**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 store and label drugs and biological's in accordance with currently accepted professional principles for 2 of 3 medication carts observed. Findings are as follows: Review of a policy titled, Medication-Storage states in part, To provide guidelines for proper storage of medications within the facility. The center will have Medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with Department of Health guidelines .Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy . Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities reveals in part, .Labeling of Drugs and Biological's .Labeling of medications and biological's dispensed by the pharmacy must be consistent with applicable federal and State requirements .Although medication delivery and labeling systems may vary the medication label at a minimum includes the medication name .prescribed dose, strength, the expiration date .the resident's name and route of administration .Additionally, to minimize contamination, facility staff should date the label of any multi-use vial when the vial is first accessed .If a multidose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days . 1) During a surveyor observation of the lower-level Certified Medication Technician (CMT) medication cart on [DATE] at 12:30 PM with CMT, Staff A the following was revealed: - A Trelegy Ellipta inhaler for Resident ID #27 open, in use and not dated. Manufacturer's instructions on the package state: Discard inhaler 6 weeks after opening. -A Trelegy Ellipta inhaler for Resident ID #25 open, in use and not dated. Manufacturer's instructions on the package state: Discard inhaler 6 weeks after opening. -A Spiriva Respimat inhaler for Resident ID #35 opened, in use and not dated. Manufacturers instruction on the box states, Discard 3 months after insertion of cartridge. During a surveyor interview with Staff A at the time of the above observation, she acknowledged that the above inhalers were open, in use and not dated. 2) During a surveyor observation of the lower-level Nurse's medication cart on [DATE] at 12:42 PM with Registered Nurse, Staff B, and the Director of Nursing Services (DNS) the following was revealed: - A lidocaine 1% (20 ml multidose vial) that was open, in use and not dated. Additionally, the vial did not have a label identifying which resident it was prescribed for. - A Humulin R 100 units/ml (3 ml multidose vial) open, and in use, that failed to identify a resident to whom is was prescribed. During a surveyor interview immediately following the above observation with the DNS, she acknowledged that the above medication vials failed to be labeled with a resident name. She further acknowledged that the lidocaine was not dated when opened.

**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 maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 1 resident reviewed for Multidrug-Resistant Organisms (MDRO), Resident ID #41. Findings are as follows: Review of the CDC's (Centers for Disease Control and Prevention) document titled, Multidrug-resistant organisms management (MDRO) 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 .Implement Contact Precautions (CP) routinely for all patients colonized or infected with a target MDRO .modify CP to allow MDRO .colonized/infected patients whose site of colonization or infection can be appropriately contained and who can observe good hand hygiene practices to enter common areas and participate in group activities When active surveillance cultures are obtained as part of an intensified MDRO control program, implement CP until the surveillance culture is reported negative for the target MDRO. Record review revealed that Resident ID #41 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, vascular dementia and chronic kidney disease Stage 2. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed s/he requires moderate to maximum assistance to complete activities of daily living (ADLs). Additionally, the MDS Assessment revealed that the resident was frequently incontinent of bladder and always incontinent of bowels during the 7 day look back period. Review of a urine culture dated 1/20/2024 revealed s/he is positive for Extended- spectrum beta-lactamases (ESBL- a bacterial infection that is resistant to many antibiotics). Record review of the document titled Toilet Use: Self Performance revealed that between 1/25 and 2/5/2024, the resident required extensive assistance on 7 occasions and was totally dependant on 8 occasions. Review of the physician orders revealed an order for Ertapenem Sodium injection 1 gram (antibiotic) intramuscularly in the evening for urinary tract infection for 7 days. This order was started on 1/30/2024 and completed on 2/5/2024. Record review failed to reveal evidence of a re-culture for ESBL following the antibiotic treatment. Surveyor observations on 2/7/2024 failed to reveal evidence that the resident was on contact precautions. Record review failed to reveal evidence that the facility followed the CDC prevention documentation for removal of contact precautions for this resident who has a MDRO and was receiving an antibiotic treatment from 1/30/2024 through 2/5/2024 for an active infection. During a surveyor interview on 2/7/2024 at 12:25 PM with Registered Nurse, Staff B and Certified Medication Technician, Staff C, they revealed that the resident was not on contact precautions for ESBL. During a surveyor interview on 2/7/2024 at 12:46 PM with the Director of Nursing Services, she revealed that the provider did not re-culture for ESBL after completion of the antibiotic on 2/5/2024. Additionally, she acknowledged that the above resident was not on contact precautions. Furthermore, she was unable to provide evidence that the facility followed the CDC standard related to the removal of contact precautions to prevent the transmission of communicable diseases and infections for this resident.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of significant medication errors for 5 of 12 residents reviewed for medication administration, Resident ID #s 3, 15, 19, 27, and 37. Findings are as follows: Review of a facility policy titled, MEDICATION ADMINISTRATION, last revised December 2019, states in part, .For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR [Medication Administration Record] may be flagged. After completing the medication pass, the nurse returns to the missed resident to administer the medication .The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones . 1. Record review revealed Resident ID #3 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, hypotension and arthritis. Record review revealed a physician's order dated 7/6/2023 for gabapentin, 400 mg (milligrams), by mouth, every morning for nerve pain. Review of the February 2024 MAR revealed the above medication was not documented as being administered on 2/1/2024 and 2/4/2024. 2. Record review revealed Resident ID #15 was admitted to the facility in March of 2021 with a diagnosis including, but not limited to, hypothyroidism (a condition resulting from decreased production of thyroid hormones). Record review revealed a physician's order dated 6/18/2023 for Levothyroxine Sodium Oral Tablet, 200mg, by mouth, every morning, for hypothyroidism. Review of the February 2024 MAR revealed the above medication was not documented as being administered on 2/2/2024 and 2/4/2024. 3. Record review revealed Resident ID #19 was admitted to the facility in August of 2019 with a diagnosis including, but not limited to, diabetes mellitus, type two, with diabetic neuropathy. Record review revealed a physician's order dated 11/18/2023 for Novolog solution (insulin), 100 unit/ml, with instructions to inject per sliding scale, 4 times daily, before meals and at bedtime, for diabetes. Review of the February 2024 MAR revealed the above medication was not documented as being administered on 2/4/2024 at 9:00 PM. 4. Record review revealed Resident ID #27 was admitted to the facility in December of 2019 with a diagnosis including, but not limited to, diabetes mellitus, type two. Record review revealed a physician's order dated 5/15/2023 for insulin glargine solution, 100 unit/ml, with instructions to inject 48 units, subcutaneously (under the skin), at bedtime, for diabetes mellitus, type two. Review of the February 2024 MAR revealed the above medication was not documented as being administered on 2/2/2024 and 2/4/2024. 5. Record review revealed Resident ID #37 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, hyperlipidemia (high levels of fat in the blood) and heart disease. Record review revealed a physician's order dated 1/5/2024 for atorvastatin calcium, 40 mg, by mouth at bedtime, for hyperlipidemia and heart disease. Review of the February 2024 MAR revealed the above medication for atorvastatin calcium was not documented as being administered on 2/2/2024. Further record review revealed a physician's order dated 1/5/2024 for insulin glargline with instructions to inject 20 units subcutaneously, at bedtime, for diabetes mellitus, type two. Further review of the February 2024 MAR revealed the above medication for insulin glargline-yfgn (long-acting insulin that works slowly, over about 24 hours) was not documented as being administered on 2/4/2024. During a surveyor interview on 2/7/2024 at 8:41 AM, with Registered Nurse, Staff D, she revealed that after the concern was brought to the facility's attention by the surveyor, she went into the February 2024 MARs for Resident ID #s 27 and 37 and signed off on administering the medications, which was several days after the medications were to be administered. During a surveyor interview on 2/7/2024 at 2:01 PM, with the Director of Nursing Services, she revealed that her expectation is for the nurses to document immediately following administering medications. Further, she was unable to provide evidence the above-mentioned residents were free from significant medication errors.

Based on record review and staff interview, it has been determined that the facility failed to ensure the residents' medical record includes documentation that the residents were offered or received the pneumococcal vaccine, or did not receive the vaccination due to medical contraindications or refusal, for 5 of 11 residents reviewed, Resident ID #s 2, 12, 13, 17, & 20. Findings are follows: 1. Record review of Resident ID #2 revealed the resident was admitted to the facility in November of 2023 with diagnoses including, but not limited to, alcoholic cirrhosis of the liver and bipolar disorder. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia or flu vaccination. 2. Record review of Resident ID #12 revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, alcohol abuse, diabetes, and anxiety disorder. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia vaccine. 3. Record review of Resident ID #13 revealed the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, atherosclerotic heart disease of native vessels and acquired absence of both right and left leg above the knee. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia vaccine. 4. Record review of Resident ID #17 revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, malignant neoplasm of the liver, malignant neoplasm of the bladder, and pneumonitis due to inhalation of food. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia vaccine. 5. Record review of Resident ID #20 revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, lung cancer and adult failure to thrive. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia vaccine. During a surveyor interview on 2/7/2024 at approximately 12:30 PM, with the Director of Nursing Services, she failed to provide evidence that the above residents were offered, had received, or had declined the pneumonia vaccine.

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for the ice machine located in the main kitchen. Findings are as follows: According to The Rhode Island Food Code 2018 Edition 5-202.13 reads in part, .an airgap between the water supply inlet and the flood level rim of the plumbing fixture equipment .shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) . A surveyor observation of the kitchen on 2/4/2024 at 8:15 AM revealed that the ice machine failed to have the required air gap. During a surveyor interview with the Food Service Director in the presence of the Administrator on 2/5/2024, they acknowledged that the ice machine failed to have an air gap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, it has been determined that the facility failed to protect the residents' right to be free from abuse relative to verbal abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident and a five-day investigation report, initially submitted to the Rhode Island Department of Health on 11/3/2023, revealed that Registered Nurse (RN), Staff A, was yelling and arguing with Resident ID #1. Record review of a facility policy titled ABUSE, last revised on 12/2022, states in part, POLICY: The facility prohibits the mistreatment, neglect, and abuse of resident/patients and misappropriation of resident/patient property by anyone including staff, family, friends, and residents of the facility .DEFINITIONS .Abuse .Willful infliction of injury, Unreasonable confinement, Intimidation resulting in physical harm, pain and/or mental anguish, Punishment resulting in physical harm or pain or mental anguish, Deprivation of goods and/or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing .DEFINITIONS . Mental/Emotional Abuse .Mental abuse is the use of verbal and nonverbal conduct which causes the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation included but not limited to harassing or yelling, intimidation, threatening or isolation and depravation of goods and services . Record review revealed that s/he was originally admitted to the facility in October of 2023 with diagnoses to include, but are not to, major depressive disorder, adjustment disorder with anxiety, anxiety disorder, bipolar II disorder and cognitive communication deficit. Additional record review revealed a Minimum Data Set Assessment, dated 10/25/2023 with a Brief Interview for Mental Status score of 13 out of 15, indicating that the resident is cognitively intact. During a surveyor interview with Resident ID #1 on 11/6/2023 at 10:40 AM, s/he revealed that s/he was having an argument with another resident when Staff A intervened and began to berate him/her. During a surveyor interview with the Administrator on 11/6/2023 at 11:10 AM, he revealed that he was made aware of the incident that occurred with Staff A and Resident ID #1; Staff A will not be allowed to return to the facility. During a surveyor interview with Nursing Assistant, Staff B, on 11/14/2023 at 11:45 AM, she indicated that she witnessed Staff A making the following comments to Resident ID #1 on 11/3/2023: 1. Telling Resident ID #1 to hit him 2. Telling Resident ID #1 to be a good doggie and stay in his/her place 3. Telling Resident ID #1 that he is like R. [NAME] (a pedophile) 4. Telling Resident ID #1 that he is going to get him/her a little doll because he knows s/he likes to play with little girls Additionally, Staff B revealed that she witnessed Staff A continuing to antagonize Resident ID #1 while following him/her back to his/her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents identified as an elopement risk received adequate supervision to prevent elopement from the facility for 1 of 1 residents reviewed, who successfully eloped from the facility, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 8/6/2023 indicated that on Sunday 8/6/2023 at approximately 3:30 PM, the resident was noted to be missing and was located at approximately 3:45 PM outside of the facility, at a neighboring property. According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards in the resident environment . Record review revealed the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 out of 15, indicating moderately impaired cognition. Further review of the MDS revealed the resident displayed wandering behaviors, 1 to 3 days, during the 7-day look back period. Additionally, the MDS revealed that the residents behaviors could put him/her at risk for wandering into potentially dangerous places, such as outside of the facility. Review of an Elopement Risk Evaluation dated 6/15/2023 revealed a score of 40, indicating the resident is at high risk for elopement. Review of the residents care plan revealed a focus area, initiated on 6/22/2023 and updated on 8/6/2023, which states, The resident is an elopement risk/wanderer [related to] Disoriented to place, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on the privacy or activities, actual elopement . Interventions include, but are not limited to, wander guard, check placement and functioning every day and distract resident from wandering by offering pleasant diversions. Review of the physician orders revealed an order dated 6/21/2023 to check wander guard placement to right ankle every shift and to test functionality daily. Review of the August 2023 Medication Administration Record failed to reveal evidence that the above order was documented as being completed on 8/6/2023, during the first shift. Review of a document titled Initial Event Documentation dated 8/6/2023 revealed the resident was last seen walking up and down the hallway of the facility around 2:30 PM. During a surveyor interview on 8/9/2023 at approximately 9:49 AM, with the Administrator and Director of Nursing Services (DNS), they indicated that they were unable to determine how the resident eloped from the facility and revealed that the resident has a wander guard located on his/her right ankle. They further revealed the main door and ambulance door are locked, alarmed, and have a wander guard system. Additionally, they revealed the four additional doors, located in the facility do not have a wander guard system but are locked and alarmed but will open if held for 15 seconds. During a surveyor interview on 8/9/2023 at 11:17 AM, with Certified Medication Technician, Staff A, she revealed around 2:30/2:45 PM she was sitting in the main dining room with another resident when she heard staff questioning the location of Resident ID #1. At this time, she revealed she began searching the facility for the resident but was unable to locate him/her. Additionally, she revealed she did not hear any door alarms going off during this time. During a surveyor interview on 8/9/2023 at 11:21 AM, with Certified Nursing Assistant, Staff B, he revealed Resident ID #1s roommate called him into his/her room and notified him that Resident ID #1 had walked past the window about 15 minutes before he entered the room. He indicated that at this time, he notified the nurse and began searching the facility. He further revealed that he did not hear any door alarms going off during this time. During a surveyor interview on 8/9/2023 at 11:28 AM, with Registered Nurse, Staff C, she revealed that after the resident was located and brought back to the facility, she tested his/her wander guards' functionality and revealed it lit up with 3 green zeros, indicating that it was working properly. Additionally, she revealed that she did not hear any door alarms go off during this time. During a surveyor observation on 8/9/2023 at 11:59 AM, revealed Resident ID #1 was wearing a wander guard to his/her right ankle. During a surveyor interview on 8/9/2023 at 12:30 PM, with Dietary Aid, Staff D, he revealed that he was in the main dining room, located near the main entrance, when he heard the main door alarm go off and overheard staff discussing the missing resident. At this time, he indicated he left the facility and began driving up the road to look for the resident but was unable to find him/her. Additional interviews conducted on 8/9/2023 failed to reveal evidence that additional staff scheduled on 8/6/2023 heard any door alarms going off, during the period when Resident ID #1 was missing. During a surveyor interview on 8/9/2023 at 2:30 PM, with the Administrator and DNS, they were unable to provide evidence that Resident ID #1 received adequate supervision to prevent him/her from eloping from the facility on 8/6/2023. Additionally, they were unable to identify how the resident eloped from the facility.

**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 drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 medication storage rooms, including a refrigerator that contained 3 vials of Tuberculin Purified Protein Derivative (Tubersol-injectable medication to detect tuberculosis infection). Findings are as follows: During a surveyor observation of the medication storage room on [DATE] at 1:09 PM with Registered Nurse, Staff A, revealed a medication storage refrigerator with the following stored: -1 Tubersol vial open and not dated. -1 Tubersol vial opened with an expiration date of [DATE]. -1 Tubersol vial opened with an expiration date of [DATE]. Tubersol manufacturer's instructions states, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Do not use after expiration. Record review of the facility Resident Matrix revealed the facility had 2 re-admissions within the last 30 days, who were administered Tubersol injections, Resident ID #s 30 and 44. Additional record review of the above-mentioned residents' November and [DATE] Medication Administration Records revealed the following: -Resident ID #30 received a Tubersol injection upon re-admission on [DATE]. -Resident ID #44 received a Tubersol injection upon re-admission on [DATE]. During a surveyor interview following the observations with Staff A, she acknowledged that 2 of the above-mentioned vials were expired and 1 vial was open and not dated. Additionally, she revealed all 3 vials should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations and staff interview, it has been determined that the facility failed to maintain a sanitary and comfortable environment relative to 8 of 9 common bathroom/shower rooms and 3 of 28 resident rooms observed, Resident ID #s 17, 23 and 43. Findings are as follows: During surveyor observations from 12/11/2022 through 12/15/2022) of all communal bathrooms, shower/tub rooms and resident rooms, the following was revealed: 1. The floor drains were corroded/rusted in the lower level bathrooms #2 (shower and tub). The shower floor drain in lower level bathroom [ROOM NUMBER] had a heavy accumulation of hair, debris and residue. The upper level bathrooms #1 and #2 (showers), and the north end bathroom (tub) floor drains were corroded/rusted. 2. The sink drains and surfaces were corroded/rusted in lower level bathroom [ROOM NUMBER] and upper level bathroom [ROOM NUMBER], double sinks. 3. Portions of the walls had missing or chipped paint in upper level bathrooms #1 and #3, the north end bathroom and the window sill in Resident ID #23's room. 4. The upper level bathroom, #4 was observed with black matter to a portion of the shower stall grout. Additionally, 2 of the 4 legs to the shower chair were observed with black matter. 5. Portions of the tile floor were patched with cement in two separate areas in the upper level bathroom, #2. 6. Portions of the baseboards were rusted in upper level bathrooms #3 and #4 and the north end bathroom. 7. Window blinds had numerous broken/missing slats in the rooms of Resident ID #17 (10 slats) and 43 (5 slats). 8. The entire wooden shelf at the window of the upper level nursing station was heavily worn/stripped. 9. The hallway floor, adjacent to the resident's common sitting area, revealed a large patch of the flooring covered with black tape. During a surveyor interview on 12/15/2022 at 9:30 AM, with the Director of Operations and the Maintenance Director, they acknowledged all of the above findings and were in agreement that they were in need of repair/cleaning.