Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 4 residents reviewed, Resident ID #1. Findings are as follows: 1a. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/20/2025 alleges that Resident ID #1 was prescribed a pain patch from the hospital to be given to Resident ID #1 on 5/15/2025 and it wasn't administered to him/her until 5/16/2025 at 8:00 PM. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #1 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, spinal fusion and orthopedic aftercare. Record review revealed a physician's order dated 5/15/2025, to administer Buprenorphine patch (a medication prescribed to treat pain) 5 micrograms (mcg) per hour; apply patch once a week on Thursday. Record review of the May 2025 Medication Administration Record (MAR) revealed that the Buprenorphine was signed off as administered as ordered on 5/15/2025. During a surveyor interview on 5/22/2025 at 11:01 AM with the Unit Manager, Registered Nurse, Staff A, she indicated that the Buprenorphine patch was not available in the facility on 5/15/2025 for administration to the resident, although it was signed off as administered by Registered Nurse, Staff B. Record review of an interview provided by the facility, dated 5/16/2025 with Registered Nurse, Staff B, she acknowledged she signed off the Buprenorphine patch as administered to the resident although it was not. 1b. Record review revealed a physician's order dated 5/20/2025, to administer Dilaudid (a medication prescribed to treat pain) 4 milligrams (mg) by mouth every six hours as needed for pain. Record review of the May 2025 Medication Administration Record (MAR) revealed that the Dilaudid was signed off as administered on 5/21/2025 at 12:16 PM. Record review of the Narcotic book revealed the resident received Dilaudid 2 mg on the following dates and times and not the 4 mg, as ordered: -5/21/2025 at 11:45 AM -5/22/2025 at 11:00 AM During a surveyor interview on 5/22/2025 at approximately 12:15 PM with Licensed Practical Nurse, Staff C, she acknowledged that she administered 2 mg of Dilaudid to the resident on 5/21/2025 and 5/22/2025 instead of the 4 mg, as ordered. During a surveyor interview on 5/22/2025 at approximately 2:10 PM with the Director of Nursing Services, he acknowledged that Resident ID #1 did not receive his/her Buprenorphine as ordered on 5/15/2025. Additionally, he indicated that it would be his expectation for the resident to have received his/her Buprenorphine and Dilaudid per the physician's order.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles relative to 1 of 1 unit observed. Findings are as follows: Record review of a facility policy titled, Ordering and Receiving Controlled Medications dated January 2023 states in part, .Only authorized, licensed nursing and pharmacy personnel have access to controlled medications . Record review of a facility policy titled, Controlled Medication Storage dated January 2025 states in part, .A controlled medication accountability record is prepared when receiving inventory if any controlled substance to establish a record of receipt and disposition in sufficient detail to enable accurate reconciliation. The following information is completed: .Name of resident .Prescription number .Name, strength (if designated), and dosage form of medication .date received .quantity received .name of person receiving medication . Review of a facility reported incident submitted to the Rhode Island Department of Health on 3/27/2025 indicated that on 3/25/2025 narcotic patches were delivered to the facility but were not able to be located. The report further alleges that the nurse had no recollection of receiving the medication from the pharmacy. Record review revealed Resident ID #1 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, a chronic inguinal (groin) wound and pain to the left hip. Record review revealed a physician order for Buprenorphine patch (a controlled opioid medication used to treat substance use disorder and pain) 10 micrograms (mcg) once every Tuesday. Review of a pharmacy shipping manifest revealed four Buprenorphine 10 mcg patches were delivered to the facility on 3/25/2025 and signed by Nursing Assistant (NA), Staff A. Review of the controlled substance count book failed to reveal evidence that the Buprenorphine had been received and added to the count. During a surveyor interview on 3/31/2025 at 10:56 AM with Staff A, he indicated that he signed for the controlled medication on 3/25/2025 and should not have. During a surveyor interview on 3/31/2025 at 11:06 AM with Registered Nurse, Staff B, she indicated that she was the nurse on the unit on 3/25/2025 and does not recall receiving any medications from the pharmacy. She further indicated that NAs should not sign and receive medications from the pharmacy. During a surveyor interview on 3/31/2025 at approximately 12:30 PM with the Director of Nursing Services, he acknowledged that the NA signed that he received the Buprenorphine and should not have. He further acknowledged that the controlled medication had not been documented as received into the narcotic book as outlined in the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident representative interview, it has been determined that the facility failed to notify the resident representative(s) when there is need to alter treatment significantly for 1 of 2 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 12/23/2024 alleges that the resident was started on several medications, had a foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body) inserted and the facility failed to notify the resident's representative regarding these changes in the residents medical status. Additionally, the complainant had multiple concerns relative to the care that the resident received while at the facility and removed the resident from their care. A. Record review revealed Resident ID #1 was admitted to the facility in September of 2024 with diagnoses including, but are not limited to, dementia and cognitive communication deficit. Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating s/he has moderately impaired cognition. The resident was discharged in November of 2024. Record review of the resident's medical record revealed that the resident had a medical power of attorney (a legal document that appoints someone as their representative and gives that person the power to act on their behalf). Record review of a facility policy titled, Resident Change in Condition dated 10/17/2023, states in part, .The facility will ensure that resident changes in condition are identified timely, reported to the Physician (and Representative when applicable), and documented in the medical record timely .changes in condition include but may not be limited to .change in vital signs . Record review revealed a nursing progress note dated 9/14/2024 at 9:17 AM which revealed that the resident had an elevated blood pressure on admission. It further revealed a new physician's order to give hydralazine (a medication to treat high blood pressure) 25 milligrams (mg) every shift for blood pressures over 145. Additional record review failed to reveal evidence that the resident's representative was notified of these changes in the resident's medical status. B. Record review revealed a nursing progress note dated 9/20/2024 at 4:44 PM, which revealed a new physician's order to give losartan (a medication to treat high blood pressure) 25 mg daily. Additional record review failed to reveal evidence that the resident's representative was notified of this change. C. Record review revealed a nursing progress note dated 9/23/2024 at 8:55 PM which revealed a new diagnosis of prostatitis (a disorder of the prostate gland usually associated with inflammation). Additionally, it revealed new physician orders to start Ciprofloxacin (antibiotic) for 10 days and start vitamin b 12 injections twice a week for 4 weeks. Additional record review failed to reveal evidence that the resident's representative was notified of these changes. D. Record review revealed a nursing progress note dated 10/7/2024 at 7:00 PM which revealed the resident was seen by the facility's Nurse Practitioner (APRN) with new orders to insert a foley catheter, schedule a urology consult and start finasteride (a medication given for an enlarged prostate) 5 mg daily. Additional record review failed to reveal evidence that the resident's representative was notified of these changes. During a surveyor interview on 12/30/2024 at 8:53 AM, with the resident's representative, s/he revealed that the facility failed to call or update on the above physician's orders. S/he further revealed s/he would have not agreed with the foley being inserted and made several requests for that to be removed. The representative indicated that s/he was in the facility frequently and felt that these changes could have been easily communicated to him/her while s/he was there. During a surveyor interview on 12/30/2024 at 11:26 AM, with Licensed Practical Nurse, Staff A, she revealed that it is the facility's policy to notify the resident's representative if there is a change in the resident's medical status or if there are new orders when the resident is cognitively impaired. During a surveyor interview on 12/30/2024 at 12:23 PM with the APRN, she revealed that the facility was responsible for updating the resident's representative with all new orders or changes in the residents condition. She further revealed that on occasion while assessing the resident there would be family or friends at the bedside, but she was unaware who his/her medical power of attorney was during that time. During a surveyor interview on 12/30/2024 at 12:49 PM, with the Assistant Director of Nursing, she was unable to provide evidence the residents representative was notified of the above changes in his/her medical status. Cross reference F 684

Based on record review, and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice and failed to follow physician orders relative to administering an as needed blood pressure medication with parameters for 1 of 1 resident reviewed, Resident ID #1 and 1 of 1 resident reviewed for the use of senna plus (two laxatives combined used to treat occasional constipation), Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 12/23/2024 alleges that the resident was receiving senna plus while having diarrhea, dehydration and an active diagnosis of clostridioides difficile (C. diff-a bacterium that causes an infection of the colon causing diarrhea and dehydration). Additionally, the resident representative had multiple concerns relative to the care that the resident received while at the facility and removed him/her from their care. During a surveyor interview on 12/30/2024 at 8:53 AM, with the complainant, s/he revealed that the resident was receiving unnecessary medications for his/her blood pressure and stated, [S/he] was being harmed by the facility administering a laxative while [s/he] was dehydrated and having diarrhea. A. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed that Resident ID #1 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, hypertension (high blood pressure) and adult failure to thrive. Record review revealed a physician's order dated 9/16/2024 for Hydralazine (a medication prescribed to regulate blood pressure) administer 25 milligrams (mg) three times per day as needed for systolic blood pressure (pressure in your arteries when your heart beats) above 145. Review of the September and October 2024 Medication Administration Records (MAR) revealed that the resident was administered the Hydralazine when the resident's SBP indicated it should be held based on the parameters on the following dates and times: -9/14/2024 133/75 HS (At bedtime) -9/15/2024 112/78 HS -9/18/2024 134/78 Early AM -9/18/2024 132/58 Early PM -9/23/2024 122/76 HS -9/24/2024 140/54 HS -9/26/2024 128/70 Early PM -9/26/2024 130/46 HS -9/27/2024 142/79 Early AM -9/28/2024 126/60 Early AM -9/28/2024 116/51 HS -9/29/2024 123/59 Early AM -10/2/2024 129/76 HS -10/3/2024 122/68 HS During a surveyor interview on 12/30/2024 at 12:23 PM via the telephone with the facility's Nurse Practitioner, she revealed that she was unaware that the staff were administering the Hydralazine outside of the parameters ordered. Additionally, she revealed that she would expect staff to follow the order as written. During a surveyor interview on 12/30/2024 at 12:51 PM with the Assistant Director Nursing Services, she was unable to provide evidence that the facility staff followed the physician order for Hydralazine. B. Record review revealed a nursing progress note dated 10/21/2024 at 9:47 AM which revealed that the resident's representative called to report that the resident had several loose stools. The note further revealed that this was reported to the Nurse Practitioner. Record review of a nursing progress note dated 10/21/2024 at 1:34 PM revealed that the resident's representative was updated of a new physician's order to test Resident ID #1's stool for C. diff. Record review of a laboratory testing document titled, Microbiology dated 10/22/2024 revealed a positive test result for C. diff. Additionally, there was a new physician's order for Vancomycin 250 mg (an antibiotic) every 6 hours for 10 days and 1 packet of Banatrol (a soluble fiber and a prebiotic which is used to solidify the stool) twice a day. Record review revealed a nursing progress note dated 11/9/2024 at 5:04 PM which revealed that the resident was warm to the touch and lethargic. His/her temperature was 100.4 degrees Fahrenheit. Additionally, Tylenol was administered and a new order was obtained from the physician to start a clysis (an infusion of fluid) and give 1 liter of normal saline. Record review revealed a physician order with a start date of 9/17/2024, for Senna Plus. Review of the October and November 1st through 11th 2024 Medication Administration Records (MAR) revealed that the resident was administered the Senna Plus daily from 9/17/2024 through 11/10/2024, while the resident was experiencing diarrhea and was being treated for C. diff. During a surveyor interview on 12/30/2024 at 12:23 PM with the APRN, she stated, Senna Plus should absolutely not be administered while a resident has C. diff. She further revealed that she was unaware that s/he was receiving this medication and would have expected it to be held and reported to her as a nursing measure to prevent harm to the resident. During a surveyor interview on 12/30/2024 at 12:49 PM with the Assistant Director of Nursing, she confirmed that the Senna Plus was given with an active diagnosis of C. diff and while the resident was experiencing diarrhea.

Based on surveyor observation, 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 following physician's orders for 1 of 2 residents reviewed for offloading heels to prevent pressure injury, Resident ID #73, and for 1 of 1 resident reviewed for glucose monitoring with parameters, Resident ID #85. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1. Record review revealed Resident ID #73 was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, adult failure to thrive and malnutrition. Record review revealed a physician's order dated 7/26/2024 to offload bilateral heels while in bed. Surveyor observations on the following dates and times revealed the resident heels were not offloaded and his/her heels were resting directly on the mattress: -9/30/2024 at 9:40 AM -9/30/2024 at 11:17 AM -10/1/2024 at 3:30 PM -10/2/2024 at 9:25 AM -10/3/2024 at 9:19 AM During a surveyor interview on 10/3/2024 at 9:02 AM with Registered Nurse, Staff B, she acknowledged that the resident's heels were not offloaded and was unable to explain why his/her heels were not offloaded per the physician's order. During a surveyor interview on 10/3/2024 at 10:37 AM with the Director of Nursing Services (DNS), he was unable to explain why the above-mentioned physician order was not followed. 2. Record review revealed Resident ID #85 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, diabetes. Record review revealed a physician's order dated 9/10/2024 for blood sugar checks twice a day, and to call the provider if the blood sugar is less than 50 milligrams per deciliter (mg/dl) or greater than 250 mg/dl. Record review of the September 2024 Treatment Administration Record revealed the following blood sugar levels: -9/10/2024: 286 mg/dl -9/11/2024: 273 mg/dl -9/12/2024: 268 mg/dl -9/15/2024: 290 mg/dl -9/16/2024: 281 mg/dl -9/18/2024: 291 mg/dl -9/21/2024: 254 mg/dl -9/23/2024: 336 mg/dl -9/24/2024: 276 mg/dl -9/27/2024: 306 mg/dl -9/28/2024: 346 mg/dl -9/30/2024: 254 mg/dl Record review failed to reveal evidence that the above blood sugar levels greater than 250 mg/dl were reported to the provider as ordered. During a surveyor interview on 10/3/2024 at 11:03 AM with the DNS, he acknowledged that the above-mentioned blood sugars were not reported to the physician. Additionally, he revealed that he would have expected the staff to follow the physician's order.

**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 with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 6 residents reviewed for pressure ulcers, Resident ID #s 35 and 103. Findings are as follows: 1. Record review revealed that Resident ID #35 was readmitted to the facility in August of 2024 with a diagnosis including, but not limited to, unstageable pressure ulcer (characterized by full-thickness skin and muscle loss, with dead tissue obstructing the wound bed) to the right heel. Record review of the Quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating the resident has severe cognitive impairment. Record review revealed a physician's order dated 7/29/2024 to utilize Heelz-up [a device designed to aid in the prevention and treatment of heel pressure injuries which suspends the heels to eliminate pressure], while in bed. Record review of the resident's care plan dated 7/31/2024 revealed the resident has potential for developing a new pressure ulcer and alterations in skin integrity related to pressure ulcers, immobility, and incontinence of urine. The assessment further revealed that the resident has actual pressure ulcers on the right heel and coccyx. Surveyor observations on the following dates and times revealed the resident was lying in bed with his/her heels resting directly on the mattress and the Heelz-up device was observed on the bedside chair: -9/30/2024 at 9:25 AM -9/30/2024 at 12:17 PM -10/1/2024 at 3:30 PM -10/2/2024 at 10:07 AM Record review of the September and October 2024 Treatment Administration Records revealed that the staff signed off that the Heelz-up device was utilized while in bed on 9/30/2024,10/1/2024 and 10/2/2024. Further record review failed to reveal evidence that the resident refused the Heelz-up device during the above observations. During a surveyor interview on 10/2/2024 at 10:07 AM with the resident, s/he revealed that sometimes the staff off load his/her feet and sometimes they do not. During a surveyor interview on 10/2/2024 at approximately 10:09 AM with Licensed Practical Nurse (LPN), Staff E, she acknowledged that the resident has an order for his/her feet to be offloaded using the Heelz-up device and that his/her heels were resting directly on the mattress. During a surveyor interview on 10/2/2024 at 11:37 AM with Director of Nursing Services (DNS), he was unable to explain why the above-mentioned physician order was not followed. 2. Record review revealed that Resident ID #103 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, right femur (thigh bone) fracture and muscle wasting. Record review revealed a physician's order dated 9/29/2024 to wash coccyx wound with Vashe (a wound cleanser that is a sterile, hypochlorous acid solution that replicates the body's natural defense against bacteria), mix medi-honey (a medical honey) with collagen powder (an absorbent wound powder) to form a paste then apply to the wound, apply skin prep (a liquid that when applied to the skin forms a protective film or barrier) to the peri wound (area around the wound), and cover with a foam bordered dressing. During a surveyor observation on 10/2/2024 at 9:29 AM with Registered Nurse, Staff C, she was observed to wash the wound with Vashe, applied skin prep to the peri wound and packed the wound with Puracol Plus AG with silver (a collagen dressing with added silver antimicrobial agent). She then proceeded to cover the wound with an absorbent dressing. During a surveyor interview immediately following the above-mentioned observation with Staff C, she acknowledged that she did not follow the physician's order for collagen powder mixed with medi-honey. During a surveyor interview on 10/2/2024 at 11:40 AM with the DNS, he was unable to explain why the above-mentioned physician's order was not followed.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to meet professional standards of practice, in accordance with physician orders and the comprehensive person-centered care plan, relative to a peripherally inserted central catheter (PICC- a long, flexible tube that's inserted into a vein in the arm and threaded into a large vein near the heart, that is used to deliver medication or other treatments), for 1 of 1 resident observed for intravenous (IV) antibiotic administration, Resident ID #273. Findings are as follows: 1 a. Review of a facility policy dated August of 2021 titled, Vascular Access Devices and Infusion Therapy Procedures Dressing Change for Vascular Access Devices states in part, . Central Venous access device will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, draining, or blood is present, or for further assessment if infection is suspected . a dressing is changed immediately if: The dressing is non-occlusive or soiled. There is drainage or moisture under the dressing . Assess site for Erythema [redness]. lndurtation [thickening or hardening of skin].Swelling.Drainage . measure external catheter length . Record review revealed that Resident ID #273 was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, abscess of the right foot, cellulitis (a skin infection) of the right toe, ulcer to the right foot, and diabetes mellitus. Record review of the physician orders revealed the following: - 9/26/2024: Linezolid (an antibiotic) 0.9% sodium chloride 600 milligrams every 12 hours for cellulitis - 9/25/2024: Assess PICC site every shift - 9/25/2024: Monitor for signs and symptoms of abnormal bleeding related to anticoagulation therapy (treatment that reduces the ability of blood to clot) - 9/25/2024: Measure length of external (PICC) catheter daily Record review of the September 2024 Medication Administration Record revealed that the measurements of the external catheter were signed off as completed, although no measurements were documented. During a surveyor observation on 10/1/2024 at 9:14 AM, the resident was noted to have a PICC line in his/her right arm. The PICC was dressed with a Tegaderm (a clear dressing) and a 4 X 4 gauze covering the insertion site. The Tegaderm and the gauze were noted to be saturated with dried blood and approximately 1/4 of the Tegaderm was no longer adhering to the resident's skin. The resident's johnny also had a large area of dried blood covering approximately 12 inches by 12 inches. During a surveyor interview on 10/1/2024 at 12:34 PM with Licensed Practical Nurse (LPN), Staff F, she acknowledged the above observation and indicated that the dressing needed to be changed and she would change it. Record review failed to reveal evidence that on 10/1/2024 Staff F documented the status of the PICC or had changed the PICC line dressing after being brought to her attention by the surveyor. 1 b. Review of a facility policy dated August of 2021, titled Vascular Access Devices and Infusion Therapy Procedures Administration Set Change states in part, . Open the administration set and close all clamps . Hang the infusate [solution that will be infused] on the IV [Intravenous] pole and squeeze the drip chamber [collection chamber within the IV tubing] until approximately half full . lf using IV pump to prime tubing (preparation of administration of IV medication tubing), place the tubing into the pump and prime per manufacture's guidelines . remove the sterile cover from the end of the administration set and attach to the needless connector on the IV catheter . During a surveyor observation of the medication administration task on 10/2/2024 at 9:44 AM with Registered Nurse, Staff C, she failed to close all the clamps after connecting the administration set to the antibiotic bag while priming, allowing approximately 20 milliliters (ml) of the medication to flow out of the tubing onto the medication cart. Additionally, Staff C, was observed entering the resident's room and removed the sterile cap from the end of the administration set. She then drained approximately 5 ml's into a plastic cup, placing the uncapped tubing on the resident's bed. Continued observation the PICC line dressing revealed a light red drainage covering the gauze under the Tegaderm. During a surveyor interview on 10/2/2024 immediately following the above observation with Staff C, she acknowledged that she did not prime per policy and stated, I'm not sure if there is another way to get the bubbles out. she indicated that there was light red drainage on the PICC line dressing, and it needed to be changed. She acknowledged that she should not have placed the uncapped IV tubing on the resident's bed. Record review failed to reveal evidence that Staff C changed the PICC line dressing per policy. During a surveyor interview on 10/2/2024 at 12:56 PM and 1 :25 PM with the Director of Nursing Services, he indicated that it would be his expectation for the residents IV to be primed per policy, that the residents PICC line dressing would be changed when moisture, drainage or bleeding is observed. Additionally, he indicated it would be his expectation of an assessment of the PICC line site and external catheter length would be documented in the residents' medical record.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain Contact Precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) relative to wound care for 1 of 1 resident reviewed with Methicillin Resistant Staphylococcus (MRSA- a bacteria that is resistant to many antibiotics) in the nares and Vancomycin Resistant Enterococci (VRE- a bacteria resistant to antibiotics) in the wound, Resident ID #273. Additionally, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to 1 of 1 resident reviewed for wound care, Resident ID #103. Findings are as follows: 1. Review of the facility policy titled Guidelines for Management of MDROs [Multi- Drug Resistant Organisms] .CONTACT PRECAUTIONS .used with specific persons known or suspected to be infected .with .micro organisms that can be transmitted by direct contact with the person or indirect contact with environmental surfaces or equipment .VRE is spread by direct patient-to-patient via .hands of personnel or indirect contact on contaminated surfaces or equipment .can persist for weeks on environmental surfaces; special attention must be paid to housekeeping efforts . Record review revealed that Resident ID #273 was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, abscess of the right foot, cellulitis (bacteria infection of the skin) of right toe, ulcer to the right foot, and diabetes mellitus. Record review revealed the following physician's orders: - 9/25/2024 maintain contact precautions for MRSA and VRE location in the wound. - 9/26/2024 wound vac, cleanse right heel with saline, skin prep (a liquid that when applied to the skin forms a protective film or barrier), peri wound (outside edges of wound), cut, and apply black foam to fit wound bed, cover with wound vac (Wound VAC, is a technique that uses negative pressure to pull the edges of a wound together and promote healing) once a day on Tuesday, Thursday, and Saturday. During a surveyor observation of the resident's wound care on 10/1/2024 at approximately 1:00 PM with the Staff Development Coordinator (SDC) and Licensed Practical Nurse (LPN) Staff F, revealed F was observed removing a urinal and other personal items from the bedside table. She failed to remove her gloves and perform hand hygiene prior to assisting the SDC with wound care for the resident. Staff F failed to clean the table prior to placing the wound care supplies for the treatment including scissors and gloves which were placed directly on the table. The SDC was observed cutting the resident's soiled dressing from his/her right heel wound with scissors, failed to clean the scissors before placing the scissors directly on the bedside table. Additionally, she was observed handling the uncapped and unclamped wound vac tubing without gloves. Staff F failed to perform hand hygiene prior to applying the new wound vac dressing, she also failed to clean the scissors prior to cutting the wound vac dressing and black foam sponge to fit the wound bed. During subsequent observation at the completion of the wound care, the SDC placed the dirty scissors on the windowsill, then moved them on to the resident's sink counter. Lastly, she failed to clean the scissors prior to exiting the resident's room nor did she clean the bedside table, windowsill or counter after the treatment was completed. During a surveyor interview immediately following the above observation with the SDC, she acknowledged that Staff F failed to remove her gloves and perform hand hygiene. Additionally, she acknowledged that she failed to clean the resident's bedside table, clean the scissors after removing the soiled dressing, donn [put on] gloves while handling the wound vac tubing and to perform hand hygiene, and that she did not clean the surfaces and scissors prior to exiting the resident's room. During a surveyor interview on 10/2/2024 with the Director of Nursing Services (DNS), he revealed he would have expected that Staff F would have removed her gloves and performed hand hygiene prior to assisting with the wound treatment. The SDC should have cleaned the resident's bedside table, cleaned the scissors after removing the soiled dressing, donned gloves while handling the wound vac tubing and to perform hand hygiene, and she should have cleaned the surfaces and scissors prior to exiting the resident's room. 2. According to Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings .Wound Care Facilitator Guide from the Centers for Disease Control and Prevention last revised on 1/27/2023, states in part, .Maintain separation between clean and soiled equipment to prevent cross contamination .Any unused disposable supplies that enter the patient/resident's care area should remain dedicated to that patient/resident or be discarded. They should not be returned to the clean supply area. If supplies are dedicated to an individual patient/resident, they should be properly labeled and stored in a manner to prevent cross-contamination or use on another patient/resident (e.g., in a designated cabinet in the patient/resident's room) .Containers entering patient/resident care areas should be dedicated for single-patient /resident use or discarded after use . Record review revealed that Resident ID #103 was admitted to the facility in March of 2024 with a diagnosis including, but not limited to, displaced fracture of the neck of the femur (the bone of the thigh). Record review revealed the following physician's orders: -5/13/2024 Enhancer Barrier Precautions for wound care every shift -9/29/2024 Wash wound with Vashe (wound cleanser), mix medi-honey (medical honey) with collagen powder (absorbent wound powder) to form a paste then apply to the wound, skin prep around the wound, and apply foam bordered dressing three times per week During a surveyor observation of the resident's wound care on 10/2/024 at 9:29 AM, revealed Registered Nurse, Staff C, entering the residents room wearing a gown and gloves. She was then observed removing the resident's soiled dressing from his/her wound. She then removed her soiled gloves and proceeded to exit the resident's room while wearing the soiled gown to retrieve additional wound care supplies from the treatment cart. She failed to perform hand hygiene prior to exiting the residents room. Staff C then returned to the room wearing the same gown to complete the wound dressing. Further she was observed packing the wound dressing directly into the residents wound by pushing the dressing into the wound with her gloved finger. During a surveyor interview immediately following the surveyor observation, Staff C acknowledged that she did not remove her gown prior to exiting the residents room and inserted her gloved finger into the resident's wound rather than utilizing another implement such as a q tip. During a surveyor interview on 10/2/2024 at 10:42 AM and 3:57 PM, with the DNS, he revealed he would have expected the nurse to utilize a q tip to pack the residents wound and that she remove her gown and perform hand hygiene prior to exiting the resident's room to retrieving items from the treatment cart.

**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 receive treatment and care in accordance with professional standards of practice relative to following physician's orders for wound care for 1 of 1 resident reviewed relative to non-pressure injuries, Resident ID #273, for 1 of 1 resident reviewed relative to lower extremity edema (swelling due to an excess fluid in the body tissues), Resident ID #64 and 1 of 2 residents reviewed with a skin tear, Resident ID #90. Findings are as follows: 1. Record review revealed that Resident ID #273 was readmitted to the facility on [DATE] with diagnoses including, but not limited to, abscess of the right foot, cellulitis (bacterial skin infection) of the right toe, ulcer to the right foot, and diabetes mellitus. a. Record review revealed a physician's order dated 9/25/2024 for an admission body audit to be completed. Record review of the September 2024 Treatment Administration Record (TAR) revealed that Registered Nurse, Staff C signed off that she completed the admission body audit on 9/25/2024. Further record review failed to reveal evidence that the admission body audit was completed. b. Record review revealed a physician's order dated 9/26/2024 for a weekly body audit to be completed on Mondays on the 3:00 PM to 11:00 PM shift. Record review of the September 2024 TAR revealed that Staff C signed off that she completed the weekly body audit on 9/30/2024. Further record review failed to reveal evidence that the weekly body audit that was signed off as completed on 9/30/2024 by Staff C, was conducted. c. Record review revealed the following physician's orders dated 9/26/2024: - cleanse large open blister to right foot and great toe with normal saline, apply xeroform (petroleum gauze), fluff gauze and wrap with cling three times per week. - cleanse right heel with saline, skin prep (a liquid that when applied to the skin forms a protective film or barrier) the peri wound (is the skin around the wound that has been affected by the wound), cut and apply black foam to fit the wound bed and cover with wound vac dressing (Wound VAC, is a technique that uses negative pressure to pull the edges of a wound together and promote healing) Record review of the September 2024 TAR revealed, the dressing to the large open blister to the right foot, right toe and the wound VAC dressing to the right heel were signed off as completed by Staff C on 9/28/2024. During a surveyor interview on 10/2/2024 at 11:18 AM, with Staff C, she acknowledged that, although she signed off that she completed the admission body audit, the weekly body audit, and the wound care treatments to the large open blister to the right foot, right toe and the wound VAC dressing to the great heel on 9/28/2024, she had not. When asked why she signed off on the above-mentioned orders and did not complete them she could not answer. Further, she stated that she was not aware of how many wounds the resident had because she had not completed any assessments or treatments to the resident wounds to his/her right foot, right toe, and right heel. This indicates that the resident did not have his/her wound dressings changed from 9/26/2024 until 10/1/2024. 2. Record review revealed a physician's order dated 9/26/2024 to cleanse the right heel with saline, skin prep to the peri wound, cut and apply black foam to fit the wound bed and cover with wound vac dressing. Record review revealed that the wound vac that was in use for this resident was the Genadyne XLR8. Record review of the Genadyne XLR8 user guide states in part .multiple layers of the transparent film dressing may decrease the moisture vapor transmission rate, which may increase the risk of maceration [a softening and breaking down of skin resulting from prolonged exposure to moisture] .do not allow wound filter to overlap onto intact skin . On 10/1/2024 at approximately 2:00 PM, Staff Development Coordinator (SDC) was observed conducting the removal of the resident's wound vac dressing. The old wound vac dressing was noted to have multiple layers of the transparent film dressing covering both the right foot and right heel although the wound vac order was only to apply the wound vac to the right heel. The disposable backing of the transparent film dressing was not removed prior to the application to the wound. The large blister to the right foot wound was observed to be dressed with an allevyn dressing (a foam dressing) applied under the layer of the wound vac dressing. The order indicated to use xeroform and gauze which were not applied. Additionally, the dressing to the right foot wound should not have been applied under the wound vac dressing. The surveyor observed his/her right foot to be white in color and macerated. During a continued surveyor observation of the reapplication of the wound vac dressing with the SDC, she failed to apply the skin prep to the peri wound of the resident's right heel and failed to apply the xeroform to the resident's great toe as ordered. During a surveyor interview with the SDC immediately following the above observation, she acknowledged that the disposable backing of the transparent film dressing was not removed and the wound vac dressing was applied to both the resident's right heel and foot and should only have been applied to the right heel. She acknowledged that, upon removal of the dressing there was an allevyn in place when the order was for xeroform. Furthermore, she acknowledged that she did not apply skin prep to the right heel peri wound or apply the xeroform to the resident's right great toe as ordered. During a surveyor interview on 10/2/2024 at 12:56 PM and 1:25 PM with the Director of Nursing Services (DNS) he was unable to provide evidence that the skin assessments were completed as ordered. Additionally, he indicated it would be his expectation for wound care treatments to be completed as ordered. 3. Record review revealed Resident ID #64 was admitted to the facility in April of 2023 with a diagnosis including, but not limited to, hypertension (high blood pressure). Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the resident has mild cognitive impairment. Surveyor observations on the following dates and times, revealed the resident with approximately 1 plus (mild) edema on both of his/her lower legs and ankles: -9/30/2024 at 1:57 PM -10/1/2024 at approximately 2:00 PM -10/2/2024 at 11:03 AM During a surveyor interview with the resident on 10/2/2024 at 11:56 AM, the resident revealed his/her legs have been swollen. During a surveyor interview on 10/2/2024 at 1:25 PM with Licensed Practical Nurse, Staff D, she revealed she was unaware of the edema on the resident's lower legs and ankles. Staff D further stated that there was no documentation and/or interventions in the resident's record relative to the edema and she was unable to provide evidence that the provider had been notified. During an additional surveyor observation of the resident on 10/2/2024 at 1:29 PM with Staff D, she acknowledged the resident's lower legs and ankles were observed with 1 plus edema. Record review revealed the following physician's orders were obtained by Staff D, after the edema was brought to her attention by the surveyor: -Discontinue Lasix (a medication prescribed to treat extra fluid in the body (edema) -Start Torsemide (a medication prescribed to to reduce extra fluid in the body) -Obtain weekly weight x 4 weeks -Discontinue Lisinopril (a medication prescribed to treat high blood pressure) -Obtain blood work including but not limited to a basic metabolic panel ( a blood test that provides information about body's fluid balance, metabolism and how well the kidneys are working) During a surveyor interview on 10/2/2024 at 1:37 PM with the DNS, he revealed it would be his expectation that staff would notify the resident's provider relative to the bilateral lower extremity edema. 4. Record review revealed Resident ID #90 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, cognitive deficit and neuropathy (nerve damage that causes weakness, numbness and pain in the hands and feet). Record review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15 indicating the resident has severe cognitive impairment. Record review revealed a care plan dated 7/1/2024 with a focus care area for potential for alteration in skin integrity with interventions including, but not limited to, monitor skin integrity every shift as needed with prompt treatment to any red or open areas that develop. Surveyor observations on the following dates and times revealed the resident with a bandage (approximately 3 inches in length by 1.5 inches in width) dated 9/30/2024 on his/her left shin: -9/30/2024 at approximately 11:00 AM -10/1/2024 at 8:52 AM -10/2/24 at 10:43 AM During a surveyor interview on 10/2/2024 at 11:06 AM with the resident, s/he revealed s/he has open areas on his/her left lower leg and that the bandage was placed two days ago. During a surveyor interview on 10/2/2024 at 11:14 AM with Staff D, she stated that she did not place the bandage on the resident's left shin. Staff D further revealed that there was no documentation or orders in the resident's record as to why the resident has the bandage on his/her left shin. Staff D further stated that the record lacked evidence that the resident's provider had been notified relative to the open area. During a surveyor observation of the resident with Staff D, on 10/2/2024 at 11:20 AM, she acknowledged the resident had a bandage with the date of 9/30/2024. After Staff D removed the bandage from the resident's left shin, in the presence of the surveyor, s/he was observed with the following: - a scab, approximately 1.25 centimeter (cm) in length by 0.5 cm in width - a skin tear, approximately 0.75 cm in length by 2 cm in width The surveyor also observed the skin tear appeared to be wet/soggy with a small amount of light tan colored drainage. Record review revealed the following physician's orders were obtained for the left shin skin tear after it was brought to the facility's attention by the surveyor: - Apply skin prep (a liquid that when applied to the skin forms a protective film or barrier) to the scab twice daily -Cleanse the skin tear with normal saline, follow by Bacitracin and apply dry clean dressing. During a surveyor interview on 10/2/2024 at 1:40 PM with the DNS, he was unable to provide evidence that the resident's provider was notified, and a treatment order was obtained relative to the open area on the left shin prior to being brought to the facility's attention by the surveyor.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment as required. Findings are as follows: Record review failed to reveal evidence that competencies and skills sets for wound vacuum-assisted closure (Wound VAC- a technique that uses negative pressure to pull the edges of a wound together and promote healing) device, peripherally inserted central catheter (PICC line, long, flexible tube that's inserted into a vein in the arm and threaded into a large vein near the heart, used to deliver medication or other treatments), and intravenous (IV) medication administration were completed for the following licensed nurses prior to it being brought to the attention of the facility by the surveyor on 9/30/2024: - Registered Nurse (RN), Staff G with a hire date of 4/19/2022 - RN, Staff C with a hire date of 10/5/2021 - Licensed Practical Nurse (LPN), Staff H with a hire date of 9/5/2023 - LPN, Staff F with a hire date of 12/18/2023 During a surveyor interview on 10/2/2024 at 11:24 AM with the Staff Development Coordinator, she was unable to provide evidence that competencies and skill sets relative to wound VAC care, PICC line dressings changes and intravenous medication administration were provided to license nurses prior to providing care. During a surveyor interview on 10/2/2024 at 12:44 PM with the Director of Nursing Services, he was unable to provide evidence that above mentioned education and competencies were completed prior to providing care. Cross reference: F684, F694, F726, and F880.

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 and 2 of 2 unit dining rooms. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 3.501.16, states in part, Time/Temperature Control for Safety Food Hot and Cold Holding .shall be maintained at .5 degrees C [Centigrade, which is 41 degrees Fahrenheit] or less . During a surveyor observation on 10/1/2024 at approximately 12:00 PM of the lunch meal service on the North unit, revealed turkey sandwiches had a cold holding temperature of 60 degrees F and chef's salads had a cold holding temperature of 59 degrees F. During a surveyor interview with the Food Service Director (FSD) immediately following the above mentioned observations, she acknowledged the food's were not within the acceptable cold holding temperature range. 2. The Rhode Island Food Code 2018 Edition 2-402.11, states in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During a surveyor observation of the main kitchen on 9/30/2024 at approximately 9:30 AM, Dietary Aide, Staff I was observed with full facial hair and not wearing a beard restraint while assisting in dessert set up. During a surveyor observation on 10/1/2024 at approximately 12:30 PM, Staff I was observed assisting in serving beverages to residents in the North unit dining room without wearing a beard restraint. An additional surveyor observation on 10/2/2024 at approximately 12:00 PM, Staff I was observed assisting in serving beverages to residents in the [NAME] dining room without wearing a beard restraint. During a surveyor interview on 10/3/2024 at approximately 11:10 AM with the FSD, she acknowledged that Staff I was not wearing a beard restraint as required. 3. The Rhode Island Food Code 6.403.11 2018 Edition states in part, .because employees could introduce pathogens to food .areas designated to accommodate employees' personal needs must be carefully located . During a surveyor observation on 10/3/2024 at 12:30 PM in the main kitchen, a reach in refrigerator that stored desserts for residents revealed staff lunches were stored in the same refrigerator on the bottom shelf. During a surveyor interview with the FSD immediately following the above mentioned observation, she acknowledged that staff lunches should not be stored with facility purchased foods for residents.

Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually. Additionally, the facility failed to review and update the assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Findings are as follows: Review of a facility provided document titled, Facility Assessment dated 8/2/2024 failed to reveal the following components as required: - The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population - The staff competencies that are necessary to provide the level and types of care needed for the resident population - The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population - Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services Further review of the document titled Facility Assessment, failed to reveal evidence of the facility's resources, which include but are not limited to: - Equipment (medical and non- medical) - Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies - All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care - Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and . During a surveyor interview on 10/2/2024 at 3:33 PM with the Administrator, she acknowledged that the facility assessment failed to address the required components. Cross reference: F 684, F 694, F726, and F 880.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed relative to skin assessment, Resident ID #1. Finding are as follows: Record review of the facility policy titled Skin Protocol, states in part .4. The weekly skin observation will be done for every resident .7. Monitoring weekly observation will be done and maintained in the residents' medical record . Record review of a community reported complaint sent to the Rhode Island Department of Health on 8/16/2024 alleges that Resident ID #1 was hospitalized for wounds and a change in mental status. Additionally, the report alleges that the resident was neglected while at a nursing home due to the wounds that were not appropriately cared for. Record review revealed Resident ID #1 was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, tinea crutis (a contagious fungal infection that affects the skin) and type 2 diabetes. Record review revealed a physician's order dated 5/10/2023 for a weekly body audit every Friday on the 3:00 PM to 11:00 PM shift. During a surveyor interview on 8/21/2024 at approximately 1:20 PM with the Director of Nursing Services (DNS), he revealed that the facility's weekly skin checks are documented in the progress notes and titled Weekly Body Audit. Review of a nursing progress note dated 5/10/2024 revealed a, Weekly Body Audit with the following indications: Red areas on the thighs with protective ointment for treatment due to the excoriation (impairment) on the buttocks. Additional review of the nursing progress note failed to reveal the weekly body audit documented as ordered on the following dates: 5/17/2024 5/24/2024 5/31/2024 6/5/2024 6/12/2024 6/19/2024 6/26/2024 which is a total of 7 weeks of missed skin audits. Record review of the Treatment Administration Record (TAR) for the months of May and June of 2024 revealed the weekly body audits were signed off as completed by the nurses on the above-mentioned dates. Although there is no evidence of the weekly body audits on the above-mentioned dates, review of a progress note dated 6/21/2024 indicated that the resident was seen by the wound physician for worsening wounds with a new order for Silver and Zinc to the buttocks. Review of the weekly body audit dated 6/28/2024 revealed in part, .Open areas buttocks with treatment in place .Treatment to buttocks ongoing, seen by wound [physician] today Record review of the wound physician's document titled wound evaluation and management summary dated 7/5/2024 revealed the following: - a non-pressure wound of the left buttock measuring 9 x 2.2 x 0.1 cm (centimeter) - a non-pressure wound of the right buttock measuring 1.4 x 1.2 x 0.1 cm - a stage 2 pressure wound on the coccyx (triangular bone area at the base of the spinal column) which measured 5.4 x 0.4 x 0.1 cm. During a surveyor interview on 8/22/2024 at approximately 11:52 AM with the DNS, he acknowledged that the weekly skin audits tasks were not completed, as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care of the resident and meets professional standards of quality, for 3 of 3 residents reviewed, Resident ID #s 1, 4, and 6. Findings are as follows: According to the Appendix PP of the State Operations Manual for Long Term Care revised on 2/3/2023, §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable . 1. Record review revealed Resident ID #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, fusion of spine lumbar region (surgery of lower spine), wedge compression fracture of the third lumbar vertebra (fracture of the front of the lower part of the spine), and weakness. Record review of a document titled Baseline Care Plan Summary completed 11/22/2023, revealed the resident's goal to return home with his/her spouse. The document failed to reveal an effective and person-centered care plan which included physician orders, a thoracic lumbar support orthotic (back brace) to be worn twenty four hours a day, seven days a week, for two weeks ending on 11/30/2023, the need of a rolling walker and gait belt during mobility, as well as recommendations for two caregiver assistance with functional mobility. Further record review failed to reveal dietary orders or social service needs were included on the baseline care plan. Additional record review revealed that the resident sustained a fall on 11/23/2023. At the time of the fall s/he was assisted by one caregiver, without a gaitbelt, and was not wearing his/her back brace. During a surveyor interview on 11/28/2023 at 12:50 PM with an unlicensed nursing assistant Staff A, he revealed that he was unaware that Resident ID #1 required a back brace to be worn or that s/he required a gait belt for transfers. During a surveyor interview on 11/29/2023 at 11:47 AM with Licensed Practical Nurse Staff B, she revealed that she was in the bathroom with Staff A and the resident just before the fall. She further revealed that she left Staff A alone with the resident and was unaware that the resident required assistance from two staff members for transfers. 2. Record review revealed Resident ID #4 was admitted to the facility in October of 2023 with diagnoses including, but not limited to; altered mental status, Alzheimer's disease, and violent behavior. Record review of a document titled Baseline Care Plan Summary dated 10/23/2023 revealed the resident was unable to state his/her goals due to the presence of severe dementia. Additionally, the document failed to reveal an effective and person-centered care plan for his/her care needs related to severe dementia, including but not limited to; potential for violent and combative behavior, level of care needed from the care giver for assistance with mobility and activities of daily living, physicians orders, dietary orders, or social services. 3. Record review revealed Resident ID #6 was admitted to the facility in July of 2023 with diagnoses including, but not limited to; sepsis, unspecified organism, unspecified atrial flutter (irregular heart rhythm), and pyogenic arthritis (an infection of the fluid in the joint). Record review of a document titled Baseline Care Plan Summary dated 7/31/2023 revealed the resident's goal was to regain function and return home. The document failed to reveal evidence of an effective plan of care including person-centered care, recommendations for care givers related to physician's orders, dietary orders, therapy, or social services. During a surveyor interview on 11/29/2023 at approximately 1:00 PM and 11/30/2023 at approximately 10:00 AM with the Minimum Data Set (MDS) Assessment nurse, she revealed that she develops the residents' baseline care plans. She further revealed that she asks the resident what their goal is and includes only that goal in the observation tool titled Baseline Care Plan Summary. Additionally, she acknowledged that the baseline care plans for all three of the above-mentioned residents did not include the required components. During a surveyor interview on 11/29/2023 at approximately 2:00 PM, with the Director of Nursing Services, he was unable to provide evidence that a baseline care plan was developed for the above-mentioned residents within 48 hours of admission, to include instructions needed to provide effective and person-centered care.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident observed for wound care, Resident ID #81. Findings are as follows: Mosby's 4th Edition, Fundamentals of nursing, page 314 states in part, .the physician is responsible for directing medical treatment. Nurses are obligated to follow physician orders unless they believe the orders are in error or would harm the clients. Record review revealed that the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, protein calorie malnutrition and Methicillin resistant Staphylococcus aureus (MRSA) infection of the wound. Record review of a care plan dated 5/3/2023 revealed a potential for alteration in skin integrity due to incontinence and a stage 3 (a full-thickness skin loss potentially extending into the subcutaneous tissue layer) on the coccyx (tailbone area) inner buttocks with an intervention including, but not limited to, treatment to stage 3 on coccyx as ordered. Review of a Wound Evaluation & Management Summary dated 10/20/2023 revealed the resident has a stage 3 pressure ulcer to his/her coccyx measuring 2.5 centimeters (cm) by 0.6 cm by 1.6 cm. Further review revealed a dressing treatment plan including, but not limited to, a collagen sheet applied to the wound daily. Record review revealed a physician's order dated 10/23/2023 with special instructions to Cleanse area on coccyx with vashe [wound cleanser], pat dry, skin prep peri wound [around the wound], [Cut] to fit collagen sheet [wound dressing for wounds with light drainage], cut to fit hydrafera blue foam and hydrate foam (absorbent foam dressings), cover with silicone border dressing. During a surveyor observation on 10/25/2023 at approximately 11:20 AM, Licensed Practical Nurse, Staff C, was observed to apply Calcium Alginate (a wound dressing for wounds with moderate to heavy drainage) instead of the collagen, as ordered. During a surveyor interview on 10/25/2023 at 11:26 AM with Staff C, she acknowledged that she applied the incorrect dressing. She further acknowledged that she did not apply the collagen sheet as ordered but applied calcium alginate instead. During a surveyor interview on 10/25/2023 at 11:30 AM with the Director of Nursing Services, he acknowledged that it was a concern that the nurse applied the incorrect dressing. He could not provide evidence that the facility ensured that the resident received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of wounds.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 2 of 5 residents reviewed for unnecessary medications, Resident ID #s 42 and 98. Findings are as follows: 1. Record review revealed Resident ID #42 was admitted to the facility in July of 2023 with a diagnosis including, but not limited to, sepsis (an infection of the blood stream). Review of physician orders revealed an order for cefpodoxime (antibiotic), 200 milligrams, twice daily, for 7 days, with a start date of 10/8/2023. Review of the October 2023 Medication Administration Record (MAR) revealed the resident received cefpodoxime, twice daily, on the following dates: - 10/8/2023 - 10/9/2023 - 10/10/2023 - 10/11/2023 - 10/12/2023 - 10/13/2023 - 10/14/2023 - 10/15/2023 Further review of the October 2023 MAR revealed the resident received cefpodoxime for a total of 8 days. During a surveyor interview on 10/26/2023 at 1:03 PM with the Assistant Director of Nursing Services (ADNS), she acknowledged the resident received cefpodoxime for 8 days total, indicating two extra doses were administered to the resident in error. 2. Record review revealed Resident ID #98 was admitted to the facility in July of 2023 with a diagnosis including, but not limited to, severe sepsis with septic shock. Review of physician orders revealed an order for ertapenem, 1 gram intravenously, once daily for 10 days, with a start date of 10/3/2023. Review of the October 2023 MAR revealed the resident received Ertapenem on the following dates: - 10/3/2023 - 10/4/2023 - 10/5/2023 - 10/6/2023 - 10/7/2023 - 10/8/2023 - 10/9/2023 - 10/10/2023 - 10/11/2023 - 10/12/2023 - 10/13/2023 Further review of the October 2023 MAR revealed the resident received Ertapenem for 11 days total. During a surveyor interview on 10/26/2023 at 1:07 PM with the ADNS, in the presence of the Director of Nursing Services, they acknowledged the resident received Ertapenem for 11 days, instead of the 10 days it was initially ordered for. They indicated their expectation would be for staff to administer medications, as ordered by the physician.

Based on record review and staff interview, it has been determined the facility failed to promptly notify the practitioner of results that fall outside of clinical reference ranges for 1 of 1 residents reviewed, relative to abnormal ultrasound results, Resident ID #79. Findings are as follows: Review of a facility policy titled Notification of Clinicians states in part, .PROCEDURE .Any results of laboratory, radiology, and other diagnostic tests that fall outside of the clinical reference range will require notification to the prescribing practitioner as per their specific orders or within the shift it was received .When necessary if the results (outside of the clinical reference range) were not able to be reported to the prescriber on the shift they were received; they will be called/reported on the next shift and documented in the residents' medical record .All notifications to a clinician should be documented in the resident's medical record . Record review revealed the resident was admitted to the facility in September of 2021 with diagnoses including, but not limited to, cerebral infarction (stroke). Record review revealed the resident was seen by a gastrointestinal specialist on 10/12/2023 and returned to the facility with a recommendation which includes, but is not limited to, obtain a right upper quadrant (abdomen) ultrasound. Review of a document titled ULTRASOUND REPORT dated 10/18/2023, states in part, .Conclusion: 1. Mild hepatomegaly (enlarged liver). 2. Questionable wall echo shadow gallbladder sign [occurs when the Gallbladder wall contracts over Gallbladder stones]. Recommend CT [cat scan] to confirm . Record review failed to reveal evidence that the physician was notified of the above ultrasound results from 10/18/2023. Additional record review failed to reveal evidence that a CT scan was ordered, scheduled, or obtained, after it was recommended on 10/18/2023. Further review of progress notes revealed a note dated 10/26/2023 which states in part, [The resident] was responsive on last care rounds (0500), however staff alerted with writer at 0700 that [the resident] was awake and not responding. This writer assessed .Resident noted to move [his/her] eyes and mouth, however no verbal response/no further motor response .appeared to have [left] sided weakness. [Staff A] updated and [new order] received to send [the resident] to the ER [Emergency Room] for STAT evaluation .transported [the resident] out of the facility at 0730. Review of Hospital emergency room documentation dated 10/26/2023 revealed a CT scan was completed, which states in part, .FINDINGS .There is intra and extrahepatic biliary dilatation [gallbladder duct enlarged]. There is a 12 mm [millimeter] stone within the common bile duct .Gallbladder: Cholelithiasis [gallstones] with contracted gallbladder .IMPRESSION .Biliary dilatation secondary to a 12 mm common bile duct calculus. Gastroenterology consultation recommend . During a surveyor interview on 10/27/2023 at 8:39 AM, with Staff A, he was not aware of the ultrasound results from 10/18/2023 and indicated that he would have ordered a CT scan to be completed. During a surveyor interview on 10/27/2023 at 9:45 AM, with the Administrator and Director of Nursing Services, they were unable to provide evidence that the provider was notified of the ultrasound results from 10/18/2023.

Based on record review and staff interview it has been determined that the physician failed to review the residents total program of care, including medications and treatments, relative to the continuity of care from outside physicians for 1 of 5 residents, Resident ID #79 and the physician also failed to sign and date orders for 6 of 8 residents reviewed, Resident ID #s 6, 14, 47, 57, 63, and 79. Findings are as follows: 1. Record review of Resident ID #79 revealed that s/he was admitted to the facility in May of 2021 with diagnoses including, but not limited to, cerebral infarction (stroke) and mood disorder. Further record review of a Referral Form from the Gastroenterologist dated 10/12/2023 revealed that the resident had elevated liver enzymes and a suspected drug induced liver injury with a recommendation to obtain laboratory testing, an ultrasound of his/her abdomen and to avoid all hepatotoxic (toxic to the liver) medications. Record review of an abdominal ultrasound dated 10/18/2023 revealed concerns regarding his/her gallbladder with a recommendation to obtain a computed tomography scan (CT scan, imaging test that uses X-rays and a computer to create detailed images of the inside of your body). During a surveyor interview on 10/27/2023 at 8:39 AM with the Medical Doctor (MD), Staff A, he revealed that he was unaware of the recommendations made from the Gastroenterologist on 10/12/2023 and he was unaware of the results of the ultrasound on 10/18/2023. During surveyor interviews on 10/27/2023 at 9:04 AM and 9:45 AM with the Director of Nursing Services (DNS), the Assistant Director of Nursing Services (ADNS), and the Administrator, they were unable to provide evidence that the provider was notified of the continuity of care form including recommendations and diagnostic testing. 2a. Record review revealed Resident ID #79 was admitted to the facility in May of 2021 with diagnoses including, but not limited to, cerebral infarction and mood disorder. Record review revealed that Staff A was his/her attending physician. Further record review revealed the following unsigned physician orders all with a start date of 7/25/2023: - Aspirin tablet, delayed release 81 milligram (mg) - Atorvastatin tablet 80 mg - Buspirone tablet 5 mg - Cholecalciferol (vitamin D3) tablet 25 micrograms (mcg) - Clopidogrel tablet 75 mg - Ezetimibe tablet 10 mg - Pramipexole tablet 0.125 mg - Losartan tablet 100 mg 2b. Record review revealed Resident ID #14 was readmitted to the facility in June of 2020 with diagnoses including, but not limited to, type II diabetes mellitus and heart failure. Record review revealed that Staff A was his/her attending physician. Further record review revealed the following unsigned physician orders: - Metformin tablet 500 mg, dated 6/1/2023 - Risperidone tablet 0.5 mg, dated 8/23/2023 - Risperidone tablet 1 mg, dated 8/23/2023 2c. Record review revealed that Resident ID #63 was admitted to the facility in July of 2018 with diagnoses including, but not limited to, Alzheimer's disease and psychotic disorder. Record review revealed that Staff A was his/her attending physician. Further record review revealed the following unsigned physician orders: - Famotidine tablet 40 mg, dated 8/4/2023 - Apply zinc to groin and buttocks with care twice a day, dated 9/11/2023 2d. Record review revealed that Resident ID #47 was admitted to the facility in March of 2022 with diagnoses including, but not limited to, dementia and anxiety. Record review revealed that Staff A was his/her attending physician. Further record review revealed the following unsigned physician orders: - clonazepam tablet 0.5 mg, dated 8/30/2023 - furosemide tablet 40 mg, dated 8/1/2023 - muscle rub to right hand at bedtime, dated 9/11/2023 2e. Record review revealed that Resident ID #6 was admitted to the facility in July of 2021 with diagnoses including, but not limited to, dementia and heart failure. Record review revealed that Staff A was his/her attending physician. Further record review revealed the following unsigned physician orders: - Cholecalciferol (vitamin D3) tablet 25 mcg, dated 7/26/2023 - Metoprolol tartrate tablet 25 mg, dated 7/26/2023 - Nitroglycerin tablet 0.4 mg, dated 8/16/2023 - Potassium chloride tablet extended release 20 milliequivalent (mEq), dated 7/26/2023 - Seroquel tablet 25 mg, dated 7/26/2023 - Xarelto tablet 15 mg, dated 7/26/2023 2f. Record review revealed that Resident ID #57 was readmitted to the facility in December of 2021 with diagnoses including, but not limited to, dementia and cerebral infarction. Record review revealed that Staff A was his/her attending physician. Further record review revealed the following unsigned physician orders: - DermaPhor (mineral oil-hydrophil petrolat) ointment dated 7/9/2023 - Losartan tablet 50 mg dated 6/21/2023 - Metoprolol succinate tablet extended release 25mg dated 6/21/2023 Review of a facility report titled, Unsigned Orders dated 10/30/2023 revealed Staff A, had 2,888 unsigned physicians' orders in the facility. During a surveyor interview on 10/30/2023 at 11:57 AM with the DNS and ADNS, they acknowledged that the above-mentioned orders had not been signed by the physician, until after brought to the facilities attention by the surveyor.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infection for 1 of 2 residents reviewed for Methycillin Resistant Staphylococcus Aureus (MRSA, an antibiotic resistant bacteria), Resident ID #42, and 1 of 1 wound dressings observed, Resident ID #81. Findings are as follows: Record review of a facility policy titled, Isolation .Infection Control dated 1/15/2023, states in part, .It is the policy of this facility to prevent the spread of infection within the facility through the use of isolation precautions .Use contact precautions for residents known or suspected to be infected with microorganism's that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident care items. The above includes organisms such as MRSA . Record review of a facility policy titled, Guidelines for Management of MDROs [multidrug resistant organisms] dated 1/13/2023 states in part, .Contact precautions should be considered and would be indicated for, residents who have wounds or other body sites heavily colonized or infected with MRSA .Other CDC [Center for Disease Control and Prevention] Recommendations .it is reasonable to discontinue Contact Precautions when three or more surveillance cultures for the target MDRO are repeatedly negative over the course of week or two in a patient who has not received antimicrobial therapy for several weeks .Contact precautions require the use of appropriate PPE [Person Protective Equipment], including gown and gloves upon entering the contact precaution room 1. Record review revealed Resident ID #42 was admitted to the facility in August of 2023 with a diagnosis including, but not limited to, MRSA infection of the nares (the nostrils). Record review of MRSA screenings dated 9/6/2023 and 9/29/2023 revealed the resident was positive for MRSA of the nares. Record review revealed a physician's order dated 10/3/2023 for Mupirocin ointment 2% (an antibiotic) three times a day to the nares. Further record review revealed s/he received the antibiotic from 10/3/2023 to 10/8/2023. Record review of a progress note dated 10/13/2023 revealed the resident was exhibiting respiratory symptoms including, diminished lung sounds, cough, and nasal congestion. Additionally, MRSA of the nares was noted. Record review of the October 2023 Medication/Treatment Administration Records revealed an order to maintain contact enhanced barrier precautions (use of gowns and gloves during high contact resident activities) for MRSA to the nares on every shift. Further review revealed that this order was in place until 10/29/2023. During a surveyor observation on 10/24/2023 at 2:05 PM signage was observed to be outside of the resident's room, indicating s/he was on both Contact and Enhanced Barrier Precautions (EBP). During surveyor observations on the remaining days of the survey from 10/25/2023 through 10/27/2023, signage was observed to be outside of the resident's room, indicating s/he was on Enhanced Barrier Precautions. Record review failed to reveal evidence that any negative surveillance cultures were obtained for MRSA. During a surveyor interview on 10/26/2023 at 12:56 PM with the Infection Preventionist and Director of Nursing Services (DNS), they indicated that the resident had not been re-cultured for MRSA following the MRSA treatment. They acknowledged the resident was currently on EBP and they were unable to explain why the resident was no longer on Contact Precautions. They further indicated that the resident will remain on EBP despite the facility policy and CDC (Centers for Disease Control and Prevention) guidelines indicating the resident should be on contact precautions. Additionally, they were unable to provide evidence that the facility followed proper precautions to prevention the spread of infection related to MRSA. Record review revealed that contact precautions were put in place on 10/29/2023, after the surveyor brought this concern to the facility attention, per facility policy and CDC guidelines. 2. Review of a Competency Validation for A Clean Dressing Change provided by the facility, states in part, .procedure actions .cleans the area as per physician's order .Removes gloves .perform hand hygiene .Dons [put on] clean gloves . Record review revealed that Resident ID #81 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, protein calorie malnutrition and MRSA infection of the wound. Record review of a care plan dated 5/3/2023 revealed a potential for alteration in skin integrity due to incontinence and a stage 3 (a full-thickness skin loss potentially extending into the subcutaneous tissue layer) on the coccyx (tailbone area)/inner buttocks with an intervention including, but not limited to, treatment to stage 3 on coccyx as ordered. Review of a Wound Evaluation & Management Summary dated 10/20/2023 revealed, the resident has a stage 3 pressure ulcer to his/her coccyx measuring 2.5 centimeters (cm) by 0.6 cm by 1.6 cm. Record review revealed a physician's order dated 10/23/2023 with special instructions to Cleanse area on coccyx with vashe [wound cleanser], pat dry, skin prep peri wound [around the wound], [Cut] to fit collagen sheet [wound dressing for wounds with light drainage], cut to fit hydrafera blue foam and hydrate foam (absorbent foam dressings), cover with silicone border dressing. During a surveyor observation on 10/25/2023 at approximately 11:20 AM, of the resident's wound dressing performed by Licensed Practical Nurse, Staff C, she failed to remove her gloves and perform hand hygiene after cleansing the wound. During a surveyor interview on 10/25/2023 at 11:26 AM with Staff C, she acknowledged that she did not change her gloves or perform hand hygiene after cleansing the wound. During a surveyor interview on 10/25/2023 at 11:30 AM with the DNS, he was unable to explain why Staff C failed to change her gloves or perform hand hygiene after cleaning the resident's wound.

Based on surveyor observation and staff interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, relative to 2 of 2 shower rooms, North and [NAME] wing, observed. Findings are as follows: Review of a job description titled HOUSE KEEPER states in part, .RESPONSIBILITIES .B. PATIENTS BATHROOMS .spot wash walls (as needed) . Review of a job description titled CUSTODIAN states in part, .RESPONSIBILITIES .Spot clean walls as needed . During a surveyor observation on 10/25/2023 at 2:34 PM, in the presence of Nursing Assistant (NA), Staff E, of the North Wing shower room, revealed black matter in the grout on the shower walls, for 3 out of 4 shower stalls. During a surveyor interview, immediately following the above observation, Staff E acknowledged the black matter in the grout of the shower stalls. During a surveyor observation on 10/26/2023 at 8:00 AM, of the [NAME] Wing shower room, revealed black matter in the grout on the shower walls, for 2 out of 4 shower stalls. During a surveyor interview on 10/26/2023 at 8:09 AM, with NA, Staff F, she acknowledged the black matter in the grout of the shower stalls. During a surveyor interview on 10/26/2023 at 8:20 AM, with the Assistant Director of Nursing Services, she acknowledged the black matter in the grout of the shower stalls and indicated the shower stalls need to be cleaned.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 1 resident reviewed who had an active order for an as needed psychotropic medication that was not limited to 14 days, Resident ID #4. Findings are as follows: Record review for the resident revealed s/he was admitted to the facility in April of 2018 with diagnoses including, but not limited to, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Further review of the record revealed a physician's order, dated 4/24/2023, for Trazodone (a medication used to treat symptoms of depression and anxiety) 12.5 milligrams, to be administered twice a day as needed for rising anxiety. Further review of this order failed to reveal evidence of a stop date. Review of the May 2023 Medication Administration Record (MAR) revealed the resident received the above-mentioned medication on 5/12/2023, 5/14/2023, 5/18/2023 and 5/23/2023, indicating the medication's use was not limited to 14 days as required. Additional review of the record failed to reveal evidence that the physician or prescribing practitioner documented a rationale as to why the Trazodone order was not limited to 14 days or documentation of the intended duration for the use of this as needed medication. During a surveyor interview with the Director of Nursing Services on 5/31/2023 at 12:00 PM, he revealed that his expectation would be that the above-mentioned as needed medication order would include a stop date. Additionally, he was unable to provide evidence of a documented rationale as to why the as needed medication was administered beyond 14 days of the date it was ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately (but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse) to the State Survey Agency in accordance with State law for 1 of 1 reportable allegations of abuse for Resident ID #164. Findings are as follows: Record Review of a policy titled, Abuse prohibition states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse, mistreatment, neglect .Definitions: Abuse .Verbal=use of oral, written or gestured language that frigthtens or demeans a resident .D. Identifying and Reporting Any instance of actual or suspected abuse, neglect .must be reported immediately to the DNS [Director of Nursing Services]/designee, i.e., supervisor on duty and a report is to be filled out. The Department of Health and the Long-Term Care Ombudsman will be contacted of allegations of abuse, neglect .within 2 hours of the allegation if the events that led to the allegation involve abuse .not later than 24 hours if the allegation did not involve abuse or serious bodily harm . Record review revealed the resident was admitted to the facility in October of 2022 with diagnoses that include, but are not limited to, Parkinson's disease and adult failure to thrive. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating s/he is cognitively intact. During a surveyor interview on 10/19/2022 at 11:35 AM with the resident, s/he revealed that a NA was rough with him/her and pulled on his/her brief when s/he was being assisted with incontinent care. S/he further revealed that s/he reported the allegation to the Social Worker. During a surveyor interview on 10/19/2022 at 11:41 AM with the Social Worker, she revealed that the resident did report to her on 10/18/2022 that an NA was rough with him/her during incontinent care. She further revealed that she reported the allegation to the Director of Nursing Services (DNS) but did not report the allegation to the State Survey Agency. During a surveyor interview with the Director of Nursing Services on 10/19/2022 at 11:56 AM and on10/20/2022 at 1:59 PM he acknowledged that he did not report the allegation to the State Survey Agency within 2 hours after it was brought to his attention.

Based on surveyor observation, 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 for 1 of 2 residents reviewed for edema, Resident ID #108. Findings are as follows: Record review of a policy titled, Policy for Vital Signs, states in part, .Taken monthly custodial care or non-skilled care . Review of the resident's record revealed s/he was admitted to the facility in July of 2022 with diagnoses including, but are not limited to; hypertension (high blood pressure, a condition in which the force of blood against the artery wall is too high), acute respiratory failure with hypoxia (impairment of blood exchange between the lungs and blood, symptoms may include: shortness of breath, confusion, and cardiac arrest) heart failure (heart doesn't pump blood as well as it should), venous insufficiency peripheral (valves in the veins are not working effectively, making it difficult for blood to return to the heart), and edema (excess fluid trapped in body's tissues). During surveyor observations on the following dates and times, the resident was observed with swelling and edema to his/her right lower leg and knee: - 10/21/2022 at 10:08 AM - 10/24/2022 at 10:24 AM Record review of a physician's progress note dated 10/11/2022, states in part, Pt [patient] seen For regular follow-up .patient continues to do well except for bilateral lower extremity edema .#3. Congestive heart failure. Continue Lasix, increase dose to 40 mg [milligrams] daily. #4. Essential hypertension. Blood pressure is on the lower side. Adjust lisinopril as needed, monitor blood pressure . Record review revealed the following physician orders: - furosemide [Lasix] tablet; 20 mg; amt [amount]: 2 tab [tablets]=40 mg; oral Twice A Day; AM, PM, dated 10/7/2022. - lisinopril tablet; 10 mg; amt: 1 tab; oral Once A Day; AM, dated 7/11/2022. - Monthly BP&P [blood pressure and pulse] Once A Day on 2nd Thu of the Month; 1st Shift, dated 5/16/2022. Further review revealed the order was discontinued on 7/11/2022. Additional record review failed to reveal evidence that the resident's blood pressure was obtained since 7/30/2022. During a surveyor interview with Licensed Practical Nurse, Staff A, on 10/24/2022 at 10:31 AM, he revealed that the resident is currently experiencing edema and has swelling in his/her lower extremities. He indicated that for non-skilled residents, blood pressure should be taken at least monthly. He also revealed that the resident's blood pressure had not been obtained since 7/30/2022. During a surveyor interview with the Medical Director on 10/24/2022 at 11:14 AM, he revealed that the resident is on Lasix and lisinopril for edema and hypertension. He further revealed that he would expect the resident's blood pressure to be obtained at least monthly for monitoring. During a surveyor interview with the Director of Nursing on 10/24/2022 at 1:33 PM, he revealed that there were no orders in place to obtain the resident's vitals including blood pressure. He was unable to provide evidence that the resident's blood pressure was obtained monthly per the facility's policy.