**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID # 1. According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage. Record review of a community reported complaint submitted to the RIDOH on 2/3/2025 alleged that Resident ID #1 was hospitalized because s/he was dehydrated and malnourished. Record review of the hospital documents dated 1/25/2025 revealed that the resident was admitted to the hospital on [DATE] with multiple diagnosis including, a urinary tract infection and an acute kidney injury (a condition where the kidneys suddenly lose their ability to function properly, leading to a decrease in urine output and an accumulation of waste products in the blood). It further revealed that Resident ID #1's indwelling catheter was improperly placed and the balloon was blown up into the prostate. Record review of a facility policy titled, Catheter Care, Urinary dated May 2023, states in part, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Changing Catheters .Documentation The following information should be recorded in the resident's medical record .1. The date and time the catheter care was given. 2. The name and title of the individual(s) giving catheter care. 3. All assessment date obtained when giving catheter care .8. The signature and title of the person recording the data .10. Report other information in accordance with facility policy and professional standards of practice . a. Record review revealed a physician's order dated 11/27/2024 for an indwelling catheter size 18 Fr (French size) with a 30 cc (cubic centimeter) balloon and to change as needed based on clinical indications such as an infection, obstruction, or if the closed system is compromised. Record review a progress note dated 1/22/2025 at 2:44 PM, revealed in part, Resident .ill appearing. replaced [indwelling catheter] on previous shift . Record review revealed a progress note dated 1/15/2025 at 7:48 AM, revealed in part, that the resident's indwelling catheter was replaced with a catheter size 16 Fr and a 10 cc balloon, not the ordered catheter size 18 Fr with a 30 cc balloon. Additional record review of a patient report sheet for Resident ID #1 for the evening shift of 1/21/2025 revealed that the resident's indwelling catheter was replaced with a catheter size 16 Fr, not the ordered catheter size 18 Fr with a 30 cc balloon. Further review of the progress notes failed to reveal evidence of a physician's order to replace the resident's indwelling catheter with a 16 Fr 10 cc catheter on 1/15 and 1/21/2025. b. Additional review of the physician's orders revealed an order dated 4/17/2024 to monitor the resident's indwelling catheter output every shift. Review of the January 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident's indwelling catheter output was monitored on every shift, as ordered, on the following dates and shifts: 1/1/2025 - third shift 1/4/2025 - second shift 1/5/2025 - second and third shifts 1/7/2025 - third shift 1/8/2025 - third shift 1/13/2025- second shift 1/15/2025- first shift 1/18/2025- third shift 1/20/2025- first shift 1/27/2025- second shift 1/28/2025-first shift 1/29/2025-first shift 1/30/2025-first shift During a surveyor interview on 2/4/2025 at approximately 2:30 PM with the Director of Nursing Services (DNS), she acknowledged that the physicians' orders for the resident's indwelling catheter were not followed. Furthermore, the DNS was unable to provide evidence that staff had contacted the physician regarding the insertion of the different sized indwelling catheter. Lastly, she acknowledged that there was no output documented for resident's urinary output on the above-mentioned dates and shifts.

**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 a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with edema (swelling due to excess fluid trapped in the body's tissues), Resident ID #260. Findings are as follows: Review of the policy titled Change in a Resident's Condition or Status dated May 2023 states in part, .Our facility shall promptly notify .his or her Attending Physician .of changes in the resident's medical/mental condition and/or status .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . Record review revealed the resident was admitted to the facility in November of 2024 with diagnoses including, but not limited to, acute kidney failure, cardiac arrhythmias (abnormal heart rhythm), and the presence of a cardiac pacemaker. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact. Further review revealed the resident requires supervision or hands on assistance by staff with transfers and walking. During a surveyor interview with the resident on the initial tour of the facility on 12/1/2024 at 12:33 PM, the resident indicated that s/he hasn't been getting out of bed as much because s/he has pain and swelling to his/her legs. S/he further indicated that the staff have been wrapping his/her legs with an ACE bandage due to the swelling. Review of the Clinical admission assessment dated [DATE] revealed the resident had No Edema issues with a goal to return home. Further review revealed the resident did not indicate pain and had a steady gait. Review of a skin assessment dated [DATE] revealed edema was not noted at that time. Review of a physician's admission note dated 11/25/2024 revealed the resident had no edema of his/her extremities at that time. Review of a skin assessment dated [DATE] revealed the resident was noted to have swollen ankles. Record review revealed the following progress notes: -11/28/2024, .[complaint of] pain to both feet [related to] edema . -11/29/2024, Resident will be discharged to home as of 12/4/24 . -11/29/2024, .BLE [bilateral lower extremities] elevated and wrapped [with] ace bandages for non-pitting edema [the accumulation of excess fluid in soft tissues which is usually localized to certain body parts] . -12/3/2024, Resident will not be discharged on 12/4/24 due to [his/her] medical condition . During a surveyor interview on 12/4/2025 at 11:57 AM with Registered Nurse, Staff A, the surveyor questioned the resident's edema and she indicated that she would make the physician aware. Further review of the resident's record failed to reveal evidence that the physician was notified of the resident's lower extremity edema until 12/4/2024, after it was brought to the facility's attention by the surveyor, and 7 days after it was initially assessed by a nurse at the facility. Additional review of the progress notes revealed a note dated 12/4/2024, which revealed the resident's physician was notified of his/her BLE edema on his/her feet/ankles and a new order was obtained to resume hydrochlorothiazide (a medication prescribed to treat edema). Record review revealed a physician's order dated 11/23/2024 for acetaminophen (Tylenol) 325 milligram by mouth every 4 hours as needed for pain. Record review of the November and December 2024 Medication Administration Records (MARs) revealed the resident received acetaminophen for pain with the associated pain levels on the following dates: -11/26, pain level of 8 -11/27, pain level of 6 -11/28, pain level of 8 -11/29, pain level of 2 -12/2, pain level of 2 -12/4, pain level of 5 -12/5, pain level of 8 Further review of the November and December 2024 MARs failed to reveal evidence that the resident's pain was addressed with acetaminophen on the following dates: -11/30/2024, pain level of 4 -12/1/2024, pain level of 3 During surveyor observations and interviews with the resident on the following dates and times, his/her BLE were edematous: -12/1/2024 at 12:09 PM -12/2/2024 at 9:44 AM and 2:00 PM -12/3/2024 at 11:13 PM -12/4/2024 at 10:50 AM -12/5/2024 at 11:59 AM Review of a physician's note dated 12/5/2024 revealed the resident was noted to have .+1 [pitting] edema [a condition where the skin remains indented after being pressed and is graded on a scale of +1 to +4 based on the depth of the depression and how quickly it rebounds] in lower leg [and] ankles . During a surveyor interview on 12/4/2024 at 10:50 AM with the resident, s/he indicated that his/her feet had started swelling a few days after s/he was admitted to the facility. The resident further revealed that s/he was experiencing a pain level of 8 out of 10 in his/her feet. Additionally, the resident indicated that the pain was preventing him/her from walking as much, so s/he could not be discharged home that day as planned. During surveyor interviews on 12/4/2024 at 11:07 AM and on 12/5/2024 at 10:47 AM with Registered Nurse, Staff A, she indicated that she was aware of the edema to the resident's feet and legs; however, she was unaware if the physician had been notified. She further indicated that the resident appeared weaker since admission related to generalized pain and pain to his/her feet. Additionally, she indicated that the resident was not safe to be discharged home at that time. During a surveyor interview on 12/4/2024 at 11:47 AM with the resident's physician, he revealed that he had not been made aware of the resident's edema by the facility. He further indicated that he would have expected to be notified if there was a change in the resident's condition. During a surveyor interview on 12/4/2024 at 12:09 PM with Licensed Practical Nurse, Staff B, she indicated that she initially observed edema to the resident's feet and legs on 11/29/2024 during his/her shower. Additionally, she could not provide evidence that the physician was made aware of the new onset of edema. During a surveyor interview on 12/5/2024 at 10:30 AM with Occupational Therapist (OT), Staff C, she indicated that the resident was having increased difficulty with standing and transferring since the initial OT assessment due to pain, therefore s/he could not be safely discharged home on [DATE], as planned. During a surveyor interview on 12/5/2024 at 11:09 AM with Physical Therapist, Staff D, she indicated that the resident had complained of pain to his/her feet and refused to walk with the therapist. During a surveyor observation and interview on 12/5/2024 at approximately 12:00 PM, in the presence of the Director of Nursing Services (DNS) and the Assistant Director of Nursing Services, Staff E, the resident was observed to have 2 + pitting edema to his/her feet. Additionally, the resident complained of pain to his/her feet and indicated that s/he could not stand due to the pain. During a surveyor interview with the DNS immediately following the above observation, she acknowledged that the resident presented with 2 + pitting edema to both of his/her feet. Additionally, she could not provide evidence that the physician had been notified of the edema to the resident's bilateral lower extremities prior to it being brought to the attention of the facility by the surveyor.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 5 residents reviewed for medication administration, Resident ID #1. Findings are as follows: Record review revealed Resident ID #1 was initially admitted to the facility in June of 2021 and readmitted to the facility in October of 2024 with diagnoses including, but not limited to, hypercholesterolemia (high cholesterol) and hypertension (high blood pressure). Record review of a document titled, Consultant Pharmacist Recommendation to Prescriber, dated 6/27/2024 revealed the resident is currently receiving Lipitor (a medication prescribed to treat high cholesterol) 20 (mg) milligrams daily. Further review of the document revealed a recommendation to decrease his/her Lipitor to 10 mg daily, which was approved by the provider. Record review revealed that the physician approved the recommendation to decrease the Lipitor to 10 mg daily with a start date of 7/9/2024. Record review of the July 2024 Medication Administration Record (MAR) revealed that both the Lipitor 20 mg daily and the Lipitor 10 mg daily were signed off as administered on 7/9, 7/10, 7/12 and 7/13/2024, indicating that the resident received a total daily dose of Lipitor 30 mg, instead of the ordered 10 mg. During a surveyor interview on 12/5/2024 at approximately 12:30 PM with Licensed Practical Nurse (LPN), Staff E, she was unable to provide evidence the Lipitor 20 mg dose was discontinued, as ordered, when starting the Lipitor 10 mg dose daily. During a surveyor interview on 12/3/2024 at 3:42 PM with the Director of Nursing Services (DNS), after bringing the medication error to the DNS's attention, she acknowledged that the resident received Lipitor 30 mg daily in error on 7/9, 7/10, 7/12 and 7/13/2024. Additionally, she could not provide evidence the order for Lipitor 20 mg daily was not discontinued, when the new order for Lipitor 10 mg daily was implemented.

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 2 of 4 residents reviewed relative to the use of transmission-based precautions, Resident ID #s 13 and 260. Findings are as follows: Review of a facility policy titled, Isolation-Categories of Transmission-Based Precautions states in part, .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .Infections requiring Contact Precautions include but are not limited to .infections with multi-drug resistant organisms .wear gloves (clean not sterile) when entering the room .wear a disposable gown upon entering the Contact Precautions room .If use of common items is unavoidable, then adequately clean and disinfect them .Signs- The facility will implement a system to alert staff to the type of precaution resident requires . 1) Record review revealed Resident ID #13 was readmitted to the facility in October of 2023 with a diagnoses including, but not limited to, type 2 diabetes mellitus and absence of left leg above the knee. Record review revealed an order dated 11/15/2024 to clean the right heel ulcer with normal saline followed by Medihoney (a wound gel with antibacterial properties) to the wound followed by calcium alginate (a highly absorbent wound dressing) then cover with an abdominal pad (a thick dressing used to help manage wound drainage) and a gauze wrap. Record review of a wound culture of the heel, reported on 11/24/2024, revealed that the wound was positive for Methicillin Resistant Staphylococci aureus (MRSA- a bacteria that is resistant to certain antibiotics). Record review of the November and December 2024 Medication Administration records revealed an order dated 11/27/2024 for Levaquin (an antibiotic) 750 milligrams (mg) daily for 10 days. The last scheduled dose of the antibiotic was due to be administered on 12/6/2024. During a surveyor observation of the wound treatment to the right heel on 12/5/2024 at 9:39 AM with Registered Nurse (RN), Staff A, the Contact Precautions sign was no longer on the resident's door, only a sign for Enhanced Barrier Precautions. Staff A entered the resident's room in a gown and gloves pushing a small black table that contained the supplies for the wound dressing change. During the dressing change Staff A placed the normal saline spray bottle, and the tube of Medihoney on the resident's bed near his/her foot, which is being treated for a MRSA infection. After the dressing was completed Staff A placed the normal saline spray bottle and the Medi honey tube back on the black table and without sanitizing, pushed the table out into the hallway outside the resident's room. She then closed the door and wearing the same gloves she had worn to put the resident's shoe on, Staff A assisted Nursing Assistant (NA), Staff F to bring the resident to the bathroom using a sit to stand mechanical lift. They then placed the mechanical sit to stand lift out into the hallway without sanitizing it. During a surveyor interview on 12/5/2024 at 10:15 AM with NA, Staff F, she acknowledged that they failed to clean the sit to stand lift after using the device to transfer the resident to the bathroom. During a surveyor interview on 12/5/2024 at 10:18 AM with RN, Staff A, she acknowledged that after she put the tube of Medihoney, which was a house stock medication (not specifically prescribed for one patient), on the resident's bed, she had returned it to the table and without sanitizing it, she pushed the table out of the room and into the hallway. Additionally, she acknowledged that after she used the sit to stand lift with the resident, she moved the lift into the hallway without sanitizing it. During a surveyor interview on 12/5/2024 at 11:47 AM with the Director of Nursing Services (DNS), she acknowledged that the resident should still be on contact precautions because s/he had not completed the antibiotics for his/her MRSA infection. Additionally, she acknowledged that the Medihoney should not have been placed on the resident's bed near his/her foot, and that the table and the lift should have been cleaned before placing them in the hallway. 2) Review of an undated facility policy titled, Enhanced Barrier Precautions [EBP] states in part, .Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition .As part of Standard Precautions, which apply to the care of all residents, the use of PPE [personal protective equipment] is based on the anticipated exposure to blood, body fluids, secretions, or excretions. Enhanced Barrier Precautions are recommended for residents .Known to be colonized or infected with a MDRO .Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care activities . Record review revealed Resident ID #260 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, urinary tract infection (UTI) and overactive bladder. Review of a hospital Continuity of Care form dated 11/23/2024, revealed the resident was on contact precautions in the hospital, due to a diagnosis of extended-spectrum beta-lactamase (ESBL; an MDRO). Further review revealed the resident completed his/her antibiotic treatment in the hospital. Record review revealed a care plan dated 12/4/2024, which revealed the resident is incontinent of bladder. Record review failed to reveal evidence that the resident was on EBP for his/her diagnosis of ESBL. During multiple surveyor observations throughout the survey from 12/1 through 12/4/2024, failed to reveal evidence that the resident was placed on EBP for his/her diagnosis of ESBL. During a surveyor interview on 12/4/2024 at 11:16 AM with Nursing Assistant, Staff F, she revealed that the resident can be incontinent of urine and requires staff assistance for all activities of daily living (ADL). She further revealed that the resident has not been on any type of precautions since his/her admission to the facility. During a surveyor interview on 12/4/2024 at 11:29 AM with Registered Nurse, Staff As she revealed that the resident requires staff assistance with ADL care and acknowledged that the resident was not on precautions. During a surveyor interview on 12/4/2024 at 11:54 AM, with the DNS and the Infection Preventionist, Staff E, they revealed that the facility does not place residents with a history of ESBL on EBP, although the facility policy indicates EBP is required for residents who are known to be infected or colonized with an MDRO. During a surveyor observation on 12/5/2024 at 11:59 AM, revealed the resident had been placed on EBP after it was brought to the facility's attention by the surveyor.

Based on record review, staff, and resident interviews, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 3 of 15 sample residents reviewed, Resident ID #s 165, 1, and 57. Findings areas follows: Review of a facility policy titled, Administering Medications states in part, .3) Medications must be administered in accordance with the order as prescribed by the physician, nurse practitioner, or physician assistant. 4) Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified . 1. Record review revealed that Resident ID #165 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, diabetes. Record review revealed a physician's order dated 1/7/2024 for SITagliptin-metformin HCl Oral Tablet Extended Release 24 Hour 50-1000 milligram (mg) (medication used to treat high blood sugar), administer one time daily in the morning at 8:00 AM. Review of the January 2024 Medication Administration Record (MAR) revealed that Resident ID #165 did not receive the above mentioned medication on 1/7/2024 and 1/8/2024. Record review revealed that on 1/8/2024 at 3:09 PM, Resident ID #165 had an elevated blood sugar of 548 milligrams per deciliter (mg/dL normal range is 80-130 mg/dL). Additionally, record review revealed Resident ID #165 has a physician's order dated 1/6/2024 for Zolpidem Tartrate Oral Tablet 5 mg (used to treat insomnia) to administer at bedtime at 8:00 PM. Review of the January 2024 Medication Administration Record (MAR) revealed the resident did not receive the Zolpidem Tartrate 5mg on 1/6/2024 and 1/7/2024. During a surveyor interview on 1/10/2024 at 1:03 PM with Registered Nurse, Staff C, she revealed that Resident ID #165's blood sugar increased to 548 mg/dL and that she received a new order to administer 18 units of Lispro insulin. During a surveyor interview with the Director of Nursing Services (DNS) on 1/11/2024 at 12:00 PM, she revealed that she was unaware that Resident ID #165 did not receive Sitagliptin-metformin HCL ER 50-1000 mg and Zolpidem tartrate 5 mg for 2 consecutive days. Additionally, she revealed that she was unaware that Resident ID #165's blood sugar was 548 mg/dL until it was brought to her attention by the surveyor. 2. Record review revealed that Resident ID #1 was admitted to the facility in September of 2022 with a diagnosis of, but not limited to, atrial fibrillation (abnormal heart rate). Record review revealed a physician's order dated 1/22/2022 for Xarelto 20 mg (blood thinner) administer in the evening related to atrial fibrillation. Review of the January 2024 MAR revealed that Resident ID #1 did not receive Xarelto on 1/7/2024 and 1/9/2024. Additionally, record review revealed Resident ID #1 has a physician's order dated 2/6/2023 for Zyprexa 5 mg (antipsychotic medication) at bedtime for bipolar disorder. Review of the January 2024 MAR revealed that the resident did not receive Zyprexa 5 mg on 1/3, 1/5, 1/6, 1/7 and 1/9/2024, as ordered. During a surveyor interview with the DNS on 1/12/2024 at 9:02 AM, she was unable to provide evidence that the resident received the above medications as ordered. The DNS further revealed that the physician was not made aware of the missed Xarelto and Zyprexa until it was brought to her attention by the surveyor. 3. Record review revealed that Resident ID #57 was admitted to the facility in December of 2023 with diagnoses of, but not limited to, dementia with anxiety, restlessness and agitation. Record review revealed the following physician orders: -Rexulti (antipsychotic) 1 (MG), one time a day, with a start date of 12/23/2023 and an end date of 1/2/2024. -Rexulti 2 MG, one time a day, with a start date of 1/3/2024. Review of the January MAR revealed that Resident ID #57 did not receive his/her Rexulti on 1/1/2024, 1/6/2024 and 1/7/2024. During a surveyor interview with the DNS on 1/11/2023 at 12:22 PM, she was unable to provide evidence that the resident received the above mentioned medication as ordered.

Based on record review, staff, and resident interview, it has been determined that the facility failed to provide routine medications to its residents for 5 of 15 residents reviewed, Resident ID #s 165, 1, 57, 21, and 46. Findings are as follows: Review of a facility policy titled UNAVAILABLE MEDICATIONS dated May 2023 states in part .The facility must make every effort to ensure that medication are available to meet the needs of each resident .Nursing staff shall: 1. Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available . 1. Record review revealed that Resident ID #165 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to diabetes. Record review of an admission Minimum Data Set (MDS) Assessment revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating the resident is cognitively intact. Record review revealed that Resident ID #165 has the following physician's orders: - Zolpidem Tartrate Oral Tablet 5 MG (milligram, hypnotic medication, Ambien) Give 1 tablet by mouth one time a day for insomnia (difficulty sleeping) with a start date of 1/06/2024 - SITagliptin-metFORMIN HCl (hydrochloride) Oral Tablet Extended Release 24 Hour 50-1000 MG (medication to lower blood sugar) Give 1 tablet by mouth one time a day related to diabetes with a start date of 1/07/2024 Record review of the January 2024 Medication Administration Record (MAR) revealed the resident did not receive the following medications due to the medications being unavailable on the following dates and times: - 1/8/2024 and 1/9/2024: Zolpidem Tartratre oral tablet 5MG bedtime doses. - 1/7/2024 and 1/8/2024: SITagliptin-metFORMIN HCl ER oral extended release 24 hour 50-1000 MG. Review of an admission note dated 1/8/2024 authored by Nurse Practitioner (NP), Staff A, states in part, . [resident] has not slept in 2 days since [his/her] Ambien had not arrived from the pharmacy . During a surveyor interview with Resident ID #165 on 1/9/2024 at 10:06 AM, s/he revealed that s/he did not receive the above medications for 2 days. Additionally, Resident ID #165 revealed that the facility did not have the medications for 2 days until his/her family brought them from home. 2. Record review revealed that Resident ID #1 was admitted to the facility in September of 2022 with a diagnosis including but not limited to atrial fibrillation (abnormal heart rate). Record review revealed that Resident ID #1 has a physician's order dated 1/22/2022 for Xarelto tablet (blood thinner) 20 MG by mouth in the evening related to atrial fibrillation. Record review of the MAR for January 2024 revealed Xarelto was not administered on, 1/7/2024 and 1/9/2024 due to the medication being unavailable. During a surveyor interview with the DNS on 1/12/2024 at 9:02 AM she acknowledged that the above medication was not administered on 1/7/2024 and 1/9/2024 due to the medication being unavailable. 3. Record review revealed Resident ID #57 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, dementia with anxiety and agitation. Record review revealed the following physician orders: -Rexulti (antipsychotic) 1 (MG), one time a day, with a start date of 12/23/2023 and an end date of 1/2/2024. -Rexulti 2 MG, one time a day, with a start date of 1/3/2024. Review of the January 2024 MAR revealed the above orders were documented with a 9 which indicates Other / See Nurses Notes on 1/1/2024, 1/6/2024, and 1/7/2024. Review of the progress notes revealed the following medication administration notes relative to Rexulti: -1/1/2024 states, not available -1/6/2024 states, med on back order -1/7/2024 states, med back ordered During a surveyor interview on 1/11/2024 at 12:22 PM with the DNS and the Assistant Director of Nursing Services (ADNS), they revealed the Rexulti was on back order during the above dates and was unable to provide evidence that the facility provided pharmaceutical services, including acquiring medication, to meet the needs of each resident. 4. Record review revealed Resident ID #21 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, Alzheimer's disease and low back pain. Record review revealed a physician's order dated 11/2/2023 for Salonpas (pain relieving patch), with instructions to apply to lower back, two times a day for pain. Review of the January 2024 MAR revealed the above order was documented with a 9 which indicates Other / See Nurses Notes on 1/9/2024, 1/10/2024, and 1/11/2024. Review of the progress notes revealed the following medication administration notes relative to Salonpas: -1/9/2024 states, not available -1/10/2024 states, not available -1/11/2024 states, on order 5. Record review revealed Resident ID #46 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of fats in the artery wall) and muscle weakness. Record review revealed a physician's order dated 11/2/2023 for Salonpas with instructions to apply to right hip one time a day for pain. Review of the January 2024 MAR revealed the above order was documented with a 9 which indicates Other/See Nurses Notes on 1/9/2024, 1/10/2024, and 1/11/2024. Review of the progress notes revealed the following medication administration notes relative to Salonpas: -1/9/2024 states, not available -1/10/2024 states, no patches -1/11/2024 states, on order During a surveyor interview on 1/11/2024 at 12:07 PM with Registered Nurse, Staff B, she revealed there were no Salonpas patches available at the facility and indicated they were on backorder. During a surveyor interview on 1/11/2024 at 12:22 PM with the DNS and the ADNS, they were unable to provide evidence that the facility provided pharmaceutical services, including acquiring medication, to meet the needs of the above mentioned residents.

**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 biologicals in accordance with currently accepted professional principles for 1 of 1 medication storage rooms and 2 of 3 medication carts observed. Findings are as follows: Review of the facility policy titled, Storage of Medications, dated [DATE], states in part, .discontinued, outdated .drugs or biological's are returned to the dispensing pharmacy or destroyed. 1. During a surveyor observation of the Watch Hill Unit medication room on [DATE] at 11:43 AM, in the presence of Registered Nurse (RN), Staff D, the following was revealed: -One multidose vial of purified protein derivative (PPD, a skin test reagent used for the diagnosis of tuberculosis), approximately half full, opened and not dated. The manufacturer's instructions indicate to discard the opened product after 30 days. -One bottle Rhopressa Solution 0.02% (a medication used to treat high pressure in the eye), approximately half full, with an expiration date of [DATE] -One Combivent Respimat inhaler 20 mcg (microgram)/100 mcg, (used to control symptoms caused by asthma and lung disease), with an expiration date of [DATE] -One Combivent Respimat inhaler 20 mcg/100 mcg, expiration [DATE] During a surveyor interview immediately following the above-mentioned observations, Staff D, acknowledged that the Combivent and Rhopressa medications were expired and should be destroyed. Additionally, she acknowledged that the PPD solution was not dated when the vial was originally opened. 2. During a surveyor observation of the Watch Hill Unit medication cart on [DATE] at 12:23 PM, in the presence of Staff D, the following was revealed: -One bottle Olopatadine 0.1% (used for treatment of allergies), approximately half full, with an expiration date of [DATE] -One bottle Travatan 0.004% (used to lower the pressure in the eye) approximately half full, with an expiration date of [DATE] -One Trelegy ellipta inhaler (used to control symptoms caused by asthma and lung disease), with an expiration date of [DATE] During a surveyor interview immediately following the above-mentioned observations, Staff D, acknowledged that the above-mentioned medications were expired and should have been removed from the medication cart. 3. During a surveyor observation of the Mystic Unit medication cart on [DATE] at 1:49 PM, in the presence of Licensed Practical Nurse, Staff E, the following was revealed: -1 multidose vial of purified protein derivative (PPD, a skin test reagent used for the diagnosis of tuberculosis), approximately half full, opened, not dated, and stored at room temperature. The manufacturer's instructions indicate to discard the opened product after 30 days and store at 35 to 48 degrees Fahrenheit (refrigerate). -One Insulin lispro injectable pen 100 units per Mililiter (a medication used for high blood sugar) expired [DATE] During a surveyor interview immediately following the above-mentioned observations, Staff E, acknowledged that the Lispro medication was expired and should have been removed from the medication cart. Additionally, she indicated that the PPD solution should be dated when opened and refrigerated. During a surveyor interview on [DATE] at approximately 3:30 PM with the Director of Nursing Services (DNS), she indicated that her expectation is that medication vials should be dated when opened and medications are discarded when they are expired.

**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 residents receive treatment and care in accordance with professional standards of practice relative to 1 of 1 resident reviewed for urinary tract infections (UTIs), Resident ID #3. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 7/26/2023 alleges in part that on 7/17/2023 the complainant requested a urinalysis secondary to Resident ID #3's history of urinary tract infections with sepsis. The urinalysis was not obtained until 7/23/2023 and then a treatment was not implemented until 7/26/2023, after the complainant inquired what antibiotic was ordered to treat the UTI. Review of the resident's record revealed s/he was admitted to the facility in June of 2021 with diagnoses including, but not limited to, traumatic brain injury, quadriplegia, cognitive communication deficit (mute), and cystitis. Record review of a Minimum Data Set assessment dated [DATE] revealed the resident is incontinent of bladder and bowel and is totally dependent on staff and requires assistance with personal hygiene and toilet use. Review of the resident's care plan dated 7/6/2021, and revised on 9/23/2022, revealed the resident has bowel and bladder incontinence and may get UTI's. Interventions include, but are not limited to: clean peri-area with each incontinence episode, monitor/document for signs and/or symptoms UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns . Further record review revealed a physician order dated 12/22/2022 to conduct urinalysis and culture and sensitivity testing (UA/C&S) via straight catheter as needed for suspected UTIs. Record review revealed the resident has had six UTIs from 2/5/2023 to 7/22/2023. During a surveyor interview on 7/27/2023 at 1:10 PM with the resident's family member, she revealed that the resident has a history of UTIs. She further revealed that on 7/17/2023 while out of the facility with the resident, she noted the resident had foul smelling and cloudy urine. She indicated that this is typically the first sign when the resident has a UTI. Additionally, she indicated that upon return to the facility with the resident, she informed Licensed Practical Nurse, Staff A, that the resident's urine was cloudy and foul smelling and needed to be tested for a suspected UTI. The family member further revealed that when she asked about the results of the urinalysis on 7/26/2023, she was informed that the urine sample had not been collected until 7/23/2023, 6 days after she brought her concern to the facility's attention. Additionally, she revealed that when she asked which antibiotic the resident was receiving to treat his/her UTI, the staff informed her that the resident had not been started on an antibiotic to treat his/her UTI. Review of the results from the UA/C&S obtained on 7/23/2023 revealed a positive test result. Additional review of physician orders revealed an order dated 7/26/2023 for Keflex (antibiotic used to treat symptoms of a UTI) 500 milligrams four times a day for 7 days. During a surveyor interview on 7/27/2023 at approximately 2:15 PM with Staff A, she acknowledged that she had a conversation with the resident's family member on 7/17/2023 during the 3-11 shift and was made aware the resident had symptoms of a UTI . In addition, Staff A acknowledged that the family member requested a urine sample to be obtained to determine if the resident had a UTI. Staff A further revealed that she did not notify the physician or nurse practitioner of the above nor did she obtain a urinalysis as per the standing physician order dated 12/22/2022. During a surveyor interview on 7/27/2023 at 2:10 PM with Nurse Practitioner, Staff C, she revealed that the resident has a history of UTI's. In addition, Staff C revealed that she first learned of the positive test result on 7/26/2023 while at the facility. Staff C indicated that the nurse had informed her that the resident's family member was asking about the test results and together, she and the nurse looked up the results. She further revealed that this is when she initiated the order for Keflex to treat the resident's UTI. During a surveyor interview on 7/27/2023 at 2:40 PM with the Director of Nursing Services, Assistant Director of Nursing Services and the Administrator, they were unable to provide evidence as to why the facility did not follow the standing physician order dated 12/22/2022 to obtain a urinalysis via straight cath as needed, why staff waited six days before obtaining a urinalysis on 7/23/2023 when it was reported to the nurse that the resident was symptomatic on 7/17/2023. Based on the above investigative findings, deficient practice was identified on the part of the facility as evidenced by the facility's failure to conduct testing in a timely manner for a resident who was symptomatic of a UTI and has a history of recurring UTI's.

**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 (Department of Health), in accordance with State law for 1 of 1 residents reviewed for abuse and injury of unknown origin, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/30/2023 alleges in part, .This patient was .seen for a left femur [bone of the upper leg or thigh] fracture on 5/22/2023 .family reported facility was being rough when getting [resident] into the shower . Record review of the facility policy titled, ABUSE POLICY revised on 2/15/2017, states in part, .all alleged violations of Federal or State laws which involve .abuse, injuries of unknown source .will also be reported to State agencies in accordance with existing State law. The facility will investigate each alleged violation thoroughly and report the results of all investigations to the Executive Director or his or her designee, as well as to State agencies as required by State and Federal Law .The results of all investigations must be reported .as required by State law with initial report in 2 hours and follow up within five (5) working days of the violation .Definitions .ABUSE: Unjustified physical contact, intentional or careless, which is likely to result in physical or psychological harm . Record review revealed that the resident was admitted to the facility in September of 2021 with diagnoses including, but not limited to, failure to thrive, history of falling, and knee pain. Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed that the resident was not ambulatory and required the assistance of two staff members for transferring. Further record review revealed a document titled, Psychological Services Supportive Care PROGRESS NOTE dated 5/18/2023 states in part, .writer met with patient for follow-up visit .Patient presented with a depressed and agitated mood .Unfortunately, [s/he] reported that [s/he] had 'not slept well in 3 days' and attributed [his/her] lack of sleep to [his/her] poor mood and quality of care [s/he] says was provided to [him/her] .The patient stated that all of [his/her] issues with [his/her] sleep and [his/her] mood stemmed from [his/her] complaints about [his/her] care, which were due to 'the person who cared for me early this week,'[S/he] stated that .[s/he] was not changed or cleaned up until nearly 3 PM and then on another day [s/he] had a shower and wasn't washed 'properly' .writer asked patient if [s/he] had utilized [his/her]communication .skills to advocate for [his/her] self-care. The patient said that [s/he] did not bother because 'it never makes any difference what I say' .The patient shared that because [s/he] didn't get proper care, [s/he] had a lot of anxiety and that led to [his/her] bouts of sleeplessness . Record review revealed a care plan dated 6/22/2022 which indicates that the resident prefers to stay in bed and is only up for showers. Record review revealed a physician's order with a start date of 4/24/2023 which indicated that the resident's showers were scheduled every Monday on the 7:00 AM - 3:00 PM shift. Record review of a Nursing Assistant skin monitoring and shower document revealed that the resident received a shower on 5/15/2023. Additional record review revealed the following progress notes which state in part: - 5/21/2023 at 2:35 PM, .Resident c/o [complained of] pain to left knee which appears to have increased edema and size greatly increased. Resident denies trauma or knowledge of incident. Call placed to Dr. [Doctor] . - 5/21/2023 at 2:36 PM, .New orders received for x-ray to the left knee . - 5/22/2023 at 6:01 AM, .Received X-ray results .Patient has a distal femoral fracture in the left knee .[s/he] is to be sent to [hospital name redacted] . Record review of the Emergency Department provider note under Medical Decision Making, states in part, .[S/he] is experiencing pain in [his/her] left femur .X-ray pelvis and femur were ordered. Pelvis x-ray was negative for any acute fractures, femur x-ray did reveal a distal femur fracture .Clinical impressions as of 5/22/2023 at 7:13 AM .fracture of left femur . During a surveyor interview with the resident's family member on 5/31/2023 at 10:44 AM, she revealed that the resident told his/her family member that a staff member was rough when s/he was being moved during his/her last shower prior to 5/22/2023. During a subsequent surveyor interview with the resident's family member on 6/2/2023 at 9:07 AM, she indicated that the resident told her that Staff A moved him/her a little too rough while in the Hoyer lift and stated resident said, he was showing off how strong he was. The resident's family member further indicated that she informed the Director of Nursing Services (DNS) of the allegations. During a surveyor interview with the DNS on 6/2/2023 at approximately 10:00 AM, she indicated that she did not report the allegation of rough care or injury of unknown origin on 5/21/2023 as required by law and indicated in the facility policy. Additionally, she indicated that she was not aware of the resident's complaint of rough care in the shower until the week of 5/30/2023. Furthermore, she indicated that she was unaware of the psych providers progress note which indicated that the resident had complaints regarding the care that s/he had received in the days prior to the psych note dated 5/18/2023. The DNS further indicated that she was unaware of this information until it was brought to her attention by the surveyor. She also indicated that the psych provider usually updates her after seeing residents. Additionally, she was unable to provide evidence that the resident's injury from 5/21/2023 and the allegations of rough care were reported or investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide adequate supervision to prevent accidents for 1 of 2 residents reviewed for transfers with a mechanical lift, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 5/30/2023 alleges in part, .On 5/28/2023 [resident] was transferred .to the emergency department .for concern of right leg fracture. There was significant deformity of the right leg .X-ray confirmed .tibia [bone of the lower leg] fracture. This patient was also seen for a left femur [bone of the upper leg or thigh] fracture on 5/22/2023. At the time of [his/her] last fracture family reported facility was being rough when getting [resident] into the shower .[S/he] is unable to walk and is a hoyer lift [type of mechanical device used to assist a resident in transferring] . Record review of the facility policy and procedure titled, Using a Mechanical Lift, with a review date of October 2019 states in part, .General Guidelines 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .Gently support the resident as he or she is moved, but do NOT support any weight . Record review of an undated facility policy and procedure titled Safe Resident Handling states in part, Royal Health Group will ensure a safe work environment for employees and residents .for the prevention of employee and resident injury .it is critical that all health care staff practice proper transfer techniques .at all times .When properly used, mechanical lifts assist in the elimination of injuries related to transfers .All lifting Aids require a minimum of two staff member to assist with a transfer . Record review revealed the resident was admitted to the facility in September of 2021 with diagnoses including but are not limited to, failure to thrive, history of falling, and knee pain. Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed that the resident was not ambulatory and requires the assistance of two staff members for transferring. Record review of an undated facility Nursing Assistant assignment document revealed that the resident required the use of a Hoyer (mechanical lift) for transfers. Record review of a care plan with a revision date of 12/9/2022 revealed a focus area indicating that the resident required assistance with activities of daily living and mobility related to weakness and pain. An intervention dated 10/29/2021 revealed that the resident required the extensive assistance of staff participation with transfers. Further record review revealed the intervention for the above-mentioned care plan was revised on 5/31/2023 and indicated that the resident transferred with a mechanical lift and the assistance of two staff members. Further record review revealed a document titled, Psychological Services Supportive Care PROGRESS NOTE dated 5/18/2023 which states in part, .writer met with patient for follow-up visit .Patient presented with a depressed and agitated mood .Unfortunately, [s/he] reported that [s/he] had 'not slept well in 3 days' and attributed [his/her] lack of sleep to [his/her] poor mood and quality of care [s/he] says was provided to [him/her] .The patient stated that all of [his/her] issues with [his/her] sleep and [his/her] mood stemmed from [his/her] complaints about [his/her] care, which were due to 'the person who cared for me early this week,' . Record review revealed a physician's order with a start date of 4/24/2023 which indicated that the resident's showers were scheduled every Monday on the 7:00 AM - 3:00 PM shift. Record review of a Nursing Assistant (NA) skin monitoring and shower document signed by NA, Staff A, revealed that the resident received a shower on Monday 5/15/2023. Record review of the facility's investigation report revealed a document titled Internal Investigation/Witness Statement, authored and signed by Staff A dated 5/15/2023 at 2:00 PM, states in part, .On 5/15 I was asked to give [resident] a shower .for a transfer I used a hoyer to and from the shower chair . Further record review revealed that the resident had increased complaints of left knee pain and an order for an x-ray was obtained on 5/21/2023 which indicated a left femoral fracture. The resident was transferred to the emergency department on 5/22/2023 for evaluation. During a surveyor interview with the resident's family member on 5/31/2023 at 10:44 AM, she revealed that the resident told her that a staff member was rough when s/he was being moved during his/her last shower prior to 5/22/2023. During a subsequent surveyor interview with the resident's family member on 6/2/2023 at 9:07 AM, she indicated that the resident told her that Staff A moved him/her a little too rough while in the Hoyer lift and stated resident said, he was showing off how strong he was. The resident's family member further indicated that she informed the Director of Nursing Services (DNS) of the allegations. During a surveyor interview with the DNS on 5/31/2023 at 2:07 PM, she revealed that when Staff A was interviewed by the Assistant Director of Nursing Services (ADNS) in her presence, he indicated that he transferred the resident with the Hoyer lift on 5/15/2023 without the help of another staff member. She further indicated that when he was prompted by she and the ADNS he changed his story and indicated that Nursing Assistant, Staff B assisted with the resident's transfer with the mechanical lift. During a surveyor interview with Staff B on 5/31/2023 at 12:07 PM and 6/1/2023 at 10:40 AM, she revealed that on 5/15/2023 she was the resident's assigned NA, however, she asked Staff A to assist the resident with his/her weekly shower because she was injured and indicated that she would not be able to maneuver the mechanical lift. She indicated that Staff A agreed to care for the resident and that she agreed to help with residents on his assignment. She further indicated that she was not present in the room or the doorway of the room when Staff A used the Hoyer lift to transfer the resident from bed to the shower chair or from the shower chair back to bed on 5/15/2023. During a surveyor interview with Staff A on 6/1/2023 at 10:59 AM, he revealed that he did agree to assist the resident with his/her shower on 5/15/2023. He indicated that Staff B was within arm's reach during the Hoyer transfer and stood at the doorway while he transferred the resident with the Hoyer lift. Additionally, he acknowledged that Staff B did not actively participate in the transfer because she was standing in the door way. During surveyor interviews on 5/31/2023 at the following times, the following staff members who worked on 5/15/2023 revealed that they did not assist Staff A transfer Resident ID #1 with a Hoyer on 5/15/2023: - at 11:36 AM, Nursing Assistant, Staff D - at 12:21 PM, Nursing Assistant, Staff E - at 12:09 PM, Registered Nurse, Staff F - at 2:41 PM, Nursing Assistant, Staff G - at 2:51 PM Nursing Assistant, Staff H During a surveyor interview with the DNS on 6/1/2023 at 11:40 AM, revealed that although there was no evidence that the transfer caused the resident's injuries, the DNS was unable to provide evidence that Staff A followed the facility policy relative to transferring the resident with the assistance of two staff members to prevent an accident.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure the residents' environment remains as free of accident hazards as possible, related to securing hazardous chemicals (Ajax Powder Cleanser). Findings are as follows: Multiple surveyor observations revealed an Ajax Powder Cleanser can (cleanser commonly used to clean bathrooms) neatly stored amongst toiletries, including baby powder and Gold Bond powder, on a cabinet adjacent and level to the sink, in the bathroom shared by Resident ID #9 and #308 on the following dates and times: 11/2/22 at 12:07 PM and 1:07 PM 11/3/22 9:32 AM and 10:37 AM During a surveyor interview on 11/3/2022 at 10:40 AM with Certified Nursing Assistant, Staff A, she revealed that Ajax is a cleaning product that housekeeping uses to clean the bathrooms and that all cleaning products should be kept in a locked closet on the unit. During a surveyor interview on 11/3/2022 at 10:49 AM with the Director of Housekeeping, he stated that leaving the Ajax Powder Cleanser in the residents' bathroom could be dangerous and that it's typically kept in a locked housekeeping cart or in a locked closet. Additionally, he revealed that he would expect the housekeepers to put the cleaning chemicals back into the locked housekeeping cart immediately after use. During a survey interview on 11/3/2022 at 11:03 AM with the Director of Nursing Services, she acknowledged the Ajax Powder Cleanser should not have been in the resident's bathroom and should be locked in a secured area.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 residents receiving oxygen therapy, Resident ID #28. Findings are as follows: According to Fundamentals of Nursing, Concepts, Process, and Practice, Sixth Edition, 2000, the five guidelines to ensure safe drug administration include the right drug, the right dose, the right client, the right route and the right time. Record review revealed the resident was admitted to the facility in August of 2022 with diagnosis including, but not limited to, asthma and acute respiratory failure. Record review revealed a physician's order dated 10/12/2022 which states, May have O2 [oxygen] as needed for SOB [shortness of breath]. Further record review failed to reveal evidence that the physician's order dated 10/12/2022 for oxygen included an oxygen flow rate. Surveyor observations on 11/1/2022 at 10:42 AM, 11/2/2022 at 12:30 PM, and 11/3/2022 at 11:07 AM, revealed the resident was receiving oxygen therapy at 1 liter via nasal cannula. An additional observation of the resident on 11/1/2022 at 1:44 PM revealed the resident was receiving oxygen therapy at 0.5 liters via nasal cannula. During a surveyor interview with Registered Nurse, Staff B, on 11/3/2022 at 11:16 AM, she acknowledged that the physician's order failed to include an oxygen flow rate. During a surveyor interview with the Director of Nursing Services on 11/3/2022 at 2:00 PM, she revealed her expectation is that the physician's order for oxygen would contain the oxygen flow rate.