7. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/5/2024 alleged that Resident ID #1 had fallen out of his/her bed a couple months ago resulting in bruising and a hospital evaluation. 1. Record review revealed Resident ID #1 was admitted to the facility in July of 2022 with diagnoses including, but not limited to, multiple sclerosis (chronic neurological disorder), spastic quadriplegia (a form of cerebral palsy that affects both arms and legs), and bilateral lower extremity contractures (a shortening of the muscles and tendons in both legs that limit ability of movement in joint). Review of a progress note dated 7/8/2024 at 12:03 PM revealed the resident had a witnessed fall. A Nursing Assistant (NA), was performing morning care, when the resident rolled off the bed and onto the floor. The resident was sent to the hospital for an evaluation. During a surveyor interview on 12/19/2024 at 9:08 AM with the resident, s/he indicated on the morning of 7/8/2024 a NA was getting him/her washed to get out of bed and s/he was laying on his/her bed, face down with his/her leg hanging off the bed. Additionally, the weight of his/her leg pulled him/her onto the floor. The resident revealed that s/he usually receives care with assistance from one staff person, sometimes two. Record review of the resident's Care Area Assessment (CAA's) dated 7/8/2024 indicates the resident is dependent for all ADL's and will proceed to plan of care (a written document that outlines the care required for an individual based on their individual health needs). Record review of the resident's comprehensive care plan failed to reveal evidence of a focused CAA for ADL's, including a person specific approach with, descriptive of the individual resident needs, that included person centered interventions the facility would implement to assist the resident, including the level of assistance needed to provide care. Additionally, the resident's care plan was revised on 12/18/2024 to include a focused CAA for ADLs, after it was brought to the attention of the facility by a surveyor. 2. Record review revealed Resident ID #4 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, muscle weakness and dementia. Record review of a CAA dated 9/11/2024 revealed the resident required set up assistance for eating, substantial assistance for bathing, showering, and dressing, and was dependent for toileting hygiene, transfers and mobility and will proceed to plan of care. Record review of a comprehensive care plan last revised on 12/16/2024 revealed a focus area for ADL's indicating the resident has a decline in function and mobility, and a goal to maximize independence with ADL self-care tasks and mobility. Interventions in place include to use an assistive device, to provide assistance with ADL's, and provide physical and occupational therapy, as needed. Review of the comprehensive care plan for Resident ID #4 failed to provide evidence of a person specific approach that was descriptive of the individual resident needs, including the level of staff assistance required to provide care. 3. Record review revealed Resident ID #5 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, Post Traumatic Stress Disorder (PTSD is a mental and behavioral disorder that can develop after someone experiences or witnesses a traumatic event), Parkinson's disease (movement disorder of the nervous system that worsens over time), and a fracture of the lower end of the right tibia (break in the shinbone that may include the inability to walk or bear weight on the leg). Record review of a CAA dated 11/5/2024 revealed that the resident required set up assistance for eating, substantial assistance for upper body dressing, personal hygiene, rolling left to right and transfers, and s/he was dependent for lower body dressing and mobility and indicated to proceed to plan of care. Record review of a comprehensive care plan dated on 7/9/2024 with a focus area for ADL's indicating the resident has a decline in function and mobility, related a right tibial plateau fracture (a break in the upper part of the shin bone, that affects the knee's stability and movement) as well as debridement (a medical procedure that removes damaged, dead, or infected tissue from a wound to help it heal) of the right lower leg with a goal to maximize the residents independence with ADL self-care tasks and mobility. Interventions in place include to use an assistive device, to provide assistance with ADL's, and provide physical and occupational therapy, as needed. Review of the comprehensive care plan for Resident ID #5 failed to provide evidence of a person specific approach that was descriptive of the individual resident needs, including the level of staff assistance required to provide care. Additionally, the care plan failed to reveal evidence of a focused care area for PTSD that is culturally competent, and trauma informed. 4. Record review revealed Resident ID #6 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, dementia and abnormal gait. Record review of a CAA dated 1/2/2024 indicated that s/he triggered by the MDS for ADL's due to impaired mobility and weakness and indicated to proceed to plan of care. Record review of a comprehensive care plan dated 1/3/2024 revealed a focus area for ADL's indicating the resident has a decline in function and mobility, and a goal to maximize independence with ADL self-care tasks and mobility. Interventions in place include to use an assistive device, to provide assistance with ADL's, and provide physical and occupational therapy, as needed. Review of the comprehensive care plan for Resident ID #6 failed to reveal evidence of a person specific approach that was descriptive of the individual resident needs, including the level of staff assistance required to provide care. 5. Record review revealed Resident ID #7 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, fracture of upper right humerus (a break at the top of the right upper arm bone, near the shoulder joint), and generalized muscle weakness. Record review of a CAA dated 11/19/2024 revealed the resident requires set up assistance for eating, and moderate assistance for oral and personal hygiene. Additionally, s/he is dependent for showering, bathing, dressing, mobility, and transfers and indicated to proceed to plan of care. Record review of a comprehensive care plan dated 11/26/2024 for ADL's revealed the resident had a deficit in function and mobility with a goal in place to maximize independence with ADL self-care and mobility. Interventions in place include to use an assistive device, to provide assistance with ADL's, and provide physical and occupational therapy, as needed. Review of the comprehensive care plan for Resident ID #7 failed to provide evidence of a person specific approach that was descriptive of the individual resident needs, including the level of staff assistance required to provide care. During a surveyor interview on 12/19/2024 at 8:56 AM with Licensed Practical Nurse, Staff A, she revealed that to learn the level of assistance needed to care for a resident she relies on verbal communication from the resident and the NA's that care for them. She further indicated that she could refer to the residents MDS Assessment, section GG of their electronic medical records. She further indicated that she was aware of the resident's care plans, however does not rely on them to direct resident care. Additionally, Staff A indicated that she was unaware of a binder used to communicate residents' individual functional status to the NA's proving care. During a surveyor interview on 12/19/2024 at 11:54 AM with NA Staff B, she revealed that NA's receive verbal reports from nursing staff on how much assistance is needed to provide care to the residents. During a surveyor interview on 12/19/2024 at 11:26 AM with Registered Nurse (RN) Staff C, she revealed that she refers to a binder kept on each unit which contain documents titled Nursing Aid Care Plans to learn a resident's level of dependency. Additionally, she acknowledged that the above-mentioned care documents for the residents on the unit were all undated, several residents on the unit lacked care information, and there were forms that contained only a resident's name. During a surveyor interview on 12/19/2024 at 12:15 PM with RN Staff D, he revealed that the level of care required for each resident can be found in the care plan binders located on the units. He indicated the information in the binders are to be updated for new admissions, when residents have a hospitalization, or there is a change in status. During a surveyor interview on 12/19/2024 at 12:55 PM with the Director of Nursing Services, he acknowledged that the resident's comprehensive care plan failed to contain a focused care area for ADL's to encompass specific approaches, the resident's individual needs, and specific interventions for each resident that s/he required pertaining to his/her level of dependency required when providing him/her with personal care.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles for 1 of 1 resident reviewed relative to storing lidocaine patches in his/her room without an assessment for self-application, Resident ID #2. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, arthritis and muscle weakness. Review of a physician's order dated 10/1/2024 revealed Lidocaine adhesive patch 4% (a medication prescribed for pain), apply 1 patch to the right shoulder every morning and to be removed at bedtime. Record review failed to reveal evidence of an assessment for the self administration of the medication, which indicated the resident is safe to store and administer his/her medications. During a surveyor observation on 11/4/2024 at approximately 12:00 PM, there was a total of 5 unopened lidocaine patches in the opened manufacturer's box observed in the resident's room. During a surveyor interview on 11/4/2024 at approximately 1:15 PM with Licensed Practical Nurse (LPN), Staff A, she acknowledged that the resident had the lidocaine patches in his/her room and s/he should not have. During a surveyor interview on 11/4/2024 at 3:10 PM with the Assistant Director of Nursing Services, she indicated the lidocaine patches should not be left in the resident's room by the nurses. Additionally, she stated she would have expected the lidocaine patches to be stored in the medication cart and not in the resident's room.

Based on record review, and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 2 residents reviewed with medication refusals, Resident ID #73. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 which 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. Record review revealed Resident ID #73 was re-admitted to the facility in August of 2022 with a diagnosis including, but not limited to, gastro-esophageal reflux disease (GERD, a condition in which stomach acid repeatedly flows back up into the esophagus, causing irritation and discomfort). Record review revealed a physician's order with a start date of 9/12/2022 for Famotidine (a medication prescribed to treat GERD) 8 milligram (mg)/milliliter (ml), give 2.5 ml once daily. Review of the Medication Administration Record revealed the medication was not administered due to the residents refusal on the following dates: - 9/1/2024 - 9/10/2024 - 9/11/2024 - 9/15/2024 - 9/17/2024 - 9/19/2024 Record review failed to reveal evidence the provider was notified of the residents refusals of the Famotidine. During a surveyor interview on 9/19/2024 at 12:16 PM with Certified Medication Technician, Staff A, she revealed the resident refuses often because the medication is a liquid. During a surveyor interview on 9/19/2024 at 12:18 PM with Licensed Practical Nurse, Staff B, she acknowledged that the provider was not notified the resident was refusing the Famotidine. She further revealed that the resident will take pills, and that she will notify the provider that the resident is refusing the liquid form of the medication. During a surveyor interview on 9/19/2024 at 2:37 PM with the Director of Nursing Services, he revealed that if the patient is not taking a medication the physician should be notified. He was unable to provide evidence that the physician was notified of the Famotidine refusals.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure a resident who is at risk for pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident who was observed during a wound dressing change, Resident ID #102. Findings are as follows: Record review revealed Resident ID #102 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, Peripheral Artery Disease (PAD, a condition in which narrowed arteries reduce blood flow to the arms or legs), Peripheral Vascular Disease (PVD, a condition in which narrowed vessels reduces blood flow to the arms, legs, or other body parts), and status post-surgery for left and right below knee amputations. Record review of the resident's care plan dated 5/5/2023 revealed, the resident is at risk for impaired skin integrity related to status post bilateral knee amputations, coccyx wound, wounds to right lateral knee and right lower shin. Record review of a wound measurement sheet dated 9/17/2024 revealed the resident has pressure ulcers to the following areas: - coccyx; 4.5 centimeter (cm) in length x 2.9 cm in width x 0.1 cm in depth - right lower shin; 3.5 cm in length x 1.6 cm in width x 0.1 cm in depth - right knee (lateral); 2.9 cm in length x 3.2 cm in width x 0.2 cm in depth Record review revealed the resident has the following physician orders: - 8/21/2024 to irrigate coccyx wound with wound cleanser then soak w [with] Vashe [wound cleanser that contains pure hypochlorous acid, a molecule produced by the human immune system to fight bacteria and infection] for 10 minutes, skin prep [a liquid that when applied to the skin forms a protective film or barrier] to peri wound [skin around the wound that has been affected by the wound] . - 9/3/2024 to cleanse right lower shin wound with Vashe, skin prep to peri-wound . - 9/3/2024 to cleanse right lateral leg wound with Vashe, skin prep to peri-wound . During a surveyor observation of the dressing changes to the resident's wounds on 9/19/2024 at 10:47 AM with License Practical Nurse, Staff C, revealed she soaked the coccyx wound with Vashe for only 2 minutes, not for the 10 minutes specified in the order. Additionally, Staff C failed to apply the skin prep to the peri-wounds of the coccyx, right lower shin, and right lateral knee, as ordered. During surveyor interviews on 9/19/2024 at 11:45 AM and 12:32 PM, Staff C acknowledged she did not provide treatments to the above wounds as ordered and that she should have followed the physician orders. During a surveyor interview on 9/20/2024 at 10:30 AM with the Director of Nursing Services, he was unable to provide evidence that Staff C administered the treatments to the wounds, as ordered.

Based on record review and staff interview, it has been determined the facility failed to ensure the residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight, relative to a weight gain for 1 of 2 residents reviewed, Resident ID #134. Findings are as follows: Review of a facility undated policy titled, Weight Policy which states in part, .Upon completion of weight, if a 3% discrepancy in one week or a 5% discrepancy in one month is noted, a reweight will be obtained in 48 hours .If a re-weight indicates a 3% discrepancy in one week or a 5% discrepancy in one month, the dietitian, physician, and resident and/or resident representative will be notified . Record review revealed Resident ID #134 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, Crohn's disease (a type of inflammatory bowel disease), rectal abscess, pressure ulcer of sacral region and chronic osteomyelitis, multiple sites (an infection in the bone). Record review of the physician's orders revealed the following: - 8/11/2024; Fluid intake not to exceed 1500 milliliters (ml) per day 1200 ml dietary 300 ml nursing - 8/14/2024; weekly weights once a week on Wednesday Review of the resident's weight record revealed the following weights: - 8/10/2024 117.4 lbs. (pounds) - 8/14/2024 122.6 lbs. - 8/21/2024 127.2 lbs. - 8/28/2024 125.4 lbs. - 9/4/2024 128.6 lbs. - 9/11/2024 131.8 lbs. - 9/18/2024 133.6 lbs. Record review revealed the resident gained a total of 14.4 lbs., a weight gain of 12.27% in one month, indicating a significant weight gain. Record review failed to reveal evidence that the physician was notified until 9/20/2024, after the surveyor brought the significant weight gain to the facility's attention. During a surveyor interview on 9/19/2024 at 9:39 AM with Registered Nurse, Staff D, he acknowledged the resident had a significant weight gain since his/her admission and that there was no evidence that reweights were obtained or that the physician was notified. Additionally, he acknowledged that the weight discrepancy would be alarming, as the resident was on a fluid restriction. During a surveyor interview on 9/20/2024 at 9:35 AM with the Dietitian, she revealed that she reviews the residents' weights weekly, but she was unaware of how much weight the resident had gained. Additionally, she was unable to provide evidence the residents weight gain had been reported to his/her physician, prior to being brought to the attention to the facility by the surveyor on 9/20/2024. During a surveyor interview with the Director of Nursing Services on 9/19/2024 at 9:52 AM, he revealed that he was unaware that Resident ID#134 had a significant weight gain until it was brought to his attention by a surveyor. Additionally, he was unable to provide evidence that the residents physician had been notified of the significant weight gain or that reweights had been obtained, per the facility policy.

Based on record review and staff interview, it has been determined that the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 2 residents reviewed for as needed antipsychotic medications, Resident ID #67. Findings are as follows: Record review of a facility policy titled Medication Regimen Review [MRR] and Reporting which states in part, .Medication Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication .The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated .In performing medication regimen review, the consultant pharmacist incorporates federally mandated standards of care .A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians and the care planning team within 48 hours of the MRR completion . Record review revealed Resident ID #67 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, major depressive disorder, anxiety disorder, post-traumatic stress disorder, and paranoid personality disorder. Record review revealed a physician's order with a start date of 8/22/2024 for Seroquel (an antipsychotic medication) 50 milligrams (mg) twice daily, as needed. This order had no stop date. Record review of the progress notes revealed, the pharmacy had reviewed the resident's medications with new recommendations made on 8/23/2024 and 9/10/2024. During a surveyor interview with the Director of Nursing Services (DNS) on 9/19/2024 at 1:22 PM, he could not provide the pharmacy reports for the above-mentioned recommendations, because they had not received them from the pharmacy. He further revealed that he would call the pharmacy and have them sent. Record review of a pharmacy document titled New Admission/ re-admission Review dated 8/23/2024, revealed in part, .Seroquel 50 mg .PRN [as needed] .PRN antipsychotic orders need a 14 day stop date . Record review of the Medication Administration Record from 8/23/2024 through 9/10/2024 revealed that the resident received the above ordered Seroquel 50 mg on 8/31/2024 and 9/12/2024. Review of the Pharmacist Consultation Recommendation Report dated 9/11/2024, failed to reveal evidence of a stop date as recommended in the previous pharmacy review dated 8/23/2024. During a surveyor interview on 9/19/2024 at approximately 2:30 PM with the DNS, he was unable to provide evidence that the pharmacist's recommendations from 8/23/2024 and 9/10/2024 were available to the facility, or acted upon until it was brought to his attention by the surveyor on 9/19/2024.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 32 opportunities for errors observed during the medication administration task there were 2 errors resulting in an error rate of 6.25%, involving Resident ID #62. Findings are as follows: Review of a facility policy titled, Administering Medications last revised December 2012 which states in part, .Medications shall be administered in a safe and timely manner, and as prescribed . Record review revealed that Resident ID #62 had the following physician's orders: - Depakote (divalproex) tablet, delayed release 500 milligrams (MG), twice daily - MiraLAX (polyethylene glycol 3350) powder, 17 gram dose, once daily During a surveyor observation on 9/19/2024 at 8:08 AM during the medication administration task with Certified Medication Technician, Staff E, she failed to administer the Miralax and then crushed the Depakote tablet. Review of the Depakote blister package revealed a directions label that indicated, Do not crush/chew. During a surveyor interview immediately following the above observation with Staff E, she acknowledged that she crushed the Depakote although the medication packaging indicated to not crush or chew. During a surveyor interview on 9/19/2024 at 11:24 AM with Registered Nurse, Staff D, he acknowledged that the Miralax was signed off, in the medical record, as administered during the medication pass. Staff D indicated that he would expect medication to only be signed off when administered, and was unable to explain why Staff E would sign off the medication if it was not administered. Additionally, he acknowledged the Depakote tablet should not be crushed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 5 medication carts reviewed and 1 of 2 medication rooms. Findings are as follows: Review of a facility policy titled, Storage of Medications last revised [DATE] states in part, The facility shall store all drugs and biological's in a safe, secure, and orderly manner . 1. During a surveyor observation of the 2 East Medication Cart on [DATE] at 8:25 AM, in the presence of Certified Medication Technician (CMT), Staff E, revealed the following: - 1 bottle of Latanoprost Solution (eye drops used to treat glaucoma) 0.005 % with an open date of [DATE]. Manufacturer's instructions indicate to discard the eye drops 6 weeks after opening, revealing the medication should have been discarded on [DATE]. - 1 bottle of Timolol Maleate Gel Forming Solution 0.5 % (eye drops used to treat high pressure inside the eye) dated as opened [DATE]. Manufacturer's instructions indicate to discard the eye drops 4 weeks after opening, revealing the medication should have been discarded on [DATE]. - 1 opened bottle of Artificial Tears Ophthalmic Solution (eye drops used to treat dry eyes) with a date of [DATE]. Manufacturer's instructions indicate to discard the eye drops 90 days after opening, revealing the medication should have been discarded on [DATE]. - 1 bottle of brimonidine-timolol drops; 0.2-0.5 % (eye drops used to treat high pressure inside the eye) dated as opened on [DATE]. Manufacturer's instructions indicate to discard the eye drops 4 weeks after opening, revealing the medication should have been discarded on [DATE]. During a surveyor interview with Staff E, at the time of the above observation, she acknowledged that the above-mentioned medications were expired and should have been discarded. During a surveyor interview immediately following the above observation with Registered Nurse, Staff D, he revealed that the staff should be writing the date when the medication is opened and then discarding when expired. 2. During a surveyor observation of the 2 [NAME] Medication Cart on [DATE] at approximately 9:00 AM, in the presence of CMT, Staff F, revealed the following: - 2 bottles of Cosopt (dorzolamide-timolol) drops (eye drops used to treat high pressure inside of the eye) opened and undated. Manufacturer's instructions indicate to discard the eye drops 15 days after opening. - 3 bottles of Artificial Tears Ophthalmic Solution opened and undated. Manufacturer's instructions indicate to discard the eye drops 90 days after opening. - 1 bottle of Systane Complete PF (propylene glycol) 0.6 % (eye drops prescribed to treat dry eyes) opened and undated. Manufacturer's instructions indicate to discard the eye drops 90 days after opening. - 1 bottle of brimonidine-timolol drops; 0.2-0.5 % opened and undated. Manufacturer's instructions indicate to discard the eye drops 4 weeks after opening. During a surveyor interview immediately following the above observation with Staff F, she acknowledged that all of the above-mentioned medications were opened and undated, and she was unsure when they expired. During a surveyor interview on [DATE] at 9:10 AM with Licensed Practical Nurse, Staff C, she revealed that the staff are supposed to date the eye drops once opened and discard when expired. 3. During a surveyor observation on [DATE] at 9:20 AM of the 2 East Medication Room in the presence of RN, Staff D, revealed one multidose vial of Aplisol, opened and undated. Manufacturer's instructions on the Aplisol box state, once entered vial should be discarded after 30 days. During a surveyor interview immediately following the above observation with RN, Staff D, he acknowledged that the vial was opened and undated. Additionally, he was unable to provide evidence when the vial had been opened. During a surveyor interview on [DATE] at 11:30 AM with the Director of Nursing Services, he revealed that he would expect the staff to date medications when opened and discard appropriately.

Based on record review, staff and resident interviews, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development of infections for 1 of 1 resident reviewed relative to the use of a Bilevel positive airway pressure (BIPAP, a device that provides breathing support which is administered through a face mask or nasal mask) device, Resident ID #77. Findings are as follows: Review of the manufacturer's instructions titled RESVENT IBREESE Series user manual dated July 2017, states in part, .Clean the flexible tube and mask before first use and daily. Disconnect the flexible tube and mask from the device. Gently wash the tube and mask in a solution of warm water and a mild detergent. Rinse thoroughly. Air dry . Record review revealed that Resident ID #77 was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, sleep apnea (a sleep disorder where breathing is interrupted repeatedly) and acute respiratory failure. Record review of a quarterly Minimum Data Set assessment completed on 8/22/2024, revealed a Brief Interview of Mental Status score of 15 out of 15, indicating intact cognition. During a surveyor interview on 9/17/2024 at approximately 11:30 AM with the resident, s/he revealed that the facility does not clean his/her BIPAP machine. Review of the Treatment Administration Record for August and September of 2024 revealed, the resident has an order to use a BIPAP machine every night at bedtime. Additional review revealed that the order was signed off as in use every night while s/he was in the facility. Further record review failed to reveal evidence of an order to clean the mask and tubing of the BIPAP machine. Record review failed to reveal evidence that the BIPAP machine tubing and mask were cleaned per the manufacturer's instructions in August or September of 2024. During a surveyor interview on 9/19/2024 at 12:31 PM with the Director of Nursing Services (DNS), he revealed that it is the facility's policy to follow the manufacturer's instructions for cleaning the BIPAP equipment. He further acknowledged, the above-mentioned resident does not have an order to clean their BIPAP equipment and was unable to provide evidence that the machine was cleaned, as required.

Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to provide person centered care in accordance with a resident's plan of care for 1 of 2 residents reviewed relative to his/her call light being within reach, Resident ID #67. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, adult failure to thrive, paroxysmal atrial fibrillation (a type of irregular heartbeat) and muscle weakness. Record review of a care plan dated 4/18/2024 revealed in part, .Potential for falls/injury r/t [related to]: impaired mobility, impaired cognition, impaired vision, incontinence, weakness and FTT [failure to thrive] . This care plan has interventions including, but not limited to, .Call light within reach & remind to call for assist as needed . During a surveyor observation on 7/15/2024 at 12:40 PM, the resident was observed to be seated in his/her wheelchair between the bed and wall, closest to the doorway, and more than halfway down the length of the bed. S/he had his/her rolling bedside table in front of him/her containing his/her meal tray, his/her bilateral lower extremities were slightly elevated on the wheelchair leg rest. Additionally, the resident's call light was tied to the bed rail on the opposite side of the bed, out of sight and reach of the resident. During a surveyor interview immediately following the above-mentioned observation with the resident, s/he revealed that s/he felt trapped, just trapped here, I have to yell for help and hope they hear me due to his/her inability to locate and utilize his/her call light for assistance. During a surveyor interview and observation on 7/15/2024 at 12:45 PM with Nursing Assistant, Staff A, she acknowledged the call bell for Resident ID #67 should be within his/her reach and it was not. Staff A, relocated the call bell so that it was within reach for the resident to use. During a surveyor interview on 7/15/2024 at 1:53 PM with the Director of Nursing Services, he acknowledged that the care plan regarding the call light being within reach had not been not followed for Resident ID #67. .

Based on 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 following a physician's order for nutritional supplements for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 5/8/2024 alleges in part, .In the course of over a month, [Resident ID #1] has lost 20 pounds. 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. Record review revealed the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, acquired absence of the right leg below the knee and type II diabetes mellitus. Record review of a progress note authored by the Licensed Dietitian/Nutritionist on 4/23/2024 at 4:05 PM states in part, .has experienced weight loss, supplement initiated to report. Record review revealed a physician order with a start date of 4/23/2024 for 60 milliliters of med pass (oral nutritional supplement) twice daily. Record review of the May 2024 medication administration record revealed the resident failed to receive the supplement for 5 of 16 opportunities. During a surveyor interview with the Director of Nursing Services on 5/9/2024 at 2:00 PM, he acknowledged that the resident did not receive the supplement per the physician's order because it was not available in the facility and it was on back order at the time.

**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 the residents' environment remains as free from accident hazards as possible for 2 of 4 residents reviewed related to fall risk prevention, Resident ID #s 2 and 3. Findings are as follows: 1. Record review revealed Resident ID #3 was re-admitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia and history of falls. Record review of the document titled Risk of Falls Assessment completed on 4/2/2024 revealed that the resident was at a moderate risk for falls. Record review of the care plan last revised on 4/9/2024 revealed a problem related to a history of falling with an intervention to keep the call light within reach. During a surveyor observation on 5/9/2024 at 9:46 AM, the resident was observed sitting in his/her wheelchair attempting to get up and calling out for help. The call light was noted to be hanging on his/her bedside rail, which was approximately 8 feet away from him/her. During a surveyor interview with the Registered Nurse, Staff A, following the above observation, he acknowledged that Resident ID #3's call light was not within his/her reach. 2. Record review revealed Resident ID #2 was re-admitted to the facility in March of 2024 with diagnoses including, but not limited to, urinary tract infection and bipolar disorder (a mental illness characterized by extreme mood swings). Record review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 of 15, indicating moderately impaired cognition. Record review of the document titled Risk of Falls Assessment completed on 5/9/2024 revealed that the resident was at a moderate risk for falls. During a surveyor observation and simultaneous interview with the resident on 5/9/2024 at 9:15 AM, s/he was observed to be lying in bed. The resident revealed that s/he was experiencing pain and wanted to call the nurse to ask for a pain medication. When asked if s/he had pressed his/her call light, s/he stated that s/he did not know where it was and asked the surveyor to get the nurse. During a surveyor interview with Licensed Practical Nurse, Staff B, immediately following the above observation, she acknowledged that the resident's call light was hanging off of the resident's bedside rail which was out of the resident's reach. During a surveyor interview with the Director of Nursing Services on 5/9/2024 at 1:15 PM, he revealed that he would expect the residents to have their call light within reach.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 1 resident reviewed related to abdominal girth measurements, Resident ID #25. 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. Record review revealed the resident was re-admitted to the facility in July of 2021 with diagnoses including, but not limited to, chronic systolic congestive heart failure (long-term condition that occurs when the heart muscle does not pump blood as well as it should), chronic kidney disease, and bladder cancer. Record review of the resident's Treatment Administration Record revealed an order dated 9/12/2023 to measure his/her abdominal girth once a day on Friday. Further review failed to reveal evidence of measurements for the resident's abdominal girth in the following dates: - 9/15/2023 - 9/22/2023 - 9/29/2023 - 10/6/2023 During a surveyor interview with the Licensed Practical Nurse, Staff E on 10/13/2023 at 11:47 AM, she was unable to provide evidence that any abdominal girth measurement was completed for the above-mentioned dates. Additionally, she acknowledged that she signed the order on 10/6/2023 without measuring the resident's abdominal girth. During a surveyor interview with the Director of Nursing Services on 10/13/2023 at approximately 1:00 PM, he was unable to provide evidence of the resident's abdominal girth measurements. Additionally, he acknowledged that he would expect the staff to follow the physician's orders and document their findings in the resident's record.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs), relative to transfers for 1 of 7 residents reviewed, Resident ID #125. Findings are as follows: Review of the resident record revealed s/he was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, acquired absence of left and right leg below knee, and stage 4 pressure ulcer of the sacral region (sores extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments). Record review of a care plan with a start date of 5/5/2023 revealed s/he has a deficit in ADL function/mobility due to a recent hospitalization related to a below the knee amputation on the left leg. Additionally, an intervention was in place to provide the resident assistance with ADLs as needed. Surveyor observations from 10/10/2023 to 10/12/2023 failed to reveal evidence that the resident was out of bed, or an attempt was made to get the resident out of bed. During a surveyor interview with the resident's family member on 10/11/2023 at 12:02 PM, s/he revealed that the resident wanted to get out of the bed to sit in the wheelchair, but the staff does not offer it and that the resident did not have a wheelchair for him/herself. During a surveyor interview with Nursing Assistant, Staff F on 10/12/2023 at 12:49 PM, she revealed that they do not get the resident up because s/he needed a special chair related to his/her pressure ulcer area. During a surveyor interview with Registered Nurse, Staff C on 10/12/2023 at 12:32 PM, she revealed that she has not seen the resident get out of bed since s/he was moved to the unit in September of 2023. During a surveyor interview with the Director of Nursing Services on 10/13/2023 at 11:34 AM, he revealed that there are recliners that the resident can utilize and would expect the staff to offer the residents to get out of bed.

**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 provide necessary treatment and services, consistent with professional standards of practice to promote wound healing and prevent new ulcers from developing for 2 of 5 residents reviewed for pressure ulcers (a localized injury to the skin or the underlying tissue due to pressure), Resident ID #'s 46 and 243. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the [pressure ulcer/pressure injury] PU/PI should be documented. At a minimum, documentation should include the date observed and: ·Location and staging; ·Size (perpendicular measurements of the greatest extent of length and width of the PU/PI), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; ·Exudate, if present: type (such as purulent/serous), color, odor and approximate amount; ·Pain, if present: nature and frequency (e.g., whether episodic or continuous); Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and ·Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate . Review of a facility policy titled, Prevention of Pressure Ulcers revealed in part, .the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, family and addressed . 1. Record review of Resident ID #46 revealed s/he was admitted to the facility in May of 2023. S/he has diagnoses including but not limited to, adult failure to thrive and non-pressure chronic ulcer of buttock with unspecified severity. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The assessment failed to reveal any pressure ulcers. Record review of a care plan initiated on 5/26/2023 revealed a focus area of .At risk for impaired skin integrity related to: Impaired cognition, incontinence, impaired mobility, Dx [diagnosis] of FTT [ failure to thrive], anemia and vitamin D deficiency . Interventions include but are not limited to, .Monitor skin integrity per facility protocol and prn [as needed] with prompt treatment to any red/open areas that develop . Record review of a physician order report dated 9/13/2023 states in part, .cleanse and apply [Triad] (a wound care paste to help provide an occlusive dressing) to right buttock wound twice a day. Surveyor observation on 10/13/2023 at 11:31 AM of the wound treatment on the coccyx with Registered Nurse, Staff G and Registered Nurse, Staff H, revealed the nurse turning resident to the side, then without measuring or cleaning the wound she applied Triad. During an interview immediately following the wound treatment observation, the staff was asked about wound measurements and she stated, they would obtain them. Surveyor observation on 10/13/2023 at 11:34 AM with Staff G and Staff H during wound measurements revealed an open area on left side of buttock which measured 0.5 by 0.5 cm (centimeters). Record review of progress note written on 9/13/2023 states, .Stage two located on resident right buttocks measuring 3 cm x 4 cm. Message sent to be seen by wound doctor. Record review of a document titled, .Wound Management Detail Report . dated 9/13/2023, revealed the resident has an ulcer on his/her right buttock three centimeters in length and four centimeters in width. Record review of the paper and electronic medical records failed to reveal that measurements or wound characteristics were documented for the ulcer during the following weeks: -9/17/2023 to 9/23/2023 -9/24/2023 to 9/30/2023 -10/1/2023 to 10/7/2023 During a surveyor interview on 10/13/2023 at 11:37 AM with Registured Nurse (RN) Staff G, she acknowledged that she had not cleansed the wound before applying Triad. Staff G was questioned about the wound size by this surveyor, and she acknowledged that she hadn't measured the wound during the observation. Additionally, she was unable to provide evidence of complete weekly measurements for the above weeks. During a surveyor interview on 10/13/2023 at 11:56 AM with the Director of Nursing Services, he was unable to provide evidence that wound measurements were completed weekly and revealed that he would expect the nurse to clean the wound prior to applying Triad. 2. Record review revealed Resident ID #243 was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, dementia and pressure ulcer of the left heel. Record review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15, indicating moderately impaired cognition. The assessment also revealed that s/he has impaired range of motion to his/her lower extremities and requires extensive assistance of two or more staff members for moving or changing positions while in bed. Additionally, the assessment failed to reveal evidence of pressure ulcers. Record review of a facility document titled, Norton Plus Pressure Ulcer Scale, completed on 10/5/2023 at 1:55 PM, revealed the resident was assessed as being at high risk for pressure ulcers. Record review of a care plan dated 10/10/2023, revealed concerns for a left heel unstageable pressure ulcer and indicates that the resident is at risk for alteration in skin and pressure ulcers related to limited mobility and incontinence. Interventions include, but are not limited to, heel lift when in bed to offload heels as needed, treatment to pressure ulcer as ordered, and Series 9000 mattress (a pressure reducing and relieving air mattress) when in bed to reduce pressure. Record review of a progress note dated 10/2/2023 at 11:50 PM, revealed the resident was noted to have an area measuring 2.5 cm x 2 cm of redness to his/her left heel. The note also indicates booties were placed on him/her. Additional record review revealed a Hospice Care Management document dated 10/3/2023 which revealed the resident was noted to have a left heel deep tissue injury (a pressure ulcer, persistent non-blanchable deep red, purple or maroon area). The note states in part, .pillow boots are on at all times . Further record review revealed a physician's order dated 10/11/2023 which states, Measure and describe wound every Wednesday if not seen by wound MD [medical doctor] and update wound management, during the 7:00 AM - 3:00 PM shift. Record review revealed the order was documented as completed by Registered Nurse, Staff C on 10/11/2023, however, the record failed to reveal evidence of wound measurements. Further record review failed to reveal evidence of a treatment order for the redness to the resident's left heel. During surveyor observations on the following dates and times, revealed the resident was in bed with the air mattress set at 400 pounds (lbs.): - 10/10/2023 at approximately 9:25 AM - 10/11/2023 at 11:13 AM - 10/12/2023 at 9:33 AM Additional record review revealed the resident's weight was documented on 10/5/2023 as 158.4 lbs. During a surveyor observation on 10/12/2023 at 9:47 AM, in the presence of, Staff C, revealed the following: -The resident was lying in bed with his/her feet placed directly on the mattress and not offloaded on a heel lift as indicated in the care plan. -His/her left heel was observed with a black scab to medial aspect and a red non blanchable area to the lateral aspect. -S/he was observed with an area of non-blanchable scattered redness to the top of his/her right foot. -his/her right heel was observed with an area measuring 4 cm x 3 cm of non-blanchable redness with dark maroon discoloration to the center. During a surveyor interview on 10/12/2023 immediately following the above-mentioned observation, with Staff C, she revealed that the areas to the resident's right foot and lateral left heel were new. She also indicated that the scabbed area to his/her left foot was previously identified and indicated that the area is being treated with skin prep (a liquid that when applied to the skin forms a protective film or barrier which protects the skin). Furthermore, she indicated she has been applying skin prep to the resident's left heel daily. Record review failed to reveal evidence of a physician's order for skin prep, or any treatment to the resident's left heel pressure ulcer. During a surveyor interview on 10/12/2023 at 9:49 AM, with Staff C, she was unable to provide evidence of the skin prep order or any order for the resident's left heel pressure ulcer. Additionally, she acknowledged that the air mattress was set at 400 lbs., and indicated the resident's last recorded weight was 158 lbs. She further indicated that the air mattress is usually set by weight and indicated that the resident had boots for his/her heels to be worn while in bed but was unable to state why they were not on or indicate where they were. Furthermore, she was unable to provide evidence of the resident's wound measurements she documented as completed on 10/11/2023. During a surveyor interview on 10/12/2023 at 10:53 AM, with the Director of Nursing Services, he indicated that the air mattress setting is based on the resident's weight. He indicated that the nurses are expected to check the air mattress setting and functioning every shift and document. Furthermore, he acknowledged that the resident was placed at greater risk for developing pressure ulcers due to lying on the air mattress with a weight setting of 400 lbs. without having his/her feet offloaded as indicated in the care plan. Additionally, he was unable to provide evidence of documented wound measurements for 10/11/2023.

**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 the residents environment remains as free of accident hazards as possible for 1 of 8 residents reviewed, relative to supervision while eating, Resident ID #46. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards . Record review revealed the resident was admitted to the facility in May of 2023, with diagnoses to include, but not limited to, dysphagia (difficulty swallowing foods and liquids). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted because the resident is rarely/never understood, indicating severe cognitive impairment. Record review of the resident's care plan, initiated on 5/26/2023 revealed the focus area At risk for aspiration r/t [related to] dysphagia. Interventions include but are not limited to, .Monitor for signs and symptoms of aspiration: coughing, shortness of breath, abnormal lung sounds, fever . Record review of the resident's care plan, initiated on 5/21/2023 revealed the focus area, .has a deficit in ADL function/mobility related to impaired cognition related to Dementia - impaired mobility. Interventions include but are not limited to, .Set up meal tray. Can feed self with supervision and set up at meal time . Review of the physician's orders revealed an order dated 5/19/2023 for House diet, pureed texture and nectar thickened liquids. During continuous surveyor observations on 10/12/2023 during the breakfast meal, the resident was in bed with the tray in front of him/her eating without supervision during the following times: -9:13 AM through 9:27 AM, -9:38 AM through 9:57 AM Additionally, throughout this period of constant surveyor observation of the resident's door only one staff member entered the room from 9:28 until 9:31 AM to see Resident ID #46's roommate. During continuous surveyor observation on 10/12/2023 during the lunch meal, the resident was in bed with the tray in front of him/her eating without supervision from 12:54 PM until 1:17 PM. Surveyor observation on 10/12/2023 at 1:17 PM revealed Licensed Practical Nurse, Staff I enter the resident's room. During a surveyor interview at this time, she revealed that she wasn't sure if the resident was supposed to be assisted with meals, but she comes in every once in a while, to see if s/he needs help eating. During a surveyor interview on 10/12/2023 at 1:25 PM with Nursing Assistant, Staff J and Nursing Assistant, Staff K, acknowledged that the resident is supposed to be assisted with meals. They further acknowledged that they did not assist the resident with his/her meal. During a surveyor interview on 10/12/2023 at 1:30 PM with Speech Therapist, Staff L, she revealed that she would expect the staff to be with the resident for his/her entire meal. She further revealed that the resident can feed him/herself, but the staff should be there to observe, and to help if s/he needs any assistance. A surveyor interview on 10/12/2023 at 2:45 PM with the Director of Nursing Services, revealed that when someone needs assistance with meals his expectation is that a staff member would be with the resident the entire time they had their meal tray.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with a nephrostomy receives care, consistent with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 sample resident who has a PCN (percutaneous nephrostomy - an artificial opening created between the kidney and the skin which allows for urinary drainage), Resident ID #243. Findings are as follows: Review of the facility's policy titled, Nephrostomy Tube , Care of, states in part: .The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube . 1.Verify that there is a physician's order for this procedure .2. Review the residents care plan to assess for any special needs of the resident . General Guidelines . 8. Change dressing every 1-3 days, or as ordered . 9. Use clean technique during dressing changes . Record review revealed the resident was readmitted to the facility in October of 2023 and has diagnoses including, but not limited to, acute Cystitis (bladder infection) without hematuria (blood in the urine). Record review revealed a care plan revised on 10/3/2023, indicating s/he requires a PCN tube due to hydronephrosis (swelling of one or both kidneys). Interventions include but are not limited to, .Monitor PCN tube, monitor site, monitor for any s/s [signs or symptoms] of infection on the site, treatment as order and report to MD [medical doctor] if any issue . During a surveyor observation on 10/12/2023 at approximately 10:15 AM, revealed an undated foam dressing in place to the resident's PCN site which was partially lifted and appeared soiled. Further record review failed to reveal evidence of orders in place for a dressing to the PCN site until after it was brought to the facility's attention by the surveyor. During a surveyor interview on 10/12/2023 at 11:03 AM, with the Director of Nursing Services, he was unable to provide evidence of a dressing order to the resident's PCN site.

Based on record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 resident reviewed related to abdominal girth measurements, Resident ID #25. 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. Record review revealed the resident was re-admitted to the facility in July of 2021 with diagnoses including, but not limited to, chronic systolic congestive heart failure (long-term condition that occurs when the heart muscle does not pump blood as well as it should), chronic kidney disease, and bladder cancer. Record review of the resident's Treatment Administration Record revealed an order dated 9/12/2023 to measure his/her abdominal girth once a day every Friday. Further review failed to reveal evidence of measurements for the resident's abdominal girth on the following dates: - 9/15/2023 - 9/22/2023 - 9/29/2023 - 10/6/2023 During a surveyor interview with the Licensed Practical Nurse, Staff E on 10/13/2023 at 11:47 AM, she was unable to provide evidence that any abdominal girth measurements were completed for the above-mentioned dates. Additionally, she acknowledged that she signed the order on 10/6/2023 without measuring the resident's abdominal girth. During a surveyor interview with the Director of Nursing Services on 10/13/2023 at approximately 1:00 PM, he acknowledged that he would expect the staff to follow the physician's orders.

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infection for 1 of 3 residents observed for wound care, Resident ID #84. Findings are as follows: Record review of the facility policy titled, Multidrug-Resistant Organisms [MDRO, are bacteria that resist treatment with more than one antibiotic], with a revision date of 2014, states in part, .Appropriate precautions will be taken when caring for individuals known or suspected to have infection with a multidrug-resistant organism .c. Risks for transmission including .draining wounds .may increase the risk for transmission may indicate the need for Contact Precautions .19. Disposable gloves should be worn if contact with body fluids is expected and hand hygiene performed after removing the gloves .21. The resident's environment should be cleaned routinely and when soiled with body fluids . Record review revealed that the resident was re-admitted to the facility in February of 2023. S/he has diagnoses which include, but are not limited to, surgical amputation of the right 2nd toe and osteomyelitis (a serious infection of the bone). Record review revealed a care plan dated 8/31/2023, indicating s/he has CRE (carbapenem-resistant Enterobacterales, a type of MDRO, that are very difficult to treat because they do not respond to commonly used antibiotics) to his/her right second toe wound. Interventions include, contact precautions (personal protective equipment) when performing wound care. Further record review revealed the following physician's orders: -Start date of 9/7/2023, clean bilateral lower extremities with normal saline, apply bacitracin to the open areas, cover with gauze Kling wrap twice a day. -Start date of 9/18/2023, to the 2nd Right Toe, and amputation site: Cleanse with normal saline, pat dry, apply silver collagen to the ulcer, cover with alginate and dry dressing three times weekly on Monday, Wednesday, and Friday during the 7:00 AM - 3:00 PM shift. During a surveyor observation on 10/13/2023 at 9:23 AM, Registered Nurse, Staff G, was observed in the resident's room. The resident was observed to be sitting in his/her wheelchair and his/her right foot was observed with the old dressing in place which was saturated with yellow colored drainage. The resident was observed to instruct Staff G to assist him/her with placing his/her right leg onto the over-the-bed table, which was covered by a towel, to complete the dressing change. Furthermore, Staff G was observed completing the following during the above-mentioned dressing change: - She failed to perform hand hygiene between gloves changes twice. - She failed to clean the scissors after cutting the soiled dressing and before she cut the clean dressing, which was placed placed on the resident's wound. - She removed the towel from the over-the-bed table and placed it directly onto the floor and did not remove it prior to exiting the resident's room. During a subsequent surveyor observation on 10/13/2023 at 10:09 AM, the towel was observed to be in the same location, directly on the floor of the resident's room. During surveyor interviews on 10/13/2023 immediately following the above-mentioned observations and at 10:09 AM, with Staff G, she acknowledged that she failed to perform hand hygiene between glove changes, failed to clean the scissors before and after use, and failed to remove the dirty towel from the floor. During a surveyor interview on 10/13/2023 at 10:06 AM, with the Director of Nursing Services, he indicated that he would have expected Staff G to perform hand hygiene between glove changes, clean the scissors before and after use, and remove the towel from the resident's room.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the services provided by the facility meet professional standards of quality for 1 of 8 residents reviewed relative to physician's order for pain medication, Resident ID #81. 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. Record review revealed the resident was admitted to the facility in March of 2022 with diagnoses including, but not limited to, fracture of right patella (kneecap), right great toe amputation and difficulty in walking. Record review of physician's orders dated 6/14/2022 revealed the following: - Oxycodone- 5 milligram (mg). Take 1 tablet by mouth every 6 hours PRN (as needed) for pain rating 5-7 - Oxycodone -5 mg; Take 2 tablets by mouth every 6 hours PRN for pain rating 8-10 Record review of the July and August Medication Administration Record from 7/3/2022 through 8/3/2022 revealed the resident incorrectly received Oxycodone 5 mg 1 tablet instead of 2 tablets on the following dates and times: - 7/7/2022 at 12:38 PM for pain rating 8 out of 10 - 7/8/2022 at 1:05 PM for pain rating 9 out of 10 - 7/22/2022 at 1:14 PM for pain rating 8 out of 10 - 7/26/2022 at 2:59 AM for pain rating 8 out of 10 - 8/1/2022 at 4:43 PM for pain rating 8 out of 10 During a surveyor interview with the Director of Nursing on 8/3/2022 at 11:27 AM, he acknowledged that the resident did not receive the above pain medication as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents that are at risk for pressure ulcers and residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 4 of 10 residents reviewed, Resident ID #'s 40, 70, 110, and 482. Findings are as follows: Record review of the 2001 facility's policy titled Pressure Ulcer Risk Assessment with a revision date of 2013 states in part: .Assessment: 3. Monitoring: c. Nurses will conduct skin assessments at least weekly to identify changes .4 Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers .13. Documentation in medical record addressing MD [medical doctor] notification if changes of plan of care if indicated . 1) Record review revealed Resident ID #40 was admitted to the facility in November of 2021 with diagnoses that include, but are not limited to; pressure ulcer of sacral region (portion of your spine between your lower back and tailbone) and an abscess to the right buttocks. Record review of the wound clinic notes revealed the following: - on 7/15/2022, wound on right buttock, measurements are 2 cm length x 0.2 cm width x 0.3 cm depth. - on 7/29/2022, wound on right buttock, measurements are 3 cm length x 0.5 cm width x 0.3 cm depth. Record review failed to reveal evidence that measurements of the wound were obtained on 7/8/2022 and 7/22/2022. During a surveyor interview with the Director of Nurses (DON) on 8/4/2022 at approximately 9:15 AM, he was unable to provide evidence that wound measurement were obtained on 7/8 and 7/22/2022. 2) Record review revealed Resident ID #70 was admitted to the facility in April of 2022 with diagnoses which include, but are not limited to, stage 4 pressure ulcer (most severe form of bedsores that reaches the muscles, ligaments, or bone) of the sacral region/left buttock, and osteomyelitis (inflammation of the bone caused by infection) of vertebra, and sacral region. Record review of a continuity of care consultation form from the wound clinic dated 7/26/2022 revealed the following recommendations: - .Wound #13, Right, lateral Ischial (5 o'clock) [lower part of your hip bone]: Dressings: Discontinue Santyl ointment [a medication that removes dead tissues from wounds] . - .Wound #14 Left buttock .Dressings: Discontinue Santyl ointment . - .Wound #15 Right, distal buttock (buttock/Thigh crease) .Dressing: Discontinue Santyl ointment . - .Wound #16 Right, Lateral, superior buttock (1o'clock) .Dressings: Discontinue Santyl . Record review of the Treatment Administration Record (TAR) from 7/26/2022 through 8/3/2022 failed to reveal evidence that the Santyl was discontinued per the wound clinic recommendations. During a surveyor interview on 8/3/2022 at 10:37 AM with the Registered Nurse, Staff A, she was unable to provide evidence that the Santyl was discontinued per the wound clinic recommendations. During a surveyor interview on 8/4/2022 at 10:50 AM with the Nurse Practitioner (NP), Staff B, she indicated that she would expect staff to notify her of the recommendations as she would have approved of the recommendations from the wound clinic. She further revealed that she was not made aware of the recommendations from the wound clinic on 7/26/2022. 3) Record review revealed Resident ID #110 was admitted to the facility in August of 2019 and has diagnoses which include, but are not limited to; pressure ulcer of the right ankle and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of a physician's order dated 5/26/2022 states, Boot in place while in wheelchair. Document refusals. Twice A Day AM 07:00 AM-03:00 PM, HS [at bedtime]03:00 PM-11:00 PM. Surveyor observation of the resident while in his/her wheelchair on 8/2/2022 at approximately 1:30 PM, and on 8/3/2022 at 11:29 AM, 12:51 PM, and at 1:12 PM, revealed him/her not wearing the boot while in his/her wheelchair. Although, record review of the TAR revealed it was signed off as being completed on 8/2/2022 and 8/3/2022 between 7:00 AM-3:00 PM. During a surveyor interview with the resident on 8/3/2022 at 9:30 AM s/he stated s/he hasn't been offered the boot in a while. The resident who is alert and oriented further stated that s/he does not refuse to wear the boot. During a surveyor interview with LPN, Staff C, on 8/3/2022 at 1:16 PM, she indicated that it is the certified nursing assistants responsibility to put the boot on in the morning when doing care and the nurse's responsibility to sign off on it. Staff C acknowledged she signed off on the TAR before seeing that the boot was applied on 8/2/2022 and 8/3/2022. She further revealed that it is her expectation for the resident to have the boot on while in his/her wheelchair. During a surveyor interview with Nursing Assistant, Staff D, on 8/4/2022 at 9:30 AM, indicated the nursing assistants are expected to put the boot on in the morning when the resident is in his/her wheelchair and that the resident does not refuse to wear the boot. 4) Record review for Resident ID #482 revealed s/he was admitted to the facility in July of 2022 with diagnoses that include, but are not limited; to sacral wound, pressure ulcer of left buttock and pressure induced deep tissue damage of unspecified site. During a surveyor observation of the resident's room on 8/1/2022 at 12:10 PM and on 8/2/2022 at 12:20 PM revealed an air mattress sitting on the floor. Record review of the physician order dated 7/24/2022 revealed in part .check air mattress gauge every shift for accuracy . Further record review revealed the wound care doctor covering in the facility, on 7/21/2022 and 7/27/2022, recommended the use of Prevalon Boots for off-loading of his/her heels. During a surveyor interview with the resident on the following dates, s/he revealed the air mattress was not in place and s/he was not wearing any type of boot on his/her feet. -8/1/2022 at approximately 9:00 AM, -8/2/2022 at approximately 10:30 AM -8/3/2022 at approximately 9:30 AM, Record review of the TAR revealed the air mattress was signed off on 8/1/2022 and 8/2/2022 on all 3 shifts as having been checked for accuracy. During a surveyor interview with the Staff B on 8/4/2022 at approximately 10:50 AM she revealed she was not aware of the Prevalon Boot recommendation and if she had been made aware she would have approved it. During a surveyor interview with the DON on 8/4/2022 at approximately 2:30 PM, he revealed the resident did not have a physician order for Prevalon Boot and the air mattress was not in place per physician order.