Based on record review and staff interview it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to insulin administration for 1 of 3 residents reviewed, Resident ID #42. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .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 that the resident was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, type II diabetes. Record review revealed the following physician's orders: - Insulin lispro (fast-acting insulin that starts to work about 15 minutes after injection) 100 units/ milliliter (ml), administer 3 units subcutaneously (the layer of tissue just below the skin) daily from 11:30 AM until 1:00 PM. - Insulin lispro 100 units/mL, administer 3 units subcutaneous daily from 4:30 PM until 6:00 PM - Insulin lispro 100 units/mL, administer 3 units subcutaneous from 4:00 PM until 5:30 PM. Record review revealed that on the following dates and times, the insulin lispro was not administered as ordered: - 4/7/2025 from 4:30 PM until 6:00 PM, with a documented blood sugar of 83 milligrams (mg)/ deciliter (dL) - 4/11/2025 from 11:30 AM until 1:00 PM, with a documented blood sugar of 71 mg/dL - 4/14/2025 from 4:00 PM until 5:30 PM, with a documented blood sugar of 88 mg/dL Record review failed to reveal evidence that the provider was notified of the insulin lispro not being administered on 4/7, 4/11 or 4/14/2025. During a surveyor interview on 4/16/2025 at 10:38 AM with Licensed Practical Nurse, Staff A, she revealed that there are no parameters to hold the insulin in the order. Additionally, she revealed that the insulin should be given during the meal and if the medication was held, it should be reported to the provider. During a surveyor interview on 4/16/2025 at 10:34 AM with the Director of Nursing Services, she was unable to provide evidence that the insulin lispro was administered, as ordered, on 4/7/2025, 4/11/2025 and 4/14/2025. During a surveyor interview on 4/16/2025 at 10:49 AM with the Nurse Practitioner, Staff B, she revealed that she would expect the staff to follow the order as written and if the medication is held, she would expect the staff to notify her.

**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 the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for 2 of 2 residents reviewed for smoking, Resident ID #s 10 and 42, and 3 of 3 residents reviewed for restraints, Resident ID #s 9, 10, and 31. Findings are as follows: 1. Review of the Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual last revised in October 2024 states in part, .Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period . 1a. Record review revealed Resident ID #10 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, tobacco use. Record review revealed a care plan dated 1/21/2025 which revealed the resident uses a vape (a device used for inhaling vapor containing nicotine and flavoring) and tobacco products. Review of an MDS assessment dated [DATE], Section J, titled, Health Conditions revealed the resident was documented inaccurately as not using tobacco products during the 7-day look-back period. 1b. Record review revealed Resident ID #42 was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, type 2 diabetes. Record review revealed a care plan dated 3/25/2025 which revealed the resident utilizes tobacco products. Record review revealed a Smoking Evaluation dated 3/5/2024, which revealed that the resident utilizes tobacco products. Review of an MDS assessment dated [DATE], Section J, titled, Health Conditions revealed the resident was documented inaccurately as not using tobacco products during the 7-day look-back period. 2. Review of the RAI Manual dated October 2024 states in part, .The intent of this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time during the day or night, during the 7-day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories .DEFINITION PHYSICAL RESTRAINTS Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body . 2a. Record review revealed Resident ID #9 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, dementia. Record review revealed a physician order dated 2/15/2025 for two 1/4 top side rails as an enabler for bed mobility and transfers, as needed while in bed. Review of an MDS assessment dated [DATE], Section P, titled, Restraints revealed the resident was coded for the use of bed rails as a restraint during the 7-day look-back period. 2b. Record review revealed Resident ID #10 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, obesity. Record review revealed a physician order dated 2/15/2025 for two 1/4 top side rails as an enabler for bed mobility and transfers as needed while in bed. Review of an MDS assessment dated [DATE], Section P, titled, Restraints revealed the resident was coded for the use of bed rails as a restraint during the 7-day look-back period. 2c. Record review revealed Resident ID #31 was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to, dementia. Record review revealed a physician order dated 2/15/2025 for two 1/4 top side rails as an enabler for bed mobility and transfers, as needed while in bed. Review of an MDS assessment dated [DATE], Section P, titled, Restraints revealed the resident was coded for the use of a bed rails as a restraint during the 7-day look-back period. During surveyor interviews on 4/16/2025 at 10:28 AM and 4/17/2025 at 10:43 AM, with the MDS Coordinator, she revealed that Resident ID #s 10 and 42 are active smokers and utilize tobacco products. Additionally, she revealed that Resident ID #s 9, 10, and 31 utilize the side rails for bed mobility and transfers, but that they are not utilized as a restraint and do not meet the definition of a restraint. Furthermore, she revealed that the MDS Assessments for Resident ID #s 9,10, 31, and 42 were coded in error and would be modified with the correct information, after being brought to the facility's attention by the surveyor. During a surveyor interview on 4/17/2025 at 10:43 AM, with the Director of Nursing Services, she acknowledged that the above MDS assessments for Resident ID #s 9, 10, 31, and 42 were coded inaccurately.

Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 residents reviewed for appointments, Resident ID #25. Findings are as follows: Record review revealed that Resident ID #25 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, adult failure to thrive and repeated falls. Record review revealed a physician's order dated 1/27/2025 to obtain a neurology consult. Review of the progress notes revealed the following: - 1/27/2025 the resident's diagnoses were reviewed by the Nurse Practitioner (NP), Staff B, and a new order was obtained for a neurology consult - 1/27/2025 authored by Staff B, which revealed that speech therapy was to see the resident due to increase tremors and trouble swallowing, as well as his/her diet had been downgraded to a chopped texture with thin liquids. Additionally, a neurology consult was placed for tremors and dysphagia, (difficulty swallowing) with concerns for Parkinson's disease versus medication induced tremors - 4/10/2025 revealed the resident had upper extremity tremors with holding objects most of the time Review a document titled, Occupational Therapy Treatment Encounter Note(s) dated 1/29/2025, revealed that the resident complained of bilateral hand tremors and complained of having difficulty with drinking with a regular cup. Record review failed to reveal evidence that a neurology consult appointment was scheduled, attended, or declined by the resident. Review of the transport calendar for the year of 2025, with the Administrator, failed to reveal evidence that a neurology consult appointment was scheduled for Resident ID #25. During a surveyor interview on 4/16/2025 at 11:00 AM with Licensed Practical Nurse, Staff A, she revealed that she was unable to find evidence that the neurology appointment was scheduled, attended, or declined by the resident. During a surveyor interview on 4/16/2025 at 11:18 AM, with the Director of Nursing Services (DNS), she revealed that the person in charge of setting up appointments for the residents was unaware that Resident ID #25 was ordered or needed a neurology consult appointment. During a surveyor interview and observation on 4/16/2025 at 11:25 AM, with the resident, in the presence of the DNS, the resident was observed to have tremors. Additionally, the resident revealed that s/he did not decline an appointment for a neurology consult. Furthermore, s/he revealed to the DNS and the surveyor that s/he was still having tremors and still needs to attend the neurology consult. During a surveyor interview on 4/18/2025 at approximately 12:30 PM with the DNS, in the presence of the Administrator, she was unable to provide evidence that the facility followed up and scheduled the neurology appointment as ordered by the provider on 1/27/2025.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: Review of the Rhode Island Food Code 2018 Edition 4-601.11, states in part, .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During surveyor observations on the initial tour of the main kitchen on 4/14/2025 at approximately 9:15 AM, in the presence of the Food Service Director (FSD), revealed the following: - A white colored component within the ice machine noted with black and pink matter, that was able to be removed by wiping it with a paper towel - A Kitchen Aid® appliance covered with a clear plastic bag, with a dark brown liquid matter leaking from a seam on the upper portion of the appliance onto the bag and appliance itself - An accumulation of a grease-like residue on the exhaust hoods above the stove and griddle. Additionally, a sticker was observed indicating that the hoods were last cleaned on 11/11/2024 During a surveyor interview immediately following the above observations on 4/14/2025 with the FSD, he acknowledged the discolored wipeable matter within the ice machine, the discolored liquid matter leaking from the kitchen appliance, and the grease-like accumulation on the exhaust hoods and indicated that they should be cleaned.

Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually. Findings are as follows: 1. Record review revealed a document titled, Facility Assessment last updated 3/10/2025, which revealed the following participants were involved in the completion of the Facility Assessment: - Administrator - Director of Nursing Services - Director of Environmental Services - Medical Director Record review failed to reveal evidence of the involvement of direct care staff including, but not limited to, Registered Nurse, Licensed Practical Nurse, Nursing Assistant, or a representative of the direct care staff, in the completion of the Facility Assessment. Further review of the Facility Assessment failed to reveal evidence that the facility solicited and considered input received from the residents, resident representatives, and family members. 2. Review of the Facility Assessment failed to reveal evidence that the facility developed and maintained a plan to maximize recruitment and retention of direct care staff. During a surveyor interview on 4/17/2025 at 10:50 AM, with the Administrator, she revealed that direct care staff, residents, family, or resident representatives were not involved in the completion of the Facility Assessment. Further, she acknowledged that the Facility Assessment did not include a plan to maximize recruitment and retention of direct care staff, per the regulation.

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 physician's orders for 8 of 8 residents reviewed relative to failing to check blood sugars as ordered, Resident ID #s 1, 4, 6, 7, 8, 9, 10, and 11. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, 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. 1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, diabetes mellitus. Review of a physician's order dated 9/27/2024 revealed to check his/her blood sugar before meals and at bedtime daily. Additionally, the order revealed to contact the physician if the blood sugar is less than 70 or greater than 300. Review of the November 2024 Medication Administration Record (MAR) revealed that Resident ID #1 did not have his/her blood sugar checked at 4:30 PM or 9:00 PM on 11/1/2024, as ordered. 2. Record review revealed that Resident ID #4 was readmitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan revealed that s/he is at risk for unstable blood sugars related to a diagnosis of diabetes with an intervention including, but not limited to, check fingerstick blood sugar, as ordered. Review of a physician's order with a start date of 10/24/2024 revealed to administer 5 units of insulin glargine (long-acting insulin to treat diabetes) subcutaneous (below the skin) in the evening. Additionally, the order revealed to check the resident's blood sugar prior to administering the medication. Review of the November 2024 MAR revealed that Resident ID #4's blood sugar was not checked on the evening of 11/1/2024, as ordered. 3. Record review revealed that Resident ID #6 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #6 revealed that s/he is at risk for unstable blood sugars secondary to a diagnosis of diabetes with an intervention including, but not limited to, check fingerstick blood sugar, as ordered. Review of a physician's order dated 8/2/2024 revealed to administer insulin Lispro (fast acting insulin) per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Review of the November 2024 MAR revealed that the resident did not have his/her blood sugar checked on 11/1/2024 at 4:30 PM, as ordered. 4. Record review revealed that Resident ID #7 was readmitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a physician's order dated 9/25/2024 revealed to administer insulin Lispro per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Review of a physician order dated 9/25/2024 revealed to check the resident's fingerstick blood sugar at bedtime daily. Additionally, it revealed to contact the physician if the fingerstick blood sugar is less than 70 or greater than 400. Review of the November 2024 MAR revealed that the resident did not have his/her fingerstick blood sugar checked on 11/1/2024 at 4:30 PM or at bedtime, as ordered. 5. Record review revealed that Resident ID #8 was readmitted to the facility in October of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a physician's order dated 10/9/2024 revealed to check his/her blood sugar twice daily and report to the physician if less than 70 or greater than 300. Review of the November 2024 MAR revealed that the resident did not have his/her blood sugar checked on 11/1/2024 in the evening, as ordered. 6. Record review revealed that Resident ID #9 was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of the physician's orders revealed the following: - An order with a start date of 2/13/2024 to check blood sugar three times a day 15 minutes prior to meals and notify the physician if blood sugar is less than 70 or greater than 400. - An order with a start date of 1/4/2024 to administer insulin Lispro per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Review of the November 2024 MAR revealed that Resident ID #9's blood sugar was not checked on 11/1/2024 at 4:30 PM, as ordered. 7. Record review revealed that Resident ID #10 was readmitted to the facility in October of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a physician order dated 10/18/2024 revealed to administer insulin Lispro per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Additionally, the order instructed to contact the physician if the resident's blood sugar is less than 70 or greater than 400. Review of the November 2024 MAR revealed that Resident ID #10's blood sugar was not checked on 11/1/2024 at 4:30 PM, as ordered. 8. Record review revealed that Resident ID #11 was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan revealed that s/he is at risk for unstable blood sugars related to a diagnosis of diabetes with an intervention including, but not limited to, check fingerstick blood sugar, as ordered. Review of a physician's order dated 9/3/2024 revealed to administer insulin Aspart (fast acting insulin) per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Additionally, the order instructed to contact the physician if the resident's blood sugar is less than 70 or greater than 400. Review of the November 2024 MAR revealed that Resident ID #11 did not have his/her blood sugar checked on 11/1/2024 at 4:30 PM, as ordered. During a surveyor interview on 11/4/2024 at approximately 1:30 PM with the Director of Nursing Services and the Clinical Consultant they acknowledged that Resident ID #s 1, 4, 6, 7, 8, 9, 10, and 11 did not have their blood sugar checked, as ordered on 11/1/2024. Cross Reference- F839

Based on record review and staff interview it has been determined that the facility failed to keep all residents free from significant medication errors for 5 of 6 residents reviewed relative to failing to administer insulin as ordered, Resident ID #s 1, 4, 5, 6 and 7. Findings are as follows: Review of a facility policy titled, Medication Administration dated 10/11/2017 states in part, It is the policy to ensure that resident medication administration is managed to ensure for resident quality of life, timeliness and safety .Medications are administered within one hour of the time noted on MAR [Medication Administration Record]. 1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, diabetes mellitus. Review of a care plan for Resident ID #1 revealed that s/he is at nutritional risk related to a diagnosis of diabetes with an intervention including, but not limited to, offer diabetic medications as ordered. Review of the physician's orders revealed the following: - An order dated 10/23/2024 to administer 8 units of Humalog insulin (fast acting insulin) between 4:00 PM and 6:00 PM daily. - An order dated 9/18/2024 to administer 20 units of Lantus insulin (long acting insulin) between 7:00 PM and 11:00 PM daily. Review of the November 2024 MAR revealed that Resident ID #1 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed doses of insulin on 11/1/2024. 2. Record review revealed that Resident ID #4 was readmitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #4 revealed that s/he is at risk for unstable blood sugars secondary to a diagnosis of diabetes with an intervention including, but not limited to, administer medication as ordered. Review of a physician's order with a start date of 10/24/2024 revealed to administer 5 units of insulin glargine (long acting insulin to treat diabetes) subcutaneous (below the skin) in the evening. Review of the November 2024 MAR revealed that Resident ID #4 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed dose of insulin on 11/1/2024. 3. Record review revealed that Resident ID #5 was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #5 revealed that s/he is at risk for unstable blood sugars secondary to a diagnosis of diabetes with an intervention including, but not limited to, administer medication as ordered. Review of a physician's order with a start date of 10/21/2024 revealed to administer 5 units of Lantus insulin subcutaneous every evening. Review of the November 2024 MAR revealed that Resident ID #5 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed dose of insulin on 11/1/2024. 4. Record review revealed that Resident ID #6 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #6 revealed that s/he is at risk for unstable blood sugars secondary to a diagnosis of diabetes with an intervention including, but not limited to, administer medication as ordered. Review of a physician's order dated 8/11/2024 revealed to administer 10 units of insulin glargine subcutaneous every evening. Review of the November 2024 MAR revealed that Resident ID #6 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed dose of insulin on 11/1/2024. 5. Record review revealed that Resident ID #7 was readmitted to the facility in August 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #7 revealed that s/he is at nutritional risk related to a diagnosis of diabetes with an intervention including, but not limited to, offer diabetic medications as ordered. Review of a physician order dated 10/21/2024 revealed to administer 20 units of insulin glargine subcutaneous every evening. Review of the November 2024 MAR revealed that Resident ID #7 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed dose of insulin on 11/1/2024. During a surveyor interview on 11/4/2024 at approximately 1:30 PM with the Director of Nursing Services and the Clinical Consultant, they acknowledged that the above-mentioned insulin doses were not administered for Resident ID #s 1, 4, 5, 6 and 7. Cross Reference- F839

Based on record review and staff interview it has been determined that the facility failed to ensure that staff are licensed, certified, or registered in accordance with applicable State laws for 1 of 1 staff reviewed, Staff A. Findings are as follows: Review of a facility reported incident received by the Rhode Island Department of Health on 11/3/2024 revealed that a Certified Medication Technician (CMT), Staff A, worked in the facility on 11/1/2024 and impersonated a licensed nurse. Additionally, it revealed that Staff A attempted to do this a second time on 11/3/2024 but was discovered to not have the proper credentials and was sent home. Review of the Rhode Island Department of Health licensing website revealed Staff A is licensed as a CMT. During a surveyor interview on 11/4/2024 at approximately 10:50 AM with the Director of Nursing Services (DNS) she revealed that Staff A, was scheduled to work as a CMT on 11/1/2024 and 11/3/2024. Additionally, she revealed that on 11/3/2024 Staff A, attempted to conduct the narcotic count and obtain the keys for the licensed nurse medication cart and was stopped by Nursing Supervisor, Staff B. Per the DNS, Staff B discovered that Staff A was a CMT and not a licensed nurse. Additionally, the DNS acknowledged that Staff A did work in the capacity of a licensed nurse on 11/1/2024 during the 3:00 PM to 11:00 PM shift and had completed the narcotic count and obtained the keys for the licensed nurse medication cart. During a surveyor interview on 11/4/2024 at 11:50 AM via the telephone with Licensed Practical Nurse, Staff C, she revealed that she conducted the narcotic count with Staff A on 11/1/2024. Additionally, Staff C revealed that Staff A was unsure how to complete a narcotic count and she instructed her how to do so. Staff C revealed that she felt unsure of Staff A competence but did not speak to the Director of Nursing Services about her concerns. A surveyor interview was attempted with Staff A on 11/4/2024 at 12:02 PM but she did not return the surveyor's call. During a surveyor interview on 11/4/2024 at 12:06 PM with Registered Nurse (RN), Staff D, she revealed that on 11/1/2024 Staff A told her she was a nurse. Per Staff D, Staff A completed the narcotic count and said that she would pass the narcotics and insulins for all of the residents. During a surveyor interview on 11/4/2024 at 12:20 PM via telephone with RN, Staff E, she revealed that she worked on 11/1/2024 with Staff A from 3:00 PM to 11:00 PM. Additionally, Staff E revealed that Staff A completed the narcotic count and was supposed to administer the narcotics and insulin to all of the residents. Staff E revealed that she was unaware that Staff A was not a nurse, however, she did acknowledge that Staff A appeared to be unsure about what she was doing while completing the narcotic count at the end of the night. Review of the November 2024 Medication Administration Record (MAR) for Resident ID #12 revealed oxycodone 5 milligrams (mg, a schedule 2 narcotic) was signed off as administered by CMT, Staff A on 11/1/2024. Review of the November 2024 MAR for Resident ID #13 revealed oxycodone 5 mg was signed off as administered by Staff A on 11/1/2024. During a surveyor interview on 11/4/2024 at approximately 1:30 PM with the DNS and the Clinical Consultant, they acknowledged that Staff A worked on 11/1/2024 and inaccurately portrayed herself as a nurse. Additionally, the DNS and Clinical Consultant acknowledged that administering schedule 2 narcotics is outside of the scope of practice for a CMT.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 1 resident reviewed relative to foley catheter (a tube that is placed in the body to drain and collect urine from the bladder) care, Resident ID #33. Findings are as follows: Review of a facility policy titled Urinary Catheter Irrigation- Intermittent (Indwelling) states in part, .explain the procedure and provide privacy . Record review revealed that Resident ID #33 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, urinary retention and low back pain. Review of a physician's order revealed the resident has a foley catheter with directions to flush the foley every shift. During a surveyor observation on 4/26/2024 at approximately 8:45 AM, the resident was observed with the door open while Licensed Practical Nurse (LPN), Staff A, and Registered Nurse (RN), Staff D, were observed flushing and then changing the resident's indwelling foley catheter. During this observation the resident was observed with his/her genitals uncovered and in full view of the hallway and his/her roommate. During a surveyor observation at approximately 9:00 AM, the Administrator offered the surveyor a chair and did not close the resident's door to offer him/her privacy. During a surveyor interview on 4/30/2024 at approximately 9:30 AM with the Infection Preventionist (IP) in the presence of the Compliance Monitor, she revealed that she would expect the staff to close the door and the privacy curtain before providing any care to the resident.

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 following a physician's order for 1 of 1 resident reviewed for double portions, Resident ID #7. 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 Resident ID #7 was admitted to the facility in October of 2023 with a diagnosis including, but not limited to, dementia. Further record review revealed the resident has a physician's order dated 2/29/2024 for .DOUBLE PORTIONS PLEASE Surveyor observations on 4/26/2024 and on 4/30/2024 at lunch revealed the resident failed to receive double portions. An additional observation on 5/1/2024 revealed the resident failed to receive double portions at breakfast, the resident received 1 piece of toast and 2 sausage links. During a surveyor interview with the Rehabilitation Director on 5/1/2024 at 8:47 AM, she acknowledged that the resident did not receive double portions on his/her breakfast tray. During a surveyor interview with the resident on 5/1/2024 at 8:48 AM, s/he revealed that they would like double portions. The resident further revealed that s/he is very tall and could use more food. During a surveyor interview on 5/1/2024 at 10:40 AM with the Infection Preventionist, she acknowledged the resident's meal slip did not reveal double portions and further indicated that it is her expectation that staff would follow the physician's order. Cross reference F 805

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives 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 reviewed for pressure ulcers, Resident ID #2. Findings are as follows: Record review revealed that the resident was readmitted to the facility in January 2023 with diagnoses including, but not limited to, need for assistance with personal care and dementia. Record review of a progress note dated 4/11/2024 revealed, the resident has a sacral (coccyx) wound with a treatment order to apply zinc and medihoney (wound treatment) daily and as needed. Further review revealed the Medical Director agreed with this treatment. Review of the April 2024 Medication Administration Record failed to reveal a treatment was in place from 4/14/2024 through 4/25/2024. During a surveyor interview on 4/25/2024 at 11:53 AM with the Wound Physician he revealed, the resident has a stage 2 pressure ulcer (an open wound that has broken through the top and bottom layers of the skin. It typically results from excessive and sustained pressure on a particular part of the body) to his/her sacrum and the resident should be receiving zinc and medihoney treatment to the wound. During a surveyor interview on 4/25/2024 at 1:43 PM with the Infection Preventionist, she revealed that she would expect the resident to have a wound treatment in place, as ordered. During a surveyor interview on 4/30/2024 at 1:44 PM with the Medical Director, she revealed that she would expect there to be a wound treatment in place for his/her sacral wound from 4/14/2024 to 4/25/2024. During a surveyor interview on 4/30/2024 at 3:40 PM with the Administrator and the Infection Preventionist, they were unable to provide evidence that the resident was provided necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 5 residents reviewed for oxygen use, Resident ID #s 1 and 29, and 1 of 1 resident reviewed for suctioning, Resident ID #19. Findings are as follows: 1. Record review revealed Resident ID #19 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dysphagia (a condition resulting in difficulty swallowing food or liquid), aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, vomit) and stroke. Review of the physician's orders revealed the following: - suctioning as needed dated 1/15/2024 - aspiration (when food or liquid goes into the airway) precautions and to monitor for signs and symptoms of aspiration every shift dated 3/21/2024 - House, Pudding Thickened, Pureed Special Instructions: NO STRAWS. ONLY NURSE TO PREPARE THIN LIQUIDS TO PUDDING CONSISTENCY . dated 4/26/2024 Record review revealed a progress note dated 4/22/2024 authored by the Nurse Practitioner which states in part, .Limited ability to tolerate oral intake with assist .Weak/ineffective cough with occasional sputum unable to clear from oral at this time .Patient currently being treated for Aspiration PNA [pneumonia] . Record review revealed a progress note dated 4/25/2024 authored by Registered Nurse (RN), Staff C, which states in part, .Resident had some difficulty swallowing and needed to be suctioned multiple times . Surveyor observation on 4/29/2024 at 2:23 PM revealed a suction canister and tubing dated 4/24/2024. The canister contents were 1/4 full with multi-colored secretions with floating sediment. During this observation, staff were observed wheeling the resident into his/her room to be suctioned. Staff A was observed to suction the resident utilizing the above-mentioned equipment. During a surveyor interview immediately following the above-mentioned observations, Staff A, revealed that she was unsure what date/time the suction machine was last used or how long the secretions had been in the canister. Additionally, she was unsure of when to clean or change the equipment. Record review failed to provide evidence of when to change, clean or replace the suction equipment. During a surveyor interview with the Administrator and the Infection Preventionist on 4/30/2024 at 3:40 PM and 5/1/2024 at 2:36 PM, they were unable to provide evidence of a policy or procedure for when to change, clean or replace the suction equipment. 2. Review of an undated facility policy titled, Oxygen Administration - Reservoir or pendent style nasal cannula [a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels] . states in part, .Replace and date cannula and tubing weekly or when visibly soiled or damaged. 2a. Record review revealed that Resident ID #1 was admitted to the facility in July of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia (levels of oxygen in the blood are lower than normal). Record review revealed a physician's order dated 3/26/2024 for humidified oxygen at 2 liters/minute (L/M) via nasal cannula for sign or symptoms of shortness of breath. During surveyor observations on 4/25/2024 at 11:34 AM and 4/26/2024 at 10:21 AM revealed the resident was receiving oxygen via nasal cannula from a concentrator with the oxygen tubing dated 2/20 and had discolored orange/reddish color on the nasal prongs. Additionally the observation revealed his/her portable oxygen tubing was dated 3/5 and had yellow discoloration on the nasal prongs. During a surveyor interview on 4/26/2024 at 10:22 AM with the Director of Nursing Services, she acknowledged that the concentrator tubing was dated 2/20 with orange/reddish discoloration and the portable oxygen tubing was dated 3/5 and was yellow in color. Additionally, she acknowledged that there was no order to change the tubing on either device. Furthermore, she revealed she would expect the oxygen tubing to have been changed weekly per the policy. 2b. Record review revealed that Resident ID #29 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and need for assistance with personal care. Record review revealed a physician's order dated 3/23/2024 for oxygen at 2 L/M via nasal cannula continuously. Further review of the physician's orders revealed an order dated 3/23/2024 to change the oxygen tubing and clean concentrator filter as needed. Review of the April 2024 Medication Administration Report, failed to reveal evidence that the oxygen tubing was changed weekly per the facility policy. During surveyor observations on 4/25/2024 at approximately 11:10 AM and 4/26/2024 at 10:22 AM revealed the resident was utilizing his/her oxygen. Further the observation revealed the tubing was undated. During a surveyor interview with the Director of Nursing Services on 4/26/2024 at 10:22 AM, she acknowledged that there was no date on the tubing. She further revealed that it was unknown when the tubing was last changed.

Based on surveyor observation, record review 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 1 of 2 nursing carts and 1 of 1 medication room observed. Findings are as follows: 1. Review of a facility provided document titled, Abridged List of Medications with Shortened Expiration Dates dated 4/2021 states in part, .eye drops/ointments beyond use date is 60 days after opening .Solutions .Lorazepam Solution (Ativan Intensol) beyond use by date 90 days after opening if refrigerated .Insulin Lantus beyond use date 28 days after opening .Insulin Lispro beyond use date 28 days . During a surveyor observation on 4/29/2024 at 9:40 AM in the presence of Licensed Practical Nurse, Staff A, of the nursing cart, revealed the following: -3 bottles of atropine 1% eye drops, open and undated -1 bottle of Ativan Intensol with a label to refrigerate, stored in the medication cart unrefrigerated -1 Lantus Insulin Pen with an open date of 3/19/2024 (indicating it is 13 days beyond the use by date) -1 Lispro Insulin Pen open and undated During a surveyor interview directly following the above observation with Staff A, she acknowledged the above medications should have been dated when opened and should be discarded after the use by date. Additionally, she acknowledged that the Ativan Intensol solution should be refrigerated and needs to be discarded. 2. During a surveyor observation on 4/29/2024 at 10:15 AM in the presence of Staff A, of the medication storage room revealed the following: -1 bottle of Ativan Intensol solution open and undated -1 bottle of Vancomycin 5 milligrams/milliliter solution with a use by date of 4/23/2024 - Multiple electronic devices stored under the sink During a surveyor interview directly following the above observation with Staff A, she acknowledged that medications should be dated when opened and should be discarded, and nothing should be stored under the sink. During a surveyor interview on 4/30/2024 at 12:15 PM with the Administrator, she was unable to provide evidence that the facility stores drugs and biologicals in accordance with currently accepted professional principles.

Based on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 1 resident reviewed relative to lung sound documentation and suctioning, Resident #19. Findings are as follows: 1a. Record review revealed Resident ID #19 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dysphagia (a condition with difficulty in swallowing food or liquid), aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, vomit) and stroke. Record review of a physician's order dated 3/21/2024 states, VS [vital signs] Q [every] SHIFT Lung sounds every shift and Document in nurse's notes. Every Shift First, Second, Third. Record review of the nurse's notes from 4/1/2024 through 4/30/2024, revealed 84 out of 90 opportunities without documentation of lung sounds per the physician's order. During a surveyor interview on 4/30/2024 at 11:54 AM with the Infection Preventionist, she was unable to provide evidence of documented lung sounds in the nurse's notes every shift. During a surveyor interview on 4/30/2024 at approximately 11:30 AM with the Medical Director, she revealed that it would be her expectation for the nurses to document lung sounds per the physician's order. 1b. Record review of a physician's order states, Suction as needed Every Shift - PRN [As Needed] . Record review of the April 2024 Treatment Administration Record (TAR) revealed that the order for suction was documented as being completed on 4/12/2024. Record review of the following progress notes states in part: 4/20/2024: .suction x 1 for shift with good effect . 4/25/2024: .Resident had some difficulty swallowing and needed to be suctioned multiple times . Surveyor observation on 4/29/2024 at approximately 2:25 PM, revealed that the resident was being transported back to his/her room by Staff A, in the presence of the Compliance Monitor. The resident was observed to be in distress, requiring suctioning. Record review failed to reveal evidence that the TAR reflected that the resident was suctioned on 4/20/2024, 4/25/2024 and 4/29/2024. During a subsequent interview with Infection Preventionist, she revealed that if an order is scheduled as a PRN, the expectation would be that the nurse would document the use and outcome. Additionally, she revealed that the resident required daily suctioning and acknowledged that this is not reflected in the residents medical record or on the TAR. During a surveyor interview on 4/30/2024 at approximately 11:30 AM with the Medical Director, she revealed that it would be her expectation for the nurses to document the need for a PRN order. Additionally, she revealed that she was unaware the resident required frequent suctioning by staff.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident assessed for falls, with major injury, Resident ID #19. Findings are as follows: Record review revealed Resident ID #19 was readmitted to the facility in December of 2023 with a diagnosis including, but not limited to, subarachnoid hemorrhage (brain bleed). Review of a progress note dated 11/14/2023 at 11:51 PM, revealed the resident was found on the floor in his/her room. The resident complained of headache, nausea, change in vision, and lethargy. Resident was assessed by the nurse, 911 was then called for emergency transfer to the hospital. Review of a progress note dated 11/15/2023 at 11:06 PM, states, Call placed to [hospital name], Resident was admitted with a brain bleed at 4:14 PM on 11/15/2023 Record review of hospital documentation dated 12/11/2023, titled Inpatient Summary states in part, .a new large right IPH [Intraparenchymal hemorrhage, bleeding within the brain] . Record review of a Minimum Data Assessment (MDS) with an assessment reference date of 11/15/2023, completed on 3/25/2024 revealed, one fall with no injuries documented and no falls with major injury documented. During a surveyor interview on 4/30/2024 at approximately 10:00 AM with the Infection Preventionist (IP), she was unable to provide evidence that the resident's assessment was accurately documented for a fall with major injury. Additionally, she revealed that MDS assessments are being completed remotely and they do not have an MDS coordinator in the facility.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 11 resident's reviewed, Resident ID #s 4, 29, and 100. Findings are as follows: 1. Record review revealed that Resident ID #4 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, osteomyelitis (infection of the bone) of right ankle and foot and peripheral vascular disease. Review of an Annual Comprehensive Minimum Data Set (MDS) Assessment, Section V dated 3/3/2024, revealed that the resident triggered for the following care areas to be added to his/her care plan: Cognitive loss/dementia Activities of daily living Falls Pressure ulcer/injury Review of the physician's orders revealed that the resident has wounds to his/her right lower extremity requiring dressing changes three times a week. Record review revealed that the resident fell on 4/21/2024 and 4/29/2024. Record review failed to reveal evidence that a care plan had been developed or implemented for any of the above-mentioned triggers from the Comprehensive MDS Assessment or known concerns, including wounds and falls. During a surveyor interview on 4/26/2024 at approximately 2:15 PM with the Infection Preventionist (IP) in the presence of the Compliance Monitor, she acknowledged that a comprehensive care plan had not been developed or implemented regarding the above triggered areas for Resident ID #4. 2. Record review revealed that Resident ID #29 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and repeated falls. Review of an admission Comprehensive MDS Assessment, Section V dated 3/14/2024 revealed that the resident triggered for the following care areas with a decision to proceed to the care plan: Activities of daily living Urinary Incontinence Falls Pressure Ulcers Psychotropic medication use Review of the resident's care plan revealed a care plan had not been developed or implemented following the above Comprehensive MDS Assessment. During a surveyor interview on 4/30/2024 at approximately 8:55 AM with the IP in the presence of the Compliance Monitor she acknowledged that a comprehensive care plan had not been created based on the admission MDS Assessment. 3. Record review revealed that Resident ID #100 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke), dependence on renal dialysis (A blood purifying treatment given when kidney function is not optimum) and type II diabetes mellitus. Record review revealed an order for renal dialysis three times per week. Review of the resident's care plan failed to reveal evidence that a care plan was implemented or developed for dialysis with interventions to mitigate risks associated with dialysis. Record review revealed an order for sliding scale insulin to be administered three times per day due to a diagnosis of type II diabetes mellitus. Review of the resident's care plan failed to reveal evidence that a care plan was implemented or developed for diabetes with interventions to mitigate the risks associated with diabetes. During a surveyor interview on 4/30/2024 at approximately 3:40 PM with the IP and Administrator they acknowledged that the above noted residents do not have comprehensive person-centered care plans that included measurable objectives and timeframes to meet these resident's medical, nursing, and mental and psychosocial needs that were identified in their comprehensive assessment.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 3 of 3 residents reviewed diagnosed with urinary tract infections (UTI), Residents ID #s 26, 29, and 39. Findings are as follows: Review of a facility policy titled, Urinary Tract Infections states in part, .If a resident presents with urinary tract symptoms, the nurse will .record intake and output for 72 hours .institute hydration program or increase fluids .the resident will be placed on intake and output and fluids will be encouraged . 1. Record review revealed that Resident ID #26 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 care plan dated 4/19/2024 revealed that the resident has a UTI with an interventions which include, but is not limited to, encourage fluids. Review of a progress note dated 4/19/2024 authored by the Nurse Practitioner states in part, Cipro 500 mg po [by mouth] daily x 7 [days] (UTI) .Nursing to encourage oral hydration with each interaction . Record review revealed a physician's order for Cipro (an antibiotic) 500 milligram (mg) capsule daily from 4/19/2024 through 4/26/2024. Record review failed to reveal evidence of fluid intake monitoring from 4/19/2024 through 4/24/2024. Further review of the resident's fluids documentation revealed one documented fluid intake was recorded on 4/25/2024. Additional record review failed to reveal evidence of documentation that fluids were encouraged per the care plan and the physician's orders for this resident while receiving treatment for a UTI. 2. Record review revealed that Resident ID #29 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and need for assistance with personal care. Record review revealed a physician's order for Augmentin (an antibiotic) 500/125 mg tablet twice a day from 4/27/2024 through 5/1/2024 for UTI. Review of a care plan dated 4/27/2024 revealed that the resident has a UTI with interventions which include, but are not limited to, encourage fluids every shift. Record review failed to reveal evidence of intake monitoring on for all shifts from 4/27/2024 through 5/1/2024. Additional record review failed to reveal evidence of documentation that fluids were encouraged per the care plan for this resident while receiving treatment for a UTI. 3. Record review revealed that Resident ID #39 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, malignant neoplasm of prostate (prostate cancer) and depression. Record review revealed a physician's order for Cipro (an antibiotic) 500 milligram (mg) capsule twice a day from 3/17/2024 through 3/23/2024. Review of a care plan dated 7/17/2023 states in part, monitor diet and fluids and document if decreasing. Further review revealed a care plan dated 2/12/2024 which revealed that the resident has a UTI and to encourage fluids every shift. Record review failed to reveal evidence of fluid intake monitoring on for all shifts for the month of March 2024. Additional record review failed to reveal evidence of documentation that fluids were encouraged per the care plan for this resident while receiving treatment for a UTI. During a surveyor interview with the Medical Director on 4/30/2024 at 1:40 PM, she revealed that she would expect the facility to follow their policy related to intake documentation for a urinary tract infection. Additionally, she revealed that she would expect the facility to encourage fluids per the care plan and the facility policy. During a surveyor interview on 4/30/2024 at 10:23 AM with the Infection Preventionist, she revealed that she would expect fluids to be documented for the above-mentioned residents. Additionally, she was unable to provide evidence that the facility was providing appropriate treatment and services relative to UTI management.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care for 3 of 3 nurses reviewed, Staff E, R, and S and for 3 of 3 Nursing Assistants (NA's) reviewed, Staff H, I, and J. Findings are as follows: 1) Multiple surveyor observations were made throughout the survey process from 4/25/2024 through 5/1/2024, nursing concerns were identified relative to wound care, clean dressing changes, glucometer (device used to assess blood glucose levels) cleaning and disinfection, foley catheter (a device that drains urine from your bladder into a collection bag) management, and suctioning (removal of secretions from the respiratory passages when the patient cannot remove them by coughing). Record review failed to reveal evidence that competencies for the above-mentioned areas of concern were completed for the following nursing staff: -Registered Nurse, Staff E -Licensed Practical Nurse (LPN), Staff R -LPN, Staff S During a surveyor interview on 4/30/2024 at approximately 9:30 AM with the Infection Preventionist during the Staffing Task, she was unable to provide evidence nursing competencies were completed for the above-mentioned staff relative to wound care, clean dressing changes, glucometer cleaning and disinfection, foley catheter management, and suctioning. During a surveyor interview with the Administrator on 4/30/2024 at 12:30 PM, she was unable to provide evidence the above-mentioned nursing staff received competencies relative to the above-mentioned skill sets. 2) Review of the personnel files revealed the following NA's did not receive the following in-services and education: -Staff H: resident rights, person centered care, basic nursing skills, basic restorative services, identification of changes in condition, infection control, compliance and ethics, neglect, and exploitation -Staff I: resident rights, person centered care, basic nursing skills, basic restorative services, identification of changes in condition, infection control, compliance and ethics, behavioral health, neglect, and exploitation -Staff J: -resident rights, person centered care, communication, basic nursing skills, basic restorative services, identification of changes in condition, infection control, compliance and ethics, behavioral health, abuse, neglect, and exploitation During a surveyor interview on 4/30/2024 at 12:30 PM with the Administrator, she was unable to provide evidence that nursing competencies for the above-mentioned nursing staff were completed, and revealed they should be completed annually and as needed. Additionally, she was unable to provide evidence the above-mentioned NA's had completed all required in-services and education and indicated they should have been done. Refer to F 550, F 684, F 690, F 695, and F 880.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being, for 1 of 1 resident reviewed for initial psychiatric evaluation, Resident ID #39. Findings are as follows: Record review revealed that Resident ID #39 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, malignant neoplasm of prostate (prostate cancer) and depression. Record review revealed a hospice visit note dated 1/4/2024 signed by the Medical Director, which states in part, Patient will be graduating from hospice with last covered date 1/6/2024. Patient reports depressed mood [and] is requesting to come off mirtazapine [antidepressant] as [s/he] feels this is contributing to [his/her] mood. Patient is also requesting something to help increase mood and would benefit from a geri psych [geriatric psychiatry] consult. Recommend .Please obtain geri psych consult to discuss antidepressant to target symptoms of depression . Record review failed to reveal evidence that a geriatric psychiatry consult was scheduled, offered, attended, or refused by the resident. During a surveyor interview with the Infection Preventionist on 4/26/2024 at 1:54 PM, she was unable to provide evidence that a geriatric psychiatry consult was scheduled, offered, attended, or refused. During a surveyor interview with the Medical Director on 4/30/2024 at 1:46 PM, she revealed that she would expect the resident to have obtained a geriatric psychiatry consult since she was in agreement with the recommendation.

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 35 opportunities for error observed during the medication administration task, there were 10 errors resulting in an error rate of 28.57%, involving Resident ID #s 19, 20, 29, 45, and 99. Findings are as follows: According to, Mosby's Drug Guide Tenth Edition 2013, section, SAFE MEDICATION ADMINISTRATION GUIDE states in part, The 5 rights of medication administration. Always adhere to the 5 rights of medication administration when transcribing, preparing, administering, and documenting medications .2. Right drug: Verify the correct medication by comparing the name on the label on the drug container with that written on the MAR [Medication Administration Record] .5. Right time: All medications should be administered within 30 minutes of the scheduled time . 1a) Record review revealed Resident ID #19 has a physician's order for Propranolol (blood pressure medication) 10 milligrams (mg) give 1 tablet at 7:00 AM - 9:00 AM. During a surveyor observation of the medication administration task on 4/26/2024 at approximately 10:00 AM with Licensed Practical Nurse, Staff A, she administered the above-mentioned medication to the resident, approximately 1 hour after the scheduled time. 1b) Record review revealed Resident ID #45 has a physician's order for Gabapentin 300mg give 1 capsule at 5:00 AM - 7:00 AM. During a surveyor observation of the medication administration task on 4/26/2024 at approximately 10:55 AM with Registered Nurse, Staff D, she administered the above-mentioned medication to the resident, approximately 4 hours after the scheduled time. 1c) Record review revealed Resident ID #99 has the following physician orders: -Nicotine patch (used to aid in smoking cessation) 14mg/24 hour apply 1 patch at 7:00 AM - 9:00 AM. -Quetiapine (anti-psychotic medication) 25 mg give a half tab at 7:00 AM - 10:00 AM and 1:00 PM - 3:00 PM. -Senna Plus (laxative) 8.6-50mg give 1 tab in the morning and evening. During a surveyor observation of the medication administration task on 4/26/2024 at approximately 11:20 AM with Staff D, she failed to apply the Nicotine patch, she administered Senna instead of Senna Plus, and administered Quetiapine at 11:21 AM, approximately 1.5 hours after the scheduled administration time. 1d) Record review revealed Resident ID #20 has the following physician orders: -Amlodipine (blood pressure medication) 5mg give 1 tab at 7:00 AM - 9:00 AM. -Brimonidine (medicated eye drops) 0.2% instill 1 drop to the left eye at 7:00 AM - 9:00 AM and 7:00 PM - 11:00 PM. -Cosopt (medicated eye drops) 22.3-6.8 mg/milliliter (mL) instill 1 drop to the left eye at 7:00 AM - 9:00 AM and 7:00 PM - 11:00 PM. -Myrbetriq (medication used to treat an overactive bladder) 50mg give 1 tab at 7:00 AM - 9:00 AM. During a surveyor observation of the medication administration task on 4/26/2024 at approximately 11:40 AM with Staff D, she administered the above-mentioned medications to the resident, approximately 2.5 hours after the scheduled time. 1e) Record review revealed Resident ID #29 has a physician's order for Pramipexole (medication used to treat Parkinson's disease and restless leg syndrome) 0.25mg give 1 tablet at 8:00 AM and 8:00 PM. During a surveyor observation of the medication administration task on 4/29/2024 at approximately 9:25 AM with Medication Technician, Staff K, she administered the above-mentioned medication to the resident, approximately 1.5 hours after the scheduled time. During a surveyor interview on 4/30/2024 at 12:15 PM with the Administrator, she revealed that she would expect the residents to receive their medications as ordered and within the scheduled timeframe. Additionally, she was unable to provide evidence that the facility ensured each resident's medication regimen is free from a medication error rate of 5% or greater.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 40 of 48 residents reviewed for medication administration, Resident ID #s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, 99, 100, and 199. Findings are as follows: According to, Mosby's Drug Guide Tenth Edition 2013, section, SAFE MEDICATION ADMINISTRATION GUIDE states in part, The 5 rights of medication administration .5. Right time: All medications should be administered within 30 minutes of the scheduled time . During a surveyor observation on 4/26/2024 at approximately 10:00 AM during the medication administration task, concerns were identified with the timeliness of the distribution and administration of the resident's medications. Review of the Administration Compliance Report dated 4/26/2024 revealed that the following 40 residents failed to receive the listed medications below on 4/26/2024 as ordered by the physician: 1) Record review revealed Resident ID #1 was readmitted to the facility in March of 2023 with diagnoses including, but not limited to, dementia, chronic obstructive pulmonary disease (COPD), major depressive disorder, atrial fibrillation (a-fib, a rapid, irregular heart rhythm that can lead to blood clots), hypertension (high blood pressure), and type II diabetes mellitus. Resident ID #1 did not receive the following medications on 4/26/2024: -Azithromycin (antibiotic) 250 milligrams (mg) give 1 tablet (tab) at 7:00 AM - 12:00 PM -Buspirone (medication used to treat anxiety) 5mg give 3 tabs at 7:00 AM - 9:00 AM -Diltiazem (cardiac medication) 120mg give 1 capsule (cap) at 7:00 AM - 9:00 AM -Duloxetine (used to treat anxiety and nerve pain) 20mg give 2 caps at 7:00 AM - 9:00 AM -Incruse Ellitpta (inhaler) 62.5 micrograms (mcg)/actuation inhale 1 puff at 7:00 AM - 9:00 AM -Lidocaine patch (for pain relief) 4% apply 1 patch to right shoulder at 7:00 AM - 10:30 AM -Metformin (diabetes medication) 1,000mg give 1 tab at 7:00 AM - 9:00 AM -Metoprolol Tartrate (blood pressure medication) 25mg give 1 tab at 7:00 AM - 9:00 AM -Pradaxa (blood thinner) 150mg give 1 cap at 7:00 AM - 9:00 AM -Salonpas patch (for pain relief) 3.1-10.6% apply 1 patch at 7:00 AM - 12:00 PM -Wixela Inhub (inhaler) 500-50mcg/dose inhale 1 puff at 7:00 AM - 9:00 AM 2) Record review revealed Resident ID #3 was readmitted to the facility in January of 2023 with a diagnosis including, but not limited to, heart failure. Resident ID #3 did not receive the following medications on 4/26/2024: -Diltiazem 180 mg give 1 cap at 7:00 AM - 10:00 AM -Prednisolone Acetate (medicated eye drops) 1% give 1 drop at 7:00 - 11:00 AM 3) Record review revealed Resident ID #4 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, type II diabetes, major depressive disorder, and hypertension. Resident ID #4 did not receive the following medications on 4/26/2024: -Atenolol (blood pressure medication) 25mg give 1 tab at 7:00 AM - 12:00 PM -Bupropion (antidepressant) 200mg give 1 tab at 7:00 AM - 10:00 AM -Jardiance (diabetes medication) 25mg give 1 tab at 7:00 AM - 10:00 AM -Furosemide (treats fluid retention and high blood pressure) 40mg give 1 tab at 7:00 AM- 11:00 AM -Sertraline (antidepressant) 100mg give 1 tab at 7:00 AM - 12:00 PM 4) Record review revealed Resident ID #5 was readmitted to the facility in September of 2023 with diagnoses including, but not limited to, low back pain, osteoarthritis of bilateral knees, and chronic pain syndrome. Resident ID #5 did not receive the following medications on 4/26/2024: -Diclofenac Sodium (pain relief gel) 1% apply 2 grams (g) at 7:00 AM - 9:00 AM 5) Record review revealed Resident ID #6 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, dementia and hypertension. Resident ID #6 did not receive the following medications on 4/26/2024: -Depakote (treats bipolar disorder, seizures, and migraines) 125mg give 1 tab at 7:00 - 11:00 AM -Metoprolol Succinate (blood pressure medication) 25mg give 1 tab at 7:00 - 11:00 AM 6) Record review revealed Resident ID #7 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, dementia, type 2 diabetes, and hypertension. Resident ID #7 did not receive the following medications on 4/26/2024: -Alogliptin (diabetes medication) 25mg give 1 tab at 7:00 - 9:00 AM -B Complex-Vitamin C-Folic Acid (vitamin) 400 mcg give 1 tab at 7:00 - 9:00 AM -Ketorolac (medicated eye drops) 0.5% give 1 drop at 8:00 AM and 10:00 AM -Lidocaine patch 4% apply 1 patch at 7:00 AM - 9:00 AM -Lisinopril (blood pressure medication) 40mg give 1 tab at 7:00 AM - 9:00 AM -Metformin 1,000mg give 1 tab at 7:00 AM - 12:00 PM -Metoprolol Succinate 100mg give 1 tab at 7:00 AM - 9:00 AM -Metoprolol Succinate 50mg give 1 tab at 7:00 AM - 9:00 AM. -Oxybutynin Chloride (treats an overactive bladder) 10mg give 2 tabs at 7:00 AM - 9:00 AM -Prednisolone Acetate 1% give 1 drop at 8:00 AM and 10:00 AM -Psyllium Husk (treats constipation) 2.6g/4.1g give 1 tablespoon at 7:00 AM - 9:00 AM -Senexon-S (laxative) 8.6-50mg give 1 tab at 7:00 AM - 9:00 AM -Vigamox (antibiotic eye drop) 0.5% give 1 drop at 8:00 AM and 10:00 AM 7) Record review revealed Resident ID #8 was readmitted to the facility in May of 2017 with diagnoses including, but not limited to, vascular dementia and convulsions. Resident ID #8 did not receive the following medications on 4/26/2024: -Keppra (anticonvulsant) 750mg give 1 tab at 7:00 AM - 12:00 PM 8) Record review revealed Resident ID #9 was admitted to the facility in February of 2023 with a diagnosis including, but not limited to, hypothyroidism (underactive thyroid gland that affects your metabolism). Resident ID #9 did not receive the following medications on 4/26/2024: -Levothyroxine (used to treat hypothyroidism) 75mcg give 1 tab at 5:00 AM - 7:00 AM 9) Record review revealed Resident ID #10 was readmitted to the facility in January of 2024 with diagnoses including, but not limited to, traumatic brain injury and major depressive disorder. Resident ID #10 did not receive the following medications on 4/26/2024: -Abilify (antipsychotic medication) 10mg give 1 tab at 7:00 AM - 10:00 AM -Aspirin (anti-inflammatory, may prevent/treat heart issues) 81mg give 1 tab at 7:00 AM - 10:00 AM -Keppra 1,000mg give 1 tab at 7:00 AM - 10:00 AM -Lactulose (laxative) 10g/15 milliliters (mL) give 20g at 7:00 AM - 10:00 AM -Venlafaxine (antidepressant) 75mg give 3 tabs at 7:00 AM - 10:00 AM 10) Record review revealed Resident ID #11 was admitted to the facility in March of 2014 with diagnoses including, but not limited to, dementia, paranoid schizophrenia (mental disorder), and bipolar disorder (mental disorder). Resident ID #11 did not receive the following medications on 4/26/2024: -Risperidone (anti-psychotic medication) 0.5mg give 1 tab at 7:00 AM - 11:00 AM 11) Record review revealed Resident ID #12 was readmitted to the facility in May of 2022 with diagnoses including, but not limited to, vascular dementia and hypertension. Resident ID #12 did not receive the following medications on 4/26/2024: -Amlodipine (blood pressure medication) 5mg give 1 tab at 7:00 AM - 11:00 AM 12)Record review revealed Resident ID #13 was readmitted to the facility in November of 2021 with diagnoses including, but not limited to, type 2 diabetes and hypertension. Resident ID #13 did not receive the following medications on 4/26/2024: -Glipizide (diabetes medication) 10mg give 1 tab at 7:00 AM - 11:00 AM -Lisinopril 40mg give 1 tab at 7:00 AM - 10:00 AM -Metformin 1,000mg give 1 tab at 7:00 AM - 10:00 AM -Procardia (blood pressure medication) 30mg give 1 tab at 7:00 AM - 10:00 AM 13) Record review revealed Resident ID #14 was readmitted to the facility in January of 2022 with diagnoses including, but not limited to, polyneuropathy (neurological condition in which nerves are damaged), bipolar II disorder (mental illness with moods cycling between high and low over time), and major depressive disorder. Resident ID #14 did not receive the following medications on 4/26/2024: -Abilify (anti-psychotic medication) 15mg give 1 tab at 7:00 AM - 11:00 AM -Gabapentin (medication for seizures, nerve pain and restless leg syndrome) 600mg give 1 tab at 7:00 AM - 9:00 AM -Wellbutrin (anti-depressant) 150mg give 1 tab at 7:00 AM - 11:00 AM 14) Record review revealed Resident ID #16 was admitted to the facility in March of 2019 with diagnoses including, but not limited to, heart failure, COPD, and hypertension. Resident ID #16 did not receive the following medications on 4/26/2024: -Amlodipine 5mg give 1 tab at 7:00 AM - 9:00 AM -Aspirin 81mg give 1 tab at 7:00 AM - 9:00 AM -Atrovent (inhaler) 17mcg/actuation inhale 2 puffs at 7:00 AM - 9:00 AM -Furosemide 20mg give 1 tab at 7:00 AM - 9:00 AM -Calcium Carbonate (used to reduce stomach acid) 500mg give 1 tab at 7:00 AM - 9:00 AM 15) Record review revealed Resident ID #17 was readmitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia, COPD, hypertension, macular degeneration (disease that affects central vision), overactive bladder, major depressive disorder, chronic pain, and seizures. Resident ID #17 did not receive the following medications on 4/26/2024: -Donepezil (medication used to treat dementia) 5mg give 1 tab at 7:00 AM - 9:00 AM -Duloxetine 60mg give 1 cap at 7:00 AM - 9:00 AM -Fluticasone Propion-Salmeterol 500-50mcg/dose inhale 1 puff at 7:00 AM - 9:00 AM -Gabapentin 300mg give 2 caps at 7:00 AM - 9:00 AM -Keppra 500mg give 1 tab at 7:00 AM - 9:00AM -Metoprolol Tartrate 25mg give a half tab at 7:00 AM - 9:00 AM -Oxybutynin Chloride 15mg give 1 tab at 7:00 AM - 9:00 AM -Prosight (vitamin) 5,000-60-30 unit-mg-unit give 1 tab at 7:00 AM - 10:00 AM 16) Record review revealed Resident ID #21 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, COPD, heart failure, and type II diabetes. Resident ID #21 did not receive the following medications on 4/26/2024: -Aspirin 81mg give 1 tab at 7:00 AM - 10:00 AM -Budesonide-Formoterol (treats COPD) 160-4.5mcg/actuation inhale 2 puffs at 7:00 AM - 11:00 AM -Cilostazol (improves blood flow/reduces pain in the legs) 50mg give 1 tab at 7:00 AM - 11:00 AM -Entresto (medication that treats heart failure) 49-51mg give 1 tab at 7:00 AM - 12:00 PM -Fluoxetine (antidepressant medication) 60mg give a half tab at 7:00 AM - 11:00 AM -Hydrochlorothiazide (treats fluid retention/hypertension) 25mg give 1 tab at 7:00 AM - 10:00 AM -Metformin 500mg give 1 tab at 7:00 AM - 12:00 PM -Metoprolol Tartrate 25mg give 1 tab at 7:00 AM - 10:00 AM 17) Record review revealed Resident ID #22 was readmitted to the facility in May of 2020 with diagnoses including, but not limited to, multiple sclerosis (chronic disease of the central nervous system) and convulsions. Resident ID #22 did not receive the following medications on 4/26/2024: -Keppra 100mg/mL give 5mL at 7:00 AM - 12:00 PM -Magnesium Oxide 400mg give 1 tab at 7:00 AM - 12:00 PM -Oxybutynin Chloride 5mg give 1 tab at 7:00 AM - 12:00 PM 18) Record review revealed Resident ID #23 was readmitted to the facility in October of 2018 with diagnoses including, but not limited to, schizoaffective disorder (mental disorder) and neurogenic bowel (loss of normal bowel function). Resident ID #23 did not receive the following medications on 4/26/2024: -Fenofibrate (helps lower cholesterol levels in the blood) 54mg give 1 tab at 7:00 AM - 9:00 AM -Fludrocortisone (steroid medication) 0.1mg give 1 tab at 7:00 AM - 9:00 AM -Lamotrigine (used to treat bipolar disorder) 100mg give 1 tab at 7:00 AM - 9:00 AM -Senokot-S 8.6-50mg give 1 tab at 7:00 AM - 9:00 AM 19) Record review revealed Resident ID #24 was readmitted to the facility in December of 2021 with a diagnosis including, but not limited to, a-fib. Resident ID #24 did not receive the following medications on 4/26/2024: -Amlodipine 5mg give 1 tab at 7:00 AM - 10:00 AM -Eliquis (medication used to prevent blood clots) 5mg give 1 tab at 7:00 AM - 10:00 AM 20) Record review revealed Resident ID #25 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia, type II diabetes, depression, hypercholesterolemia (high cholesterol levels in the blood), overactive bladder, urge incontinence, and urinary tract infection (UTI). Resident ID #25 did not receive the following medications on 4/26/2024: -Tylenol 325mg give 2 tabs at 7:00 AM - 9:00 AM -Cranberry (medication used to prevent recurrent UTIs) 450mg give 1 tab at 7:00 AM - 9:00 AM -Fenofibrate 40mg give 1 tab at 7:00 AM - 9:00 AM -Finasteride (medication used to treat urinary urgency) 5mg give 1 tab at 7:00 AM - 9:00 AM -Folic Acid (vitamin) 400mcg give 2 tabs at 7:00 AM - 9:00 AM -Gabapentin 100mg give 2 caps at 7:00 AM - 9:00 AM -Jardiance 10mg give 1 tab at 7:00 AM - 9:00 AM -Lidocaine patch 4% apply 1 patch at 9:00 AM -Metformin 1,000mg give 1 tab at 7:00 AM - 9:00 AM -Multivitamin 0.4-600mg-mcg give 1 tab at 7:00 AM - 9:00 AM -Sertraline 100mg give 1 tab at 7:00 AM - 9:00 AM 21) Record review revealed Resident ID #26 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, compression fracture of spine, multiple fractures of the left ribs, diabetes mellitus, heart failure, and hypertension. Resident ID #26 did not receive the following medications on 4/26/2024: -Duloxetine 20mg give 1 cap at 7:00 AM - 12:00 PM -Gabapentin 400mg give 1 cap at 7:00 AM - 9:00 AM -Lisinopril 10mg give 1 tab at 7:00 AM - 12:00 PM -Metformin 500mg give 1 tab at 7:00 AM 22) Record review revealed Resident ID #27 was admitted to the facility in November of 2021 with diagnoses including, but not limited to, dementia, hypothyroidism, chronic pain, hypertension, and lymphedema (abnormal fluid buildup in the body). Resident ID #27 did not receive the following medications on 4/26/2024: -Amlodipine 5mg give 1 tab at 7:00 AM - 10:00 AM -Depakote 125mg give 1 cap at 7:00 AM - 11:00 AM -Eliquis 5mg give 1 tab at 7:00 AM - 10:00 AM -Furosemide 20mg give 1 tab at 7:00 AM - 10:00 AM -Levothyroxine 25mcg give 1 tab at 7:00 AM - 12:00 PM -Potassium Chloride (treats low blood levels of potassium) 20 milliequivalents (mEq)/15mL give 10mEqs at 7:00 AM - 12:00 PM -Salonpas (pain relief patch) 0.025-1.25% apply 1 patch at 7:00 AM - 10:00 AM -Timolol Maleate (medicated eye drops) 0.5% give 1 drop at 7:00 AM - 11:00 AM 23) Record review revealed Resident ID #28 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, major depressive disorder, seizures, myocardial infarction (heart attack), and atrial fibrillation. Resident ID #28 did not receive the following medications on 4/26/2024: -Aspirin 325mg give 1 tab at 7:00 AM - 10:00 AM -Buspirone 5mg give 1 tab at 7:00 AM - 9:00 AM -Phenytoin (medication used to treat seizures) 200mg give 1 cap at 7:00 AM - 10:00 AM 24) Record review revealed Resident ID #30 was admitted to the facility in September of 2021 with diagnoses including, but not limited to, hypertension and pseudobulbar affect (PBA, episodes of sudden uncontrollable laughing or crying). Resident ID #30 did not receive the following medications on 4/26/2024: -Carvedilol 12.5mg give 1 tab at 7:00 AM - 12:00 PM -Nuedexta (medication used to treat PBA) 20-10mg give 1 cap at 7:00 AM - 12:00 PM 25) Record review revealed Resident ID #31 was admitted to the facility in September of 2020 with diagnoses including, but not limited to, benign paroxysmal vertigo (a false sensation of moving or spinning) and hypertension. Resident ID #31 did not receive the following medications on 4/26/2024: -Meclizine (medication used to treat vertigo) 25mg give a half tab at 10:00 AM - 11:00 AM -Nadolol 40mg give 1 tab at 7:00 AM - 10:00 AM 26) Record review revealed Resident ID #32 was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, dementia with psychotic disturbance, hypertensive heart disease with heart failure, anemia (low levels of healthy red blood cells), major depressive disorder, and type II diabetes. Resident ID #32 did not receive the following medications on 4/26/2024: -Amlodipine 10mg give 1 tab at 7:00 AM - 9:00 AM -Aspirin 81mg give 1 tab 7:00 AM - 9:00 AM -Bisoprolol Fumarate (blood pressure medication) 5mg give a half tab at 7:00 AM - 9:00 AM -Calcium carbonate 600mg give 1 tab at 7:00 AM - 9:00 AM -Ferrous Sulfate (iron supplement) 325mg give 1 tab at 7:00 AM - 9:00 AM -Gabapentin 100mg give 1 cap at 7:00 AM - 9:00 AM -Januvia 50mg give 1 tab at 7:00 AM - 9:00 AM -Furosemide 20mg give 1 tab at 7:00 AM - 9:00 AM -Olmesartan (blood pressure medication) 40mg give 1 tab at 7:00 AM - 9:00 AM -Potassium Chloride 20 mEqs give 2 tabs at 7:00 AM - 9:00 AM -Risperidone 0.5mg give 1 tab at 7:00 AM - 9:00 AM -Sertraline 100mg give 1 tab at 7:00 AM - 9:00 AM 27) Record review revealed Resident ID #33 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, a-fib and urinary retention. Resident ID #33 did not receive the following medications on 4/26/2024: -Aspirin 81mg give 1 tab at 7:00 AM - 10:00 AM -Eliquis 5mg give 1 tab at 8:00 AM -Metoprolol Succinate 50mg give 1 tab at 7:00 AM - 10:00 AM -Multivitamin give 1 tab at 7:00 AM - 10:00 AM -Potassium Chloride 20mEq give 2 tabs at 7:00 AM - 11:00 AM -Senna Plus 8.6-50mg give 2 tabs at 7:00 AM - 10:00 AM -Torsemide (medication used to treat fluid retention) 20mg give 1 tab at 7:00 AM - 11:00 AM 28) Record review revealed Resident ID #34 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, Parkinsonism (a group of conditions that affect movements and mimic Parkinson's disease), asthma, chronic bronchitis (respiratory disease), seizures, and irritable bowel syndrome. Resident ID #34 did not receive the following medications on 4/26/2024: -Advair Diskus (medication used to treat asthma) 250-50 mcg/dose inhale 1 puff at 8:00 AM -Celebrex (medication that reduces inflammation and pain) 200mg give 1 cap at 7:00 AM - 10:00 AM -Furosemide 20mg give 1 tab at 7:00 AM - 10:00 AM -Keppra 500mg give 1 tab at 8:00 AM -Linzess (medication used to treat bowel problems) 72mcg give 1 cap at 7:00 AM - 10:00 AM -Methenamine Hippurate (medication used to treat recurrent UTIs) give 1g at 7:00 AM - 11:00 AM 29) Record review revealed Resident ID #36 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, Parkinson's disease, chronic pain syndrome, hypertension, and major depressive disorder. Resident ID #36 did not receive the following medications on 4/26/2024: -Aspirin 81mggive 1 tab at 12:30 PM -Amlodipine 5mg give 1 tab at 7:00 AM - 12:00 PM -Gabapentin 400mg give 1 cap at 7:00 AM - 9:00 AM. -Magnesium (mineral supplement) 200mg give 2 tabs at 7:00 AM - 12:00 PM -Probiotic (improves gut health and boosts immunity) 250mg give 2 caps at 7:00 AM - 12:00 PM -Sertraline 100mg give 1 tab at 7:00 AM - 9:00 AM 30) Record review revealed Resident ID #37 was admitted to the facility in March of 2023 with a diagnosis including, but not limited to, hypothyroidism. Resident ID #37 did not receive the following medications on 4/26/2024: - Levothyroxine 25mcg give 1 tab at 5:00 AM - 7:00 AM 31) Record review revealed Resident ID #38 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, UTI, type II diabetes, and hypertension. Resident ID #38 did not receive the following medications on 4/26/2024: -Gabapentin 100mg give 1 cap at 7:00 AM - 9:00 AM -Lisinopril 20mg give 1 tab at 7:00 AM - 9:00 AM -Metformin 500mg give 1 tab at 7:00 AM - 9:00 AM 32) Record review revealed Resident ID #39 was admitted to the facility in July of 2023 with a diagnosis including, but not limited to, hypertension. Resident ID #39 did not receive the following medications on 4/26/2024: -Amlodipine 10mg give 1 tab 7:00 AM - 9:00 AM -Aspirin 81mg give 1 tab at 7:00 AM - 9:00 AM -Cranberry 450mg give 1 tab at 7:00 AM - 9:00 AM -Lisinopril 5mg give 1 tab at 7:00 AM - 9:00 AM 33) Record review revealed Resident ID #40 was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, paranoid schizophrenia and hypertension. Resident ID #40 did not receive the following medications on 4/26/2024: -Losartan (blood pressure medication) 25mg give 1 tab at 11:00 AM - 1:00 PM -Metoprolol Succinate 50mg give 1 tab at 11:00 AM - 1:00 PM -Olanzapine (anti-psychotic medication) 5mg give 1 tab at 9:00 AM - 11:00 AM 34) Record review revealed Resident ID #41 was readmitted to the facility in September of 2023 with diagnoses including, but not limited to, Alzheimer's disease and cerebral infarction (stroke). Resident ID #41 did not receive the following medications on 4/26/2024: -Ketotifen fumarate (medicated eye drops) 0.025% (0.035%) give 1 drop at 7:00 AM - 11:00 AM -Senna 8.6mg give 2 tabs at 7:00 AM - 11:00 AM 35) Record review revealed Resident ID #42 was readmitted to the facility in September of 2023 with a diagnosis including, but not limited to, necrotizing fasciitis (flesh eating disease). Resident ID #42 did not receive the following medications on 4/26/2024: -Probiotic give 1 tab at 7:00 AM - 9:00 AM -Aspirin 81mg give 1 tab at 7:00 AM - 9:00 AM -Ibuprofen 400mg give 1 tab at 7:00 AM - 12:00 PM 36) Record review revealed Resident ID #43 was readmitted to the facility in January of 2024 with diagnoses including, but not limited to, diabetes mellitus, chronic pain syndrome, hypertension, and gastro-esophageal reflux disease (GERD). Resident ID #43 did not receive the following medications on 4/26/2024: -Acetaminophen 500mg give 2 tabs at 7:00 AM - 12:00 PM -Famotidine (medication used to treat GERD) 20mg give 1 tab at 7:00 AM - 12:00 PM -Metformin 500mg give 1 tab at 7:00 AM - 10:00 AM -Oxybutynin Chloride 5mg give 1 tab at 7:00 AM - 12:00 PM -Propranolol (blood pressure medication) 40mg give 1 tab 7:00 AM - 12:00 PM 37) Record review revealed Resident ID #44 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, hypertension. Resident ID #44 did not receive the following medications on 4/26/2024: -Irbesartan (blood pressure medication) 75mg give 1 tab at 7:00 AM - 11:00 AM -Metoprolol Succinate 50mg give 1 tab at 7:00 AM - 11:00 AM 38) Record review revealed Resident ID #99 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, COPD and depression. Resident ID #99 did not receive the following medications on 4/26/2024: -Nicotine patch 14mg/24hr apply 1 patch at 7:00 AM - 9:00 AM 39) Record review revealed Resident ID #100 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, dependence on renal dialysis, nasal congestion, and old myocardial infarction. Resident ID #100 did not receive the following medications on 4/26/2024: -Flonase Allergy Relief (nasal spray) 50mcg/actuation give 1 spray per nare at 7:00 AM - 12:00 PM -Plavix (prevents blood clots) 75mg give 1 tab at 7:00 AM - 12:00 PM -Renvela (treats high blood phosphate levels typically for an individual that requires dialysis) 800mg at 7:00 AM - 9:00 AM and 11:00 AM - 12:00 PM 40) Record review revealed Resident ID #199 was readmitted to the facility in January of 2024 with diagnoses including, but not limited to, dementia with behavioral disturbance and major depressive disorder. Resident ID #199 did not receive the following medications on 4/26/2024: -Quetiapine (anti-psychotic medication) 25mg give 2 tabs at 7:00 AM - 10:00 AM During a surveyor interview on 4/30/2024 at 1:33 PM with the Medical Director, she revealed that she received a phone call from staff at approximately 7:00 PM on 4/26/2024 indicating that many residents did not receive their medications. She further revealed she spent approximately 1.5 hours reviewing the resident's missed medications with staff and indicated that she expects the medications to be given as ordered. During a surveyor interview on 4/30/2024 at 3:41 PM with the Administrator, she acknowledged that the above-mentioned residents and their respective medications were not administered on 4/26/2024. Additionally, she was unable to explain why the medications were not administered to the residents.

Based on record review, resident and staff interview, it has been determined that the facility failed to ensure nourishing snacks were offered to residents who desired them outside of scheduled meal service times for 5 of 5 residents reviewed for bedtime snacks, Resident ID #s 3, 7, 14, 21, and 99. Findings are as follows: Review of the meal service times revealed that breakfast is served at 8:00 AM, lunch is served at 12:00 PM, and supper is served at 4:30 PM. This indicates there is a 15 ½ hour time span between a substantial evening meal and breakfast the following day. During surveyor observations of the breakfast meal throughout the survey from 4/26/2024 through 4/30/2024, breakfast was observed to be served no earlier than 8:10 AM. Record review of the menu for week 3 revealed the following snacks at night: Sunday: orange drink ½ cup and 1 cookie Monday: lemonade ½ cup and 3 vanilla wafers Tuesday: blush punch ½ cup and 1 pkg (package) of graham crackers Wednesday: orange drink and 1 assorted cookie Thursday: lemonade ½ cup and 3 vanilla wafers Friday: blush punch ½ cup and 1 pkg of graham crackers Saturday: orange drink and 1 assorted cookie Record review of the menu for week 4 reveals the same snacks and drinks as above. Week 3 and week 4 menus were used during the survey. During a resident council meeting held on 4/29/2024 at 11:10 AM, residents in attendance indicated bedtime snacks were not offered. These residents further indicated that they have to ask if they want a bedtime snack but would prefer to be offered a snack. During a surveyor interview on 4/29/2024 at 8:47 AM with Resident ID #99, s/he revealed that s/he would like to be offered a bedtime snack every night and is not. Record review of the resident's intake section for Bedtime Snack from 4/12/2024 to 4/26/2024, failed to reveal evidence that a bedtime snack was documented as received. During a surveyor interview on 5/1/2024 at approximately 10:30 AM with Resident ID #21, s/he indicated that it would be nice to have a bedtime snack offered to him/her. Record review of the resident's intake section for Bedtime Snack from 3/26/2024 to 4/26/2024, failed to reveal that a bedtime snack was documented as received. During a surveyor interview on 5/1/2024 at 8:47 AM with Resident ID #7, s/he revealed that no one passes out snacks at night and that s/he would like to be offered one. S/he further revealed that s/he is 6 feet 5 inches tall and would like a snack at night. Record review of the resident's intake section for Bedtime Snack from 1/1/2024 to 5/1/2024, failed to reveal evidence that bedtime snacks were documented as received. During a surveyor interview on 5/1/2024 at 10:20 AM with Resident ID #3, s/he revealed that s/he likes to be in bed by 7:00 PM. S/he further revealed s/he used to get a snack at night when the facility had a refreshment girl that went room to room delivering snacks after dinner. S/he indicated that no one passes out snacks anymore, so now s/he buys their own. During a surveyor interview on 5/1/2024 at 10:25 AM with Resident ID #14, s/he revealed that snacks after dinner are not offered, you have to ask for them. S/he indicated that there used to be someone that passed them out and would like them offered to him/her again. During a surveyor interview on 5/1/2024 at 8:08 AM with Nursing Assistant, Staff N, she revealed that if a resident wants a snack they can come to the nurses' station. Additionally, she added that no one passes them out. During a surveyor interview on 5/1/2024 at 8:17 AM with the Infection Preventionist, she acknowledged that there is more than 14 hours between a substantial evening meal and breakfast the following day. Additionally, she revealed not every resident is able to go to the nurses' station to get a snack. Furthermore, she revealed there is no designated person at night to go room to room to pass out the drinks and snacks and was unable to provide evidence that every resident is offered a nourishing snack at night. During a surveyor interview on 5/1/2024 at approximately 11:40 AM with the Registered Dietitian, she indicated that a nourishing snack for almost a 16-hour time span would include 2 food groups. Additionally, she acknowledged that one cookie and a ½ cup of lemonade is not a nourishing snack.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store food in accordance with professional standards of food service safety relative to the main kitchen and kitchenette. Findings are as follows: 1. Record review of the Rhode Island Food Code, 2018 Edition, states: Section 3-501.17 Ready-to Eat, Time/Temperature Control for Safety, Date Marking .(B) .(1) The day the original container is opened in the Food establishment shall be counted as Day 1 . Section 3-602.11 Food Labels states, .(B) Label information shall include: (1) The common name of the food . During the initial tour of the main kitchen on 4/25/2024 at 8:39 AM revealed the following observations in the walk-in refrigerator: - A long rectangular pan with sliced zucchini and squash, not covered or labeled with a small container resting directly on top of the squash medley - An opened clear plastic bag of shredded yellow cheese, not labeled or dated - An opened clear plastic bag of white shredded cheese, not labeled or dated Following the above observations, the Food Service Director (FSD) was unable provide evidence that the above items were labeled and dated or that the squash medley was kept free from contamination. 2. During the initial tour of the main kitchen on 4/25/2024 at 8:39 AM revealed the following observations in the dry storage room: - 9 bags of pearled barley with an expiration date of 11/10/2019 - 1 can of sausage gravy with an expiration date of 9/11/2022 During a surveyor interview with the FSD immediately following the above observations he acknowledged the above items were expired. 3. During the initial tour of the main kitchen on 4/25/2024 at 8:39 AM revealed the following observations in the dish room and in the wash room respectively: - the three bay sink pipe was leaking - 4 kick board ceramic tiles were missing and several separating from the wall where ants were observed During a surveyor interview on 4/25/2024 immediately following the above observation, the FSD revealed pest control was at the facility last week to spray in the kitchen. Additionally, he let maintenance know that the pipe on the three bay sink needed repair as well as the kick board ceramic tiles. Review of the work order for the three bay sink revealed it was created on 3/25/2024 by the FSD and indicated that a plumber was needed to fix the issue. Review of the work order for the repair of the ceramic tiles revealed it was created on 10/19/2023 by the FSD and indicated that the facility was waiting on contractors to give quotes for the repair. During a surveyor interview with the Maintenance Director on 4/30/2024 at 8:07 AM, he revealed that within the next week a plumber will be coming out to repair the sink after the surveyor brought this to his attention. Additionally, he revealed he is getting a floor contractor to come in to fix the ceramic tiles. 4. Record review of the Rhode Island Food Code 2018 edition, Section 4-501.112 states in part, Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 [degrees]C [Celsius] 194 degrees F [Fahrenheit] . During a surveyor observation on 4/25/2024 at 10:23 AM with Dietary Aide, Staff O, of the hot water dish machine, the final rinse cycle reached 200 degrees F. A subsequent observation at 10:40 AM in the presence of the FSD, the final rinse cycle reached 195 degrees F. Review of the hot water dish machine log for April of 2024 revealed that on 4/18/2024 for supper the temperature of the final rinse cycle reached 195 degrees F. Review of the hot water dish machine log for March of 2024 revealed the following dates when the temperatures of the final rinse cycle reached above 194 degrees F for supper: - 3/1/2024, 3/3/2024, 3/4/2024, 3/5/2024, 3/6/2024, 3/7/2024, 3/8/2024, 3/9/2024, 3/12/2024, 3/13/2024, 3/14/2024, 3/15/2024, 3/16/2024, 3/18/2024, 3/25/2024, and on 3/27/2024. During a surveyor interview on 4/25/2024 at approximately 11:00 AM with the FSD, he revealed that he was unaware that the temperature of the final rinse cycle should not exceed 194 degrees F. Additionally, he revealed he would inform maintenance of the concern and the facility would utilize the three bay sink and use paper products until the dish machine is fixed. During a surveyor observation on 4/26/2024 at 10:07 AM in the presence of Dietary Aide Staff P, the temperature of the final rinse cycle read 200 degrees F. During surveyor observations on 5/8/2024 during the breakfast meal revealed the meals continued to be served on Styrofoam plates. 5. During a surveyor observation on 4/26/2024 at 9:15 AM of the kitchenette resident refrigerator, revealed a thermometer temperature reading of 48 degrees F. Review of a form titled, UPPER LEVEL REFRIGERATION TEMPERATURE CHART attached to the refrigerator states, PLEASE CHECK REFRIGERATION TEMPERATURES AT THE TIMES SPECIFIED AND INITIAL. IF TEMP IS 40 OR OVER, NOTIFY THE SUPERVISOR ON DUTY. Further review of the form reveals the refrigeration temperatures are taken twice a day, once at 7:00 AM and then at 7:00 PM. Record review of the refrigerator temperature chart reveals 17 temperatures out of 59 were documented as being over 40 degrees F. There was no evidence that the supervisor on duty was notified of the temperatures of 40 degrees. During a surveyor interview with the FSD following the above observation, he was unable to provide evidence that the refrigerator was maintained at a safe temperature.

Based on record review, surveyor observation, and staff interview it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 2 of 2 residents reviewed requiring pudding thick liquids, Resident ID #s 19 and 16 , for 40 of 48 residents reviewed relative to medication administration, Resident ID #s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, 99, 100, and 199, and for 1 of 1 resident reviewed for foley catheter (a flexible tube inserted into the bladder in order to drain urine) care, Resident ID #33. Findings are as follows: 1a. Record review revealed that Resident ID #19 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dysphagia (a condition with difficulty in swallowing food or liquid), aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, or vomit) and stroke. Review of a physician's order dated 4/26/2024 states, House, Pudding Thickened, Pureed. Special Instructions: NO STRAWS. ONLY NURSE TO PREPARE THIN LIQUIDS TO PUDDING CONSISTENCY. During a surveyor observation on 4/26/2024 at 10:10 AM with Licensed Practical Nurse (LPN), Staff A, she crushed the resident's medication in applesauce and then thickened the fluid to a nectar thick consistency to serve to the resident. The surveyor intervened to ensure the resident received the ordered pudding thick consistency. During a subsequent interview with Staff A, she was unaware of the correct consistency of fluid ordered. Additionally, she was unable to determine how to thicken the fluid to the pudding thick consistency. During a surveyor observation on 4/26/2024 at 1:06 PM with LPN, Staff B, she was observed thickening the resident's liquid on a lunch tray to a nectar thick consistency. Additionally, the nurse was unsure what the resident's fluid consistency order was and how to thicken to the pudding thick consistency. During a surveyor interview on 4/26/2024 at 1:09 PM with the Director of Nursing Services (DNS) she acknowledged that the staff was unaware how to thicken the correct consistency to achieve pudding thick. Additionally, the DNS was unaware how to achieve the appropriate consistency. During a surveyor observation on 5/1/2024 at approximately 8:50 AM of Registered Nurse (RN), Staff L, in the presence of the Compliance Monitor, he was attempting to thicken Resident ID #19's fluids and breakfast food to honey thick versus the ordered pudding thick consistency until the Compliance Monitor intervened. 1b. Record review revealed that Resident ID #16 was admitted to the facility in March of 2019 with diagnoses including, but not limited to, dysphagia and gastro-esophageal reflux disease. During a surveyor observation on 5/1/2024 at approximately 9:00 AM of Staff L, mixing fluids for Resident ID #16, he was observed mixing the incorrect amount of thicker as he was using a larger cup then the manufacturers instructions indicated. Cross Reference F 726 and F 805. 2. Record review of a Medication Compliance Report dated 4/26/2024 revealed that 40 residents did not receive medication scheduled during the 7:00 AM to 3:00 PM shift on 4/26/2024. During a surveyor interview on 4/30/2024 at approximately 2:10 PM with the Infection Preventionist and the Administrator they acknowledged that 40 residents did not receive their medications on 4/26/2024. Additionally, they were unable to explain the cause of the medication not being administered. Cross Reference F760 3. Record review revealed that Resident ID #33 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, urinary retention and low back pain. Review of the physician orders revealed the resident has a foley catheter with directions to flush the foley every shift. During a surveyor observation on 4/26/2024 at approximately 8:45 AM, the resident was observed with the door open while LPN, Staff A, and RN, Staff D, were observed flushing and then changing the resident's indwelling foley catheter. During this observation the resident was observed with his/her genitals uncovered and in full view of the hallway and his/her roommate. During a surveyor interview on 4/30/2024 with the Administrator on 5/1/2024 she acknowledged the above findings and indicated that the Compliance Monitor has been very beneficial to her. Cross Reference F 550, F 726 and F 880

**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 an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections relative to the disinfection of glucometers (a device used to monitor blood glucose). Additionally, the facility failed to ensure that staff utilized Personal Protective Equipment (PPE) properly for 2 of 2 residents reviewed relative to foley catheter (a device that drains urine from your bladder into a collection bag) care and multi drug resistant organism (MDRO), Resident ID #2 and #33. Findings are as follows: 1. Record review of a facility policy titled Glucose Monitoring Equipment states in part, .Glucometers will be cleaned with a bleach wipe and/or manufacturer guidelines after each use . During a surveyor observation on 4/26/2024 at approximately 9:28 AM, Registered Nurse, Staff E, was observed checking a resident's blood glucose level, she proceeded to remove her used gloves, utilize hand sanitizer and exit the room. She then continued to check another resident's blood glucose level immediately after and then placed the glucometer in a basket on top of clean supplies in the nurse's medication cart, failing to clean the glucometer after each use. During a surveyor interview on 4/26/2024 immediately following the above observations with Staff E, she revealed that the facility does not have the correct wipes to clean the glucometers and was unsure how long it has been since they have had them available. During a surveyor interview on 4/26/2024 at 9:45 AM with the Director of Nursing Services, she revealed the facility does have the correct wipes in the basement and it would be her expectation that the staff would go and get them prior to using the glucometer. 1b. During a surveyor observation on 5/1/2024 at approximately 8:21 AM, Registered Nurse, Staff Q, was checking a resident's blood glucose level, immediately after she was observed cleaning the glucometer with an alcohol wipe. During the above observation bleach wipes were observed in the nurse's cart drawer. During a surveyor interview on 5/1/2024 immediately following the above observations with Staff Q, she revealed that she would typically use an alcohol pad to clean the glucometer and not use the bleach wipe per the facility policy. During a surveyor interview on 5/1/2024 at 8:29 AM with the Infection Preventionist, she revealed that the staff should be using PDI wipes (Highly compatible disinfection wipe for non-invasive medical devices and non-porous hard surfaces) to clean the glucometers. Additionally, she was unable to provide evidence that the glucometers were cleaned per the facility policy and unable to provide evidence that the facility maintained an infection control program that provided a sanitary environment to help prevent the development of infections. 2. Record review revealed that Resident ID #33 was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, retention of urine. A surveyor observation on 4/26/2024 at 9:28 AM of the signage outside Resident ID #33's room, the sign stated in part, Enhanced Barrier Precautions, everyone must: wear gloves and gown for the following High-Contact Resident Care Activities .Device care or use .urinary catheter . A surveyor observation on 4/26/2024 at 9:28 AM revealed Licensed Practical Nurse, Staff A, assessing and then flushing the resident's urinary catheter wearing only gloves. During this observation Registered Nurse, Staff D, then entered the resident's room with supplies, wearing only gloves to assist Staff A in changing the residents foley catheter. During a surveyor interview immediately following the above observation with Staff A, in the presence of Staff D, she indicated that she was not aware of the required PPE that should have been worn and was unsure if the resident had an active infection. At this time Staff D, acknowledged they should have worn a gown while providing foley catheter care as indicated on the signage. During a surveyor interview on 4/29/2024 at 9:29 AM with the Infection Preventionist, she revealed that the staff should be wearing gowns and gloves while performing foley catheter care. She further acknowledged that the resident was on enhanced barrier precautions. 3. Record review revealed Resident ID #2 was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, urinary tract infection. Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed s/he requires dependent assistance for toileting. Additionally, the MDS Assessment revealed that the resident is always incontinent of bladder and occasionally incontinent of bowels. Record review of a facility document titled, Continuity of Care Consultation and Referral Form dated 3/30/2024 states in part, .ESBL [Extended-spectrum beta-lactamases: enzymes that confer resistance to most beta-lactam antibiotics]/CRE [carbapenem-resistant Enterobacterales: develop resistance to the group of antibiotics] in Urine . A surveyor observation on 4/29/2024 at 8:59 AM of the signage outside of Resident ID #2's room, the sign stated in part, Enhanced Barrier Precautions, everyone must: wear gloves and gown for the following High-Contact Resident Care Activities .Transferring .dressing . A surveyor observation on 4/29/2024 at 8:59 AM revealed Nurse Assistant, Staff I, boosting the resident in bed and then adjusting the resident's gown in bed. During a surveyor interview immediately following the above observation with, Staff I, she acknowledged that she should have been wearing a gown and gloves during patient care, as indicated on the Enhanced Barrier Precautions signage. During a surveyor interview on 4/29/2024 at 9:29 AM with the Infection Preventionist, she revealed that the staff should be wearing a gown and gloves while providing care for Resident ID #2, she further acknowledged that the resident was on enhanced barrier precautions related to an MDRO. Additionally, she was unable to provide evidence that the facility maintained an infection control program that provided a sanitary environment to help prevent the development of infections.

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 3 residents reviewed for antibiotic use, Resident ID #s 26, 29, and 39. Findings are as follows: According to the Centers for Disease Control and Prevention document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available .Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions .Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT [days of therapy] . 1. Record review revealed that Resident ID #26 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, diabetes and chronic obstructive pulmonary disease. Record review revealed a physician's order for Cipro (an antibiotic) 500 milligram (mg) capsule daily from 4/19/2024 through 4/26/2024 for a urinary tract infection (UTI). Record review failed to reveal evidence that the facility implemented an antibiotic review process, also known as an antibiotic time-out to determine if the antibiotic is still indicated or adjustments should be made. 2. Record review revealed that Resident ID #29 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and need for assistance with personal care. Record review revealed a physician's order for Augmentin (an antibiotic) 500/125mg tablet twice a day from 4/27/2024 through 5/1/2024 for UTI. Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made. 3. Record review revealed that Resident ID #39 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, malignant neoplasm of prostate (prostate cancer) and depression. Record review revealed a physician's order for Cipro (an antibiotic) 500 mg capsule twice a day from 3/17/2024 through 3/23/2024. Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made. During a surveyor interview on 4/29/2024 at 10:09 AM with the Infection Preventionist, she revealed that she does not have a process for reviewing residents receiving antibiotics, or obtaining of laboratory or diagnostic testing to determine if the antibiotic is still indicated or adjustments should be made, for current residents in the facility when started on an antibiotic.

Based on record review and staff interview, it has been determined that the facility failed to provide a minimum of 12 hours per year of in-service training to ensure the continuing competence of nurse aides for 3 of 3 Nurse Aides (NA) reviewed, Staff H, I and J. Findings are as follows: Record review of Staff H, I and J's employee records revealed that they have all worked in the facility greater than one year. Additional review failed to reveal evidence of a minimum of 12 hours per year of in-service training. During a surveyor interview on 4/30/2024 at 12:39 PM with the Administrator during the staffing task she acknowledged that annual 12-hour in-service training for NAs was not provided for the above-mentioned staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident representative interview, it has been determined that the facility failed to protect and promote the rights of the resident for 5 of 5 residents reviewed who had their picture posted on social media, Resident ID #s 5,6, 7, 8, and 9. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health of [DATE] alleges that Resident ID #6's photograph was posted to Facebook without the consent of the resident or of the resident's representative. 1. Record review revealed that Resident ID #6 was admitted to the facility in December of 2021 with diagnoses including, but not limited to, dementia and major depressive disorder. Further review revealed that the resident expired at the facility on [DATE]. Record review failed to reveal evidence that a consent for photographs to be taken or posted on a social media platform was signed by the resident or the resident's representative. Review of the facility's public social media Face Book page revealed that a photograph of the resident taken at the facility, to include his/her face, had been posted on [DATE]. Further review revealed the photograph was still online for the public to view on [DATE], approximately 2 1/2 months after the resident expired. During a surveyor interview of [DATE] at 9:05 AM with the resident's family member, s/he indicated that the resident's photograph had been posted on the facility's social media Facebook page multiple times without the consent of the resident or of the resident's representative. S/he further indicated that it was upsetting to view the resident's photograph posted after his/her death. 2. Record review revealed that Resident ID #5 was originally admitted to the facility in February of 2021 with diagnoses including, but not limited to, dementia and Post Traumatic Stress Disorder (PTSD). Record review failed to reveal evidence that a consent for the photograph to be taken or posted on a social media platform was signed by the resident or the resident's representative. Review of the facility's public social media Face Book page revealed that a photograph of the resident taken at the facility, to include his/her face, had been posted on [DATE]. Further review revealed the photograph was still available for the public to view on [DATE], indicating that the resident's photo had been posted for approximately, 39 days. 3. Record review revealed that Resident ID #7 was admitted to the facility in September of 2020 with a diagnosis including, but not limited to, cerebral infarction (stroke). Record review failed to reveal evidence that a consent for the photograph to be taken or posted on a social media platform was signed by the resident or the resident's representative. Review of the facility's public social media Face Book page revealed that a photograph of the resident taken at the facility, to include his/her face, had been posted on [DATE] and was still available for the public to view on [DATE]. 4. Record review revealed that Resident ID #8 was admitted to the facility in March of 2014 with diagnoses including, but not limited to, dementia and paranoid schizophrenia. Record review failed to reveal evidence that a consent for the photograph to be taken or posted on a social media platform was signed by the resident or the resident's representative. Review of the facility's public social media Face Book page revealed that a photograph of the resident taken at the facility, to include their face, had been posted on [DATE] and on [DATE]. Further review revealed the photographs were still available for the public to view on [DATE], indicating that the resident's photos had been posted for approximately, 86 days. 5. Record review revealed that Resident ID #9 was originally admitted to the facility in July of 2022 with diagnoses including, but not limited to, dementia and PTSD. Record review failed to reveal evidence that a consent for the photograph to be taken or posted on a social media platform was signed by the resident or the resident's representative. Review of the facility's public social media Face Book page revealed that a photograph of the resident taken at the facility, to include his/her face, had been posted on [DATE]. Further review revealed the photograph was still available for the public to view on [DATE], indicating that the resident's photo had been posted for approximately, 86 days. During a surveyor interview on [DATE] at 2:25 PM with the Activities Director, she indicated that the facility utilizes an outside company to post photos on the their Facebook page. She further indicated that she would expect a consent to be obtained from the resident or resident representative prior to a photograph to be taken and posted on the facility's social media page. Additionally, she could not provide evidence that any of the above-mentioned residents had a consent form signed in regards to publicly sharing photographs. During a surveyor interview on [DATE] at 3:10 PM with the Administrator, she indicated that she would expect that a consent form would be obtained from the resident or the resident's representative prior to any photographs to be taken and posted for public view. Additionally, she could not provide evidence that the facility protected and promoted the rights of the resident.

Based on record review 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 (ADL) for 5 of 5 residents reviewed who are not independent with transfers and/or ambulation, Resident ID #s 1, 2, 3, 4, and 5. Findings are as follows: 1. Record review revealed that Resident ID #1 was re-admitted to the facility in January of 2024 with diagnoses including, but not limited to, Wernicke's encephalopathy (a neurological disorder marked by mental confusion and unsteady gait- a person's manor of walking), cognitive communication deficit, and abnormalities of gait and mobility. Review of a care plan dated 1/2/2023 revealed the resident was at risk for falls with an intervention to assist the resident when standing or ambulating. Review of a Physical Therapy [PT] Discharge Summary dated 2/16/2024 revealed the resident required supervision with transfers and ambulation with his/her rolling walker. This document was requested by the surveyor as the PT Discharge Summary is not in Matrix (the electronic medical record). It is in a separate program that only therapy has access to. Record review failed to reveal evidence that the resident required supervision with transfers and ambulation with his/her rolling walker. Record review of the Nursing Assistant's (NA) assignment sheet failed to reveal the level of assistance the resident required for safety relative to transfers or ambulation. During a surveyor interview on 4/4/2024 at 11:07 AM with the Director of Rehab, she indicated that she would expect that a staff member would be visually supervising Resident ID #1 while transferring and ambulating. She further indicated that each resident is screened or evaluated upon admission to assess the level of assistance that is needed for transfers and ambulation. Additionally, she indicated that she verbally informs the nursing staff of the assistance each resident requires, as the nursing staff does not have access to the PT Discharge Summary as it is in a different program. 2. Record review revealed that Resident ID #2 was originally admitted to the facility in April of 2021 with diagnoses including, but not limited to, dementia and abnormalities of gait and mobility. Review of a care plan last revised 2/29/2024 revealed the resident was at risk for falls with an intervention to encourage the use of a gait belt (a device that is put around a resident's waist to assist with transfers or ambulation for safety). Review of a Physical Therapy Discharge Summary dated 4/1/2024 revealed the resident required contact guard assistance (CGA- assistance of one hand to steady the resident) for transfers. This document was requested by the surveyor as the PT Discharge Summary is in not in Matrix (the electronic medical record). It is in a separate program that only therapy has access to. Record review failed to reveal evidence that the resident required CGA for transfers. Record review of the NA assignment sheet failed to reveal the level of assistance the resident required for safety relative to transfers or ambulation. During a surveyor interview on 4/4/2024 at 11:07 AM with the Director of Rehab, she indicated that Resident ID #2 required the assistance of one staff member for transfers. Additionally, she indicated that she verbally informs the nursing staff of the assistance each resident requires, as the nursing staff does not have access to the PT Discharge Summary as it is in a different program. 3. Record review revealed that Resident ID #3 was admitted to the facility in September of 2023 with diagnoses including, but not limited to, necrotizing fasciitis (a bacterial disease that causes death to soft tissue), and diabetes type two. Review of a care plan last revised 4/3/2024 revealed the resident was at risk for falls. Review of a PT Evaluation & [and] Plan of Treatment dated 3/18/2024 revealed the resident required MI [modified independence] for transfers and CGA for ambulation. This document was requested by the surveyor as the PT Discharge Summary is in not in Matrix (the electronic medical record). It is in a separate program that only therapy has access to. Record review failed to reveal evidence that the resident required CGA for ambulation. Record review of the NA assignment sheet failed to reveal the level of assistance the resident required for safety relative to transfers or ambulation. During a surveyor interview on 4/4/2024 at 11:07 AM with the Director of Rehab, she indicated that Resident ID #3 required staff supervision and the assistance of a walker for ambulation in the hallways. Additionally, she indicated that she verbally informs the nursing staff of the assistance each resident requires, as the nursing staff does not have access to the PT Discharge Summary as it is in a different program. 4. Record review revealed that Resident ID #4 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, severe persistent asthma and necrosis of the bone (death of bone tissue). Review of a care plan last revised 3/14/2024 revealed the resident was at risk for falls. Review of a Physical Therapy Discharge Summary dated 3/25/2024 revealed the resident required a varied level of assistance from maximum assistance to stand by assistance with transfers. This document was requested by the surveyor as the PT Discharge Summary is in not in Matrix (the electronic medical record). It is in a separate program that only therapy has access to. Record review failed to reveal evidence of any indication that the resident required maximum to stand by assistance for transfers. Record review of the NA assignment sheet failed to reveal the level of assistance the resident required for safety relative to transfers or ambulation. During a surveyor interview on 4/4/2024 at 11:07 AM with the Director of Rehab, she indicated that Resident ID #4 required a varied level of assistance ranging from the maximum assistance of two staff members to the supervision of staff for transfers. Additionally, she indicated that she verbally informs the nursing staff of the assistance each resident requires, as the nursing staff does not have access to the PT Discharge Summary as it is in a different program. 5. Record review revealed that Resident ID #5 was re-admitted to the facility in December of 2021 with diagnoses including, but not limited to, hemiplegia and hemiparesis (loss of function on one side of the body) following a stroke and dementia. Review of a care plan last revised 1/3/2024 revealed the resident was at risk for falls related to dementia with an intervention to encourage the resident to request assistance with transfers. Review of a Physical Therapy Discharge Summary dated 12/22/2023 revealed the resident required minimal assistance of staff for transfers. This document was requested by the surveyor as the PT Discharge Summary is in not in Matrix (the electronic medical record). It is in a separate program that only therapy has access to. Record review failed to reveal evidence of any indication that the resident required minimal assistance for transfers. Record review of the NA assignment sheet failed to reveal the level of assistance the resident required for safety relative to transfers or ambulation. During a surveyor interview on 4/4/2024 at 11:07 AM with the Director of Rehab, she indicated that Resident ID #5 required minimal assistance for transfers. She further indicated that minimal assistance requires the assistance of one staff member for safety. Additionally, she indicated that she verbally informs the nursing staff of the assistance each resident requires, as the nursing staff does not have access to the PT Discharge Summary as it is in a different program. During a surveyor interview on 4/4/2024 at approximately 8:35 AM with Registered Nurse, Staff A, she acknowledged that the residents' transfer and ambulation status were not included in the record or on the NA assignment sheets. Additionally, she indicated that a verbal report is typically given to the NA's regarding the resident's transfer and ambulation status. During a surveyor interview on 4/4/2024 at approximately 8:45 AM with NA, Staff B, she indicated that the NA's are expected to ask nursing of the level of assistance needed for each resident. Additionally, she acknowledged that the resident's transfer status is not documented or accessible to the NA's who provide direct care for the residents. During a surveyor interview on 4/4/2024 at 11:24 AM with the Director of Nursing Services, she acknowledged that residents' transfer and ambulation status were not documented in the medical record or on the NA assignment sheets for the above mentioned residents. She further indicated that she would expect that the level of assistance required to safely transfer a resident should be documented in the resident's record and be readily accessible to direct care staff.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 2 new admissions reviewed, Resident ID #4. Findings are as follows: 1. Record review revealed that Resident ID #4 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, cytomegaloviral disease (CMV- which is a virus that can infect almost anyone, but if you have a weakened immune system, CMV can be serious or even fatal) and kidney transplant status. Review of the hospital discharge document titled After Visit Summary dated 3/20/2024 revealed the following medication orders for the facility: -Valganciclovir (antiviral for CMV) 450 milligram (mg) tablet, take 2 tablets by mouth for a total of 900 mg twice daily. -Gabapentin (used for neuropathy) 300 mg capsule, take 1 capsule by mouth at bedtime. With special instruction which states in part, Another medication with the same name was removed. Continue taking this medication and follow the directions you see here. -Magnesium oxide (a supplement to treat low magnesium) 400 mg tablet, take 1 table by mouth with lunch. -Tamsulosin (used for enlarged prostate) 0.4 mg capsule, take 2 capsules to equal 0.8 mg by mouth daily. Review of the physician orders revealed that the resident was ordered for the following medications: - Gabapentin capsule 100 mg, administer 1 capsule twice a day with a start date of 3/20/2024 - Gabapentin capsule 300 mg, administer 1 capsule at bedtime with a start date of 3/20/2024 - Tamsulosin 0.4 mg capsule administer 1 capsule daily with a start date of 3/20/2024 Record review failed to reveal evidence that the Gabapentin and Tamsulosin were transcribed accurately, therefore the resident received the incorrect dosages of these medications for 7 days. Further record review failed to reveal evidence that the Magnesium oxide and Valganciclovir were ordered by the provider, therefore the resident did not receive these ordered meds for 7 days. During a surveyor interview with the resident's physician on 3/28/2024 at 1:32 PM, she acknowledged that the admitting nurse transcribed the medications from a January 2024 hospitalization into the resident's medical record, rather than his/her updated medication orders from his/her March 2024 hospital discharge After Visit Summary. She further revealed that when she was discussing medications with a nurse, she remembered the nurse saying that the list of medications that she reviewed were from January and would expect the nurse to utilize the most recent medication list. Additionally she revealed that she would have expected the resident to receive the medications according to the most recent medication list from the hospital. During a surveyor interview on 3/28/2024 at 1:53 PM with the Director of Nursing Services, she acknowledged that the medications from the After Visit Summary dated 3/20/2024 were not accurately transcribed into the resident's orders. 2. According to the American Nephrology Nurses Association, 2023, Arteriovenous Fistula .(AV fistula, arteriovenous fistula is when an artery and a vein are surgically connect for dialysis treatments) care will help maintain the patency of the vascular access. Measures can be taken to prevent clotting or infection to the access. Patency is assessed by feeling the 'thrill' or vibration of blood through the access or using a stethoscope to listen to the 'bruit' or 'whoosh' of blood through the access. Staff should monitor for signs of infection including pain, tenderness, drainage, swelling, or redness. Review of the hospital discharge document titled After Visit Summary dated 3/20/2024 revealed the resident has an AV fistula and a double lumen power port (a device which is inserted into the chest wall to allow the infusion of medications). Record review failed to reveal evidence that the facility monitored the AV fistula for patency, signs of infection including pain, tenderness, drainage, swelling, or redness. Further record review failed to reveal evidence that the facility was assessing or monitoring the resident's double lumen power port. During a surveyor interview with the resident's physician on 3/28/2024 at 1:32 PM, she revealed that she would expect that the facility would monitor the AV fistula and the double lumen power port. During a surveyor interview on 3/28/2024 at 1:53 PM with the Director of Nursing Services, she acknowledged that the facility was not monitoring the resident's AV fistula or double lumen power port. Furthermore, she revealed that she would expect the facility to monitor the AV fistula and double lumen power port.

**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 provide appropriate treatment and services relative to Urinary Tract Infections (UTI) and/or Indwelling catheters (a flexible tube that collects urine from the bladder and leads to a drainage bag), for 3 of 3 residents reviewed, Resident ID #s 1, 2 and 4. Findings are as follows: Review of the facility's undated policy and procedure titled Urinary Incontinence and Indwelling catheter, states in part, .assessment should include the risks and benefits of an indwelling catheter .the potential for removal of the catheter .Documentation must support why the Foley catheter is necessary .With all indwelling catheter (temporary or permanent), the size and type of catheter must be written in the order . Review of the facility's undated policy titled UTI Protocol states, .Check resident for Constipation .Obtain CBC w/dif [Complete Blood Count with differential, a blood test that helps detect a range of disorders and conditions including infections] .Cranberry Tab 1 Tab [tablet] Daily x 7 days .V/S [Vital Signs] x 72 hours . According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage. 1. Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/20/2024 alleges that Resident ID #1 was observed with blood in his/her catheter, and shortly after, s/he went sepsis [a life-threatening response to an infection that can cause organ failure and death]. Record review revealed Resident ID #1 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, status post fall with compression fracture of the lumbar spine (lower back) and the thoracic spine (mid section of spine), Diabetes Mellitus, type 1 (Insulin dependent), and left leg amputation. Further record review revealed the resident was also admitted with a Foley catheter. Record review of nursing progress notes revealed the following: -3/3/2024 at 6:30 AM: .had slight hematuria [blood in urine] . -3/3/2024 at 4:47 PM: .foul smelling hematuria . -3/4/2024 at 3:33 PM: The resident stated .I feel like I need to pee and can't .frank blood [blood in urine that can be seen with the naked eye] . Record review revealed a physician's order was obtained on 3/4/2024 to initiate the facility's UTI Protocol related to .urinary c/o [complaints] . Record review of a nursing progress note dated 3/7/2024 at 6:23 AM revealed the resident had .Hematuria . Record review failed to reveal evidence that the UTI protocol was implemented in its entirety regarding obtaining vital signs from 3/4-3/7/2024. Review of a nursing progress note dated 3/8/2024 at 4:02 AM indicates the resident was complaining of .Foley catheter discomfort .had light hematuria . Record review revealed a blood draw for a CBC (complete blood count) was completed on 3/8/2024 which revealed the resident's white blood cell count (WBC) was elevated and at 13.7 K/ul (thousand cells per cubic milliliter, high WBC can indicate an infection. A normal WBC range is 4.0-10.0 K/ul). Additional, record review revealed that on 3/8/2024 at 4:57 PM, the physician was notified of the resident's elevated WBC and a new order was provided for Ciprofloxacin (antibiotic) 500 milligrams (mg) once daily for 7 days. Record review revealed a progress note dated 3/8/2024 at 5:18 PM which states in part, .is having urinary pain from [his/her] foley .Foley cath [catheter] intact, drainage hematuria .Resident noted pulling at the tubing . Further review of the progress note revealed .Resident continued with leaning over in [his/her] wheelchair and at times, standing for urinary relief. Resident noted on the floor in front of his/her wheelchair . Record review lacked evidence that the antibiotic was ever administered to the resident in accordance with the physician's order. Further record review revealed that on 3/9/2024 at 6:19 AM, the resident was in his/her wheelchair at 5:30 AM, and at approximately 5:40 AM, the resident was found on the floor on the right side of his/her bed. The resident was noted to have a skin tear to his/her right hand, and was not answering or responding appropriately to questions. Staff called 911 and the resident was transferred to the hospital. Record review of a nursing progress note dated 3/10/2024 revealed the resident was admitted with a diagnosis of sepsis. Review of the resident's care plan failed to reveal evidence that a care plan was developed relative to the use of a Foley catheter. Further record review revealed the following: -there was no assessment completed relative to the Foley catheter as per the facility's policy -there is no order relative to the size and type of catheter as per the facility's policy upon admission, an order was not obtained until 3/4/2024 -there is no evidence that fluid intake was monitored between 2/24/2024 through 3/8/2024 -urinary output was documented only 4 times between 2/24/2024 through 3/3/2024 -there is no evidence that Foley catheter care was provided between 2/24/2024 through 3/3/2024 During a surveyor interview with the resident's primary care physician on 3/21/2024 at 2:20 PM, she revealed that when she orders the UTI protocol, her expectation is that staff would obtain vital signs every shift for 72 hours and encourage the resident to increase their fluid intake. The primary care physician further revealed that she would expect staff to follow a physician's order and administer the antibiotic as soon as possible and to notify her if the medication is unavailable as to ensure the resident receives the prescribed medication in a timely manner. During a surveyor interview with License Practical Nurse, Staff E, on 3/21/2024 at 2:30 PM, she revealed that Ciprofloxacin is available in the facility's emergency medication kit. Staff E further revealed when a medication is not available and not in the emergency medication kit, they can call the pharmacy for a stat delivery and usually get a delivery of the medication within a couple of hours. During a surveyor interview with the Acting Director of Nursing Services (DNS) on 3/22/2024 at approximately 1:00 PM, she acknowledged that there was not a care plan in place for the resident's Foley catheter. The Acting DNS further indicated that she would have expected the orders for the Foley catheter (size, flushing, changing bag, intake and out put as well as catheter care, etc) to be included in the care plan. Additionally, she revealed that her expectation is that physician orders for the UTI protocol to be implemented, would include a specific order to obtain vital signs every shift for 72 hours, despite this being part of the facility's UTI protocol. Furthermore, the Acting DNS acknowledged that the resident did not receive the prescribed antibiotic and was unable to explain why staff did not administer the medication as ordered when it was available in the facility's emergency medication kit. 2. Record review revealed Resident ID #2 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, cancer, and recurrent urinary tract infections. Record review revealed the resident has a care plan dated 2/14/2024 for .has a UTI . with an intervention including but not limited to .Temp [check temperature] q [every ] shift . Review of a nursing progress note dated 3/10/2024 revealed the resident continues to complain of a burning sensation with urination. Review of a nursing progress note dated 3/16/2024 revealed .Symptom of Urinary Tract Infection .still feeling burn on urination along with feeling pain inside . Further record review revealed new orders were obtained on 3/16/2024 including, but not limited to, Ciprofloxacin 500 mg once a day for 7 days. Record review failed to reveal evidence that his/her temperature was checked every shift as per the resident plan of care (31 out of 114 opportunities between 2/12/2024 through 3/22/2024). During a surveyor interview on 3/22/2024 at 11:16 AM, with the Acting DNS, she acknowledged that the resident's temperature was not checked every shift as per the plan of care. The Acting DNS was unable to provide evidence that the resident's V/S were obtained every shift for 72 hours, as per the facility's UTI Protocol. 3. Record review revealed Resident ID #4 was originally admitted to the facility in November of 2022 with diagnoses including, but not limited to, encephalopathy (damage or disease that affects the brain), and multiple fractures. Record review revealed the resident was transferred to the hospital and was re-admitted to the facility on [DATE] with diagnoses of a UTI, sepsis and a Foley catheter. Record review of the physician orders failed to reveal evidence of an order for a Foley catheter until 1/21/2024, despite the Foley catheter being in place since 12/20/2023. Further review of this order revealed that the resident's Foley catheter output was to be measured three times a day. Record review failed to reveal evidence that the resident's urine output was measured three times daily between 2/1/2024 through 3/10/2024 and that an order was not put in place until 3/11/2024 for the foley catheter indicating the size and type of catheter. Further record failed to reveal evidence that a care plan was developed relative to the use and the care of the Foley catheter. During a surveyor interview with the Acting DNS on 3/14/2024 at approximately 3:00 PM, she acknowledged the above findings and was unable to provide an explanation as to why there was not a care plan in place for the Foley catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/28/2024 alleges that on 2/22/2024 Resident ID #1's mail was opened prior to him/her receiving it. The resident approached the Administrator about it and told her that it was an invasion of his/her privacy and she said that it was her right. The resident became very upset and she then made a comment that she was going to egg [him/her] on to get [him/her] out of here because this is not a psych ward. The Administrator continued to antagonize the resident and 911 was called. The police and rescue showed up and the responding officer told the Administrator that he was shocked that she was behaving this way towards a resident. He recorded the events on his body camera. Record review revealed the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, parkinsonism and anxiety disorder. Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 out of 15, indicating the resident has moderately impaired cognition. Record review revealed the following progress notes: - 1/24/2024 at 4:15 PM, authored by Licensed Practical Nurse, Staff A, revealed that the resident was angry that his/her mail was opened and after speaking with the Social Worker and the Administrator the resident demanded to call the police along with the Department of Health. Staff A was able to deescalate the resident. - 2/22/2024 at 11:58 AM, authored by the Social Worker, indicated that Resident ID #1's mail was accidentally opened and s/he was very upset about the situation. The Social Worker was informed that the resident banged his/her fist on the counter and showed outward aggression toward staff. The police were called to deescalate the situation. During a surveyor interview with the resident on 2/29/2024 at 8:42 AM, s/he revealed that on 2/22/2024, his/her mail was brought to him/her already opened and s/he was mad and felt very bad about it being opened. S/he further revealed that when s/he questioned the Administrator related to his/her mail being opened the Administrator called the police. During a surveyor interview on 2/29/2024 at 9:47 AM with Licensed Practical Nurse, Staff A, she revealed that the resident's mail was delivered by activities staff, and it was already opened. She revealed that this was not the first time it has happened. She revealed that the resident became upset, the Administrator called 911, and the resident called the police. Review of an incident report from the Burrillville Police Department dated 2/22/2024 stated in part, .Prior to speaking with [the resident], I activated my BWC [Body Worn Camera]. [The resident] advised that [s/he] was upset that staff opened [his/her] mail without permission. Units were able to calm [him/her] down, where [s/he] became very apologetic about [his/her] behavior .I stepped out of the room to speak with the Building Administrator .She was advised that [the resident] was upset about [his/her] mail being opened without [his/her] permission. However due to [him/her] being calm and mentally stable, rescue personnel could not force [him/her] into going to the hospital. [The Administrator] immediately stepped away from the conversation and entered the room. She began questioning [him/her] about [his/her] behavior, asking, ' .are you going to behave?' [the resident] became very agitated with [the Administrator's] tone and line of questioning. At that time medical personnel and I advised [the Administrator] she was the one escalating the situation and needed to step away. She snapped back, stating, 'No, I am not escalating.' I advised her she was not asking [him/her] but telling [him/her] instead .[The Administrator] was not sure who opened [the resident's] mail, but added it was their policy to check [his/her] mail prior to [him/her] getting it . During a surveyor interview on 2/29/2024 at 2:28 PM with the Administrator, she revealed that she doesn't remember saying that to the resident and she doesn't think she was escalating the resident. She further revealed that if that's what the police report says then she is not sure. Additionally, she was unable to provide evidence that this resident was treated with respect and dignity in an environment that promotes maintenance of his/her quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview it has been determined that the facility failed to respect the residents right to personal privacy for 1 of 2 residents reviewed who receive mail at the facility, Resident ID #1. Findings are as follows: Review of a facility policy titled, Residents Rights undated, states in part, .15. You have the right to send and receive mail promptly and unopened . Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/28/2024 alleges that on 2/22/2024 Resident ID #1's mail was opened prior to him/her receiving it. The resident approached the Administrator about it and told her that it was an invasion of his/her privacy and she said that it was her right. The resident became very upset and she then made a comment that she was going to egg [him/her] on to get [him/her] out of here because this is not a psych ward. The Administrator continued to antagonize the resident and 911 was called. The police and rescue showed up and the responding officer told the Administrator that he was shocked that she was behaving this way towards a resident. He recorded the events on his body camera. Record review revealed that the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, parkinsonism and anxiety disorder. Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 out of 15, indicating the resident has moderately impaired cognition. Record review revealed the following progress notes: - 1/24/2024 at 4:15 PM, authored by Licensed Practical Nurse, Staff A, revealed that the resident was angry that his/her mail was opened and after speaking with the Social Worker and the Administrator the resident demanded to call the police along with the Department of Health. Staff A was able to deescalate the resident. - 2/22/2024 at 11:58 AM, authored by the Social Worker, indicated that Resident ID #1's mail was accidentally opened and s/he was very upset about the situation. The Social Worker was informed that the resident banged his/her fist on the counter and showed outward aggression toward staff. The police were called to deescalate the situation. During a surveyor interview with the resident on 2/29/2024 at 8:42 AM, s/he revealed that on 2/22/2024 his/her mail was brought to him/her already opened and s/he was mad and felt very bad about it being opened. S/he further revealed that when s/he questioned the Administrator related to his/her mail being opened, the Administrator called the police. During a surveyor interview on 2/29/2024 at 9:47 AM with Licensed Practical Nurse, Staff A, she revealed that the resident's mail was delivered by activities staff, and it was already opened. She revealed that this was not the first time it has happened. She revealed that the resident became upset, the Administrator called 911, and the resident called the police. During a surveyor interview with the Activity Aide, Staff B, on 2/29/2024 at 10:08 AM, she revealed that when she was passing the mail, the resident's mail was opened and that she knew that s/he was going to be mad. During a surveyor interview with the Administrator on 2/29/2024 at 10:20 AM, she revealed that she was called to the unit for the resident having an outburst. She revealed that she has opened the resident's mail in the past, but that she was unsure who opened it this time. Furthermore, she indicated that it was not her practice to open resident's mail. Review of an incident report from the Burrillville Police Department dated 2/22/2024 states in part, .[The Administrator] was not sure who opened [the resident's] mail, but added it was their policy to check [his/her] mail prior to [him/her] getting it . During a surveyor interview with the Administrator on 2/29/2024 at 2:28 PM, she was unable to provide evidence that the resident's right to personal privacy regarding his/her mail was respected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that resident's receive treatment and care in accordance with professional standards of practice, for 1 of 1 resident reviewed for an ordered dermatology consult, Resident ID #1. Findings are as follows: Record review revealed that the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, parkinsonism, anxiety disorder and psoriasis vulgaris (chronic skin disease which results in scaly, often itchy areas in patches). Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 out 15, indicating the resident has moderately impaired cognition. During a surveyor interview with the resident on 2/29/2024 at 8:42 AM, s/he revealed that s/he has been complaining about his/her skin for months and was told that s/he would be going to the dermatologist, however, s/he has not been yet. Further review of the record revealed the following: - 8/19/2023 at 2:15 PM, ADDED -To -Weekly Skin Check : Resident has scabs on top of left foot . Red , dry, scale on left sideburn and behind right ear. Resident told this writer It is a Psoriasis . It comes and goes . - 10/12/2023 at 11:40 AM, Dry Skin . - 11/17/2023 at 8:39 PM states in part, [the physician] in to see resident this evening. Resident [complaint] of dry lips, dry skin on [his/her] Hands .New orders per [the physician] as follow .Dermatology consult for hand eczema .Schedule Triamcinolone 0.5% BID [twice a day] for 7 days THEN BID PRN [as needed] . Record review of an emergency room Visit Note dated 1/17/2024 states in part, .Patient apparently called 911 on [his/her] own accord .[S/he] is alert and oriented for me as well as for EMS [emergency medical services]. [S/he] explained to EMS that [s/he] was not trying to call 911, rather [s/he] was trying to find somebody to talk about regarding being mistreated at [his/her] facility .[S/he] stated that [s/he] had a chronic rash .concerned that [s/he] has not had an appointment set up with dermatology for [his/her] chronic skin complaints . Record review revealed documentation dated 2/20/2024 at 11:12 AM which indicated, ADD-To-Body Check : .Both hands -dry and cracking -fingers along with both feet-toes-soles of the feet All dry areas washed, and dried well. Moisturizing lotion applied with resident's permission . During a surveyor interview on 2/29/2024 at 9:57 AM with Licensed Practical Nurse, Staff A, she revealed that the resident's hands are itchy and breaking down and was unsure if the resident went to the dermatologist. During a surveyor interview on 2/29/2024 at 10:28 AM with the resident's physician, Staff C, she revealed that she has spoken with the facility multiple times over the course of the resident's stay related to his/her skin and a need for a dermatology consult. She further revealed that she ordered one in November and is unsure as to why it has not been completed. Additionally, she revealed that the resident's skin is one of his/her biggest complaints and would have expected the resident to have been seen by a dermatologist as ordered. During a surveyor interview on 2/29/2024 at 11:47 AM with the Interim Director of Nursing Services, she revealed that the resident has not been seen by dermatology. Additionally, she was unable to provide evidence that the physician's order was followed related to a dermatology consult.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, it has been determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/28/2024 alleges that on 2/22/2024 Resident ID #1's mail was opened prior to him/her receiving it. The resident approached the Administrator about it and told her that it was an invasion of his/her privacy and she said that it was her right. The resident became very upset and she then made a comment that she was going to egg [him/her] on to get [him/her] out of here because this is not a psych ward. The Administrator continued to antagonize the resident and 911 was called. The police and rescue showed up and the responding officer told the Administrator that he was shocked that she was behaving this way towards a resident. He recorded the events on his body camera. Record review revealed the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, parkinsonism and anxiety disorder. Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 out of 15, indicating the resident has moderately impaired cognition. Record review revealed a progress note dated 2/22/2024 at 11:58 AM authored by the Social Worker which indicated that Resident ID #1's mail was accidentally opened, and s/he was very upset about the situation. The Social Worker was informed that the resident banged his/her fist on the counter and showed outward aggression toward staff. The police were called to deescalate the situation. During a surveyor interview with the resident on 2/29/2024 at 8:42 AM, s/he revealed that on 2/22/2024, his/her mail was brought to him/her already opened, s/he was mad and felt very bad about it being opened. S/he further revealed that when s/he questioned the Administrator related to his/her mail being opened, the Administrator called the police. During a surveyor interview on 2/29/2024 at 9:47 AM with Licensed Practical Nurse, Staff A, she revealed that the resident's mail was delivered by activities, and it was already opened. She revealed that this was not the first time it has happened. She revealed that the resident became upset, the Administrator called 911, and the resident called the police. Review of an incident report from the Burrillville Police Department dated 2/22/2024 stated in part, .Prior to speaking with [the resident], I activated my BWC [Body Worn Camera]. [The resident] advised that [s/he] was upset that staff opened [his/her] mail without permission. Units were able to calm [him/her] down, where [s/he] became very apologetic about [his/her] behavior .I stepped out of the room to speak with the Building Administrator .She was advised that [the resident] was upset about [his/her] mail being opened without [his/her] permission. However due to [him/her] being calm and mentally stable, rescue personnel could not force [him/her] into going to the hospital. [The Administrator] immediately stepped away from the conversation and entered the room. She began questioning [him/her] about [his/her] behavior, asking, ' .are you going to behave?' [the resident] became very agitated with [the Administrator's] tone and line of questioning. At that time medical personnel and I advised [the Administrator] she was the one escalating the situation and needed to step away. She snapped back, stating, 'No, I am not escalating.' I advised her she was not asking [him/her] but telling [him/her] instead .[The Administrator] was not sure who opened [the resident's] mail, but added it was their policy to check [his/her] mail prior to [him/her] getting it . During a surveyor interview on 2/29/2024 at 10:20 AM and 2:28 PM with the Administrator, she revealed that she was called to the unit for the resident having an outburst. She revealed that she has opened the resident's mail in the past, but that she was unsure who opened it this time. Furthermore, she indicated that it was not her practice to open resident's mail. When presented with the initial complaint she revealed she did not feel as though she was antagonizing the resident. When notified of the police report statement, she revealed that she doesn't remember saying that to the resident, she doesn't think she was escalating the resident and did not remember stating, .it was their policy to check [his/her] mail prior to [him/her] getting it . When notified that the police officer involved was wearing a body camera, she further revealed that if that's what the police report says then she is not sure. Additionally, the Administrator was unable to provide evidence that the facility was being administrated in a manner to ensure the highest practicable physical, mental, and psychosocial well-being of each resident was maintained.

Based on record review and staff interview, it has been determined that the facility failed to provide written notice of the facility's bed-hold policy to the resident or resident representative, prior to the transfer of the resident to the hospital, for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review revealed the resident was admitted to the facility in March of 2017 with diagnoses including, but not limited to major depressive disorder, visual hallucinations, low vision right eye, and blindness in left eye. Record review revealed the resident was transferred from the facility to the hospital on 2/19/2024. Record review failed to reveal evidence of a written bed-hold policy that was provided to the resident or the resident's representative. During a surveyor interview on 2/27/2024 at 10:30 AM with the Administrator, in the presence of the Director of Nursing Services, she was unable to provide evidence of a written notice of the facility's bed-hold policy being given to the resident or resident's representative. Cross reference: F 558 and F 684

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for falls, Resident ID #1. Findings are as follows: Record review of a document titled Falls Management states in part .A fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. Once the resident/patient is clinically evaluated as being stable, vital signs, neurological signs, range of motion, and evaluation of cognitive status will be documented . Record review revealed the resident was admitted to the facility in March of 2017 with diagnoses including, but not limited to major depressive disorder, visual hallucinations, low vision in the right eye and blindness in the left eye. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating s/he is cognitively intact. During a surveyor interview with the resident on 2/26/2024 at 12:20 PM, s/he revealed that s/he was approached by the Administrator in the weeks previous requesting that s/he change rooms, as the Administrator wanted to make his/her private room an isolation room. The resident refused as s/he explained to the Administrator that s/he is legally blind and had been in his/her current room for 5 years. S/he indicated to the Administrator that s/he was familiar with the layout of the environment and it would difficult to acclimate to a new room as s/he can't see. The resident further revealed during a brief hospital stay on 2/19/2024 s/he returned to the facility on 2/21/2024 to find his/her belonging from the private room were packed into boxes and moved into a semi private room without his/her permission. Additionally, s/he revealed that while in the new room s/he tripped over his/her belonging that were packed into the boxes and placed near his/her bed as s/he couldn't see them as s/he was unfamiliar with the new environment. The resident indicated to the surveyor that his/her knees were sore from the fall. Record review failed to reveal evidence that a post fall assessment was completed after the fall. During a surveyor interview on 2/27/2024 at 9:50 AM, with Licensed Practical Nurse, Staff A, she revealed that she was familiar with the resident and regularly cared for him/her. When the surveyor questioned Staff A about the fall she revealed that she was unaware that a fall had occurred. During a surveyor observation immediately following the above interview, Staff A, assessed the resident for injuries indicated to the surveyor that the resident's right knee appeared swollen and she would get the Medical Director as she was in the building. The Medical Director came to the room and assessed the resident and indicated that the resident did not appear to have a current injury. During a surveyor interview with the Medical Director on 2/27/2024 at 10:20 AM, she revealed that she was unaware the resident sustained a fall, until it was brought to her attention that day by Staff A. Record review failed to reveal evidence that a documented assessment had been completed by the physician and or nurse after an assessment was performed in the presence of this surveyor on 2/27/2024 at approximately 10:20 AM. During a surveyor interview with the Administrator on 2/27/2024 at 11:25 AM, she revealed that she was made aware on 2/23/2024 that the resident sustained a fall as s/he tripped over the boxes in his/her semi private room on 2/21/2024. She was unable to explain why the resident was not assessed for injury once she was made aware of the resident's fall on 2/23/2024. She was unable to provide evidence that a completed fall assessment including vital signs, neurological signs, range of motion and evaluation of cognitive status were completed per the facility policy. Cross Reference: F 558 and F 625

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds, relative to petty cash. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities dated 2/3/2023, states in part, Residents should have access to petty cash on an ongoing basis and be able to arrange for access to larger funds. Although the facility need not maintain $100.00 ($50.00 for Medicaid residents) per resident on its premises, it is expected to maintain petty cash on hand to honor resident requests . Record review of a community reported complaint sent to the Rhode Island Department of Health on 1/3/2024, alleges that the resident's do not have access to their funds in a timely manner and the accounts are not up to date. Record review of Funds Balance Report for 1/8/2024 revealed, that the facility manages personal funds for 30 residents equaling a total amount of $11,119.49. During a surveyor telephone interview on 1/8/2024 at approximately 3:00 PM with the Administrator, she revealed that the residents have not had access to their funds because the Business Office/Human Resource Manager is on medical leave. However, she indicated that she, and the charge nurse have access to the residents' personal funds box and can access it if needed. During a surveyor observation and simultaneous interview on 1/8/2024 at approximately 3:30 PM with the acting Director of Nursing Services (DNS) and the Infection Control Preventionist (ICP), the residents' personal funds box was observed to contain only change, equaling approximately $3.50, at which time the DNS and ICP acknowledged that there was not a reasonable amount of petty cash readily available for the residents to access.

**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 an ongoing program which includes group activities and/or one-on-one visits (1:1), on 1 of 4 units reviewed for activities for residents with cognitive impairment that resided on the Subacute Unit, including those residents that were admitted on the unit and recently discharged , Resident ID #s 1, 2, 3, 4 and 5. Findings are as follows: Review of the facility document titled, RECREATION POLICIES/PROCEDURES with a revision date of 9/2015, states in part, I. PURPOSE The facility provides a recreation program suited to the abilities, needs, and interests of each individual resident in effort to encourage resumption and maintenance of normal activities .The recreation program is designed to improve and maintain the physical and mental health of each resident through individual and group activities. Interdisciplinary resident care planning sessions act as the medium whereby each resident's specific care plan is designed. II. PROVISION OF SERVICES Recreational activities are designed to contribute to the achievement of the long and short-term goals established for each resident. Activities are designed to take into consideration both ambulatory and non-ambulatory residents and takes place both inside and outside the facility .Provisions are made by the Recreation staff in accordance with the resident's level of participation .Participation in these activities are documented in a timely manner . III. GOAL OF SERVICE The goal of this department is to assist each resident in the resumption of normal activities and maintain the optimal level of psychosocial functioning. In order to achieve this, a wide and diversified leisure service program has been developed based on the needs and personal interests of each resident. These leisure services encompass a versatile scope of activities that promote the cultural, spiritual, social, intellectual, and physical growth and fulfillment of each resident . IV. DEPARTMENTAL OBJECTIVES 1. To evaluate each resident's needs and interests within seven days of admission, and identify measures to meet these needs. 2. To maintain accurate daily attendance records on each resident's progress and use these notes as a reference for accurately assessing each resident's Recreation Plan . 3. To provide leisure activities that promote the cultural, spiritual, social, intellectual, and physical growth and fulfillment of each resident. 4. To assist each resident in planning and achieving their own leisure pursuits . VII. DOCUMENTATION A. admission Process Recreation is advised that a new resident has been admitted .Recreation staff review the admission Face Sheet .interview and assess the individual as to interest areas and the development of a Recreational Plan with short term goals . B. admission Evaluation - Recreation Plan . The Initial Recreation plan includes: 1. Background information 2. Interests and hobbies, special skills/interests, leisure/cultural activities and religious affiliation . During a surveyor interview with the Administrator on 11/30/2023 at 9:23 AM, she revealed the majority of the residents' residing on the Subacute Unit have a diagnosis of dementia. Record review of the facility bed listing on 12/1/2023 revealed there were 8 residents currently residing on the Subacute Unit and 2 residents had been recently discharged . During a surveyor interview on 12/1/2023 at 4:14 PM and again on 12/6/2023 at approximately 1:30 PM with Licensed Practical Nurse, Staff D, she revealed she works 4-5 days a week on the Subacute Unit. Additionally, she revealed there are no group activities or 1:1 activities on the Subacute Unit for the residents. During surveyor observations of the Subacute Unit on the following dates and times failed to reveal any activities being conducted on the unit: 11/30/2023 at 3:05 PM to 3:20 PM, 3:35 PM 12/1/2023 at 11:13 AM and 4:14 PM 12/4/2023 at 11/37 AM, 12:08 PM to 12:27 PM, 1:35 PM, at approximately 3:15 PM, and 4:50 PM 12/6/2023 at approximately 9:00 AM and approximately 11:00 AM Record review for Resident ID #1 revealed an annual Minimum Data Set (MDS) assessment dated [DATE], within Section F-Preferences for Customary Routine and Activities revealed an interview was conducted by staff with the resident, with the question asked, While you are at the facility ., which revealed it is somewhat important to have books, newspapers, magazines to read, listen to music that I like, be around animals and pets, keep up with the news, do things with groups of people, do your favorite activities, go outside to get fresh air when the weather is good, and participate in religious services. Record review of Resident ID #1's current comprehensive care plan dated 6/24/2023 revealed s/he is a Veteran of the Navy, enjoys watching sports, Grit, and the news on T.V., listening to oldies music, religious programs, dogs, and favorite holiday is Christmas. Further review of the care plan revealed a goal for him/her to participate in preferred activities daily over the next review. Interventions revealed a date of 6/22/2021 which include, include in current events groups, invite to religious programs according to denomination, pet visits or animal therapy when available as desired, post a calendar of facility activities where it is accessible to the resident, provide in room visits by staff , as desired. Additionally, review of the care plan failed to reveal any additional intervention(s) since 6/22/2021. Record review for Resident ID #2 revealed an admission MDS assessment dated [DATE], within Section F-Preferences for Customary Routine and Activities revealed an interview was conducted by staff with the resident, with the question asked, While you are at the facility ., which revealed it is very important to have books, newspapers, magazines to read, listen to music that I like, keep up with the news, do things with groups of people, do your favorite activities, go outside to get fresh air when the weather is good, and participate in religious services. Record review of Resident ID #2's comprehensive care plan failed to reveal evidence that a care plan relative to activities was developed. Record review for Resident ID #3 revealed an admission MDS assessment dated [DATE], within Section F-Preferences for Customary Routine and Activities revealed an interview was conducted by staff with the resident, with the question asked, While you are at the facility ., which revealed it is very important to have books, newspapers, magazines to read, be around animals such as pets, and it is somewhat important to listen to music that I like, do things with groups of people and participate in religious services. Record review of Resident ID #3's comprehensive care plan failed to reveal evidence that a care plan relative to activities was developed. Record review for Resident ID #4 revealed an annual MDS assessment dated [DATE] within Section F-Preferences for Customary Routine and Activities revealed an interview was conducted by staff with the resident's family or significant other, with the question asked, While you are at the facility ., which revealed it is somewhat important to have books, newspapers, magazines to read, listen to music that I like, be around animals such as pets, keep up with the news, do things with groups of people, do your favorite activities, go outside to get fresh air when the weather is good, and participate in religious services. Record review of Resident ID #4's care plan dated 7/6/2023 revealed s/he is a veteran of the Marines, enjoys rock & roll music, dogs, old cars & motorcycles. Further review of the care plan revealed a goal for him/her to engage in independent and preferred leisure pursuits daily. Interventions revealed a date of 12/19/2022 which include, bring outdoors when the weather is good, check in on a daily basis to ensure that s/he has materials desired, convenient access, supportive assistance, and transportation as needed, offer calendar and review some of the programs available, and pet visits or animal therapy when available as desired. Additionally, review of the care plan failed to reveal any additional intervention(s) since 12/19/2022. Record review for Resident ID #5 revealed an annual Minimum Data Set assessment dated [DATE] within Section F-Preferences for Customary Routine and Activities revealed an interview was conducted by staff with the resident, with the question asked, While you are at the facility ., which revealed it is very important to have books, newspapers, magazines to read, listen to music that I like, be around animals such as pets, keep up with the news, do things with groups of people, do your favorite activities, go outside to get fresh air when the weather is good, and participate in religious services. Record review of Resident ID #5's care plan dated 9/16/2023 revealed s/he enjoys going outdoors to smoke, eating Italian food, dirt bikes, listening to classic rock music, black lab dogs, sweet & salty snacks, and the 4th of July is his/her favorite holiday. Further review of the care plan revealed a goal for him/her to engage in independent and preferred leisure pursuits daily. Interventions revealed a date of 10/12/2022 which include, check in on a daily basis to ensure that Resident ID #5 has materials desired, convenient access, supportive assistance, and transportation as needed, offer calendar and review some of the programs and available materials and equipment available, offer social, recreational one-one visits, as desired, pet visits or animal therapy when available as desired. Additionally, review of the care plan failed to reveal any additional intervention(s) since 10/12/2022. Surveyor observation on 12/4/2023 from 12:08 PM to 12:27 PM of the Subacute Unit, revealed a November activities calendar was posted in all of the residents' rooms, except for Resident ID #6's room, which had an October activities calendar posted. During a surveyor interview on 12/4/2023 at 11:40 AM with Resident ID #5, s/he was observed sitting in his/her recliner watching television. When asked by this surveyor what activities does the unit have, s/he responded, pretty much nothing, I go out and have a few cigarettes. During a surveyor interview on 12/4/2023 at 4:50 PM with Nursing Assistant, Staff E, she revealed there are never any activities on this unit. Additionally, she could not recall how long exactly, but she revealed it has been this way for approximately 2 months. During a surveyor interview on 12/6/2023 at 11:37 AM with Licensed Practical Nurse, Staff F, when asked about the activities on the Subacute Unit, she revealed there are no group activities or 1:1 activities on the Subacute Unit for the residents and there hasn't been since September of this year. During a surveyor interview on 12/4/2023 at 4:28 PM with the Administrator, she acknowledged there are no activities on the Subacute Unit for those residents. Additionally, she revealed the Activities Director was hired in September of this year and she indicated it is the Activities Director that develops the residents' activity care plans. Lastly, she was unable to provide evidence that the care plan interventions were reviewed, revised or updated for Resident ID #s 1, 4 and 5 and she was unable to provide evidence of an activity care plan for Resident ID #s 2 and 3. During a surveyor interview on 12/6/2023 at 9:13 AM with the Activities Director, she revealed she was recently hired in September of 2023 and she was not aware that it was her responsibility to develop the residents' care plans relative to activities. Further, she was unable to explain how to update each residents' care plan, but rather states she writes a progress note weekly in their records. Further, she was unable to provide evidence of a weekly progress note written for the residents' mentioned above, evidence of 1:1 activities for the residents, or provide an activities care plan for Resident ID #2 and 3. Additionally, she revealed a priest visits the residents monthly, but she acknowledged that spiritual services are not provided for the residents that reside on the Subacute Unit. Lastly, she revealed she does not have a specific calendar of activities geared for the residents who reside on the Subacute Unit.

Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program for all newly hired employees, consistent with their expected roles, relative to orientation education involving abuse, dementia and behavioral health management per the facility assessment, for 4 of 5 newly hired employees, Staff G, H, I, and J. Findings are as follows: According to the Facility Assessment, dated 4/13/2023, which states in part, Existing Competency process (Type and Time Frames i.e , on hire, quarterly, annually) .Dementia- Orientation .Behavioral Management .Abuse . Record review revealed Registered Nurse (RN), Staff G, was hired on 10/24/2023. Additionally, her personnel file failed to reveal evidence that she received education or training upon hire relative to abuse, dementia and behavioral health management. Record review of RN, Staff H, was hired on 11/6/2023. Additionally, her personnel file failed to reveal evidence that she received education or training upon hire relative to abuse, dementia and behavioral health management. Record review of Licensed Practical Nurse (LPN), Staff I, was hired on 9/14/2023. Additionally her personnel file failed to reveal evidence that she received education or training upon hire relative to abuse, dementia and behavioral health management. Record review of Nursing Assistant (NA), Staff J, was hired on 10/2/2023. Additionally her personnel file failed to reveal evidence that she received education or training upon hire relative to abuse, dementia and behavioral health management. During a surveyor interview on 12/1/2023 at 2:50 PM with Staff G, she revealed that she did not receive training or education relative to abuse, dementia or behavioral health management upon hire. During a surveyor interview on 12/1/2023 at 3:10 PM with Staff H, she revealed that she was hired recently in November of 2023 and she did not receive training or education relative to abuse, dementia or behavioral health management upon hire. Additionally, she revealed that on 11/30/2023 she had to call the facility consultant services to refer a resident for a psychiatric evaluation and during the call she was informed about the facility's referral system process, by the consultant services team. During a surveyor interview on 12/4/2023 at 1:20 PM with the Human Resource Director, she revealed that, upon hire, staff are given a training packet and she retains a signed copy of the completed trainings. Additionally, she revealed there is no formal orientation or training, but rather the employees are to read the education packet and complete the test. Lastly, she was unable to provide evidence that Staff G, H, I or J received training or education relative to abuse, dementia and behavioral health management. During a surveyor interview on 12/4/2023 at 3:10 PM with the Administrator, she revealed the orientation process should be organized by the Human Resource Director. She further explained that the management team should all have a part of the education/training. Additionally, the Administrator was unable to provide evidence that staff G, H, I and J received education or training upon hire involving abuse, dementia and behavioral health management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview, it has been determined that the facility failed to ensure residents are free from neglect for 11 of 14 residents reviewed, Resident ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11. Findings are as follows: Record review of a facility reported incident received by the Rhode Island Department of Health on 9/9/2023 states in part, On 9/9/23 when [staff] came on shift they noted a strong odor of urine, which is not the norm for us . Record review of a facility policy titled, Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention last revised on 3/16/2023, states in part, .Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient/resident care and services to assure care is provided as required . During a surveyor interview on 9/12/2023 at approximately 9:00 AM with the Director of Nursing Services (DNS), she revealed that a contracted agency employee, Nursing Assistant (NA), Staff A, was assigned to work the Birch unit on 9/8/2023 from 11:00 PM to 7:00 AM. She further revealed that on the morning of 9/9/2023 when first shift staff arrived on the Birch unit at approximately 7:00 AM, it was noted that 10 of the 14 residents were found to be saturated in urine and 2 of those 10 residents were incontinent of feces. 1a) Record review revealed Resident ID #1 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, unspecified dementia and Parkinson's disease. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed s/he is frequently incontinent of bladder and bowel and requires an extensive assist of 1 person for toileting. Record review of a written statement dated 9/12/2023 authored by NA, Staff B, states in part, .[Resident ID #1] was laying in bed saturated [in urine] Resident also stated no one had changed [him/her] . Record review of a written statement dated 9/9/2023 authored by NA, Staff C, states in part, .I walked into [Resident ID #1's] room and found resident saturated in urine. [His/her] clothes, chucks, and bed were a amber color . 1b) Record review revealed Resident ID #2 was admitted to the facility in September of 2020 with a diagnosis including, but not limited to, Alzheimer's disease. Record review of an MDS assessment dated [DATE] revealed s/he is always incontinent of bladder and bowel and requires total dependence and a two person assist for toileting. Record review of a facility document states in part, .[Resident ID #2] saturated through [his/her] linens with urine dripping onto the floor . 1c) Record review revealed Resident ID #3 was admitted to the facility in January of 2015 with diagnoses including, but not limited to, personal history of traumatic brain injury and mild cognitive impairment. Record review of an MDS assessment dated [DATE] revealed s/he is always incontinent of bladder and bowel and requires total dependence and a one person assist for toileting. Record review of a facility document states in part, .[Resident ID #3] saturated through [his/her] linens and stated 'no one came in the whole night' . 1d) Record review revealed Resident ID #4 was admitted to the facility in February of 2021 with diagnoses including, but not limited to, unspecified dementia and Parkinson's disease. Record review of an MDS assessment dated [DATE] revealed s/he is always incontinent of bladder and bowel and requires total dependence and a one person assist for toileting. Record review of a facility document states in part, .[Resident ID #4] was found in a full bed saturated with urine and feces . 1e) Record review revealed Resident ID #5 was admitted to the facility in April of 2023 with a diagnosis including, but not limited to, need for assistance with personal care. Record review of an MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Additionally, s/he is always incontinent of bladder and bowel and requires total dependence and a two person assist for toileting. Record review of a written statement dated 9/12/2023 authored by NA, Staff B, states in part, .[Resident ID #5] stated no one changed [him/her] and [Staff A] told nurse resident refused when [s/he] did not. Record review of a facility document states in part, .[Resident ID #5] stated 'no one checked on me all night'. [S/he] was also completely saturated in urine . During a surveyor interview on 9/12/2023 at 11:31 AM with the resident, s/he revealed the nurse came in to administer early morning medications and told him/her the NA would be in soon to change him/her. The resident further revealed s/he awoke after 7:00 AM realizing his/her brief was wet and nobody had come to change him/her. 1f) Record review revealed Resident ID #6 was admitted to the facility in July of 2023 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease. Record review of an MDS assessment dated [DATE] revealed s/he requires limited assistance of one person for toileting. Record review of a care plan problem area dated 7/21/2023 revealed a baseline care plan for activities of daily living (ADLs) with an intervention including, but not limited to, assisting the resident with ADLs as needed. Record review of a progress note dated 9/4/2023 at 9:08 PM revealed in part that the resident is continent of bladder and bowel. Record review of a facility document states in part, .[Resident ID #6] was dry; however, [s/he] stated 'no one helped me all night to the bathroom' . 1g) Record review revealed Resident ID #7 was admitted to the facility in February of 2023 with a diagnosis including, but not limited to, adult failure to thrive. Record review of an MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. Additionally, s/he is frequently incontinent of bladder and bowel and requires an extensive assist of one person for toileting. Record review of a facility document states in part, .[Resident ID #7] was found saturated in urine through [his/her] linens . During a surveyor interview on 9/12/2023 at 11:21 AM with the resident, s/he revealed a few days ago s/he awoke and was soaked to the skin and recalled nobody came in to change him/her that night. 1h) Record review revealed Resident ID #8 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, adult failure to thrive and need for assistance with personal care. Record review of an MDS assessment dated [DATE] revealed s/he is frequently incontinent of bladder and bowel and requires an extensive assist of one person for toileting. Record review of a facility document states in part, .[Resident ID #8] was saturated in urine . 1i) Record review revealed Resident ID #9 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, unspecified dementia, need for assistance with personal care, and adult failure to thrive. Record review of an MDS assessment dated [DATE] revealed s/he is always incontinent of bladder and bowel and requires an extensive assist of two people for toileting. Record review of a facility document states in part, .[Resident ID #9] saturated in [his/her] urine . 1j) Record review revealed Resident ID #10 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, need for assistance with personal care and adult failure to thrive. Record review of an MDS assessment dated [DATE] revealed s/he is always incontinent of bladder and bowel and requires total dependence of one person for toileting. Record review of a facility document states in part, .[Resident ID #10] saturated in urine through [his/her] brief. [S/he] is usually not a heavy wetter . 1k) Record review revealed Resident ID #11 was admitted to the facility in February of 2021 with a diagnosis including, but not limited to, unspecified dementia. Record review of an MDS assessment dated [DATE] revealed s/he is occasionally incontinent of bladder and bowel and requires limited assistance of one person for toileting. Record review of a facility document states in part, .[Resident ID #11] was found soiled in [his/her] urine and feces . During a surveyor interview on 9/12/2023 at 10:14 AM with Licensed Practical Nurse (LPN), Staff D, she revealed she was the nurse scheduled to work the following morning on 9/9/2023 at 7:00 AM. She further revealed while walking down the Birch unit hallway, the stench of urine was so overwhelming, she was able to smell it through her N-95 respirator mask. Additionally, she indicated two of her NA's approached her and informed her that the residents were not cared for on the shift prior and she contacted the DNS. During a surveyor interview on 9/12/2023 at 10:35 AM with Staff A, she acknowledged she was the NA assigned to work the Birch unit on 9/8/2023 on the 11:00 PM to 7:00 AM shift. She revealed she changed all the residents on the Birch unit at almost 2:00 AM. Additionally, she claims to have checked the residents again at 5:00 AM and changed only the incontinent residents as the rest were dry, but could not recall the names of the residents she provided care to at that time. Furthermore, she indicated she worked the unit as the only NA and did not ask for help from any other staff members because she felt she did not need it. Telephone calls were made to both nurses that worked the Birch unit on 9/8/2023 from 11:00 PM to 7:00 AM, LPN's, Staff E and Staff F, at 12:41 PM and 12:43 PM, respectively. A voice message was left. No return call was received. During a surveyor interview on 9/12/2023 at approximately 9:00 AM with the DNS, she revealed that on the 11:00 PM to 7:00 AM shift, staff are expected to conduct rounds and perform incontinence care for the residents when they come on for their shift, and twice more at 1:30 AM and 5:30 AM. She was unable to provide evidence that the residents received the necessary care and services and kept free from neglect. Additionally, as a result of this survey, Staff A was referred to the state licensing board.

Based on record review and staff interview it has been determined that the facility failed to ensure that residents are free from significant medication errors for 2 of 3 residents reviewed related to medication delivery, Resident IDs #1 and 2. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 8/11/2023 alleges in part, Patient [Resident ID #1] was discharged to SNF [skilled nursing facility] on 8/8 on IV [intravenous] antibiotics. SNF was notified in the referral about the antibiotic and accepted patient. Two days later, patient sent back to the ED [emergency department] at [hospital] and had not received the antibiotic since discharge. Informed due to price, the SNF would not obtain the med and asked the resident to pay out of pocket which [s/he] could not afford. 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. 1.Record review revealed that Resident ID #1 was admitted to the facility in August of 2023 with a diagnosis including, but not limited to, Cryptococcal Meningitis (an infection and inflammation of the meninges, which are the membranes that cover the brain and spinal cord caused by fungi). Record review revealed a physician's order dated 8/9/2023 for Flucytosine 500 milligrams (MG), (a medication used for treatment of meningitis) administer four capsules (2,000 mg) by mouth every six hours. Record review of the Medication Administration Record (MAR) dated August 2023, revealed that Resident ID #1's Flucytosine order was documented as not administered due to the drug being unavailable on the following dates and times: 8/9/2023 12:00 AM 8/9/2023 6:00 AM 8/9/2023 12:00 PM 8/10/2023 12:00 AM 8/10/2023 6:00 AM 8/10/2023 12:00 PM During a surveyor interview on 8/15/2023 at 12:55 PM with the Director of Nursing Services, she was unable to provide evidence that the Flucytosine was administered as ordered. During a surveyor interview on 8/15/2023 at 1:42 PM with the Pharmacist, he revealed that the pharmacy had nine bottles of the Flucytosine available for order. Additionally, he revealed that if the medications were ordered by the facility there would be a one-day time frame for delivery. He further reveled that the facility would need to approve the medication prior to ordering it, related to the high cost of the medication. However, approval was not received from the facility. During a surveyor interview on 8/15/2023 at 3:31 PM with the physician, she revealed she would expect the facility to have ordered and administered the medication to the patient as soon as possible but not later than noon the day after the patient is admitted . 2. Record review revealed that Resident ID #2 was admitted to the facility in July of 2023 with a diagnoses including, but not limited to, pulmonary hypertension and chronic respiratory failure. Record review revealed a physician's order dated 7/25/2023 for Revatio 20 mg (a medication used for the treatment of pulmonary hypertension) administer one tablet by mouth three times per day. Record review of the July 2023 MAR revealed that Resident ID #2's Revatio order was documented as not administered due to the drug being unavailable on 7/26/2023 for the scheduled dose at 5:00 AM -7:00 AM. Additional review of the physician's orders revealed that the medication was discontinued on 7/26/2023 at 2:20 PM by Registered Nurse, Staff A. Additional record review failed to reveal evidence that the physician provided an order to discontinue the Revatio medication on 7/26/2023. During a surveyor interview on 8/15/2023 at approximately 3:00 PM, with the Director of Nursing Services, she was unable to provide evidence that the resident received his/her Revatio for the above-mentioned dose on 7/26/2023. Additionally, she was unable to provide evidence of a physician's order to discontinue the Revatio medication on 7/26/2023. During a surveyor interview on 8/15/2023 at approximately 3:20 PM, with Staff A, she revealed that she did not recall discontinuing the Revatio medication. During a surveyor interview on 8/15/2023 at 3:31 PM with the Physician, she revealed she could not recall providing an order to discontinue the Revatio medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with eating during meals, for 1 of 3 residents reviewed, Resident ID #34. Findings are as follows: Review of the resident's record revealed s/he was admitted to the facility in November of 2021 with diagnoses including, but not limited to, cerebral infarction (stroke) and dementia. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a Brief Interview for Mental Status score of 2 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed the resident requires limited assistance of one staff member for eating. Surveyor observations of the resident during meal times revealed the following: - 7/11/2023 at 9:22 AM, observed alone in his/her room with scrambled eggs on his/her shirt, no breakfast tray in front of him/her - 7/11/2023 at 12:35 PM, observed in the dining room eating lunch without staff assistance, spilling pasta with sauce down the front of his/her shirt - 7/12/2023 at 9:12 AM, observed alone in room, laying in bed with French toast and sausage on his/her chest, with no breakfast tray in front of him/her During a surveyor interview with Registered Nurse, Staff A, on 7/13/2023 at 9:06 AM, she acknowledged that the resident is receiving his/her meals without staff assistance and frequently spills food on his/her clothing. She was unable to provide evidence that the resident was receiving assistance with feeding or that a clothing protector was being provided to him/her. During a surveyor interview with the Director of Nursing Services on 7/13/2023 at 10:55 AM, she revealed she would have expected the resident to be eating in the dining room with assistance and not in his/her room alone.

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality relative to following a physician's order for a fluid restriction for 1 of 1 resident reviewed, Resident ID #213. Findings are as follows: Review of the facility policy titled FLUID RESTRICTIONS states in part, Policy: Restricted fluid intake will be maintained for an individual resident, as ordered by the physician, as part of a treatment protocol for certain medical conditions .Maintain accurate Intake .Document, as necessary, the resident's compliance with the fluid restriction, and notify MD [Medical Doctor] if any issues . Record review revealed Resident ID #213 was admitted to the facility in July of 2023 with diagnosis including, but not limited to, acute respiratory failure. Record review of the Continuity of Care form dated 6/29/2023 revealed that the resident has severe aortic stenosis (a condition that prevents the aortic valve from opening properly) with a plan for strict intake and output including a 1200 milliliters (mL) fluid restriction. Record review revealed a physician's order dated 7/3/2023 for a 1.2 liter (1200 milliliters, mL) fluid restriction. Record review of the resident's fluid intake revealed the following entries: - 7/12/2023 8:33 PM Fluids: 600 mL - 7/12/2023 2:07 PM Fluids: 1500 mL - 7/11/2023 1:16 PM Fluids: 1000 mL - 7/7/2023 11:55 AM Fluids: 480 mL Record review failed to reveal documentation for the resident's fluid intake on 7/3/2023, 7/4/2023, 7/5/2023, 7/6/2023, 7/8/2023, 7/9/2023, 7/10/2023 and failed to reveal complete documentation of his/her fluid intake for all meals and medication passes for 7/7/2023 and 7/11/2023. During several surveyor observations of the resident on the following dates and times revealed: - 7/11/2023 at 12:38 PM a cranberry juice full, approximately 240 mL, and water cup on a tray from the medication pass approximately 140 mL of water - 7/12/2023 at 12:32 PM a 240 mL cup of fluid on the bedside table - 7/13/2023 at 8:48 AM a 240 mL plastic coffee cup, a 240 mL juice, approximately 140 mL cup of water empty from the medication pass, and approximately 340 mL cup left at the resident's bedside. During a surveyor interview on 7/13/2023 at 8:48 AM with the resident, s/he revealed s/he is aware of the fluid restriction of 1200 mL and acknowledged that staff provide his/her drinks, but s/he is unaware of how much is in each cup for him/her to calculate. During a surveyor interview on 7/13/2023 at 9:08 AM with Registered Nurse (RN), Staff A, she acknowledged the order does not specify how much fluid to administer for each meal or how much fluid to administer with the medication pass. She further revealed that the order should indicate that. Additionally, she acknowledged that the above mentioned days were not documented for fluid intake. Furthermore, the physician was not notified that the resident consumed 900 mL over the ordered fluid restriction on 7/12/2023. During a surveyor interview on 7/13/2023 at 10:42 AM with the Director of Nursing Services she acknowledged the order did not indicate the amount of fluid to administer to the resident with the medication pass or with each meal. Additionally, she would expect the staff to document the amount of fluid consumed by the resident per shift including fluids consumed with meals and during the medication pass. Furthermore, she would expect that the physician would be notified if the resident went over his/her fluid restriction. During a surveyor interview on 7/13/2023 at 2:30 PM with the physician, she revealed she would expect the staff to follow the fluid restriction as ordered and to be notified if the resident consumed more fluid than the allotted amount.

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 for 1 of 1 resident reviewed relative to the failure to administer an as needed blood pressure medication, Resident ID #20. Findings are as follows: Record review revealed that Resident ID #20 was admitted to the facility in April of 2021 with a diagnosis including, but not limited to, hypertension (high blood pressure). An additional diagnosis was added to the resident's record in May 2023 for hypertensive urgency (defined as a blood pressure of more than 180/120. The normal blood pressure is 120/80). Record review revealed a physician's order dated 6/12/2023 for Hydralazine (a medication to regulate blood pressure) administer 25 milligrams (mg) daily as needed for systolic blood pressure (pressure in your arteries when your heart beats) above 180 or diastolic blood pressure (pressure in your arteries between each heartbeat) above 100. Record review revealed the resident's blood pressures on the following dates: - 6/13/2023 195/76 - 6/14/2023 186/80 - 6/15/2023 185/78 - 6/17/2023 186/77 - 6/18/2023 184/74 - 6/18/2023 185/97 - 6/18/2023 220/80 - 6/19/2023 188/70 - 6/19/2023 190/70 - 6/21/2023 182/60 - 6/21/2023 188/70 - 6/22/2023 185/68 - 7/3/2023 188/72 - 7/5/2023 188/72 - 7/6/2023 186/68 - 7/8/2023 182/60 - 7/9/2023 182/82 Record review failed to reveal evidence that the Hydralazine was administered to the resident on the above dates as per the physician's order. During a surveyor interview on 7/13/2023 at 10:51 AM with the Director Nursing Services, she was unable to provide evidence that the as needed medications was administered as ordered. During a surveyor interview on 7/13/2023 at 2:29 PM with the physician she revealed would expect the staff to have administered the medication when the blood pressure is greater than 180.

**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 residents environment remains as free from accident hazards as possible for 1 of 1 resident reviewed, Resident ID #34. Findings are as follows: Record review revealed that Resident ID #34 was admitted to the facility in November of 2021 with diagnoses including, but not limited to, cerebral infarction (stroke) and dementia. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed that the resident requires limited assistance of one staff member for eating. Record review of the resident's care plan last revised on 5/13/2023 revealed that the resident has been noted to put inedible items in his/her mouth. Further review of the care plan revealed an intervention that includes, but not limited to, no styrofoam cups with meals, remove paper wrapping from food items. During multiple surveyor observations of the resident on the following dates and times revealed: - 7/11/2023 at 12:35 PM s/he had drinks in 2 Styrofoam cups with plastic covers and straws. - 7/12/2023 at 9:12 AM s/he was lying in bed with a Styrofoam cup with a plastic lid on his/her bedside table. - 7/12/2023 at 9:52 AM s/he was lying in bed with a Styrofoam cup at his/her bedside. - 7/13/2023 at 8:46 AM s/he was lying in bed, eating alone, and had 2 Styrofoam cups at his/her bedside. - 7/13/2023 at 9:06 AM s/he was eating alone in his/her room with 2 Styrofoam cups unattended. During a surveyor interview on 7/13/2023 at 9:15 AM with Registered Nurse, Staff A, she acknowledged that the resident received Styrofoam cups . Additionally, she acknowledged that the care plan indicates that the resident should not have Styrofoam cups because s/he puts them in his/her mouth. During a surveyor interview on 7/13/2023 at 10:55 AM with the Director of Nursing Services, she was unable to provide evidence that the facility kept the resident's environment as free from accident hazards as possible related to the resident receiving Styrofoam cups on the above-mentioned dates and times.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections relative to following contact precautions for 1 of 2 residents reviewed, Resident ID #47. Findings are as follows: Record review of a facility policy titled, TITLE: Guidelines for Management of MDROs [Multi-drug resistant organism] states in part, .Vancomycin resistant enterococci [VRE] .bacteria usually found in the bowel .VRE is spread by direct patient-to-patient via transient carriage on the hands of personnel or indirect contact on contaminated surfaces or equipment .can persist for weeks on environmental surfaces .Contact Precautions should be considered and would be indicated for .MDRO urinary tract infection or colonization . Record review revealed that Resident ID #47 was admitted to the facility in April of 2023 with a diagnosis including, but not limited to, urinary tract infection. Record review of a progress note dated 7/10/2023 at 1:14 AM revealed that the resident was receiving intravenous antibiotics for VRE in his/her urine and is on precautions. During a surveyor observation on 7/11/2023 at approximately 12:00 PM revealed a bin of personal protective equipment and signage posted outside the resident's door that stated, CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry .Put on gown before room entry . During a surveyor observation on 7/11/2023 at 12:05 PM revealed a Social Worker, Staff G, present in the resident's room without a gown or gloves on. Additionally, she was observed in direct contact with the resident's bedside table while engaging in conversation with the resident. Furthermore, she exited the room at 12:18 PM and did not perform hand hygiene and proceeded down the hallway passing 2 hand sanitizer dispensers before she was stopped by the surveyor. During a surveyor interview on 7/11/2023 at approximately 12:20 PM following the above observation with Staff G, she acknowledged that she did not don a gown or gloves prior to entering the resident's room. Additionally, she acknowledged that she did not perform hand hygiene after exiting the resident's room. During a surveyor interview on 7/12/2023 at 12:30 PM with the Director of Nursing Services, she acknowledged that the resident is on contact precautions for VRE in his/her urine. She further acknowledged that Staff G should have donned a gown and gloves prior to entering the resident's room and performed hand hygiene prior to exiting. She was unable to provide evidence that the facility maintained proper infection control practices.

Based on record review and staff interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 1 resident reviewed related to an as needed blood pressure medication, Resident ID #20. 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 that Resident ID #20 was admitted to the facility in April of 2021 with a diagnosis including, but not limited to, hypertension (high blood pressure). An additional diagnosis was added to the resident's record in May 2023 for hypertensive urgency (defined as a blood pressure of more than 180/120. The normal blood pressure is 120/80). Record review revealed a physician's order dated 6/12/2023 for Hydralazine (a medication used to lower blood pressure) administer 25 milligrams (mg) daily as needed for systolic blood pressure (pressure in your arteries when your heart beats) above 180 or diastolic blood pressure (when your heart is at rest) above 100. Record review revealed the resident's blood pressures on the following dates: - 6/13/2023 195/76 - 6/14/2023 186/80 - 6/15/2023 185/78 - 6/17/2023 186/77 - 6/18/2023 184/74 - 6/18/2023 185/97 - 6/18/2023 220/80 - 6/19/2023 188/70 - 6/19/2023 190/70 - 6/21/2023 182/60 - 6/21/2023 188/70 - 6/22/2023 185/68 - 7/3/2023 188/72 - 7/5/2023 188/72 - 7/6/2023 186/68 - 7/8/2023 182/60 - 7/9/2023 182/82 Further record review failed to reveal evidence that hydralazine was administered to the resident on the above dates per the physician's order. During a surveyor interview on 7/13/2023 at 10:51 AM, with the Director of Nursing Services, she acknowledged the medication parameters and documented vital signs. She was unable to provide evidence that the Hydralazine was administered as ordered. During a surveyor interview on 7/13/2023 at 2:29 PM with the physician, she revealed she would expect the staff to have administered the medication when the resident's systolic blood pressure was greater than 180.

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 2 of 2 medication storage rooms. Findings are as follows: Record review of a facility policy titled, POLICY: MEDICATION STORAGE states in part, .Discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed. Record review of a facility policy titled, POLICY: MEDICATION ADMINISTRATION states in part, 7. Expired medications are to be properly discarded. Medications are labeled and expiration dates are checked regularly. 1. Record review revealed that Resident ID #34 was admitted to the facility in November of 2021 with a diagnosis including, but not limited to, dementia. Record review revealed a physician's order dated 6/22/2023 for Ativan Intensol 2 milligrams per milliliter (mL) administer 0.125 mL for agitation/restlessness/anxiety every 8 hours as needed. During a surveyor observation of the long-term medication storage room on 7/13/2023 at 9:24 AM in the presence of Registered Nurse, Staff D, revealed an opened bottle of Ativan Intensol for Resident ID #34 with an expiration date of 5/9/2023. Record review of the June and July 2023 Medication Administration Records (MAR) revealed that the resident was administered the expired Ativan Intensol on the following dates: - 6/14 - 6/25 - 6/26 - 7/3 - 7/9 During a surveyor interview on 7/13/2023 at 9:24 AM following the above observation with Staff D, she acknowledged that the Ativan was expired and should be discarded. 2. Record review revealed Resident ID #214 was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, altered mental status. Record review revealed a physician's order dated 7/11/2023 for Tubersol solution(an injectable protein used to determine if you have tuberculosis; a serious lung infection) inject 0.1 mL one time. Surveyor observation of the sub-acute medication storage room on 7/13/2023 at 8:11 AM in the presence of Licensed Practical Nurse, Staff E, revealed an opened bottle of Tubersol solution with an expiration date of 6/30/2023. Record review of the July 2023 MAR revealed that the resident was administered the expired Tubersol solution on 7/11/2023. During a surveyor interview on 7/13/2023 at 8:11 AM with Staff E, she acknowledged that the Tubersol solution was expired and should be discarded. Additionally, she revealed that she administered the expired Tubersol solution to the resident on 7/11/2023. During a surveyor interview on 7/13/2023 at 9:35 AM with the Director of Nursing Services, she revealed that the expired medications should have been discarded and not used for the residents.