Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported allegation submitted to the Rhode Island Department of Health on 12/17/2024 revealed that a family member of the resident alleged that the resident did not receive his/her inhaler resulting in a hospitalization. Record review revealed the resident was admitted to the facility in September of 2023 and readmitted in December of 2024 with diagnoses including, but not limited to, pneumonia and dysphagia (difficulty swallowing). Record review revealed a physician's order dated November 19, 2024, for Ipratropium-Albuterol solution 0.5-2.5 milligram/3 milliliter inhaler four times a day at 7:30 AM, 11:30 AM, 4:30 PM and 9:30 PM (before meals and at bedtime ), for wheezing and shortness of breath. Record review of the Medication Administration Record failed to reveal evidence that the resident received his/her inhaler on the following dates and times: - 11/19/2024 at 4:30 PM and 9:30 PM - 11/20/2024 at 7:30 AM, 11:30 AM, 4:30 PM, and 9:30 PM - 11/21/2024 at 7:30 AM, 11:30 AM, and 4:30 PM Additional record review failed to reveal evidence that the provider was notified that the resident had not received his/her inhaler on the above-mentioned dates and times, as ordered. During a surveyor interview on 12/18/2024 at 12:06 PM with the Director of Nursing Services (DNS), she acknowledged that the resident did not receive his/her inhaler on the above-mentioned dates and times as ordered. The DNS acknowledged that when the order was entered in the resident's record by the provider on 11/19/2024, the nurse on duty did not verify the order therefore is was not sent to the pharmacy for delivery, as per the facility's process. She further acknowledged that because of this failure, the inhaler was not delivered to the facility until 11/21/2024 at 9:18 PM, which led to the resident not receiving the inhaler on the above-mentioned dates and times. During a surveyor interview on 12/18/2024 at 12:32 PM with a Nurse Practitioner, Staff A, she revealed that she was unaware that the inhaler was not administered on the above-mentioned dates and times until after 11/21/2024. She indicated that she would have expected the nurse to have sent the order to the pharmacy on 11/19/2024 and would expect the staff to have administered the inhaler, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 2 residents reviewed relative to falls resulting in injury, Resident ID #24. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, muscle weakness, cognitive communication deficit, and a history of falling. Review of the care plan dated 7/22/2024 revealed the resident was at risk for falls related to impaired mobility with interventions including, but not limited to, providing the resident with opportunities for choices, and to assist the resident in creating a clutter-free environment. Record review revealed the resident had fallen at the facility on the following dates: -8/1- twice -8/6 -8/8 Record review revealed the resident was sent to the hospital on 8/8/2024 following a fall. Further review revealed the resident was noted to have bruising around his/her eyes and forehead following the fall. Record review failed to reveal evidence that the comprehensive care plan had been updated with new interventions following each fall. The care plan was not updated until after the resident's fourth fall on 8/8/2024. During a surveyor interview on 8/16/2024 at 12:01 PM with the Director of Nursing Services, she could not provide evidence that the comprehensive care plan had been updated to include interventions to reduce falling risk on 8/1 and 8/6.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision by staff to prevent accidents relative to 1 to 1 supervision while eating for 1 of 4 residents reviewed, Resident ID #255. Findings are as follows: Record review revealed Resident ID #255 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, traumatic subarachnoid hemorrhage (when blood bleeds into the space between the brain's surface), depression and cognitive communication deficit. Review of hospital documentation revealed the resident was observed after sustaining a traumatic brain injury. Additional review of the document dated 8/12/2024 revealed that s/he may need someone to help open container and lids, cut-up the food and may need help with eating. Record review revealed a physician order dated 8/13/2024 at 10:06 AM for regular/liberalized, dysphagia (difficulty swallowing) puree texture diet with a 1 to 1 supervision for all meals. During surveyor observation on 8/13/2024 from 12:18 PM to 12:51 PM, the resident was observed in bed with the lunch meal tray in front of him/her. Additional observation revealed that the plates were uncovered and set-up, but no staff was present for 1 to 1 supervision, as ordered. During a surveyor interview on 8/13/2024 at 12:25 PM with the resident, s/he indicated that s/he is afraid to feed him/herself because each time s/he does, s/he has a feeling of choking. During a surveyor observation on 8/14/2024 from approximately 8:30 AM to 8:53 AM, the resident was observed in bed with his/her meal tray set-up in front of him/her with no staff present for 1 to 1 supervision as ordered. During a surveyor interview on 8/14/2024 at 9:13 AM with NA, Staff B, she revealed that she does not know how the resident eats because s/he is not on her assignment. During a surveyor interview on 8/14/2024 at 9:28 AM with NA, Staff D, she revealed that she was unaware that the resident required 1 to 1 supervision for meals. During a surveyor interview on 8/14/2024 at 9:24 AM with the Unit Manager, Staff F, she stated the resident independently feeds him/herself. However, after checking the medical record she acknowledged that the resident needs 1 to 1 supervision with meals. During a surveyor interview on 8/14/2024 at approximately 10:30 AM with the Speech Therapist, Staff G, she revealed that the 1 to 1 supervision with all meals is for safety related to the diagnoses of dysphagia. During a surveyor interview on 8/15/2024 at approximately 11:00 AM, with the Director of Nursing Services, she was unable to provide evidence the resident's order for 1 to 1 supervision while eating was followed.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 5 of 13 residents reviewed related to documentation in the medical record, Resident ID #s 8, 22, 26, 29 and 34. Findings are as follows: 1) Record review revealed Resident ID #8 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, mononeuropathy (damage or dysfunction of a single nerve usually affecting hands, arms, or feet) and arthropathy (disease of the joints). Record review revealed a physician's order dated 6/14/2024 for Lidocaine external Patch 4% apply to left shoulder every morning and remove at bedtime. During a surveyor observation on 8/15/2024 at 8:52 AM during the medication administration task, Certified Medication Technician (CMT) Staff B, was observed removing a Lidocaine patch 4% from the resident's shoulder. This indicated that the patch failed to be removed at bedtime the night before. During a surveyor interview on 8/15/2024 at 9:24 AM, with Staff B, she acknowledged that the patch should have been removed at bedtime on 8/14/2024, per the physician's order. Record review of the Medication Administration Record revealed CMT, Staff C, had signed that the Lidocaine patch had been removed at bedtime on 8/14/2024. During a surveyor interview on 8/15/2024 at 11:29 AM with Staff C, she acknowledged that she failed to take the Lidocaine patch off the resident. She further acknowledged that she had initialed in the MAR that she had removed the patch. 2) Record review revealed Resident ID #22 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, muscle wasting, atrophy, type 2 diabetes mellitus and dementia. Record review revealed a physician's order dated 5/21/2024 to offload heels with pillows while in bed, as tolerated, every day and night shift for prevention and skin integrity. Additional review of the order dated 7/17/2024 revealed heel protectors when in bed as tolerated every shift to maintain skin integrity. During surveyor observations on the following dates and times there was no evidence of the bilateral heels protectors, nor were heels offloaded while the resident was in bed. - 8/14/2024 at 8:26 AM - 8/16/2024 at 8:34 AM Record review of the Treatment Administration Record (TAR) revealed that the heel protector and the heels offloading with pillows tasks were signed off as completed on the above mentioned dates, but were not completed. During a surveyor interview on 8/16/2024 at approximately 12:00 PM with the DNS, she acknowledged that the resident's heels were not offloaded, and the heel protector were not on, as ordered. Additionally, she indicated that she would expect the nurse to only sign off an order if it had been completed. 3) Record review revealed Resident ID #26 was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, localized swelling, muscle weakness, and hypotension. Record review revealed a physician's order dated 8/5/2024 for [NAME] stockings to be applied to bilateral lower extremities in the morning and to be removed at night for hypotension. During surveyor observations on the following dates and times there was no evidence of the bilateral [NAME] stockings observed while the resident was sitting in the wheelchair. - 8/13/2024 at 10:30 AM, 2:00 PM and 5:09 PM - 8/14/2024 at 10:00 AM, 12:00 PM During a surveyor interview on 8/14/2024 at approximately 11:30 AM with Resident ID #26 s/he revealed that s/he was never given [NAME] stockings. During a surveyor interview on 8/14/2024 at 1:05 PM with the NA, Staff D, in the presence of Registered Nurse, Staff E, they acknowledged that the resident was not wearing the [NAME] stockings. Record review of the Treatment Administration Record (TAR) revealed that Registered Nurse, Staff E, had signed off that the [NAME] stockings had been applied on 8/13/2024 and 8/14/2024, but these tasks were not completed. During a surveyor interview on 8/14/2024 at 1:48 PM with the DNS, she indicated that she would expect the nurse to only sign off on an order if it had been completed. 4) Record review revealed Resident ID #29 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, protein calorie malnutrition and age-related osteoporosis. Record review revealed a physician's order dated 7/25/2024 to obtain the residents weight weekly every Monday for 4 weeks. Review of the August Medication Administration Record (MAR) revealed that a nurse documented that the resident's weight had been obtained on 8/5/2024; however, no weight was recorded. Record review of the recorded weights in the electronic medical record (EMR) and of the written weight log, failed to reveal evidence that the resident's weight was obtained on the week of 8/5/2024, as ordered. During a surveyor interview on 8/16/2024 at 10:16 AM, with the DNS, she acknowledged that the resident's weight had not been obtained and documented for the week of 8/5/2024 as ordered. Additionally, she indicated that she would expect the nurse to only sign off on an order if it had been completed. 5) Record review of Resident ID #34 revealed s/he was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, altered mental status, respiratory failure, and pneumonia. Record review revealed a physician's order dated 7/15/2024 to obtain the resident's weight every Monday for 4 weeks. Review of the July and August MARS revealed that a nurse documented that the resident's weight had been obtained on 7/29/2024 and 8/5/2024. Record review of the recorded weights in the EMR and on the written weight log failed to reveal evidence that the resident's weight was obtained on the weeks of 7/29/2024 and 8/5/2024. During a surveyor interview on 8/16/2024 at approximately 10:00 AM, with the DNS, she indicated that she would expect the nurse to only sign off on an order if it had been completed.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 1 resident reviewed with a physician's order for a Lidocaine patch, Resident ID #8; for 1 of 2 residents reviewed with orders for heel protectors, Resident ID #22; for 1 of 1 resident reviewed with a physician's order for TED stockings, Resident ID #26; and for 2 of 6 residents reviewed for weight loss, Resident ID #s 29 and 34. 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. 1. Record review revealed Resident ID #8 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, mononeuropathy (damage or dysfunction of a single nerve usually affecting hands, arms, or feet) and arthropathy (disease of the joints). Record review revealed a physician's order dated 6/14/2024 for, Lidocaine external Patch 4% (used for pain) apply to left shoulder every morning and remove at bedtime. During a surveyor observation on 8/15/2024 at 8:52 AM during the medication administration task, Certified Medication Technician (CMT), Staff B, was observed removing a Lidocaine patch 4% from the resident's shoulder. This indicated that the patch failed to be removed at bedtime the night before. During a surveyor interview on 8/15/2024 at 9:24 AM, with Staff B, she acknowledged that the patch should have been removed at bedtime on 8/14/2024 per the physician's order. During a surveyor interview on 8/15/2024 at 11:29 AM with CMT, Staff C, she acknowledged that she failed to take the resident's Lidocaine patch off, as ordered, on 8/14/2024 at bedtime. 2. Record review revealed Resident ID #22 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, muscle wasting, atrophy, type 2 diabetes mellitus and dementia. Record review revealed a physician's order dated 5/21/2024 to offload heels while in bed with pillows as tolerated every day and night shift for prevention and skin integrity. Additional review of an order dated 7/17/2024 revealed to wear heel protectors when in bed as tolerated every shift to maintain skin integrity. During surveyor observations on the following dates and times there was no evidence of the bilateral heel protectors, nor heels being offloaded while the resident was in bed. - 8/14/2024 at 8:18 AM - 8/16/2024 at 8:34 AM During a surveyor interview on 8/16/2024 at approximately 12:00 PM with the DNS, she acknowledged that the resident's heel protectors were not on and the heels were not offloaded, as ordered. 3. Record review of Resident ID #26 revealed s/he was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, localized swelling, muscle weakness, and hypotension. Record review revealed a physician's order dated 8/5/2024 for TED stockings to be applied to bilateral lower extremities in the morning and to be removed at night for hypotension. During surveyor observations on the following dates and times there was no evidence of the bilateral TED Stockings observed while the resident was sitting in the wheelchair. - 8/13/2024 at 10:30 AM, 2:00 PM and 5:09 PM - 8/14/2024 at 10:00 AM During a surveyor interview on 8/14/2024 at 1:05 PM with Nursing Assistant, Staff D, in presence of the Registered Nurse, Staff E, they acknowledged that the resident was not wearing the TED Stockings as ordered. During a surveyor interview on 8/14/2024 at 1:48 PM with the DNS, she indicated that she expects staff to follow the physician's order. 4. Record review revealed Resident ID #29 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, protein calorie malnutrition and age-related osteoporosis. Record review revealed a physician's order dated 7/25/2024 to obtain the residents weight weekly every Monday for 4 weeks. Record review of the recorded weights in the electronic medical record (EMR) and of the written weight log, failed to reveal evidence that the resident's weight was obtained on the week of 8/5/2024 as ordered. During a surveyor interview on 8/16/2024 at 10:16 AM with the DNS, she acknowledged that the resident's weight had not been obtained and documented for the week of 8/5/2024 as ordered. 5. Record review of Resident ID #34 revealed s/he was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, altered mental status, respiratory failure and pneumonia. Record review revealed a physician's order dated 7/15/2024 to obtain the resident's weight every Monday for 4 weeks. Record review of the recorded weights in the EMR and of the written weight log, failed to reveal evidence that the resident's weight was obtained on the weeks of 7/29/2024 and 8/5/2024. During a surveyor interview on 8/16/2024 at approximately 10:00 AM with the DNS, she acknowledged that the resdient's weights had not been obtained and documented for the weeks of 7/29/2024 and 8/5/2024, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (nursing assistant; NA), at least once every 12 months, for 3 of 3 NA personnel records reviewed, Staff H, I, and J. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NAs: -Staff H, Date of hire-11/2007 -Staff I, Date of hire- 5/2023 -Staff J, Date of hire- 9/2015 During a surveyor interview with the Director of Nursing Services on 8/16/2024 at 9:45 AM, she was unable to provide evidence that performance evaluations were completed within the last 12 months for the above-mentioned employees prior to 8/15/2024 when it was brought to her attention by the surveyor.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 2 of 2 residents reviewed for insulin administration, Resident ID #s 15 and 204. Findings are as follows: 1. Record review revealed Resident ID #15 was re-admitted to the facility in June of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review revealed a physician's order dated 6/7/2024 for Lispro (insulin) inject 5 units with meals for diabetes. Hold if blood sugar (BS) is less than 150. Review of the July 2024 Medication Administration Record (MAR) revealed that his/her Lispro was given outside of parameters on the following dates and times: 7/6/2024 at 4:30 PM - BS 101 7/10/2024 at 4:30 PM - BS 120 7/12/2024 at 4:30 PM - BS 140 7/16/2024 at 7:30 AM - BS 120 7/18/2024 at 7:30 AM - BS 145 7/23/2024 at 4:30 PM - BS 128 7/26/2024 at 4:30 PM - BS 137 7/27/2024 at 4:30 PM - BS 119 Review of the August 2024 MAR revealed that his/her Lispro was given outside of parameters on the following dates and times: 8/2/2024 at 4:30 PM - BS 123 8/10/2024 at 4:30 PM - BS 140 8/11/2024 at 4:30 PM - BS 131 8/12/2024 at 11:30 AM - BS 121 8/12/2024 at 4:30 PM - BS 124 During a surveyor interview on 8/15/2024 at 1:30 PM with Registered Nurse, Staff K, she acknowledged that she administered the insulin outside of parameters on 8/12/2024. During a surveyor interview on 8/15/2024 at 1:34 PM with Registered Nurse, Staff L, she revealed that the facility's hold parameter is usually at 100 so she acknowledged that she administered the insulin outside of parameters on 7/6/2024 and 7/26/2024. 2. Record review revealed Resident ID #204 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review of a Nurse Practitioner's progress note dated 8/12/2024 at 8:42 PM revealed, .Orders .Okay to hold insulin glargine per conversation between resident and MD [physician] this morning and start [every AM] administrations tomorrow . Review of the August 2024 MAR failed to reveal evidence that the Glargine was administered to the patient on 8/13/2024, as ordered. Further record review of the MAR revealed an order for insulin Glargine 100 unit/ milliliter inject 20 units in the morning with a start date of 8/14/2024. During a surveyor interview on 8/15/2024 at approximately 9:20 AM with the Director of Nursing Services, she could not provide evidence that the Glargine was administered as ordered on 8/13/2024.

**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 assessment accurately reflected the resident's status for 1 of 1 resident reviewed for the use of mechanical lifts, Resident ID #1. Findings are as follows: Review of an anonymous community reported complaint submitted to the Rhode Island Department of Health on 2/9/2024 revealed the resident sustained a fall from a hoyer lift (mechanical lift) during a transfer resulting in a hematoma (swelling of clotted blood within the tissue) on his/her head. Record review revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, muscle weakness, disorders of the muscles, and repeated falls. Record review of a Lift Transfer Evaluation dated 1/9/2024 revealed the Recommendation/Care Plan for transfers was for a Total Lift [mechanical lift] Divided Leg Sling. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required extensive assistance for transfers. Further record review failed to reveal evidence that the resident required a mechanical lift for transfers. Record review of the Nursing Assistant (NA) assignment sheet dated 1/27/2024 revealed the resident required a hoyer lift for transfers. Record review revealed the resident sustained a fall on 1/27/2024 while being transferred with one staff member into bed and without the use of a mechanical lift. During a surveyor interview on 2/12/2024 at approximately 12:00 PM with the Director of Rehab, she indicated that therapy had been working with the resident with transfers, however she would expect nursing to transfer the resident using the mechanical lift for safety. She further indicated that the resident's transfer status was communicated verbally to nursing following the completion of the Lift Transfer Evaluation on 1/9/2024. Additionally, she acknowledged a mechanical lift should be utilized by nursing for transfers for safety. During a surveyor interview on 2/12/2024 at 12:07 PM with the Director of Nursing Services, she was unable to provide evidence that the assessment accurately reflected the resident's status relative to the use of a mechanical lift. Cross Reference F689

**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 the residents' environment remains as free from accident hazards as possible for 1 of 2 residents reviewed with an actual fall, Resident ID #1. Findings are as follows: Review of an anonymous community reported complaint submitted to the Rhode Island Department of Health on 2/9/2024 revealed Resident ID #1 sustained a fall from a hoyer lift (mechanical lift) during a transfer resulting in a hematoma (swelling of clotted blood within the tissue) on his/her head. Record review revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, muscle weakness, disorders of the muscles, and repeated falls. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required extensive assistance for transfers. Record review of the resident's care plan dated 1/10/2024 revealed the resident was at risk for falls related to impaired mobility. Record review of a Lift Transfer Evaluation dated 1/9/2024 revealed the Recommendation/Care Plan for transfers was for a Total Lift [mechanical lift] Divided Leg Sling. Record review of the Nursing Assistant (NA) assignment sheet dated 1/27/2024 revealed the resident required a hoyer lift for transfers. Record review revealed the resident sustained a fall on 1/27/2024 while being transferred with one staff member into bed and without the use of a mechanical lift. During a surveyor interview on 2/12/2024 at 11:34 AM with the resident's family member, she indicated that the resident had sustained multiple falls during his/her short admission to the facility, one resulting in injury. She further indicated that the resident was moved to another facility due to feeling as though the care was inconsistent and in fear that something detrimental could happen to the resident. During a surveyor interview on 2/12/2024 at 1:03 PM with the NA, Staff A, she revealed that on 1/27/2024 she assisted the resident from the bedside chair into the bed without the mechanical lift or the assistance of an additional staff member. She further revealed that the resident became weak, and they both fell to the floor. Additionally, she indicated that she frequently transferred the resident by herself and without the mechanical lift. During a surveyor interview on 2/12/2024 at approximately 12:00 PM with the Director of Rehab, she indicated that therapy had been working with the resident with transfers, however she would expect nursing to transfer the resident using the mechanical lift for safety. She further indicated that the resident's transfer status was communicated verbally to nursing following the completion of the Lift Transfer Evaluation on 1/9/2024, Additionally, she acknowledged a mechanical lift should be utilized by nursing for transfers for safety. During a surveyor interview on 2/12/2024 at 12:07 PM with the Director of Nursing Services, she acknowledged that the resident sustained a fall on 1/27/2024 while being transferred by one staff member and would have expected the resident to be transferred with the mechanical lift. Cross Reference F641

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed who receives nutrition via feeding tube, Resident ID #22. Findings are as follows: Record review revealed the resident was re-admitted to the facility in July of 2022 with a diagnosis including, but not limited to, gastrostomy complication (G-tube; an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review revealed a physician's order for Jevity (nutrition delivered through a feeding tube) 1.5 calories (cal), 300 milliliters, three times a day and to hold if the resident consumes 50% or more for meals by mouth. Record review of the August 2023 Medication Administration Record revealed Jevity 1.5 cal was documented as being administered, when the resident had documentation of 50% or more of intake, on the following dates and mealtimes: - 8/21/2023 for lunch with a documented intake of 75% - 8/22/2023 for breakfast with a documented intake of 100% - 8/22/2023 for lunch with a documented intake of 100% - 8/22/2023 for dinner with a documented intake of 75% - 8/23/2023 for dinner with a documented intake of 50% - 8/24/2023 for breakfast with a documented intake of 75% - 8/26/2023 for dinner with a documented intake of 50% - 8/28/2023 for breakfast with a documented intake of 100% - 8/28/2023 for lunch with an intake of 100% - 8/28/2023 for dinner with a documented intake of 50% - 8/29/2023 for breakfast with a documented intake of 100% - 8/29/2023 for lunch with a documented intake of 100% - 8/30/2023 for dinner with a documented intake of 100% During a surveyor interview with Licensed Practical Nurse (LPN), Staff A in the presence of LPN, Staff B on 8/31/2023 at 9:45 AM, she revealed that she would expect the nurses to hold the resident's G-tube supplement when his/her intake is documented as 50% or more, per physician order.

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 27 opportunities for errors observed during the medication administration task, there were 3 errors resulting in an error rate of 11.1%. Findings are as follows: 1. Record review revealed Resident ID #43 has the following physician's orders - Lactulose (a medication used to treat constipation) Oral Solution 10 GM (gram)/15ML (milliliter) Give 30 ml by mouth every morning and at bedtime for Constipation. -MiraLax Oral Packet 17 GM (a medication used to treat constipation) Give 1 packet by mouth as needed for bowel management. Record review of the medication drug label for the Miralax revealed the bottle cap is a measuring cup designed to contain 17 grams of the powder when filled to the top rim. During a surveyor observation of the medication administration task on 8/30/2023 at 8:11 AM with Certified Medication Technician(CMT), Staff C, the resident's lactulose was not administered. Further observation, Staff C, was then observed to pour the Miralax into the cap of the medication bottle and fill approximately ¾ of the cap. She then mixed the powder with the resident's beverage and administered the medication to the resident. During a surveyor interview immediately following the above observation with Staff C, she acknowledged she did not administer the Lactulose as ordered as it was unavailable. She further acknowledged she did not fill the Miralax to the top rim of the cap. 2. Record review revealed Resident ID #249 has a physician's order dated 8/25/2023 for Calcium-Vitamin D Tablet (600-200 Milligram-UNIT) Give 1 tablet by mouth one time a day for supplementation. During a surveyor observation of the medication administration task on 8/30/2023 at 8:15 AM with Staff C, the Calcium-Vitamin D was not administered. During a surveyor interview immediately following this observation with Staff C, she acknowledged she did not administer the Calcium-Vitamin D as ordered. During a surveyor interview with the Unit Manager, Staff D on 8/30/2023 at 3:00 PM, she acknowledged the above-mentioned errors. Additionally, she indicated she would expect that the staff reorder medication to be available and administered as ordered. She further acknowledged she would expect the resident to receive the correct dosage of medication.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 8 residents reviewed for opioid administration, Resident ID #18 Findings are as follows: Record review revealed the resident was admitted to the facility in September of 2021 with a diagnosis including, but not limited to, low back pain. Record review revealed a physician order dated 6/9/2023 for Oxycodone (a narcotic medication that is counted and recorded when administered) 15 milligrams (mg) every 3 hours as needed. Review of the August 2023 controlled substance log revealed on the following dates and times the Oxycodone was documented as being removed from the medication cart: - 8/2/2023 at 10:00 AM - 8/6/2023 at 11:00 AM, 2:00 PM, and 5:00 PM - 8/7/2023 at 11:00 PM - 8/11/2023 at 6:30 AM - 8/18/2023 at 3:30 PM - 8/20/2023 at 3:10 PM and 6:35 PM - 8/21/2023 at 6:45 PM - 8/25/2023 at 3:50 AM Review of the August 2023 Medication Administration Record (MAR) failed to reveal evidence that on the above dates and times the Oxycodone was documented as being administered. During a surveyor interview on 8/30/2023 at 2:53 PM, with the Unit Manager, Staff D, she acknowledged the inaccuracy of the August MAR and the controlled substance log. She indicated that nurses should be documenting in the MAR and in the controlled substance log, when administering the medication.

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. Additionally, the facility failed to review and update the assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Findings are as follows: Record review revealed an undated document titled; Facility Assessment Tool which failed to reveal the following components, according to Appendix PP: - The overall acuity levels of the resident population - The staff competencies that are necessary to provide the level and types of care needed for the resident population - Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services - Staffing ratios for Licensed Nurses and direct care staff During a surveyor interview on 8/30/2023 at 11:20 AM with the Administrator, she acknowledged that the facility assessment was not complete. During a surveyor interview on 8/31/2023 at 9:55 AM with the Administrator, she revealed the facility assessment was last reviewed on 6/29/2022 and acknowledged that there were no signatures for the Medical Director, Infection Control Nurse, Food Service Manager, Human Resources, and Laundry Director. Additionally, she was unable to provide evidence that the template tool that the facility utilizes for their facility assessment was completed in its entirety.

Based on record review and staff interview, it has been determined the facility failed to implement a comprehensive person-centered care plan for 1 of 5 residents reviewed relative to skin integrity, Resident ID #1. Findings are as follows; The facility policy and procedure for Skin Integrity Management revised on 6/1/2021 states in part, .Identify patient's skin integrity status and need for prevention or treatment modalities through review of all appropriate assessment information .Perform skin inspection on admission/re-admission and weekly. Document on Treatment Administration Record (TAR) or in PointClickCare . Record review revealed the resident was admitted to the facility in July of 2022 with diagnoses including, but not limited to, dementia, stroke, insulin dependent diabetes mellitus (high blood sugar), vascular disease and vascular wounds of the right foot. Further record review revealed the resident has a current care plan which indicates .has actual skin breakdown .vascular wound .decrease activity , frail fragile skin, impaired cognition , limited mobility .vascular disease, incontinence. This care plan has interventions to include, but are not limited to, .Weekly skin check by license nurse . Record review failed to reveal evidence that a weekly skin check was completed for the two weeks following his/her admission, as per the plan of care. During a surveyor interview with the Director of Nursing Services (DNS) on 7/20/2022 at 2:18 PM, she was unable to provide evidence that the weekly skin checks were completed, following the resident's admission to the facility. Additionally, the DNS revealed the weekly skin checks should be completed as per the plan of care and the facility policy.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration for 1 of 1 resident reviewed with a fluid restriction, Resident ID #11. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2020 with diagnoses including, but not limited to, rapidly progressive nephritic syndrome (damage to the blood vessels in the kidneys to filter waste and excess water), end stage kidney disease (damage to the kidneys which can cause waste to build up in your body) and dependence on renal dialysis. Record review revealed a physician's order with a start date of 3/29/2021 which states in part, Monitor Daily Fluid Restriction Total 1000ml [milliliters] ; Breakfast tray 240 ml; Free Fluids day shift 120 ml; Lunch tray 240 ml; Free Fluids Evening Shift 120 ml; Dinner tray_240 ml; Free Fluids Night Shift 40 ml . Record review of the June and July 2022 Medication Administration Record failed to reveal evidence of the resident's fluid intake. Further record review failed to reveal any evidence of the amount of fluid intake consumed by the resident. During a surveyor interview on 7/20/2022 at 12:41 PM with the Director of Nursing Services, she was unable to provide evidence of the resident's fluid intake.

Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. Findings are as follow: The facility's policy for Smoking revised on 11/20/2018 states in part, .recognizes the myriad of health risks associated with tobacco use, both for the smokers and for those exposed to second hand smoke .For centers that allow smoking, smoking (including the use of electronic cigarettes) will be permitted in designated areas only . PURPOSE To ensure that patients who choose not to smoke are not exposed to smoke . Record review revealed that Resident ID #152 was admitted to the facility in July of 2022 and s/he is a cigarette smoker. Record review revealed a smoking agreement dated 7/14/2022 indicating the resident will be allowed to go out to smoke at the following times; 7:30 AM, 9:30 AM, 11:00 AM, 1:30 PM, 3:30 PM, 6:30 PM and 8:00 PM. Surveyor observations on 7/20/2022 revealed the following: -8:40 AM and 9:02 AM while walking down the Long Unit corridor, revealed a strong cigarette odor beginning at the middle of the unit corridor to the end of the unit. Additionally, at the end of the hallway, outside of the exit doors on the patio, was a metal receptacle used for discarding cigarette butts. -9:42 AM Resident ID #152, Staff A and Staff B were observed outside of the Long Unit exit door in the designated smoking area. The resident and Staff B were smoking and Staff A was sitting nearby the resident. All three were observed within 5-10 feet from the door. During a surveyor interview on 7/20/2022 at 8:51 AM, with the unit nurse, Staff C, she revealed residents smoke right outside that door (pointing to the exit door of the Long Unit). Further revealing that residents and staff who smoke, have been smoking there since she has been working at the facility, which is approximately 8 years. During a surveyor interview on 7/20/2022 at 9:12 AM with Resident ID #2 and #4, who are alert and oriented and have been residing in the room which is close to the exit door, revealed the smell of smoke is terrible in their room. They further revealed that the strong cigarette odor is noted right after breakfast and intermittently throughout the day until approximately 8:00 PM. During an interview on 7/20/2022 at 9:48 AM with the Director of Nursing Services (DNS), she acknowledged that both staff and residents have been smoking right outside the exit door in this designated area.