Based on record review and staff interview, it has been determined that the facility failed to protect identifying information for 3 of 4 current residents residing in the facility, who were identified in the survey results binder, Resident ID #s 3, 4 and 17. Findings are as follows: During an observation of the facility's surveyor results binder the survey dated 5-16-2024 and the Resident/Staff Roster were revealed. The roster identified Resident ID #s 3, 4, and 17. Further review of the above survey contained information including, but not limited to, the resident's diagnoses and their physician orders. During a surveyor interview with the Administrator on 5/29/2025 at approximately 10:45 AM, following the above observation, he revealed that he was unaware that the Resident/Staff Roster was in the survey binder and that it should not have been. The Administrator was unable to provide evidence that the facility protected the identifying information of the residents listed in the survey results binder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 2 medication carts and the 1 of 1 medication storage room observed. Findings are as follows: Review of a facility policy titled Medication Labeling and Storage with a revision date of February 2023 states in part, .Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding .destroying these items . 1. During the medication storage and labeling task on [DATE] at approximately 9:00 AM through 10:15 AM, in the presence of Registered Nurse (RN), Staff A, observation of the treatment cart and the medication room revealed the following: -One vial of tuberculin purified protein derivative (tuberculin skin test solution) opened and not dated. Additionally, the manufacturer's instructions indicate to discard the vial after 30 days of opening. -One Insulin lispro injectable pen (a medication prescribed to treat high blood sugar) 100 units per milliliter (ml) with an open date of [DATE] and an expiration date of [DATE]. Additionally, manufacturer's instructions indicate to discard the vial after 28 days of opening. -One lorazepam intensol oral suspension (a medication prescribed to treat anxiety) 2 milligrams (mg) per ml with an open date of [DATE]. Additionally, the manufacturer's instructions indicate to discard it after 90 days of opening. During a simultaneous interview with Staff A, she acknowledged the opened date for the lorazepam was greater than 90 days and the medication should be discarded, Additionally, she acknowledged that the insulin was expired and in use, and that the tuberculin purified protein derivative vial should have been dated when opened. 2. During a surveyor observation of the medication cart on [DATE] at 12:17 PM in the presence of Certified Medication Technician (CMT), Staff B, a medication prescription card was observed with twenty-two tablets of lorazepam 0.5 mg. Further observation revealed this medication had been discontinued in March of 2025. During a subsequent interview immediately following the above observation with Staff B, she acknowledged that the order for the lorazepam tablets had been discontinued and the medication should have been discarded per the facility policy. During a surveyor interview with the Director of Nursing Services on [DATE] at 11:20 AM and 1:06 PM, he revealed that he would expect that the medication bottles would be dated once opened, and that the lorazepam intensol, lispro and tuberculin purified protein derivative vial should be discarded.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: Review of the Rhode Island Food Code, 2022 Edition, section 3-501.17 (B) states in part, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED .shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . 1. During the initial tour of the main kitchen on 5/27/2025 at 9:40 AM, with the Food Service Manager (FSM), the following was observed in the reach-in refrigerator: -One, 5 pound (lb.) container of ricotta cheese approximately ¾ full, opened, with a manufacturer's use by date of 5/22/2025. -One, 2.5lb. sealed package of cooked sliced roast beef with a use or freeze by date of 5/18/2025. -One, 6.11lb. bag of nacho cheese sauce without a use by date or a manufacturer's expiration date. -Three, 1lb. sealed packages of bologna with a use by date of 5/25/2025. 2. Observation during the initial tour, of the reach-in freezer, the following was observed: -One, frozen, rectangular block of split pea soup with the occlusive packaging unsealed, the contents were exposed, discolored, and covered in ice crystals. 3. Observations during the initial tour of the dry storage room, the following was observed: -One, 6.6lb. can of mandarin oranges with a manufacturer's date of 12/25/2023 and without an expiration date. -One 2.5lb. box of Nabisco Entertainment Crackers, opened, with a use by date of 3/5/2025. During a surveyor interview with the FSM immediately following the above observations, she revealed that she would expect food and beverages to be labeled and dated when opened. She further acknowledged that the expired items, undated items and the exposed pea soup should have been discarded.

Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to continuous oxygen administration for 2 of 2 residents reviewed, Resident ID #s 18 and 30, for 1 of 1 resident reviewed who had an order to offload their heels, Resident ID #6 and for 1 of 1 resident reviewed for a hand splint, Resident ID #20. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1a. Record review revealed Resident ID #18 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (COPD, a lung condition that restricts your breathing) and dependence on supplemental oxygen. Record review revealed a physician's order dated 4/21/2025 for oxygen at 2 liters per minute via nasal cannula (medical device used to provide supplemental oxygen therapy) continuously. During surveyor observations the resident was observed with oxygen at 4 liters per minute via nasal cannula on the following dates and times: - 5/27/2025 at 10:16 AM - 5/28/2025 at 11:37 AM - 5/29/2025 at 8:58 AM - 5/30/2025 at 9:06 AM During a surveyor interview on 5/30/2025 at 9:06 AM with Registered Nurse (RN), Staff A, she acknowledged that the resident was not being administered oxygen at 2 liters continuously, as ordered. During a surveyor interview on 5/30/2025 at 9:17 AM with the Director of Nursing Services (DNS), he indicated it would be his expectation that the resident's order would be followed relative to oxygen liter flow. 1b. Record review revealed Resident ID #30 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, COPD, pneumonia, acute respiratory failure, and dyspnea (shortness of breath). Record review revealed a physician's order dated 3/11/2025 for oxygen at one liter per minute continuously via nasal cannula. During surveyor observations the resident was observed with oxygen at 2.5 liters per minute via nasal cannula on the following dates and times: - 5/27/2025 at 9:42 AM - 5/27/2025 at 11:45 AM - 5/28/2025 at 11:44 AM - 5/28/2025 at 1:10 PM During a surveyor interview on 5/30/2025 at approximately 12:17 PM with the DNS, he was unable to provide evidence that the oxygen order was followed. 2. Record review revealed Resident ID #6 was admitted to the facility in January of 2016 with a diagnosis including, but not limited to, transient ischemic attack (a temporary change in the nerve function caused by disruption of blood flow to an area of the brain or spinal cord). Record review revealed a physician's order dated 3/4/2025 to off load both of the resident's heels when in bed as tolerated. During surveyor observations the resident's heels were lying directly on the mattress and not off loaded on the following dates and times: - 5/27/2025 at 9:55 AM - 5/27/2025 at 11:24 AM - 5/28/2025 at 9:59 AM - 5/28/2025 at 10:17 AM - 5/30/2025 at approximately 8:20 AM Record review failed to reveal evidence that the resident could not tolerate his/her heels being offloaded while in bed. During a surveyor interview on 5/30/2025 at 8:26 AM with RN, Staff A, she acknowledged that the resident's heels were not offloaded. During a surveyor interview on 5/30/2025 at 9:37 AM with the DNS, he revealed it would be his expectation for the order to be followed. 3. Record review revealed Resident ID #20 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, left hand muscle wasting and atrophy (a wasting or thinning of muscle mass). Record review of a physician's order dated 3/6/2025 revealed to apply a left-hand splint after morning care and to remove it during the afternoon rounds During surveyor observations on the following dates and times the resident was observed not wearing his/her left-hand splint: - 5/27/2025 at approximately 9:50 AM - 5/27/2025 at 11:21 PM - 5/28/2025 at 10:00 AM - 5/28/2025 at 11:36 AM During a surveyor interview on 5/29/2025 at approximately 1:18 PM with RN, Staff A, she acknowledged that the resident was not wearing his/her left hand splint as ordered. During a surveyor interview on 5/30/2025 at 9:10 AM with the DNS, he indicated it would be his expectation that the resident would be wearing his/her left-hand splint as ordered.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment relative to window air conditioning units, for 4 of 4 air conditioning units observed. Findings are as follows: During surveyor observations on the following dates and times the window air conditioning units in occupied resident rooms were observed to have an accumulation of visible black matter on the adjustable louvers (adjustable flaps) and beyond the louvers within the air conditioners: -5/28/2025 at 10:46 AM and 5/30/2025 at 8:40 AM rooms [ROOM NUMBERS]. -5/28/2025 at 11:05 AM and 12:34 PM rooms 13 (C/D) and 14. During a subsequent surveyor observation and simultaneous interview on 5/30/2025 at 8:40 AM with the Director of Nursing Services of rooms 8, 13 (C/D), 14, and 17, he acknowledged that an accumulation of black matter was visible on the adjustable louvers and beyond the louvers within the air conditioners. Additionally, he revealed that the air conditioning units should be cleaned. During a surveyor interview on 5/30/2025 at 9:59 AM with the Administrator, he was unable to provide evidence that the facility maintained a safe, functional, and comfortable environment.

Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective in-service training program including no less than 12 hours per year, to ensure competence of nurse aides (NAs) with their expected roles for 2 of 4 NAs reviewed, Staff D and E. Findings are as follows: Record review revealed that NA, Staff D, was hired on 2/3/2017. Additional review revealed that Staff D did not receive at least 12 hours of training in 2024. Record review revealed that NA, Staff E was hired on 3/1/2022. Additional review revealed that Staff E did not receive at least 12 hours of training in 2024. During a surveyor interview on 5/30/2025 at 10:03 AM with the Director of Nursing Services, he was unable to provide evidence of at least 12 hours of training for 2024 for Staff D and E.

**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 all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or, no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Rhode Island Department of Health- RIDOH), in accordance with State law, for 2 of 2 residents reviewed for allegations of abuse, Resident ID #s 1 and 2. Findings are as follows: Record review of a facility policy last revised in January of 2024 titled, Reporting Patient Abuse states in part, This facility will report all cases of suspected or actual abuse or neglect to the Department of Health .Any person that has reason to believe that a .resident has been abused, neglected or mistreated should contact the .DNS [Director of Nursing Services .at the time of the incident. In turn, the incident will be reported to the Department of Health .in written format within 2 hours of the suspicion and/or incident . 1. Record review of a facility reported incident submitted to the RIDOH on 8/22/2024 at 3:54 PM, alleges that on 8/21/2024 at 12:45 PM, Resident ID #1 was in tears and alleged Staff A of inappropriate sexual behaviors with him/her. Record review failed to reveal evidence that this allegation of sexual abuse was reported to the RIDOH within 2 hours as required. Record review revealed Resident #1 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, heart failure and myocardial infarction (heart attack). Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 out of 15, indicating moderately impaired cognition. During a surveyor interview on 8/29/2024 at 12:25 PM with the Minimum Data Set Assessment Coordinator, she revealed that on 8/21/2024 Resident ID #1 had revealed that Staff A, had touched Resident ID #1 in all the right places while in the shower. Additionally, she revealed she informed the DNS immediately. 2. Record review of a facility reported incident submitted to the RIDOH on 8/14/2024, alleges that on 8/4/2024 Staff B squeezed Resident ID #2's left leg causing him/her pain. Record review failed to reveal evidence that this allegation of staff to resident abuse was reported to the RIDOH within 2 hours as required. Record review revealed Resident ID #2 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, acute kidney failure and acquired absence of the right foot and other toes of the left foot. Record review of a Quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. During a surveyor interview on 8/29/2024 at 11:56 AM with the resident s/he revealed that this incident occurred a few weeks ago with Staff B. Resident ID #2 stated that Staff B squeezed his/her left leg causing him/her pain. During a surveyor interview on 8/29/2024 at 12:52 PM, with the DNS, he acknowledged that he was made aware of Resident ID #1's sexual abuse allegation on 8/21/2024 and Resident ID #2's allegation of staff to resident abuse on 8/4/2024. Additionally, he acknowledged that he did not report the allegations to the RIDOH or other officials within 2 hours as required.

Based on record review, surveyor observation, resident and staff interview, it has been determined that the facility failed to meet the nutritional needs of residents relative to increased protein for 1 of 1 dialysis resident reviewed, Resident ID #19. Findings are as follows: Record review revealed that the resident was admitted to the facility in March of 2021 with diagnoses including, but not limited to, acute kidney failure and obesity. Additional review revealed that the resident requires dialysis (a blood purifying treatment given when kidney function is not optimum) three times per week. Review of the resident's care plan revealed an intervention including, but not limited to, provide ordered diet. Review of a physician's order dated 3/15/2024 revealed the resident is to have double portions of protein with each meal. Review of a dialysis plan note for February 2024 revealed that the resident's albumin (protein in blood) in February 2024 was 3.1 and below the goal of 4 or higher. Review of the resident's meal ticket for breakfast, lunch and dinner revealed s/he is to have double portions of protein with each meal. During a surveyor observation on 5/29/2024 at 12:19 PM of the resident's lunch tray revealed shepards pie with brussel sprouts. Additionally, the serving was not double protein as ordered. During an interview with the resident directly following the above observation, s/he revealed that s/he would like to get the double portions of protein with each meal but rarely does. During a surveyor observation on 5/30/2024 at 8:22 AM of the resident's breakfast tray revealed a biscuit and cream of wheat cereal. Additionally, no protein was observed on the resident's meal tray. During a surveyor observation on 5/30/2024 at 12:22 PM of the resident's lunch tray revealed a bowl of beef stew and a bowl of peaches. Additionally, the serving of beef stew was not double protein as ordered. During a surveyor interview on 5/30/2024 at 12:30 PM with Cook, Staff M, she revealed that the resident does not get protein in the morning unless there is bacon or sausage because s/he does not like eggs. The resident typically gets a large bowl of cereal for breakfast. During a surveyor interview on 5/30/2024 at 3:32 PM with the Registered Dietitian she revealed that she was unaware that the resident was not getting the double protein portions as ordered. Additionally, she revealed that she would expect the staff to provide substitute protein options if the resident does not like what is being served. During a surveyor interview on 5/31/2024 at 10:38 AM with the Director of Nursing Services he was unable to provide evidence that the facility was providing the resident with double portions of protein at each meal, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a blood purifying treatment given when kidney function is not optimum) receive such services consistent with professional standards of practice for 1 of 1 resident reviewed for dialysis, Resident ID #19. Findings are as follows: Record review revealed the resident was admitted to the facility in March of 2021 with a diagnosis including, but not limited to, end stage renal disease (ESRD, when your kidneys can no longer support your body's needs). Record review of the resident's comprehensive care plan revealed that the resident receives dialysis three days a week on Tuesdays, Thursdays, and Saturdays at 9:45 AM. a) Record review failed to reveal evidence of a physician's order for dialysis to include the name of the center, the type of dialysis, and the scheduled days the resident is to receive dialysis. During a surveyor interview on 5/31/2024 at 10:23 AM with Registered Nurse, Staff A, she acknowledged that there was no order in place relative to dialysis that includes the above-mentioned information. b) Review of a facility policy titled, End-Stage Renal Disease, Care of a Resident with, states in part, .Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed . Record review revealed a document titled, Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement that states in part, This Agreement is made by and between [Facility] and [Dialysis Center], expressly for the purpose of care coordination .and is effective upon the date of last signature . Further review of the above-mentioned document failed to reveal evidence that it was signed and dated by either the dialysis center or the nursing facility. During a surveyor interview on 5/31/2024 at 11:17 AM with the Director of Nursing Services, he acknowledged that the dialysis service agreement lacked a signature and date from either party and was unable to explain why the facility nor dialysis center signed or dated the dialysis service agreement. He further revealed that it should be signed and dated by both parties. Additionally, he revealed that he was unaware that a physician's order relative to dialysis was required.

Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program, which includes but is not limited to communication, residents rights, abuse, quality assurance and performance improvement, infection control and behavioral health, for all new and existing staff consistent with their expected roles for 4 of 4 staff members reviewed, Staff C, E, F and G. Findings are as follows: Record review revealed that Registered Nurse, Staff C, was hired on 3/27/2019. Additional review revealed that Staff C did not receive any mandatory education in 2023. Record review revealed that Registered Nurse, Staff E was hired on 2/15/2022. Additional review revealed that Staff E did not receive any mandatory education in 2023. Record review revealed that Certified Medication Technician (CMT), Staff F was hired on 2/17/2014. Additional review revealed that Staff F did not receive any mandatory education for all of 2023. Further review revealed that she has not received an annual performance evaluation or 12 hours of mandatory in-services as required. Record review revealed that Nursing Assistant, Staff G was hired on 7/5/2017. Additional review revealed that Staff G did not receive any mandatory education for all of 2023. Further review revealed that he has not received an annual performance evaluation or 12 hours of mandatory in-services as required. During a surveyor interview on 5/30/2024 at 12:03 PM with the Director of Nursing Services, he was unable to provide evidence of any mandatory education for 2023 for any of the above mentioned staff. Additionally, he was unable to provide evidence of annual performance reviews or proof of 12 hours of inservice training for the Staff F and G.

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 in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1. Record review of the Rhode Island Food Code, 2018 Edition, section 4-601.11 states in part, .(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT .shall be kept free of encrusted grease deposits and other soil accumulations. (C) NON-FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . During the initial tour of the main kitchen on 5/29/2024 at 8:55 AM and 9:15 AM in the presence of the Administrator, the following was observed: - A microwave on the back counter was noted to have dried food particles, orange and brown in color, on the inside of the door, walls, ceiling and glass turning plate. - In the refrigerator labeled as the Defrosting Fridge in the basement, there were two wrapped pieces of red meat resting directly on the shelves. The bottom of the refrigerator was covered in red liquid, both stained and wet. 2. Record review of the Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, Ready-to Eat, Time/Temperature Control for Safety, Date Marking .(B) .(1) The day the original container is opened in the Food establishment shall be counted as Day 1 . During the initial tour of the main kitchen on 5/29/2024 at 8:55 AM in the presence of Cook, Staff B, the following was observed in the refrigerator labeled White Fridge/Freezer: - One 46 ounce (oz) nectar thickened apple juice opened and not dated. Manufacturer's instructions indicate to use the product within 10 days upon opening. - One 46 oz nectar thickened sugar free peach mango juice opened and not dated. Manufacturer's instructions indicate to use the product within 10 days upon opening. - One 46 oz nectar thickened cranberry juice opened and not dated. Manufacturer's instructions indicate to use the product within 10 days upon opening. During a surveyor interview with Staff B at the time of the above observation, she acknowledged that the nectar thickened juices should have been dated when opened. During a surveyor interview with the Administrator on 5/29/2024 at approximately 9:15 AM, he acknowledged that the microwave and refrigerator were dirty and needed to be cleaned and that the nectar thickened juices should have been dated when opened.

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 (IPCP) to help prevent the transmission of communicable diseases and infections for 2 of 3 residents reviewed for multidrug-resistant Organisms (MDRO), Resident ID #s 6 and 28. Additionally, the facility failed to conduct appropriate infection control practices relative to personal protective equipment during foley catheter (a flexible tube that is inserted through the urethra to help drain urine from the bladder) removal for 1 of 1 resident observed, Resident ID #3. The facility further failed to implement a water management program based upon industry standards and/or the Centers for Disease Control and Prevention (CDC) toolkit and to perform and document specified testing for the prevention of Legionella disease (a very serious type of lung infection caused by the bacteria called Legionella which can be found in water). This deficient practice could impact 31 of 31 residents, as well as an indeterminable number of staff and visitors. Findings are as follows: Review of the Centers for Disease Control and Prevention's (CDC) document titled, Multidrug-resistant organisms management states in part, .For ill residents (e.g. those totally dependent upon healthcare personnel for healthcare and activities of daily living) .use Contact Precautions [use of gown and gloves when entering a resident's room] in addition to Standard Precautions . Review of a facility policy titled Isolation - Categories of Transmission-Based Precautions states in part, .Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environment contamination and risk of transmission of a pathogen, even before specific organism has been identified .Contact precautions are used for residents infected or colonized [If you are colonized with an MDRO, these germs are living on or in your body. You may not be sick with an infection, but you can still spread the infection] with MDROs in the following situations .when a resident has wounds, secretions, or excretions that are unable to be covered or contained .the individual on contact precautions is placed in a private room if possible . Review of a policy title Enhanced Barrier Precautions last revised on 1/8/2024 states in part, Post the appropriate Enhanced Barrier Precautions (EBP) sign on the patient's room door .Enhanced Barrier Precautions (EBP) are to be utilized for the duration of the patients stay .All patients with any of the following: Infection or colonization with an MDRO when Contact Precautions do not apply .PPE Used for These Situations .During high contact patient care activities: Dressing .bathing/showering .transferring .providing hygiene .changing linens .changing briefs or assisting with toileting .device care or use, central line, urinary catheter, enteral feeding . 1 a. Record review revealed that Resident ID #6 was re-admitted to the facility in May of 2024 with diagnoses including, but not limited to, Vancomycin-resistant Enterococci (VRE, a type of bacteria present in the gastrointestinal tract that develop resistance to many antibiotics, especially vancomycin.) Review of a care plan dated 5/21/2024 revealed s/he tested positive for VRE. Interventions include, but are not limited to, contact precautions. Review of a hospital continuity of care form dated 5/6/2024-5/15/2024 revealed, Isolation Status s/he was on infection control precautions for VRE. During a surveyor observation on 5/29/2024 at 9:00 AM of the resident's room revealed a sign for contact precautions. The sign states in part, Everyone must put on gloves before room entry .put on a gown before room entry . During a surveyor observation on 5/29/2024 at 9:52 AM of Registered Nurse, Staff C, she obtained the resident's vital signs without wearing a gown or gloves. During a surveyor interview immediately following the above observation on 5/29/2024 with Staff C, she acknowledged that she should have worn a gown and gloves as required. Additionally, she acknowledged the resident was on contact precautions related to VRE. During a surveyor observation on 5/29/2024 at 12:24 PM of the Director of Nursing Services (DNS), he entered the resident's room and lifted the residents blanket up to assess his/her legs without wearing a gown or gloves. During a surveyor interview immediately following the above observation with the DNS, he acknowledged that he should have worn a gown and gloves to enter the resident's room as required. Additionally, he acknowledged the resident was on contact precautions for VRE. During a surveyor observation on 5/29/2024 at 2:10 PM of Physical Therapist Assistant, Staff D, entered the resident's room without wearing a gown or gloves and performed therapeutic exercises with the resident for approximately 20 minutes. During a surveyor interview immediately following the above observation with Staff D, she acknowledged that she should have worn a gown and gloves to enter the room per the signage on the resident's door but was unaware of why the resident was on contact precautions. During a surveyor interview on 5/30/2024 at 10:06 AM with the DNS, he revealed that the resident was on contact precautions for VRE and would expect staff to wear a gown and gloves when entering the resident's room. 1 b. Record review revealed that Resident ID #28 was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, cerebral infarction (stroke). Review of a urine culture dated 4/29/2024 revealed that s/he is positive for extended-spectrum beta-lactamase (ESBL, infection resistant to common antibiotics and may require complex treatments). Review of a urine culture dated 5/18/2024 revealed that s/he is positive for ESBL and was treated with antibiotics from 5/20/2024 through 5/27/2024. Record review failed to reveal evidence of a re-culture to determine if the resident remained positive for ESBL. During surveyor observations from 5/29/2024 through 5/31/2024 revealed the resident was not on contact precautions. During a surveyor interview on 5/31/2024 at approximately 9:00 AM with Registered Nurse, Staff A, she revealed that the resident was not on any precautions after completing his/her antibiotic treatment for ESBL. During a surveyor interview on 5/31/2024 at 11:17 AM with the DNS, he acknowledged that Resident ID #28 was not on contact precautions or EBP per the CDC, Rhode Island Department of Health and the facility policy. Additionally, he was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to MDROs. 2. Record review revealed that Resident ID #3 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, acute kidney failure. Review of a physician's order dated 5/24/2024 states in part, Insert 16 Fr [French] 3-way foley .for irrigation .(Foley to be removed immediately following treatment) . During a surveyor observation on 5/30/2024 at approximately 8:30 AM of the resident's room failed to reveal evidence that s/he was on EBP. Further observation revealed Registered Nurse, Staff A, removing the resident's foley catheter while wearing only gloves. She was not observed to be wearing a gown relative to enhanced barrier precautions. During a surveyor interview immediately following the above observation with Staff A, she indicated that she only needs gloves to remove the foley catheter and no other precautions were necessary. During a surveyor interview on 5/30/2024 at 10:06 AM with the DNS, he revealed that the resident should be on enhanced barrier precautions and the nurse should be wearing a gown and gloves during foley catheter insertion and removal. 3. Record review of the CDC document titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated June 2021, version 1.1 states in part, .The key to preventing Legionnaires' disease is maintenance of the water systems in which Legionella may grow .Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant. Common issues that contribute to water stagnation include .reduced building occupancy .Stagnation can also occur when fixtures go unused, like a rarely used shower . During a surveyor interview with the Administrator on 5/29/2024 at approximately 8:00 AM he revealed that the facility has not been flushing any empty rooms as they are at full capacity. Additionally, he revealed that there were no unused sinks in the facility. Surveyor observation of a shower room on 5/30/2024 at 9:15 AM located in a housekeeping room, revealed there was a shower that was not in use. Further observation of the facility revealed a utility room with two sinks that were not in use. During a surveyor interview at the time of the above-mentioned observations with the Administrator, he indicated that the shower and the two sinks were not being utilized by anyone in the facility. Record review of the facility's water management binder failed to reveal evidence that the water flow assessment was filled out in its entirety to indicate how many sinks, toilets, and water reservoirs were in place. Further review of the water management binder failed to reveal evidence that the facility conducted flushing maintenance of the unused shower and sinks that were identified on 5/30/2024. During a surveyor interview with the Administrator on 5/30/2024 at 11:50 AM, he was unable to provide evidence that the facility maintained or implemented a water management program based upon industry standards and the CDC toolkit for the prevention of Legionella, as required. During a surveyor interview on 5/31/2024 at 9:14 AM with the DNS he was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of communicable diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to provide an ongoing program to support a resident in their choice of activities designed to meet the interests of and support the well-being of each resident, based on the comprehensive assessment, care plan and preferences for 3 of 5 residents reviewed, Resident ID #s 1, 2, and 3. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/8/2024 alleges in part, .No activities for residents . Record review of the May 2024 Activities Calendar provided by the Administrator, revealed one activity was listed for each day without a designated start or end time. Additionally, the calendar indicated that on 5/14/2024 an activity of Beach Ball was to take place. During a surveyor observation on 5/14/2024 from 10:45 AM through 3:00 PM, there was no evidence of a group activity taking place, including but not limited to, Beach Ball. Additional record review of the May 2024 Activities Calendar revealed one activity was listed for each day without a designated start or end time. Additionally, the calendar indicated that on 5/16/2024 an activity of Hangman was to take place. During a surveyor observation on 5/16/2024 from approximately 10:00 AM through 12:00 PM there was no evidence of a group activity taking place, including but not limited to Hangman. During a surveyor interview on 5/16/2024 at approximately 10:15 AM with the Activities Assistant, Staff A, she was unable to provide evidence that a morning activity had occurred. She also revealed the activities at the facility 'generally includes one scheduled activity a day, a movie every other Sunday, music entertainment two times a month, and a Catholic mass and communion one time a month. Upon further interview she revealed that on 5/15/2024 Bingo did not occur per the calendar and that there were no group activities for the day. 1. Record review for Resident ID #1 revealed s/he was admitted to the facility in March of 2019 with diagnoses including but not limited to inflammatory polyneuropathy (damage to the peripheral nerves which are located outside of the brain and spinal cord) and insomnia. A Brief Interview for Mental Status (BIMS) was completed in April of 2024 with a score of 15 of 15, which indicates his/her cognition is intact. Record review of the Minimum Data Set (MDS) assessment dated [DATE] section F: Preferences for Customary Routine and Activities revealed that while the resident is at the facility, it is very important for him/her to have: - Be around animals such as pets - Keep up with the news - Participate in religious services or practices - Do things with groups of people Record review of a care plan dated 4/18/2024 revealed in part, . need for therapeutic recreation, encourage activity participation . During a surveyor interview on 5/14/2024 at approximately 2:00 PM with the resident s/he stated if activities were to take place throughout the day s/he would be interested in attending. During a surveyor interview on 5/16/2024 at approximately 11:00 AM with the resident s/he indicated no group activity took place on 5/15/2024 and that the activity program does not include pets or the local/world news. 2. Record review for Resident ID #2 revealed s/he was admitted to the facility in January of 2024 with diagnoses including, but not limited to, major depressive disorder and anxiety disorder. A BIMS was completed in May of 2024 with a score of 13 of 15, which indicates his/her cognition is intact. Record review of the MDS assessment dated [DATE], Section F: Preferences for Customary Routine and Activities revealed that while a resident at the facility, it is very important for him/her to have: - Be around animals as pets - Keep up with the news - Participate in religious services Record review of a care plan dated 5/3/2024 revealed in part, .need for therapeutic recreation and to inform and assist to upcoming activities . During a surveyor interview on 5/14/2024 at approximately 1:45 PM s/he revealed that s/he attends the one scheduled activity a day and then stays in his/ her room and does puzzles or colors for the remainder of the day. S/he further revealed s/he would attend more group activities if they were offered. During a surveyor interview on 5/16/2024 at approximately 11:00 AM, s/he revealed there are no activities that include pets or the world news. Additionally, s/he revealed that Bingo did not take place on 5/15/2024 per the calendar. 3. Record review for Resident #3 revealed s/he was admitted to the facility in June of 2022 with diagnoses including, but not limited to, bipolar disorder (a condition that causes emotional highs and lows) and atherosclerotic heart disease (hardening of the arteries). A BIMS was completed on 3/14/2024 with a score of 15 of 15, which indicates that his/her cognition is intact. Record review of the MDS assessment dated [DATE], Section F: Preferences for Customary Routine and Activities revealed that while a resident in the facility it is very important for him/her to have: - Keep up with news - Do things with groups of people - Participate in religious services or practices Record review of a care plan with a start date of 3/25/2024 revealed in part, .anxiety disorder with a goal to attend activities and to encourage activity involvement . During a surveyor interview on 5/16/2024 at approximately 10:45 AM with the resident s/he revealed there are no group activities in the afternoon. S/he further revealed s/he would attend if there were more group activities. Additionally, s/he revealed the activity calendar does not include group activities with pets or the world news. During a surveyor interview on 5/16/2024 at approximately 12:05 PM with Staff A, she revealed that the activity program does not include current events or pet therapy. She further stated the activity programming does not include non-denominational religious services. During a surveyor interview on 5/16/2024 at approximately 10:30 AM with the Director of Nursing Services he revealed there were no group activities on 5/15/2024. During a surveyor interview on 5/14/2024 at approximately 2:30 PM and on 5/16/2024 at approximately 11:40 AM with the Administrator, he was unable to provide evidence that an activity program was developed based on the comprehensive assessment, care plan and the preferences of each resident.

Based on surveyor observation, record review and resident and staff interview, it has been determined that the facility failed to provide reasonable accommodation of resident needs and preferences, relative to individualizing the physical environment of the resident's bedroom, for 1 of 1 residents reviewed for call light accessibility, Resident ID #28. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, cerebral infarction (stroke), and right hemiplegia (paralysis of one side of body that causes weakness). Record Review of a care plan dated 2/14/2023, states in part, impaired physical mobility (upper extremity) right (lower extremity) right with interventions to place items in reach on left side, call light in reach, left side . During surveyor observations on 5/10/2023 at approximately 8:25 AM and 10:00 AM, the resident was observed lying in bed with his/her call light on the right side of the bed. During a surveyor interview with the resident on 5/10/2023 at approximately 10:00 AM the resident indicated that s/he could not access the call light. During a surveyor interview on 5/10/2023 at approximately 10:05 AM with Certified Nursing Assistant, Staff A, she acknowledged that the resident was unable to reach his/her call light. During a surveyor interview on 5/10/2023 at approximately 10:20 AM with the Director of Nursing Services, she acknowledged that the resident has right sided paralysis and therefore, is unable to reach items placed on his/her right side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, surveyor observation, resident, and staff interview, it has been determined that the facility has failed to assure that a resident has the right to self-determination with services inside the facility for 1 of 1 residents reviewed relative to activities, Resident ID #12. Findings are as follows: Record review revealed the resident was admitted to the facility in September of 2021 with diagnoses that include but are not limited to, cerebral vascular accident (stroke) and right sided hemiparesis/hemiplegia (residual weakness due to the stroke). Record review of the most recent comprehensive Minimum Data Set assessment dated [DATE] page 13 titled, Section F Preferences for Customary Routine and Activities, revealed documentation that it is very important for the resident to do his/her favorite activities while s/he is in the facility. During a surveyor observation on 5/8/2023 at 12:14 PM, revealed the resident was seated in a recliner in the common area. S/he was wearing a sling to the right upper extremity. Additionally, the resident was observed to be eating his/her lunch meal without staff assistance. During the observation, Activities Staff, Staff B was overheard telling the resident that s/he could attend bingo when his/her arm was better. During a surveyor interview on 5/10/2023 at 9:54 AM with the resident and Nursing Assistant, Staff A, she indicated that the resident does not attend activities since s/he injured his/her arm. The resident indicated that s/he would like to attend bingo and stated, they don't come and get me. Record review revealed the resident was diagnosed with a injury to his/her right arm on 4/13/2023. During a surveyor interview on 5/10/2023 at 9:56 AM with Staff B, she indicated that bingo is held three times per week. She also indicated that the resident has not attended since his/ her arm was injured and was unable to provide evidence that the resident was offered to attend. During a surveyor interview with Registered Nurse, Staff C on 5/10/2023 at 10:04 AM, she was unable to explain why the resident has not attended the activity of his/her choice. During a surveyor interview on 5/10/2023 at 10:05 AM with the Director of Nursing Services (DNS) in the presence of Staff C, she indicated that the resident should be able to attend bingo and was unable to provide evidence that the resident was offered to attend since injuring his/her arm. Additionally, the DNS acknowledged that the resident has chronic right upper extremity impairment and was previously attending bingo. During a surveyor observation on 5/10/2023 at 10:46 AM revealed the resident was escorted to bingo by staff and s/he was observed to be smiling and thanking staff for bringing him/her to bingo after it was brought to the attention of the facility by the surveyor. During a surveyor observation and interview on 5/10/2023 at 11:34 AM, the resident was observed in the corridor with bingo winnings on his/her lap. The resident was observed to be smiling and indicated that s/he won.

**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 conduct periodic accurate, standardized reproducible assessments of each resident ' s functional capacity, for 2 of 8 residents reviewed, Resident ID #s 5 and 12. Findings are as follows: 1. Record Review for Resident ID #5 revealed s/he was admitted to the facility in October of 2021. Further record review failed to reveal evidence that quarterly assessments were completed as required since the last completed quarterly assessment dated [DATE]. During a surveyor interview with the Director of Nursing Services on 5/9/2023 at approximately 4:10 PM, she acknowledged that the assessments were not completed as required. 2. Review of the RAI manual page 2-21 states in part, .The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA [Significant Change in Status Assessment] .has been completed since the most recent comprehensive assessment was completed . Record review for Resident ID #12 revealed s/he was admitted to the facility in September of 2021. Additional record review revealed a Minimum Data Set, admission Comprehensive assessment, dated 9/15/2021. Further record review failed to reveal evidence that a comprehensive assessment was completed after the above-mentioned admission assessment. During a surveyor interview with the Administrator on 5/10/2023 at 10:31 AM, he was unable to provide evidence that a comprehensive reassessment was completed for Resident ID #12 after the initial admission assessment dated [DATE].

**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 implement a comprehensive person-centered care plan for 1 of 1 residents reviewed, relative to fluid restrictions, Resident ID #20. Findings are as follows: Review of the facility policy titled, Fluid Restriction Policy, revealed .resident's with orders for fluid restrictions will have their fluid intake strictly monitored by the charge nurse and total intake will be recorded in the TAR [Treatment Administration Record] daily . Record review revealed the resident was admitted to the facility in March of 2021 with a diagnosis including, but not limited to, chronic kidney disease, stage 3. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition is intact. Record review of the care plan dated 1/27/2023 revealed a problem of renal failure and to record intake every shift. Record review of physician's orders revealed an order dated 7/28/2022, .Fluid restriction 1500 ml (milliliter) per day=5 small water bottles. Record review of the April and May 2023 TAR failed to reveal evidence the resident's intake was monitored or recorded per the facility's policy or the resident's care plan. During a surveyor interview on 5/9/2023 at 9:52 AM with Registered Nurse, Staff C she revealed the resident has a 1500 ml fluid restriction and his/her fluid intake is not recorded by the staff. During a surveyor interview on 5/9/2023 at 9:54 AM with the Director of Nursing Services, she revealed that the resident's fluid intake was not being recorded. Additionally, she revealed that she would expect his/her fluid to be recorded as outlined in the facility's policy and the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and resident and staff interview it has been determined that the facility failed to assist a resident in obtaining routine and emergency dental services for 1 of 1 residents reviewed, Resident ID #13. Findings are as follows: Review of the facility policy titled Dental Care, states in part, .It is the policy .to assist residents in obtaining routine and/or emergency dental services . Review of the record revealed the resident was admitted to the facility in June of 2022 with a diagnosis including but not limited to anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). Review of a Quarterly Minimum Data Set Assessment (MDS), dated [DATE], Section C, revealed a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition. Further review revealed the resident has mouth or facial pain and discomfort or difficulty with chewing. Review of the care plan revealed alteration in dental status and potential for alteration in comfort with interventions to notify dentist as needed and .difficulty eating as of 12/7/2022 resident has lost [his/her] denture . Review of a 2/3/2023 note revealed in part, .[Resident's name redacted] appetite varies as [s/he] is edentulous [sic] having lost [his/her] newly replaced dentures a few months ago . Further review of the record failed to reveal evidence that the lost dentures were reported to the physician, resident's family, the dentist, or the Director of Nursing Services. Surveyor observation of the resident's super meal tray on 5/9/2023 at 5:30 PM, revealed two slices of pizza, one had only one bite eaten. During a surveyor interview with the resident immediately following the above-mentioned observation, it was indicated that s/he has trouble chewing and cannot eat the pizza because s/he no longer has his/her lower denture. It was further stated that s/he has not had them for a few months and usually will eat either cereal or a peanut butter and jelly sandwich if s/he cannot eat the meal provided. During a surveyor interview with the Director of Nursing Services on 5/10/2023 at approximately 12:00 PM, she acknowledged that the resident's denture was missing and indicated that her expectation would be that the physician, resident's family, and she would have been notified that the denture was missing. Additionally, she would expect that his/her diet would be changed to accommodate chewing difficulties until s/he could be assessed by the dentist.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality for 1 of 2 residents reviewed relative to blood sugar monitoring, Resident ID #6. 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 of the facility policy titled, HYPERGLYCEMIA [an excess of glucose in the bloodstream] - THE MANAGEMENT AND TREATMENT OF, states in part, .If the physician has not indicated otherwise, the facility parameter requiring notice to the physician of hyperglycemia is > [greater than] 400 .The physician is to be immediately informed of the confirmed critical results > 400 per this policy unless a different parameter has been set by the physician .indication of the physician notification and resulting follow up orders and action taken are to be documented in the electronic medical record . Additional record review of the facility policy titled, HYPOGLYCEMIA [low blood sugar] - THE MONITORING AND TREATMENT OF, states in part, .Whenever the finger stick indicates a blood sugar level of less than 70 .THE PHYSICIAN IS TO BE NOTIFIED IMMEDIATELY. Documentation of the event is to follow all of the above. Record review revealed the resident was admitted to the facility in June of 2022 with diagnosis including, but not limited to, type 2 diabetes mellitus. Record review of the April and May 2023 Medication Administration Records (MAR) revealed the following physician orders and start dates: - 2/28/2023 for blood glucose monitoring 7:30 AM, 11:00 AM, 4:00 PM, and 8:00 PM - 4/19/2023 for Humalog Insulin per sliding scale. Less than 70 call MD [Medical Doctor]. - 6/9/2022 for Glucagon 1 milligram solution for hypoglycemia (low blood sugar) to be administered for blood sugar less than 60 and unresponsive Further record review revealed the following blood sugars: April 2023: - 4/1 at 4:00 PM, 65 - 4/2 at 7:30 AM, 518 - 4/3 at 11:00 AM, 486 - 4/4 at 7:30 AM, 52 and 8:00 PM 29 - 4/5 at 8:00 PM, 29 - 4/7 at 8:00 PM, 35 - 4/9 at 4:00 PM, 30 - 4/16 at 4:00 PM, 30 - 4/18 at 8:00 PM, 30 - 4/19 at 4:00 PM, 427 - 4/20 at 7:30 AM, 487 - 4/26 at 11:00 AM, 548 - 4/28 at 7:30 AM, 440 May 2023: - 5/1 at 7:30 AM, 453 - 5/5 at 4:00 PM, 61 - 5/7 at 11:00 AM, 483 and at 4:00 PM, 44 - 5/8 at 11:00 AM, 553 Record review failed to reveal evidence that the physician was notified when the resident had blood sugar levels greater than 400 or less than 70, as indicated in the the above-mentioned facility policies. During a surveyor interview on 5/9/2023 at 4:35 PM with the Director of Nursing Services, she indicated that she would expect staff to notify the physician and document in the resident's record per the facility policy.

Based on surveyor observation, record review, and staff and resident interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status relative to dietary supplements for 3 of 5 residents reviewed, Resident ID #s 7, 18, and 28. Findings are as follows: 1. Review of the facility policy titled, Weight, states in part, .Monitor residents with unplanned weight loss to ensure that interventions and documentation are appropriate . Review of the record for Resident ID #7 revealed that s/he was admitted to the facility in November of 2022 with a diagnosis including, but not limited to, mild protein-calorie malnutrition. Review of the January through April 2023 weight documentation revealed the resident weighed 85 lbs. (pounds) on 1/17/2023 and 77 lbs. on 4/18/2023, indicating a severe weight loss of 8 lbs. or 9.41% in three months. Review of a Registered Dietitian note, dated 4/19/2023, revealed that she spoke with the resident regarding his/her recent four-pound weight loss and discussed an intervention to retrial the magic cup. Review of a Physician Order dated 4/19/2023 revealed an order for a magic cup meal supplement with all meals. Review of a document titled, CNA [Certified Nursing Assistant] Care Plan Reference Sheet, revealed a dietary intervention for magic cup supplements with all meals for weight loss. Surveyor observations failed to reveal evidence that a magic cup supplement was provided to the resident for the lunch meal on 5/8/2023 and both the breakfast and lunch meals on 5/9/2023. During a surveyor interview with the Registered Dietitian on 5/10/2023 at 12:22 PM, she indicated that the magic cup was stopped after a trial when the resident was admitted . Additionally, was unable to explain why the order was not discontinued or provide evidence of other interventions implemented for the resident's severe weight loss. During a surveyor interview with the Director of Nursing Services (DNS) on 5/10/2023 at 1:24 PM, she was unable to provide evidence that the supplement was given to the resident as indicated in the order. 2. Record review for Resident ID #18 revealed that s/he was admitted to the facility in July of 2021 with a diagnosis including, but not limited to, dementia. Review of a Physician Orders dated 12/13/2022 revealed an order for a magic cup meal supplement daily with lunch and supper. Review of a document titled, CNA Care Plan Reference Sheet, revealed a dietary intervention for a magic cup to be provided with lunch and supper. Review of the resident's care plan, dated 3/13/2023, revealed that s/he has a potential for weight fluctuations with interventions to give a food supplement and to provide the ordered diet. Surveyor observations failed to reveal evidence that a magic cup supplement was provided to the resident for both the lunch and supper meals on 5/8/2023 and the supper meal on 5/9/2023. Review of the meal ticket on the resident's tray during the 5/9/2023 supper meal revealed in part, .MEAL SUPPLEMENT: Magic cup with lunch, supper, daily . During a surveyor interview with Nursing Assistant, Staff D on 5/9/2023 at 5:37 PM, he acknowledged that the magic cup was not provided on the meal tray. During a surveyor interview with Registered Nurse, Staff E on 5/9/2023 at 5:40 PM, he indicated that his expectation would be that the staff would provide a magic cup to the resident on his/her meal tray. During a surveyor interview with a Kitchen Cook, Staff F on 5/9/2023 at approximately 6:00 PM, it was stated that the facility has not had magic cup supplements in the building since the previous weekend. 3. Record review revealed Resident ID #28 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, type 2 diabetes, depression, cerebral infarction (stroke), and anorexia. Review of a physician order, dated 2/13/2023, revealed, Meal Supplement .house supplement: 120 mL (milliliter) with breakfast, lunch, supper. Review of the Medication Administration Record (MAR) failed to reveal evidence that the resident received a supplement with lunch on 4/2/2023 or with supper on 4/9/2023. Further record review revealed a care plan, dated 2/14/2023, was developed upon assessment after it was determined the resident was identified at risk for potential weight fluctuation due to decreased appetite, poor intake and disease process. Additionally, record review revealed that the dietitian has assessed the resident and recommended a house supplement due to poor intake. Surveyor observations on 5/9/2023 at 12:05 PM and 5:09 PM, failed to reveal evidence that the resident had received a house supplement. During a surveyor interview on 5/9/2023 at approximately 5:10 PM with Nursing Assistant, Staff G she acknowledged that the house supplement was not provided with the resident's meal. During a surveyor interview with the DNS on 5/9/2023 at approximately 5:10 PM, she indicated that her expectation is that staff would adhere to physician orders. Furthermore, she was unable to explain why the resident did not receive a house supplement with his lunch and supper meals.

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection prevention and control program (IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use, for 2 of 2 resident's reviewed for antibiotic use, Resident IDs # 2 and 8. Findings are as follows: 1. Record review revealed Resident ID #2 was initially admitted to the facility in March of 2005 with a diagnosis including, but not limited to, multiple sclerosis. Record review of physician's orders revealed an order with a start date of 3/19/2023 for an antibiotic, Amoxicillin-Pot Clavulanate 500mg (milligram)-125MG. Record review of the March 2023 Medication Administration Record (MAR) revealed the above medication was administered as ordered on 3/19/2023. 2. Record review revealed Resident ID #8 was admitted to the facility in January of 2016 with a diagnosis including, but not limited to, nontraumatic subdural hemorrhage (brain bleed). Record review of physician's orders revealed an order with a start date of 3/7/2023 and end date of 3/12/2023 for Cephalexin (antibiotic) 500 mg, 3 times a day. Further review revealed a physician's order with a start date of 3/20/2023 and end date of 3/26/2023 for Cephalexin 500 mg, 3 times a day. Record review of the March 2023 MAR revealed the above medications were administered as ordered. Review of the antibiotic stewardship monthly records failed to reveal documentation of tracking information for the above mentioned antibiotic orders. During a surveyor interview on 5/10/2023 at 2:40 PM with the Director of Nursing Services, she revealed that she would expect the above mentioned antibiotics to be documented on the antibiotic tracking list.

**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 food is stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings are as follows: 1)Record review of the facility policy titled, Food Storage states in part, .all foods should be covered, labeled, dated and routinely monitored to assure that food (including left overs) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. During the initial tour of the kitchen and storage room on 5/8/2023 at approximately 8:00 AM in the presence of the Cook, Staff F, revealed the following; in the refrigerator labeled Defrosting Fridge/Freezer: -3 unopened 4 oz packages of Block & Barrel Fully cooked sliced roast beef with a use or freeze by date of 4/13/2023 -1 16.96 pound [NAME] Hardwood smoked pit ham with a sell by date of 4/12/2023 In the freezer labeled I Breakfast freezer: -a bag of approximately 10 chocolate croissants with ice accumulation that was open and not labeled or dated. During a surveyor interview immediately following the above findings with Cook, Staff F, she revealed that the above mentioned items had not been previously frozen. Additionally, she acknowledged that the food items had expired and should be discarded. Additional surveyor observation of the kitchen on 5/9/2023 at approximately 8:35 AM in the presence of Staff F revealed the following: -Admiration Lite Italian Dressing in a 1 gallon container open and not dated with the expiration date of 4/5/2023 -Sahara Burst tomato juice from concentrate in a 1 quart bottle, approx. half full, open and not dated -1.5 pound package of Block & Barrel sliced swiss cheese with a best by date of 3/23/2023 -A box of approximately 40 1-ounce containers of Wholesome Farms Cultured sour cream grade A with a use by date of 2/20/2023. During a surveyor interview immediately following the above findings with Staff F, she acknowledged that the above mentioned items had expired and that the tomato juice was not dated when opened. 2. Review of the facility's Resource Infection Control Cleaning Agents revealed GC 2010 was the chemical used for cleaning all appliances and countertops. Review of the GC-2010 Surface Sanitizer For Food & Medical Facilities instructions revealed it .is an effective sanitizer at 200 ppm (parts per million) active quat for use of food contact surfaces . During a surveyor observation of the kitchen on 5/9/2023 at approximately 8:20 AM, a red plastic bucket was on the food preparation counter with fluid and a cloth inside. During a surveyor interview during the above observation, Staff F revealed the red plastic bucket contained the sanitizing solution, GC-2010, that is used to sanitize the food preparation counter. She further revealed that the sanitizer pump was currently not working and she mixed the sanitizer and water herself. Additionally, she was unable to explain what the appropriate sanitizer concentration should be, per the manufacturer's instructions. Immediately following the above observation and interview, Staff F used a Krowne QAC (quaternary ammonium compounds) test strips (test strips to test the concentration of the sanitizer). The test strip read approximately 100 ppm. Staff F discarded the solution, made another solution and tested it with the same results. Three solutions were mixed before the solution read approximately 200 ppm, the effective amount to sanitize food contact surfaces. 3. During a surveyor observation on 5/9/2023 at approximately 8:44 AM in the presence of Staff F, revealed the following stacked while wet on a storage shelf : -24 plate covers -4 small plastic cups, approximately 4 ounces -9 larger plastic cups, approximately 8 ounces During a surveyor interview immediately following the above observation, Staff F revealed the dishes are not dried after coming out of the dishwasher and are stacked while wet. During a surveyor interview with the Administrator on 5/10/2023 at 10:19 AM, he indicated that he would expect expired foods to be discarded and foods to be labeled and dated when opened. Additionally, he indicated that he would expect the sanitizer solution to be mixed according to the instructions and the dishes to be dried prior to being stacked on a storage shelf.