Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide services that meet professional standards of practice for 1 of 1 resident observed relative to wound care, Resident ID #23. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed the resident was admitted to the facility with diagnoses including, but not limited to, dementia and skin cancer. Record review revealed a physician's order dated 1/6/2025, to cleanse the open area to the left side of the face with normal saline (NS), pat dry, apply A&D ointment (a treatment used to treat minor skin irritations), followed by a non-adhesive pad and a transparent dressing, once daily. Review of the Treatment Administration Record (TAR) revealed the treatment order was signed off as completed on 2/3 and 2/4/2025. During a surveyor observation of the resident on 2/5/2025 at 3:09 PM, the dressing to the left side of his/her face revealed the initials EJS with a date of 2/3. During a surveyor observation of the resident on 2/5/2025 at 3:13 PM in the presence of Registered Nurse, Staff A, she acknowledged the dressing to his/her face was dated 2/3, with the initials EJS. Staff A removed the dressing to the resident's face and the wound bed was observed to be approximately 1.5 centimeters (cm) x 1.5 cm and there was a light yellow drainage observed in the wound bed and on the dressing. During a surveyor interview on 2/5/2025 at 3:10 PM with Licensed Practical Nurse (LPN), Staff B, he revealed that he worked on the evening of 2/3/2025, but he did not work on 2/4/2025. Additionally, he confirmed that the initials EJS were his initials and that he completed the dressing change on 2/3/2025. During a surveyor interview on 2/5/2025 at 3:13 PM with Staff A, she acknowledged although the TAR indicates that the treatment to the resident's face was signed off as completed on 2/4/2025 by LPN, Staff C, the dressing was dated 2/3/2025 with Staff B's initials, indicating that the treatment was not completed on 2/4/2025. During a surveyor observation of the resident on 2/5/2025 at 3:29 PM in the presence of Staff A and Staff B, they acknowledged the resident had a dressing on his/her right elbow with a date of 2/1. Additionally, when Staff B removed the resident's elbow dressing, a bruise was noted with an approximate size of 4.5 cm x 4.5 cm and a small, scabbed area was adjacent to the bruise. Record review failed to reveal evidence of a physician's order for a treatment to the right elbow. Further review failed to reveal evidence of any documentation indicating a skin impairment to the resident's right elbow. During a surveyor interview with the Director of Nursing Services on 2/5/2025 at the time of the observation, she revealed that she was not aware of the bruise and scab to the resident's elbow. Additionally, she revealed staff should have notified the resident's physician and obtained a treatment order for the right elbow. Further, she could not provide evidence that the dressing to the left side of the resident's was completed, as ordered on 2/4/2025.

Based on record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed with a respiratory illness, Resident ID #13. Findings are as follows: Review of an undated facility policy titled, Practice for Change in Condition states in part, .Suspected Respiratory Illness .follow physician orders .test as ordered .follow order set for [positive] + virus .follow respiratory event orders .all other respiratory illness follow respiratory event and order set .document . Record review revealed Resident ID #13 was readmitted to the facility with a diagnosis including, but not limited to, asthma. Record review of a chest x-ray completed on 1/28/2025 indicated the resident had pneumonia. Record review of the physician's orders revealed an order, with a start date of 1/29/2025 for Levaquin (an antibiotic prescribed to treat infections), 500 mg daily for 10 days. Record review failed to reveal evidence that a Respiratory Event document was completed for the resident once s/he was diagnosed with pneumonia. Additional review of the record failed to reveal any order sets to follow for the resident, per facility policy. During a surveyor interview on 2/4/2025 at 11:38 AM with Registered Nurse, Staff E, she acknowledged that a Respiratory Event document was not completed for the resident when s/he was diagnosed with pneumonia on 1/28/2025, as per the facility's policy. Staff E revealted that a Respiratory Event document triggers for physician orders that include; obtaining a temperature, oxygen saturation levels, to assess lung sounds every shift and to document the findings in the progress notes until the antibiotics are completed. Record review of a Respiratory Event document completed by Staff E on 2/4/2025, after it was brought to her attention by the surveyor, indicates the following physician's orders: - obtain oxygen saturation levels, temperature, and lung sounds every shift and document under progress notes. Additional record review failed to reveal evidence that a care plan was developed for pneumonia. During a surveyor interview on 2/4/2025 at 12:26 PM with Registered Nurse, Staff F, she acknowledged that a care plan had not developed for the resident relative to his/her diagnosis of pneumonia. During a surveyor interview on 2/4/2025 at 12:03 PM with the Director of Nursing Services (DNS), she revealed that the Respiratory Event document should have been completed for the resident when s/he was diagnosed with pneumonia and that s/he should have had his/her temperature, oxygen saturation level and lung sounds assessed every shift. Additionally, the DNS acknowledged that a care plan was not developed for pneumonia.

**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 the appropriate treatment and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents reviewed with a diagnosis of dementia, Resident ID #23. Findings are as follows: Record review revealed the resident was admitted to the facility with a diagnosis including, but not limited to, dementia. Record review of a Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 0 out of 15, indicating s/he has severe cognitive impairment. Record review revealed a physician's order dated 8/2/2024, to administer Trazodone (a medication prescribed to treat depression and other conditions determined by health care providers) 25 milligrams (mg) by mouth prior to morning care. Further review revealed the Trazodone is scheduled to be administered between 7:00 AM to 9:00 AM daily. Record review revealed a physician's order dated 1/17/2025 for Trazodone 25 mg by mouth every 8 hours PRN (as needed) for restlessness, anxiety, irritability, or inconsolable crying. During a surveyor observation of the resident on 2/4/2025 at approximately 11:00 AM, s/he was observed lying in his/her bed quietly with his/her eyes closed. Nursing Assistant (NA), Staff G, was observed entering the resident's room shortly after and drew the curtain closed. At 11:15 AM, the resident was overheard crying and sobbing in his/her room while Staff G was assisting the resident. Staff G opened the curtain, the resident was now observed sitting in a shower chair (a chair used to transport residents and shower them in) crying and sobbing. Record review of the Medication Administration Record (MAR) revealed the resident received his/her standing order for Trazodone 25 mg at 8:03 AM on 2/4/2025. Further review of the MAR failed to reveal evidence that the resident received a PRN dose of Trazodone on 2/4/2025 for his/her crying. During a surveyor interview on 2/5/2025 at 2:34 PM with Registered Nurse (RN), Staff E and RN, Staff A, they revealed that they both worked during the day on 2/4/2025. Additionally, both Staff A and Staff E revealed that they were not made aware that the resident was crying that morning. If they had been made aware, they would have administered the resident his/her PRN Trazodone. During a surveyor interview on 2/5/2025 at 3:39 PM with Staff G, she revealed that she provided morning care for the resident on 2/4/2025 and that the resident was crying out during care, she tried to console the resident but s/he would not stop crying. Staff G further revealed that she did not notify any of the nurses that the resident was crying, because this was common behavior for the resident. During a surveyor interview on 2/5/2025 at 2:54 PM with the Director of Nursing Services, she revealed that she would have expected the NA to notify the nurse when the resident was crying so that the resident could have received his/her PRN Trazodone, as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents observed during the use of a glucose meter to obtain a blood sugar, Resident ID #s 52 and 48, for 1 of 1 resident observed during a dressing change, Resident ID #179 and for 1 of 1 resident receiving an inhaler, Resident ID #278. Findings are as follows: 1. Review of the facility's policy titled CLEANING AND DISINFECTING THE [glucose] METER, provided to the surveyor on 2/5/2025, revealed two disposable wipes are needed for the meter, one wipe for cleaning and the second wipe for disinfecting the meter. 1a. Record review revealed Resident ID #52 was admitted to the facility with a diagnosis including, but not limited to, diabetes. Record review revealed a physician's order dated 6/25/2024 to administer Admelog SoloStar insulin per the sliding scale, before meals and at bedtime. During a surveyor observation on 2/4/2025 at 11:02 AM revealed Licensed Practical Nurse (LPN), Staff D using the glucose meter to obtain the resident's blood sugar. Staff D then placed the used meter on top of the treatment cart without cleaning and disinfecting the glucose meter. Staff D removed her gloves and performed hand hygiene and then touched the used glucose meter again. Staff D continued to touch multiple items and surfaces including the treatment cart, computer, the computer mouse and a set of keys prior to cleaning the meter. Further observation revealed Staff D cleaned the glucose meter using only 1 disposable wipe and not 2, per the facility's policy. Additionally, Staff D failed to clean and disinfect the top of the treatment cart, the computer, the computer mouse, and keys. 1b. Record review revealed Resident ID #48 was admitted to the facility with a diagnosis including, but not limited to, diabetes. Record review revealed a physician's order dated 4/24/2024 to obtain a fingerstick blood sugar (FSBS) twice daily, 6:00 AM and 12:00 PM. During a surveyor observation on 2/4/2025 at 11:16 AM revealed LPN, Staff D using the glucose meter to obtain the resident's FSBS. Staff D then placed the used meter on top of the treatment cart without cleaning and disinfecting the glucose meter. Staff D removed her gloves and performed hand hygiene and then touched the used glucose meter again. Staff D continued to touch multiple items and surfaces including the treatment cart, computer, the computer mouse. Further observation revealed Staff D cleaned the glucose meter using only 1 disposable wipe and not 2, per the facility's policy. Additionally, Staff D failed to clean and disinfect the top of the treatment cart, the computer, the computer mouse. During a surveyor interview on 2/5/2025 at 12:36 PM with the Education Coordinator, she revealed that she would have expected Staff D to follow the facility policy and use 2 disposable wipes to clean and disinfect the glucose meter. She further revealed that she would have expected Staff D to disinfect the glucose meter after obtaining the resident's blood sugar and to disinfect the top of the medication cart, the computer and the computer mouse after handling the used glucose meter. 2. Review of the facility document titled, Competency Validation for A Clean Dressing Change revealed the following procedure actions which include, but are not limited to: -wash hands and don (put on) disposable clean gloves -remove old dressing -dispose the soiled dressing in a waterproof bag -clean the area as per the physician's order, discard contaminated material into the waterproof bag -remove gloves and perform hand hygiene -prepare sterile or clean dressing supplies as appropriate -don clean gloves -apply dressing and fasten the dressing a. Record review revealed Resident ID #179 was admitted to the facility with diagnoses including, but not limited to, stroke, gastrostomy tube (g-tube, a tube that is inserted into the stomach through the abdominal wall to provide nutritional support, medication and hydration) and two stage 4 ulcers (the most serious pressure ulcer that extends below the subcutaneous fat into deep tissues, including muscle, tendons, and ligaments) to the coccyx and left ankle. Record review revealed a physician's order dated 12/2/2024 to cleanse the area around the G-tube site and to change the dressing daily and as needed. During a surveyor observation of the dressing change on 2/5/2025 at 9:55 AM with LPN, Staff D, she removed the old dressing from the G-tube site then with the same used gloves, she proceeded to clean the g-tube site with Normal Saline (NS), dried the skin and then applied the drainage gauze dressing. Staff D failed to remove the used gloves and perform hand hygiene after removing the old g-tube dressing and prior to applying the new treatment and dressing. b. Record review for Resident ID #179 revealed a physician's order dated 1/22/2025, to cleanse the stage 4 left lateral ankle wound with NS, pat dry, apply collagen (treatment that promotes wound healing), then apply Hydrofera blue (absorbent dressing) moistened with NS, and cover the area with a bordered gauze dressing daily. During a surveyor observation of of the dressing change with Staff D on 2/5/2025 at 10:05 AM, she removed the old dressing, which had a small amount of yellow and green drainage, from the resident's left ankle. While wearing the same used gloves, she proceeded to clean the wound with NS, pat the wound dry, apply the collagen and the Hydrofera blue, and lastly apply the bordered gauze dressing to the wound. Staff D failed to remove the used gloves and perform hand hygiene after cleaning the wound and prior to applying the new treatment and dressing. c. Record review for Resident ID #179 revealed a physician's order dated 1/22/2025, to cleanse the coccyx wound with NS, pat dry, apply collagen, then apply Hydrofera blue moistened with NS, and cover the area with a foam dressing daily. During a surveyor observation of the dressing change with Staff D on 2/5/2025 at 10:14 AM, she cleansed the wound with NS, patted the wound dry and did not change her gloves or perform hand hygiene before applying the collagen, Hydrofera blue treatments, or the foam dressing to the wound. During a surveyor interview on 2/5/2025 at 12:08 PM with the Director of Nursing Services (DNS), she acknowledged that Staff D should have removed her gloves and washed her hands after she removed the old dressings from the g-tube site and the left ankle. The DNS further revealed that Staff D should have removed her gloves and washed her hands after cleaning the g-tube site, left ankle, and coccyx wounds and before applying a new treatment and dressing. 3. During the medication administration pass on 2/2/2025 at 11:08 AM with Medication Technician, Staff I, she was observed preparing to administer Resident ID #268 his/her inhaler. A sign was observed affixed to the wall outside of the resident's room, indicating the resident's roommate was on Contact Precautions (a means to prevent transmission of infections through direct contact by wearing personal protective equipment such as a gown and gloves when performing care). Staff I donned a gown and gloves and proceeded to enter the resident's room with his/her inhaler to administer the medication. Staff I administered the inhaler and then placed the inhaler on the only bureau in the room. She then removed her gown and gloves, removed the inhaler from the bureau, exited the room and placed the inhaler on top of the medication cart. Staff I performed hand hygiene, then removed the inhaler from the top of the cart and placed the inhaler in its box and into the med cart drawer, without disinfecting the inhaler and without disinfecting the medication cart. During a surveyor interview immediately following the observation with Staff I, she revealed that she should have placed a barrier down prior to placing the resident's inhaler on the bureau. Additionally, she acknowledged she should have cleaned the inhaler prior to returning it to the cart. During a surveyor interview on 2/4/2025 at approximately 12:00 PM with the DNS, she revealed that Staff I should have used a barrier prior to placing the inhaler down on the resident's bureau. Additionally, she acknowledged that Staff I should have disinfected the inhaler prior to placing it back to the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving sexual abuse are thoroughly investigated for 1 of 2 residents reviewed, Resident ID #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 7/5/2024 alleges in part, that Resident ID #1 reported to the Physical Therapy Assistant, Staff A, that Nursing Assistant (NA), Staff B, touched him/her inappropriately. Resident ID #1 reported that Staff B was on top of him/her with his clothes on. Record review revealed that the resident was admitted to the facility in February of 2024 with diagnoses including, but are not limited to, dementia, Alzheimer's disease, and anxiety disorder. Record review of the quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 9 out of 15, indicating that s/he had moderately impaired cognition. Review of Physical Therapy Assistant, Staff A's, daily skilled note dated 7/4/2024 revealed that during a physical therapy session, the resident had asked her if she knows Nursing Assistant (NA), Staff B. Additionally, the note indicated that Staff B jumped on top of Resident ID #2 while s/he was in bed, but s/he told him s/he is not interested. Staff A revealed after finishing her therapy session with Resident ID #2 she went to work with Resident ID #1. At this time Resident ID #1 also reported a sexual allegation by Staff B. She indicated that at this time she went and reported both sexual allegations of Resident ID #s 1 and 2 to the charge nurse. During a surveyor interview on 7/12/2024 at approximately 10:30 AM with Staff A, she revealed that on 7/4/2024 at 10:30 AM, during a physical therapy session, Resident ID #2 reported to her that Staff B was weird because he had tried to come on to him/her during the previous overnight shift. Additionally, Staff A indicated that she did not immediately report this allegation. Record review failed to reveal evidence that the allegation of sexual abuse by Staff B to Resident ID #2 was investigated by the facility. During a surveyor interview on 7/12/2024 at 10:36 AM with the Administrator, he was unable to provide evidence that the sexual allegation made by Resident ID #2 against Staff B was thoroughly investigated and then reported to the State Survey Agency in accordance with State law.

**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 events that do not involve abuse and do not result in serious bodily injury (i.e. accident resulting in hospitalization admission, elopement) were reported to other officials (Department of Health), in accordance with State law for 1 of 1 resident reviewed for elopement, Resident ID #1. Findings are as follows: According to [NAME] Department of Health State Regulations for Nursing Facilities, 1.15.G, indicates that any elopement of an resident that results in the police being called must be reported in writing to the licensing agency within 24 hours or by the end of the next business day. Record review of a community reported complaint sent to the Rhode Island Department of Health on 3/6/2024 alleges that on 3/3/2024, a resident eloped from the nursing home. A neighbor allegedly alerted the police. Record review revealed that the resident was admitted to the facility in February of 2024 with diagnoses including, but are not limited to, dementia with psychotic disturbances, Alzheimer's disease, and anxiety disorder. Record review of his/her admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 out of 15, indicating moderately impaired cognition. During a surveyor interview with the complainant on 3/7/2024 at 1:30 PM, he indicated that on the morning of 3/3/2024, he heard his doorbell ring and observed someone standing on his front steps. He asked what his/her name was, but he was unable to understand what the resident was saying. He realized that s/he must have been a resident of the neighboring nursing home, so he attempted to call the facility, but the phone was busy, so he called the police to alert them of the resident's presence on his property. He then indicated that Nursing Assistant, Staff A, showed up at his house and she transported the resident back to the facility with police presence. During a surveyor interview with Staff A on 3/7/2024 at 11:09 AM she revealed that on 3/3/2024 she was passing the breakfast trays when the charge nurse told her to go to the neighbor's house and bring a resident back. She further revealed that Resident ID #1 was found at a neighbor's house, located one street behind the nursing facility. She further acknowledged that she assisted in transporting the resident back to the facility in her car while the police followed. During a surveyor interview on 3/7/2024 at 10:10 AM and at 2:15 PM with the Administrator, he acknowledged that he didn't report the elopement of Resident ID #1 to the Department of Health in accordance with State law as required.

**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 care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices relative to assessment and implementation of the bowel protocol for 7 of 20 residents reviewed, Resident ID #s 9, 26, 42, 54, 68, 71, and 189. Findings are as follows: Review of a facility provided policy titled, Bowel Protocol states in part, It is the policy of the facility to manage each resident's bowel function in order to promote regular, voluntary, controlled bowel evacuation of normal consistency . Further review of the policy revealed the following protocol: 1. Two days without bowel movement on day 3: 7-3 offer prune juice as ordered. 2. Two days without bowel movement day 3: 3-11 offer MOM [Milk of Magnesia] as ordered, if no bowel movement. 3. Three days without bowel movement day 4:7-3 offer Bisacodyl tabs as ordered, with no bowel movement. 4. Three days without bowel movement day 4: 3-11 offer Bisacodyl Suppository as ordered, with no bowel movement. 5. Four days without bowel movement day 5: 7-3 offer fleet enema as ordered. 6. After final implementation of protocol, call the physician and notify the family, if no bowel movement. 1. Record review revealed that Resident ID #71 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, adult failure to thrive and weight loss. Review of a Quarterly MDS assessment dated [DATE] revealed that s/he is frequently incontinent of his/her bowels and requires substantial to maximum assistance with toileting. Review of the bowel movement record revealed that s/he had a bowel movement on 2/14/2024 and then a small bowel movement was recorded on 2/18/2024. Additional record review revealed that a small bowel movement was recorded on 2/19/2024 and then not again until 2/21/2024. During a surveyor interview on 2/21/2024 at 11:20 AM with Resident ID #71 s/he revealed that s/he has not had a bowel movement in 6 days. Additionally, s/he revealed that s/he was extremely uncomfortable and requested to have a fleet enema. During a surveyor interview on 2/22/2024 at 11:22 AM with the Director of Nursing Services (DNS) she revealed that a recorded small bowel movement is not adequate, and the bowel protocol should be initiated as ordered regardless of a small bowel movement. Review of the physician's orders revealed the following: -90 ml prune juice give on day 2 with no bowel movement. -Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml on day 2 if no bowel movement. -bisacodyl tablet, delayed release 5 mg, administer 10mg (2 tabs), give on day 3 if no bowel movement. -bisacodyl suppository 10 mg administer once a day as needed for constipation - polyethylene glycol powder; 17gram/dose administer once a day as needed for constipation -Fleet Enema administer on day 3 of no bowel movement Review of the February 2024 MAR revealed that the resident did not receive milk of magnesia as ordered on 2/17/2024 or a bisacodyl tablet or suppository on 2/18/2024 per the facility bowel protocol. Additional review of the MAR revealed the resident received a fleet enema on 2/19/2024 without any results. Further review revealed that the resident received a fleet enema on 2/21/2024 after the surveyor questioned staff about the resident's previous request for one. Additional record review failed to reveal evidence that a physician was notified following administration of a fleet enema without adequate results on 2/19/2024. 2. Record review revealed that Resident ID #9 was admitted to the facility in January of 2022 with diagnoses including, but not limited to, chronic pain and chronic respiratory failure. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that s/he is occasionally incontinent of his/her bowels and requires substantial to maximum assist with toileting. Review of the bowel movement record revealed s/he had a bowel movement on 2/7/2024 and not again until 2/11/2024, 4 days without a bowel movement. Further review revealed that s/he had a bowel movement on 2/11/2024 and then not again until 2/16/2024, 5 days without a bowel movement. Review of the physician's orders revealed the following: -90 milliliter (ml) prune juice give on day 2 with no bowel movement. -Milk of Magnesia suspension; 400 milligram 9 mg/5 ml, administer 30 ml on day 2 if no bowel movement. - bisacodyl tablet, delayed release 5 mg, administer 10 mg (2 tabs), give on day 3 if no bowel movement. -bisacodyl suppository 10 mg administer once a day as needed for constipation. -Fleet Enema administer on day 3 of no bowel movement. Review of the February 2024 Medication Administration Record (MAR) failed to reveal evidence that the facility administered any of the above medications as ordered although the resident did not have a bowel movement for 4 days between 2/7/2024 and 2/11/2024. Additional review of the MAR failed to reveal evidence that any of the above medications were administered as ordered although the resident did not have a bowel movement for 5 days between 2/12/2024 and 2/16/2024. 3. Record review revealed that Resident ID #26 was admitted to the facility in July of 2022 with diagnoses including, but not limited to, dementia and protein calorie malnutrition. Review of a Quarterly MDS assessment dated [DATE] revealed that s/he is frequently incontinent of his/her bowels and requires substantial to maximum assist with toileting. Review of the bowel movement record revealed that s/he had a bowel movement on 2/16/2024 and then not again until 2/21/2024, 5 days between bowel movements. Review of the physician's orders revealed the following: -90 ml prune juice give on day 2 with no bowel movement. -Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml on day 2 if no bowel movement. -bisacodyl tablet, delayed release 5 mg, administer 10 mg (2 tabs), give on day 3 if no bowel movement. -polyethylene glycol powder; 17 gram/dose administer once a day as needed for constipation. Review of the February 2024 MAR failed to reveal evidence that milk of magnesia was administered to the resident on 2/19/2024 per the bowel protocol. Further review of the MAR failed to reveal evidence that polyethylene glycol powder was provided to the resident for constipation. 4. Record review revealed that Resident ID #42 was admitted to the facility in March of 2022 with diagnoses including, but not limited to, Alzheimer's disease and hypertension. Review of an Annual MDS assessment dated [DATE] revealed s/he is occasionally incontinent of his/her bowels and requires moderate assistance with toileting. Review of the bowel movement record revealed that s/he had a bowel movement on 2/15/2024 and then not again until 2/20/2024, 5 days without a bowel movement. Review of the physician's orders revealed the following: -90 ml prune juice give on day 2 with no bowel movement. -Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml on day 2 if no bowel movement. -bisacodyl tablet, delayed release 5 mg, administer 10 mg (2 tabs), give on day 3 if no bowel movement. -Fleet Enema administer on day 3 of no bowel movement. Review of the February 2024 MAR failed to reveal evidence that the facility administered any of the above medication as ordered although the resident did not have a bowel movement for 5 days. 5. Record review revealed that Resident ID #54 was admitted to the facility in January of 2021 with diagnoses including, but not limited to, Parkinson's disease and chronic constipation. Review of a Quarterly MDS assessment dated [DATE] revealed s/he is occasionally incontinent of his/her bowels and requires substantial to maximum assist with toileting. Review of the bowel movement record revealed that s/he had a bowel movement on 2/14/2024 and then not again until 2/20/2024, 6 days without a bowel movement. Review of the physician's orders revealed the following: -90 ml prune juice give on day 2 with no bowel movement. -Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml on day 2 if no bowel movement. -bisacodyl suppository 10 mg administer once a day as needed for constipation. -Fleet Enema administer of day 3 of no bowel movement. -lactulose solution; 10 gram/15 ml administer 15 ml twice a day as needed for constipation. Record review of the February 2024 MAR revealed that s/he was not administered prune juice or milk of magnesia on 2/17/2024 per the bowel protocol. Further review of the MAR revealed that Bisacodyl 10 mg oral was administered on 2/17/2024 and 2/19/2024 without effect. The MAR failed to reveal evidence that a bisacodyl suppository or fleet enema were utilized per the bowel protocol. 6. Record review revealed that Resident ID #68 was admitted to the facility in May of 2022 with diagnoses including, but not limited to, dementia and heart failure. Review of a Quarterly MDS assessment dated [DATE] revealed that s/he is frequently incontinent of his/her bowels and requires substantial to maximum assist with toileting. Review of the bowel movement record revealed that s/he had a documented bowel movement on 2/15/2024 and then not again until 2/20/2024, 5 days without a bowel movement. Review of the physician's orders revealed the following: -90 ml prune juice give on day 2 with no bowel movement. -Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml on day 2 if no bowel movement. -bisacodyl suppository 10 mg administer once a day as needed for constipation. -Fleet Enema administer of day 3 of no bowel movement. -lactulose solution; 10 gram/15 ml administer 15 ml twice a day as needed for constipation. Review of the February 2024 MAR failed to reveal evidence that the facility administered any of the above medications as ordered although the resident did not have bowel movements for 5 days. 7. Record review revealed that Resident ID #189 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, Alzheimer's disease and chronic kidney disease. Review of an admission MDS assessment dated [DATE] revealed s/he is occasionally incontinent of his/her bowels and requires substantial to maximum assist with toileting. Review of the bowel movement record revealed that s/he had a bowel movement on 2/16/2024 and then not again until 2/20/2024. Review of the physician's orders revealed the following: -90 ml prune juice give on day 2 with no bowel movement. -Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml on day 2 if no bowel movement. -bisacodyl tablet, delayed release 5 mg, administer 10 mg (2 tabs), give on day 3 if no bowel movement. -bisacodyl suppository 10 mg administer once a day as needed for constipation -Fleet Enema administer on day 3 of no bowel movement Review of the February 2024 MAR failed to reveal evidence that the facility administered any of the above medications as ordered although the resident did not have a bowel movement for 4 days. During a surveyor interview on 2/22/2024 at 11:22 AM with the DNS. she acknowledged that the bowel protocol was not followed for the above residents. The DNS was unable to provide evidence that the facility provided care in accordance with professional standards of practice relative to initiating the bowel protocol. During a surveyor interview on 2/23/2024 at 10:13 AM with the Nurse Practitioner she revealed that she would expect the staff to follow the bowel protocol as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the Clinical Consultant Pharmacist identified irregularities during the monthly pharmacist Medication Regimen Review (MRR) for 1 of 5 residents reviewed for unnecessary medications, Resident ID #38. Findings are as follows: Record review revealed that the resident was re-admitted to the facility in December of 2022 with diagnoses including, but not limited to, vascular dementia with other behavioral disturbance and generalized anxiety disorder. Record review revealed a progress note dated 9/1/2023 which states in part, New orders .Increase buspirone [medication used to treat anxiety] to 15 mg [milligrams] po [by mouth] bid [twice daily] . Record review revealed a physician order dated 9/1/2023 and discontinued 2/21/2024, which states, buspirone tablet; 15 mg; Amount to Administer: 1 tablet =15 mg; oral Frequency: Once a morning Special Instructions: 15mg PO BID. Review of the Medication Administration Records from September 2023 through February 2024, revealed the resident was receiving busprione, 15mg, once daily. Record review revealed the following dates a MRR was completed: - 9/16/2023 - 10/7/2023 - 11/8/2023 - 12/12/2023 - 1/6/2024 - 2/15/2024 Further record review failed to reveal evidence that any irregularities were identified during the above listed MRRs. Although the buspirone order contained a transcription error for once daily rather than twice as ordered. During a surveyor interview on 2/21/2024 at 11:36 AM, with the Minimum Data Set (MDS) Coordinator, Registered Nurse, Staff A, she acknowledged the buspirone order was transcribed inaccurately and indicated the error should have been identified by the pharmacy during their monthly reviews. During a surveyor interview on 2/22/2024 at 10:32 AM, with the Director of Nursing Services, she was unable to provide evidence that the facility ensured that the Clinical Consultant Pharmacist identified irregularities during the monthly pharmacist Medication Regimen Reviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview it has been determined that the facility failed to ensure that residents are free from significant medication errors for 4 out 18 residents reviewed for medication administration, Resident ID #s 9, 38, 187, and 188. Findings are as follows: Review of the facility policy titled Medication Administration; Lower Level indicates that some medications require specific administration times. Those times will be specified in the Medication Administration Record. 1a. Record review revealed Resident ID #38 was re-admitted to the facility in December of 2022 with diagnoses including, but not limited to, vascular dementia with other behavioral disturbance and generalized anxiety disorder (GAD). Record review revealed a progress note dated 9/1/2023 which states in part, New orders .Increase buspirone [Buspar, a medication used to treat anxiety] to 15 mg [milligrams] po [by mouth] bid [twice daily] . Record review revealed a physician order dated 9/1/2023, which states, buspirone tablet; 15 mg; Amount to Administer: 1 tablet =15 mg; oral Frequency: Once a morning Special Instructions: 15mg PO BID. Review of the Medication Administration Records from September 2023 through February 2024, revealed the resident was receiving busprione, 15mg, once daily. Review of a psychiatric evaluation dated 9/26/2023 states in part, .Chief Complaint .Increased agitation, yelling out, confusion .Pt [patient] has been receiving the following psych meds: Buspar 15mg po 2 times a day .CONTINUE Buspar 15mg po 2 times a day for GAD . Record review failed to reveal evidence that the resident's buspirone order was increased to two times a day, after the recommendation was initially made on 9/1/2023. During a surveyor interview on 2/21/2024 at 11:36 AM, with the Minimum Data Set Coordinator, Registered Nurse, Staff A, she acknowledged the buspirone order was transcribed inaccurately in September of 2023. Record review revealed a physician order dated 2/21/2024 for buspirone, 15mg, by mouth, twice daily. During a surveyor interview on 2/22/2024 at 10:32 AM, with the Director of Nursing Services (DNS), she acknowledged the resident did not receive the correct dose of his/her buspirone as it was transcribed inaccurately. Additionally, she was unable to provide evidence that Resident ID #38 was free from significant medication errors dating back to when the order should have been implemented in September of 2023. During a surveyor interview on 2/23/2024 at 9:52 AM, with the Nurse Practitioner, she acknowledged the buspirone order was transcribed inaccurately and the resident was receiving the buspirone in the incorrect frequency. 1b. According to the Institute for Safe Medication Practices, they indicate to take Eliquis exactly as directed. Take your Eliquis at the same time or times each day and do not skip any doses. Record review revealed a physician's order for Eliquis (anticoagulant medication), dated 6/13/2023, 2.5 mg, twice daily at 8:00 AM and 8:00 PM. Review of the February 2024 MAR revealed on 2/20/2024, the resident's 8:00 AM dose of Eliquis was documented as being administered at 1:09 PM, approximately 5 hours after it was due. During a surveyor interview on 2/23/2024 at 9:52 AM, with the Nurse Practitioner, she revealed that her expectation is to be notified if a resident's Eliquis is administered late but was unable to provide evidence that she was notified of the above-mentioned late administration. During a surveyor interview on 2/23/2024 at 11:10 AM, with the DNS, she revealed that her expectation is for medication to be administered as ordered. Further, she was unable to provide evidence that the facility kept this resident free from any significant medication errors. 2a. Record review revealed Resident ID #9 was re-admitted to the facility in June of 2023 with diagnoses including, but not limited to, paroxysmal atrial fibrillation (irregular heartbeat) and anxiety disorder. Record review revealed a physician's order dated 6/13/2023 for Eliquis, 2.5mg, twice daily, at 8:00 AM and 8:00 PM. Review of the February 2024 MAR revealed the following dates and times the resident's 8:00 AM dose of Eliquis was documented as being administered late: - 2/2/2024 at 10:29 AM - 2/6/2024 at 9:53 AM - 2/7/2024 at 9:53 AM - 2/10/2024 at 12:33 PM - 2/16/2024 at 10:42 AM - 2/19/2024 at 10:37 AM - 2/20/2024 at 12:30 PM - 2/21/2024 at 9:26 AM During a surveyor interview on 2/23/2024 at 9:52 AM, with the Nurse Practitioner, she revealed that her expectation is to be notified if a resident's Eliquis is administered late but was unable to provide evidence that she was notified of the above-mentioned late administrations. During a surveyor interview on 2/23/2024 at 11:10 AM, with the DNS, she revealed that her expectation is for medication to be administered as ordered. Further, she was unable to provide evidence that the facility kept the resident free from any significant medication errors. 2b. Record review revealed a physician's order dated 12/28/2023 for lorazepam (anti-anxiety medication), 0.5 mg, three times a day, at 8:00 AM, 2:00 PM, and 8:00 PM. Review of the February 2024 MAR revealed the following dates and times the resident did not receive his/her lorazepam: - 2/10/2024 at 2:00 PM with a note that states, Not Administered: Other Comment: Morning dosage given late. - 2/16/2024 at 2:00 PM with a note that states, Not Administered: Other Comment: Morning given too late due to resident wanting medication later in the morning. - 2/20/2024 at 8:00 AM, with a note that states, Not administered: On Hold Comment: Giving afternoon order. Record review failed to reveal evidence that the physician was notified that the above doses of lorazepam were not administered. During a surveyor interview on 2/23/2024 at 8:30 AM, with Certified Medication Technician (CMT), Staff E, she revealed that she would inform the charge nurse if a resident was not administered their medication. During a surveyor interview on 2/23/2024 at 8:34 AM, with Registered Nurse (RN), Staff C, she revealed that if a medication is not administered, the process is to notify the physician, either immediately or during the same shift, depending upon the medication. Further, she was unable to provide evidence that the physician was notified of the resident's lorazepam doses that were not administered. During a surveyor interview on 2/23/2024 at 8:47 AM, with the DNS, she revealed that if a medication is not administered, the CMT should notify the charge nurse, who would then notify the physician, either immediately or within the same shift. Further, she indicated that her expectation is for the physician notification to be documented in the resident's progress notes. 3. Record review revealed that Resident ID #187 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, Cellulitis (skin infection) of left lower limb and Cellulitis of right lower limb. Review of a Hospital Discharge summary dated [DATE], revealed an order for amoxicillin-clavulanate (Augmentin, antibiotic) 875-125 mg tablet, with instructions to take one tablet by mouth, two times a day for 28 days. Record review revealed a physician's order with a start date of 1/19/2024 and end date of 2/14/2024 for Augmentin 875-125 mg, twice a day. Review of the February 2024 MAR revealed Augmentin was documented as being administered from 1/19/2024 through 2/14/2024 at 8:00 AM, for a total of 27 days and 53 doses, versus the 28 days and 56 doses as ordered. Record review of an Event report titled Safety Events- Medication Error dated 2/22/2024 states in part, .Description: date miscalculation. Event Details: Medication Error. Describe the Error: Medication ordered for 27 days instead of the prescribed 28 days . During a surveyor interview with RN, Staff D on 2/22/2024 at approximately 1:41 PM, she acknowledged that the resident did not receive the correct amount of Augmentin doses, per the hospital physician order. During a surveyor interview with the DNS on 2/22/2024 at approximately 2:30 PM, she acknowledged that the resident was documented as receiving his/her antibiotics for a total of 27 days, 53 doses versus the 28 days, 56 doses as ordered. 4a. Record review revealed that Resident ID #188 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, ischemic cardiomyopathy (a condition of weakened heart muscles due to heart attack or coronary heart disease), heart failure, and type 2 diabetes mellitus with other circulatory complications. Record review revealed a physician's order dated 1/18/2024 for metformin tablet; 500 mg; Amount to Administer: 1000 mg (2tabs); oral Once A Morning Administer with breakfast at 8:00 AM. Review of the February 2024 MAR revealed the medication was administered late on the following dates and times: - 2/1/2024 at 10:40 AM -2/9/2024 at 10:02 AM -2/13/2024 at 9:57 AM -2/14/2024 at 10:03 AM -2/17/2024 at 10:38 AM -2/19/2024 at 10:20 AM -2/21/2024 at 10:48 AM -2/23/2024 at 9:57 AM During a surveyor observation immediately following the administration of Metformin on 2/23/2024 at 9:47, revealed CMT, Staff B, was in the resident's room, administering the above medication without breakfast, as ordered. During a surveyor interview on 2/20/2024 at 8:57 AM, with the Dietary Supervisor, she revealed that the breakfast meal is scheduled from 7:00 AM through 7:45 AM. During a surveyor interview with Staff B, following the above observation, she acknowledged that the abovementioned medication was administered late and not per the physician's order. 4b. Record review revealed a physician's order dated 1/18/2024 for carvedilol tablet; 6.25 mg; Amount to Administer: 6.25mg (1tab); oral .Twice A Day at 8:00 AM and 5:00 PM. Review of the February 2024 MAR revealed the medication was administered late on the following dates and times: -2/1/2024 at 10:40 AM -2/13/2024 at 9:57 AM -2/17/2024 at 10:39 AM -2/19/2024 at 10:20 AM -2/21/2024 at 10:48 AM -2/23/2024 at 9:57 AM 4c. Record review revealed a physician's order dated 1/18/2024 for ferrous sulfate tablet; 325 mg (65 mg iron); Amount to Administer: 325 mg; oral Twice A Day at 8:00 AM and 8:00 PM. Review of the February 2024 MAR revealed the medication was administered late on the following dates and times: -2/1/2024 at 10:40 AM -2/17/2024 at 10:38 AM -2/21/2024 at 10:48 AM -2/23/2024 at 9:57 AM During a surveyor interview on 2/23/2024 at 10:22 AM with RN, Staff, C, she revealed that she was not aware of the medications being administered late, and indicated that medications administered late are considered a medication error and she would expect to be notified by the CMT. During a surveyor interview on 2/23/2024 at 10:11 AM with the Nurse Practitioner, she revealed that if a medication is scheduled for a specific time, then she would expect the medication to be administered at that time. During a surveyor interview on 2/22/2024 at 10:32 AM and 2/23/2024 at 11:01 AM with the Director of Nursing Services, she revealed that she would expect medications to be given at the time they are ordered. She further revealed that there is a window of an hour before and an hour after the time to administer medications. Furthermore, she was unable to provide evidence that the facility kept the above residents free from significant medication errors.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 1 of 1 resident reviewed who has an actual pressure ulcer, Resident ID #65. Findings are as follows: Record review revealed that the resident was admitted to the facility in May of 2021 with diagnoses which include, but are not limited to, stage 4 pressure ulcer [sores that extend below the skin into deep tissues, including muscle, tendons, and ligaments] of the sacrum and peripheral vascular disease [condition affecting the blood vessels]. Review of the care plan, revised on 11/8/2022, revealed that s/he has a stage 4 pressure ulcer of the sacral area and impaired areas on his/her bilateral heels with interventions for a low air loss mattress and treatments as ordered for wound healing. Review of the current physician orders revealed the following: - 11/23/2022: apply heel cuff to both heels twice daily, 7:00 AM-3:00 PM and 3:00 PM-11:00 PM - 11/23/2022: low air loss mattress for pressure relief, check functionality and set at resident's current weight [lbs.] each shift Review of the December 2022 weight documentation for this resident revealed the following: - 12/6/2022: 156.2 lbs. - 12/7/2022: 156.4 lbs. Surveyor observation revealed the bilateral heel cuffs were not worn by the resident and the air mattress was set at 250 lbs. on the following dates and times: - 12/6/2022 at 9:59 AM - 12/7/2022 at 9:25 AM and 1:45 PM During a surveyor observation at 2:00 PM on 12/7/2022, in the presence of Registered Nurse. Staff A, she acknowledged that the resident was not wearing the bilateral heel cuffs and that the air mattress was not set at the resident's current weight per the physician's order.

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 1 of 2 residents reviewed for oxygen therapy, Resident ID #45. Findings are as follows: According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, states in part, .as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician. According to Basic Nursing, Mosby, 3rd Edition: after administering a drug, the nurse records it immediately on the appropriate record form. Recording the drug includes the name of the drug, dosage, route of administration and exact time of administration. Record review of the facility's policy titled, Oxygen Administration states in part, The purpose of this procedure is to provide guidelines for safe oxygen administration .Equipment and Supplies .2. Nasal cannula [a device used to deliver supplemental oxygen] .changed once weekly .Documentation: the date and time that the procedure was performed .The rate of oxygen flow, route, and rationale .The reason for p.r.n. [as needed] administration . Record review revealed the resident was admitted to the facility in March of 2022 with diagnoses which include, but are not limited to, congestive heart failure (a condition in which the heart doesn't pump blood as efficiently as it should), and ischemic cardiomyopathy (a condition where the heart can no longer pump enough blood to the rest of the body). Record review of a physician's order dated 3/29/2022, states in part, Oxygen 2-4 L/min [liter per minute] nasal cannula Every Shift-prn as needed for chest pain/SOB [shortness of breath] . During surveyor observations of the resident revealed s/he receiving oxygen at 2 liters via a nasal cannula and the cannula was not dated on the following dates and times: - On 12/6/2022 at 9:54 AM, 10:38 AM, and 11:39 AM - On 12/7/2022 at 9:17 AM, 9:37 AM, 9:56 AM, 1:21 PM, and 2:03 PM Record review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to reveal documentation of oxygen administration from 12/6/2022 through 12/7/2022 as indicated in the facility's policy. Additional record review of the MAR and TAR failed to reveal evidence for an order to change the nasal cannula and failed to reveal evidence of when it was last changed. During a surveyor observation of the resident on 12/7/2022 at approximately 2:03 PM in the presence of Registered Nurse, Staff A, she acknowledged the resident was receiving oxygen and his/her nasal cannula was not dated. Additionally, she acknowledged the oxygen order on the MAR and TAR was not signed off as per the facility's policy and could not provide evidence as to when the nasal cannula was last changed. During a surveyor interview on 12/8/2022 at 2:27 PM with the Director of Nursing Services, she indicated that the oxygen tubing should be changed weekly on Wednesdays and dated when it is changed as per the facility's policy. Additionally, she indicated that she would expect the staff to document as per the facility's policy when oxygen is being administered to the resident.

Based on surveyor observation and staff interview, it has been determined that the facility failed to 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 related to biohazard sharps containers (used to collect devices or objects with corners, edges, or capable of cutting or piercing skin and used to isolate dangerous substances) for 1 of 3 wings observed, North Wing. Findings are as follows: Review of the Occupational Safety and Health Administration Bloodborne Pathogens standard 29 CFR 1910.1030 states in part, .Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are .Closable .Puncture resistant .Leakproof on sides and bottom .During use, containers for contaminated sharps shall be .Replaced routinely and not be allowed to overfill . During surveyor observations of the North Wing medication cart, revealed the medication cart was left unattended in the hallway with a biohazard sharps container overflowing with needles attached to syringes that were exposed and accessible to the residents on the following dates and times: - On 12/6/2022 at 11:29 AM and 12:16 PM - On 12/7/2022 at 9:15 AM, 9:36 AM, 9:57 AM, 1:03 PM During the above observations multiple ambulatory residents were observed in the vicinity of the unattended medication cart. During a surveyor observation of the North Wing medication cart on 12/7/2022 at 1:05 PM in the presence of Licensed Practical Nurse, Staff B, she acknowledged the biohazard sharps container was overflowing with used needles attached to syringes that were exposed and accessible to the residents. During additional surveyor observations on 12/7/2022 of the North Wing medication cart in the hallway, after this concern was brought to the facility's attention, revealed the medication cart was again left unattended in the hallway, with residents in the vicinity, with a biohazard sharps container overflowing with needles attached to syringes that were exposed and accessible to the residents at the following times: 1:33 PM, 1:37 PM, and 1:54 PM During a surveyor observation of the North Wing medication cart in the presence of the Director of Nursing Services (DNS) on 12/7/2022 at 1:46 PM, she acknowledged the above-mentioned container was overflowing with needles attached to syringes that were accessible to the residents. Additionally, the DNS indicated that the staff are expected to empty the sharps container and items in the container should not be exposed and accessible to the residents.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed and served in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1) The Rhode Island Food Code 2018 Edition 3-501.17 states in part (A), .refrigerated ready to eat prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened and held for a maximum of 7 days .(D), a date marking system that meets the criteria in (A) for food .that is frequently rewrapped . During a surveyor observation of the walk in refrigerator in the main kitchen on 12/6/2022 at approximately 9:30 AM revealed the following: -One piece of deli pastrami in the original packaging which was opened and rewrapped without a use by date. -One piece of deli roast beef in the original packaging which was opened and rewrapped without a use by date. -One piece of cooked ham in the original packaging which was opened and rewrapped without a use by date. 2) The Rhode Island Food Code 2018 Edition 2-402.11 revealed in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During a surveyor observation on 12/8/2022 at approximately 12:10 PM, Dietary Aides, Staff C and D were observed without beard restraints while in the main kitchen area. Further surveyor observations on 12/9/2022 at approximately 12:08 PM revealed Dietary Aide, Staff E, without a beard restraint while in the main kitchen. During a surveyor interview with the Food Service Director on 12/9/2022 at approximately 1:00 PM, she acknowledged the dietary aides were not wearing beard restraints. She further acknowledged the three opened and rewrapped meats did not have a use by date once they were opened at the facility.