Every finding on record at AdviniaCare Newport, LLC

Based on surveyor observations, resident and staff interviews, the facility failed to maintain a safe and clean environment relative to 3 of 3 nursing units observed and the main building.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/8/2026, alleged in part, .Unsanitary Environment: The cleanliness of the facility was dangerously substandard. Floors in patient areas were left unswept and unwashed for days at a time. This was clearly evident by the exact same pieces of food and trash remaining on the floor in the same spots for consecutive days.Multiple surveyor observations on 8/12/2026 during the initial tour, revealed the following:-Surveyor observations of the Third-Floor Unit revealed the following:-Flooring observed with dust, dirt, debris, food particles, dried substances, and other accumulated material throughout the common area hallway.-The dining area flooring and tables observed with dried liquid stains and food debris.-room [ROOM NUMBER]- observed with an accumulation of black debris, dried liquid stains and food crumbs on the floor.-Black staining and debris accumulated where the wall meets the floor along the hallway wall for approximately two feet.-A resident mechanical lift device was observed with a heavy accumulation of dusty grey material, dried substances and food particles.During a surveyor interview immediately following the above observations with Licensed Practical Nurse (LPN), Staff A she acknowledged the above observations. Additionally, she stated in part, she would expect The resident's rooms to look like where someone lives. When asked if this is the normal condition of the unit and equipment, Staff A stated, It's obvious it is not clean .Surveyor observations of the Second-Floor Unit revealed the following:-Heavy accumulation of dirt, grime and staining the hallway flooring.-room [ROOM NUMBER]- dried alcohol wipes, plastic packaging and generalized dirt, grime and debris on the floor. The Intravenous (IV) pole was observed with a visible buildup of dried, brown colored substance accumulated on the base and wheels. -One clean linen cart observed with an accumulation of black matter along the outside cover with red staining along the top of the cover.-room [ROOM NUMBER] (as referenced on the facility floor plan) was observed with a deployed mouse trap in corner of the room, heavy accumulation of dirt, grime and food debris on flooring. The windowsill was observed with brown matter and a urinal with approximately 1/4 inch of dried black matter inside the container.-Three resident mechanical lift devices observed with a heavy accumulation of dusty grey material, dried substances and food particles.During a surveyor interview immediately following the above observations with LPN, Staff B, she acknowledged the above observations. When asked by the surveyor the normal condition of the cleanliness of the unit and equipment, Staff B stated, This is the worst floor.During a surveyor interview on 8/12/2026 at 9:35 AM with Resident ID #2 s/he indicated that at times his/her room is not cleaned for up to 10 days. S/he further revealed that s/he cleans his/her own bathroom to maintain cleanliness.Surveyor observations of the First-Floor Unit revealed the following:-Dining room accumulation of dirt and grime on the flooring-Two resident lift devices observed with a heavy accumulation of dusty grey material, dried substances and food particles.-room [ROOM NUMBER]- gouges in the flooring-room [ROOM NUMBER]- the moulding along the door was splintered revealing an exposed sharp wooden point-Two elevator track doors observed with an accumulation of dirt, dust and debrisSurveyor observations of the Basement Level revealed the following:-A ceiling tile with an accumulation of black matter, and a dried substance built up in the lighting fixture cover. Additionally, a bucket and wet floor sign were observed below the tile.-Staff Development office- lighting fixture cover observed with an accumulation of dried substance, as well as rusting observed on the ceiling tile and flooring. Further, the ceiling tile was observed with active dripping of water from the encasement.During surveyor interviews with the Director of Maintenance on 8/12/2026 at approximately 9:50 AM and 10:26 AM he acknowledged the observations on the second-floor unit. Additionally, he acknowledged that the black matter on the tile in the basement level and in the staff development office was caused by moisture from above that needs to be addressed. Additionally, he indicated that the cleanliness of the unit and equipment was not within expectation.During an additional surveyor observation and simultaneous interview on 8/13/2026 at approximately 2:00 PM with LPN, Staff C she acknowledged the molding pulled away from the door of room [ROOM NUMBER] revealing a sharp point of wood, the gouging on the floor in room [ROOM NUMBER]A and that the floor in the dining room had an accumulation of dirt and debris.During surveyor interviews on 8/12/2026 at 10:26 AM and 8/14/2026 at 9:06 AM with the Administrator, he was unable to provide evidence that the facility maintained a safe and clean environment relative to the main building and the three nursing units.Cross Reference F940

Based on record review and staff interview the facility failed to develop, implement, and maintain an effective training program for annual training for existing employees consistent with their expected housekeeping roles, relative to environmental cleaning, per the facility assessment, for 3 of 5 employees reviewed, Staff D, E, and F.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/8/2026, alleged in part, .Unsanitary Environment: The cleanliness of the facility was dangerously substandard. Floors in patient areas were left unswept and unwashed for days at a time. This was clearly evident by the exact same pieces of food and trash remaining on the floor in the same spots for consecutive days.Review of the Facility Assessment, last revised 6/15/2026, revealed in part, the facility resources identified to provide competent resident support and care include, but is not limited to, housekeeping services. Additional review of the assessment revealed skills-based competencies are completed upon hire, annually, and on an as needed basis. During a surveyor interview on 8/13/2026 at 2:46 PM with the Regional Director of Nursing Services, she acknowledged that the skills-based competencies are required for housekeeping based on the facility assessment including, but is not limited to, environmental cleaning.Record review of the housekeeping staff training records for Staff D, E, and F revealed the following:-Staff D was hired on 1/30/2026. Review of training records failed to reveal evidence that he received competencies relative to environmental cleaning.-Staff E was hired on 1/30/2026. Review of training records failed to reveal evidence that he received competencies relative to environmental cleaning.-Staff F was hired on 4/28/2026. Review of training records failed to reveal evidence that he received competencies relative to environmental cleaning.During surveyor interviews on 8/13/2026 at 2:54 PM and 8/14/2024 at 9:53 AM, with the Administrator, he was unable to provide evidence that the above-mentioned competencies were completed for Staff D, E, and F, as per the facility assessment.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure residents who are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for a continuous feeding and water flush via a Jejunostomy tube (J-tube, a surgically placed device used to give direct access to the small intestine for supplemental feeding, hydration or medicine), Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/29/2026, alleged in part, The resident has required multiple hospital transfers to replace his/her J-tube.Review of a facility policy titled, Enteral Feedings last revised October of 2022, states in part, .Verify physician order.document assessment, findings and interventions in the medical record .Record review revealed that Resident ID #1 was readmitted to the facility in May of 2026 with diagnoses including, but not limited to, severe protein calorie malnutrition and adult failure to thrive. Additional record review revealed Resident ID #1 has a j-tube.Record review revealed the following physician's orders:-3/6/2026 flush feeding tube with 100 milliliters (ml) of water every shift-3/9/2026 Administer enteral feeding order every shift for a water flush 30 ml per hour via a feeding pumpDuring a surveyor observation on 8/13/2026 at 10:30 AM, in the presence of Licensed Practical Nurse, Staff C the residents tube feeding water flush rate was set to 50 ml/hour not the 30 ml/hour as ordered.During a surveyor interview with Staff C, immediately following the above observation she acknowledged that she had completed the resident's flush earlier in her shift and she acknowledged the water flush rate was set to 50ml/hour. Additionally, she revealed she should have reviewed the pump setting with the physician's order to identify the error prior to it being brought to her attention by the surveyor.During a surveyor interview on 8/13/2026 at 11:50 AM, with the Regional Director of Nursing Services she revealed she would expect the resident to have received the water flush amount per the Physician's order.

Based on clinical record review, surveyor observation, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections relative to a clean dressing change for 1 of 1 residents observed for Jejunostomy tube (j-tube- is a feeding tube placed directly into the small intestines.) site care, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/29/2026, alleged in part, The resident has required multiple hospital transfers to replace his/her j-tube.Review of a facility policy titled, Non-sterile dressing last revised January of 2023 states in part, .prepare a clean, dry work area at bedside.wash hands and apply gloves prepare/open dressing items on table.place initials and date on a piece of tape or on the dressing.remove soiled dressing; place it in the trash bag.remove gloves, wash hands, apply new gloves.clean the wound .pat dry.Remove gloves, wash hands and apply new gloves.apply prescribed topical agent to wound.discard gloves.wash hands.Record review revealed that Resident ID #1 was readmitted to the facility in May of 2026 with diagnoses including, but not limited to, severe protein calorie malnutrition and adult failure to thrive. Additional record review revealed Resident ID #1 has a J-tube.Record review revealed the following Physician's orders:-3/6/2026 J-tube care cleanse with normal saline followed by a split gauze to the site twice daily-3/25/02026 Apply Calmoseptine (a moisture barrier) ointment to J-tube site twice dailyDuring a surveyor observation on 8/13/2026 at 10:30 AM, Licensed Practical Nurse (LPN), Staff C performing the J-tube site care, she failed to establish a clean field. Staff C was observed to place all of her supplies including, but not limited, unwrapped gauze directly on a wheelchair in the hallway prior to entering the resident's room. Staff C, proceed to enter the resident's room with the gauze and revealed she was ready to complete the J-tube site care until she was stopped by the surveyor prior to completing the J-tube site care. After retrieving new gauze, Staff C entered the resident's room and failed to perform hand hygiene prior to applying her gloves. Staff C removed the soiled dressing from the J-tube site. Staff C, failed to remove her gloves and/or perform hand hygiene. Staff C with the same dirty gloves was observed to cleanse the J-tube site she then applied the topical cream directly to the finger of the soiled glove and rubbed her gloved finger directly on the resident's tube insertion site. Staff C, then reached into her pocket without removing her dirty gloves and removed a marker, she then wrote the date directly on the dressing that had been applied to the resident. Further, she removed her gloves and exited the resident's room. Staff C, failed to perform hand hygiene after exiting the resident's room or clean the marker prior to returning it to her pocket.During a surveyor interview with LPN, Staff C, immediately following the above observation she acknowledged putting the J-tube supplies including unwrapped gauze directly on the wheelchair for another resident in the hallway. Additionally, she acknowledged she did not clean her hands prior to, during or after the J-tube site care and she should have. Further, she indicated that it is her typical practice to apply topical ointments with her finger.During a surveyor interview on 8/13/2026 at 11:50 AM with the Regional Director of Nursing Services, she revealed she would expect the nurses to set up a clean field for their supplies. Additionally, she revealed that it would be her expectation for staff to wash their hands prior to applying their gloves, washing their hands and change gloves after removing the soiled dressing and before applying a clean dressing. Further, she indicated that it would be the expectation that Staff C would have apply the topical cream with an applicator.Cross reference F693

Based on clinical record review and staff interview, the facility failed to provide written notification, including the reason for the room change, prior to changing a resident's room or roommate assignment for 1 of 1 resident reviewed whose room and roommate were changed without prior notification, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/8/2026 alleged in part, Resident ID #1 reported an allegation his/her room was changed, and s/he was assigned a new roommate. Furthermore, the complaint alleged that the new roommate yelled and screamed out at the top of their lungs which impacted the resident's quality of life as s/he could no longer receive visitors in his/her own room. Record review of a facility policy titled Room Change last revised in October of 2022, states in part, .The resident has the right to refuse transfer to another room in the facility if the purpose of the transfer is.Solely for the convenience of staff.When a resident room change is occurring, the resident being moved.will be informed of the room change. The resident receiving a new roommate will also be notified.The notice of a change in room or roommate assignment will be both verbal and in writing including the reason(s) for the change. Staff should complete a room change notice and provide to the resident.placed in the resident's medical record.Record review revealed Resident ID #1 was originally admitted to the facility in May of 2026 with a diagnosis including, but not limited to, infection or inflammatory reaction due to internal fixation device (implanted surgical hardware) of the spine.Record review of a Brief Interview for Mental Status score dated 5/15/2026, revealed a score of 11 out of 15, indicating a moderate cognitive impairment.Record review revealed the resident was transferred to the hospital on 5/27/2026 for an evaluation due to an elevated temperature and returned to the facility the following day.Record review of a progress note dated 5/28/2026 at 2:19 PM, revealed that Resident ID #1 was upset upon his/her return from the hospital because his/her room was changed. Additionally, s/he was unhappy with his/her roommate.Record review failed to reveal evidence the resident was informed of the room change prior to the transfer.Further record review failed to reveal evidence that Resident ID #1 received written notification of the room change, including the reason for the change, per the facility policy.During a surveyor interview on 6/17/2026 at 12:17 PM, with the Director of Nursing Services, she acknowledged that the resident's room assignment had been changed and that the resident had been assigned a new roommate. She was unable to provide evidence that Resident ID #1 received written notification of the room change, including the reason for the change, prior to the room change occurring.

Based on clinical record review and staff interview, the facility failed to meet professional standards of quality regarding not following physician orders for obtaining weights for 1 of 3 residents reviewed for nutrition, Resident ID #1. Additionally, the facility failed to follow the policy to reweigh residents to ensure accuracy when the weight falls outside of the established parameters for 2 of 3 resident's reviewed, Resident ID #s 1 and 3.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/12/2026 alleges that Resident ID #1 has had a drastic weight loss.Review of a facility policy titled, Weight Assessment and Interventions reveals in part, .Monthly weights will be obtained each month or as ordered by physician.Weights will be recorded in the medical record.for each resident.any weight change of 5 [pounds] lbs in a month and 3lbs in a week since their last weight assessment should be retaken within 72 [hours] hrs for confirmation and verified by Nursing.1a) Record review revealed Resident ID #1 was readmitted to the facility in October of 2025 and had diagnoses including but not limited to, hemiplegia ( a condition that causes weakness of the face, arm or leg on one side of the body), hemiparesis ( a condition that causes complete paralysis on one side of the body), and adult failure to thrive.Record review of the resident's physician's orders revealed the following:8/18/2025 to present - monthly weight1/9/2026 to 2/2/2026 - weekly weights for 4 weeksRecord review of the resident's weights revealed the following:9/12/2025 - 130.6 lbs.11/7/2025 - 134.6 lbs.1/8/2026 - 121.2 lbs.1/16/2026 -117.4 lbs.1/20/2026 - 118.8 lbs.1/26/2026 - 120 lbs.2/18/2026 - 115.8 lbs.Review of the weights failed to reveal evidence that weights were obtained during the months of October and December 2025, as ordered, by the physician.b) Additional record review failed to reveal that the resident was reweighed to ensure accuracy of the weights per the facility policy after the following weight losses occurred:13.4 lb. weight loss between 11/7/2025 and 1/8/20263.8 lb. weight loss between 1/8/2026 and 1/16/20264.2 lb. weight loss between 1/26/2026 and 2/18/20262) Record review revealed Resident ID #3 was admitted to the facility in November of 2025 and had a diagnosis including but not limited to, type 2 diabetes mellitus.Record review of the resident's physician's orders revealed the following:11/5/2025 to 12/1/2025- weekly weights for 4 weeksRecord review of the resident's weights revealed the following:11/5/2025 - 136.8 lbs.11/17/2025 - 144.6 lbs.12/2/2025 - 155 lbs.1/7/2026 -162.8 lbs.2/3/2026 - 168.8 lbs.The record failed to reveal that the resident was reweighed to ensure accuracy of the weights per the facility policy after the following weight gains occurred:7.8 lb. weight gain between 11/5/2025 and 11/17/202510.4 lb. weight gain between 11/17/2025 and 12/2/20257.8 lb. weight gain between 12/2/2025 and 1/7/20266 lb. weight gain between 1/7/2026 and 2/3/2026During a surveyor interview on 2/26/2026 at 11:00 AM with the Dietitian, she acknowledged that the facility failed to obtain reweights for the above residents per the facility policy. She further acknowledged that they failed to follow the physician's order for Resident ID #1 by failing to obtain the resident's weight in October and December of 2025.During a surveyor interview on 2/26/2026 at 1:35 PM with the Director of Nursing Services, she was unable to provide evidence that Resident ID #1's weights were obtained per the physician's order in October and December of 2025. Additionally, she was unable to provide evidence reweights were obtained for Resident ID #s 1 and 3, per the facility policy.

Based on surveyor observation, record review, and staff interview, 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 3 nourishment units observed.Findings are as follows:1.Record review of the Food and Drug Administration (FDA) Food Code 2022 Edition, Section 3-501.17 states in part, .refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked .The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .Surveyor observations during the initial tour of the main kitchen on 12/16/2025 at 9:35 AM, revealed eight, one-quart cartons of cultured buttermilk with a use by date of 12/8/2025.During a surveyor interview with the Food Service Director (FSD) immediately following the above observation, she acknowledged that the cartons of buttermilk were expired and should be discarded.2.Record review of the FDA Food Code 2022 Edition, Section 4-601.11 states in part, .NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .Additional review of the FDA Food Code 2022 Edition, Section 3-307.11 state in part, .FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306 .During a surveyor observation of the second-floor nourishment unit on 12/19/2025 at 10:39 AM, the following were observed:- A packaged tuna fish sandwich in the refrigerator without a label or date.- The inside of the microwave had brown food matter stuck to the ceiling and walls in addition to a greasy residue on the door. The rotating plate was also covered in a brown liquid.During a surveyor interview with Nursing Assistant, Staff M, immediately following the above observation, she acknowledged the sandwich was not labeled and should be. Additionally, she acknowledged that the microwave was dirty and should be cleaned.During a surveyor observation of the third-floor nourishment unit on 12/19/2025 at approximately 11:00 AM, the following were observed:- In the freezer, there was a 16 oz Styrofoam cup with a plastic bag inside which appeared to contain milk. The cup was labeled Don't touch please in Spanish.- The inside of the microwave had rust lining the edges of the ceiling. The rust flaked off when touched.During a surveyor interview with Licensed Practical Nurse, Staff B, immediately following the above observation, she acknowledged that the microwave had rust on the inside. Additionally, she indicated that the milk in the freezer was breast milk belonging to another staff member and should not be stored in the resident's freezer.During a surveyor interview with the FSD on 12/19/2025 at 11:07 AM, she acknowledged that the second-floor microwave should be cleaned and that the third-floor microwave should be replaced. Additionally, she indicated that she would expect all food to be labeled and that food/personal items belonging to staff member should not be stored in the resident's refrigerator or freezer.

Based on clinical record review and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life, related to 2 of 2 certified medication technicians (CMT) evaluations reviewed, Staff N and O. Findings are as follows:Record review of the QAPI binder on 12/19/2025 at 12:00 PM with the Administrator and Regional Director of Nursing Services, revealed a performance improvement plan was implemented on 6/17/2024 to establish a tracking system for employee evaluations which included CMT evaluations. This tracking failed to reveal evidence that the quarterly evaluation for CMTs, Staff N and O, were completed until it was brought to their attention by the surveyor during the survey.During a surveyor interview on 12/19/2025 at 12:00 PM with the Regional Director of Nursing Services, she was unable to provide evidence that the facility implemented and maintain an effective QAPI program.Cross reference: RI state 1.16.10.B.

Based on surveyor observation, staff and resident interview, the facility failed to provide a private space for resident council meetings that are held monthly as required. Findings are as follows:During the resident council interview task on 12/17/2025 at 1:18 PM with 14 residents in attendance, collectively they indicated that they are not given privacy when having their regular resident council meetings. The residents indicated that the meetings are typically held in the 1st floor dining room, where the current meeting was being held. Surveyor observations during the resident council meeting on 12/17/2025 from 1:18 PM until approximately 1:55 PM, staff interrupted the meeting at the following times:-1:20 PM - a staff member entered the room and went into the kitchenette area. -1:25 PM - the Director of Nursing Services (DNS) entered the room to get water from the cooler.-1:30 PM- the DNS entered the room again and went into her office, which is adjacent to the dining room area. -1:38 PM - a staff member entered the room to use the sink. -1:50 PM - a staff member entered the room for an unknown reason.During a surveyor interview on 12/18/2025 at 1:18 PM with the Activities Director, she indicated that she is aware that staff frequently interrupts the resident council meetings, however the facility does not have another area for the residents to conduct a private meeting. Additionally, she indicated that she would expect the facility to provide a private space for the residents to conduct the resident council meetings.

Based on record review, staff, and resident interviews, the facility failed to follow and implement physician's orders related to the facility's Bowel Evacuation Protocol for 2 of 2 residents reviewed who did not have a bowel movement for over three days, Resident ID #s 78 and 11. Findings are as follows:Review of a facility policy titled, Bowel Evacuation Protocol dated March 2016, states in part, The facility has the responsibility to ensure that each resident develops regular bowel habits with or without cathartic assistance.to prevent impaction and.promote psychological and social well-being.If the resident has had no bowel movement for 9 consecutive shifts, begin the bowel protocol on the 3:00 PM to 11:00 PM shift. The Bowel protocol is to give Milk of Magnesia (MOM) on the 3:00 PM to 11:00 PM shift. If the MOM is ineffective, then the resident is to receive a Bisacodyl suppository on the 11:00 PM to 7:00 AM shift. If the Bisacodyl suppository is ineffective, then the resident is to receive a Fleets enema on the 7:00 AM to 3:00 PM shift. Record the results of the Bowel Protocol.Notify the physician if the Bowel Protocol is ineffective . 1. Record review revealed Resident ID #78 was admitted to the facility in March of 2025 with a diagnosis of severe protein-calorie malnutrition. Further review revealed this resident was receiving hospice services. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident requires maximum assistance with activities of daily living (ADLs) including toileting and is in incontinent of bowel and bladder.Record review revealed the following nursing notes:12/7/2025- The resident was awake for most of the overnight shift with frequent medical complaints. The resident stated s/he .had non-stop bubbles down the left side of [his/her] abdomen and flatulence that was not normal . 12/8/2025- The resident was seen by the Physician's Assistant, and he ordered an abdominal X-ray (KUB- Kidney, Ureter, and Bladder X-Ray) to rule out a bowel obstruction.Record review revealed a progress note dated 12/9/2025 indicating that the nurse called the hospice supervisor to notify her that the KUB was ordered. Further review revealed .Nursing supervisor at hospice does not approve orders, they will not be paid for by hospice. Message left for PA [Physician's Assistant] to review .Record review revealed a provider's order dated 12/9/2025 for a KUB. Record review failed to reveal evidence that the KUB was completed as ordered. Review of the bowel movement (BM) record revealed the resident did not have a BM from 12/13/2025 through 12/17/2025, which is five days. Record review of the December 2025 Medication Administration Record (MAR) revealed the following orders:-3/20/2025- Milk of Magnesia (MOM)- administer 30 milliliters orally as needed if no BM for three days.-3/20/2025- Dulcolax (Bisacodyl) Suppository- administer 10 milligrams rectally as needed if no BM from MOM.-3/20/2025- Fleet Enema- administer 1 enema rectally as needed if no results from Dulcolax suppository, give fleet enema on the 4th day.Further review of the MAR failed to reveal evidence that any of the above medications were administered after three days without a bowel movement as ordered until it was brought to the facility's attention by the surveyor on 12/18/2025. During a surveyor interview on 12/18/2025 at 12:00 PM with Registered Nurse, Staff F, she indicated that she did not have a bowel list printed at that time and was unaware if anyone was on the bowel list. After requested by the surveyor, she was unaware how to print the bowel list and required assistance from another staff member. She acknowledged that Resident ID #78 had not had a bowel movement recorded in five days and no interventions were implemented as ordered. Additionally, she acknowledged that Resident ID #78 did not have the KUB completed as ordered. During a surveyor interview on 12/19/2025 at 1:13 PM with the Hospice Nursing Supervisor, she indicated that obtaining a KUB would not affect the resident's eligibility for hospice services and that it can be billed to a non-hospice insurance. During a surveyor interview on 12/19/2025 at 1:49 PM with PA, Staff C, he indicated that he had not been made aware that the KUB had not been completed and would have expected the KUB to have been completed as ordered.During a surveyor interview on 12/19/2025 at 2:29 PM with the Director of Nursing Services (DNS), she indicated that she would have expected the nurse to have called the provider back to clarify the order for the KUB, after speaking with the hospice team. Additionally, she could not provide evidence that the bowel protocol had been followed as ordered. 2. Record review revealed Resident ID #11 was admitted to the facility in May of 2025 with diagnoses including, but not limited to, adult failure to thrive and constipation. Record review of the MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15, indicating moderately impaired cognition. Further review revealed the resident is incontinent of bowel and bladder and is dependent on staff for ADLs, toileting and hygiene. During a surveyor interview on 12/16/2025 at approximately 10:30 AM, Resident ID #11 indicated that s/he should be having bowel movements more often and indicated s/he had not received any medication to assist with having a bowel movement. Review of the resident's BM record revealed the resident did not have a bowel movement for five days, from 12/13/2025 through 12/17/2025. Review of the December 2025 MAR revealed the following orders: -5/7/2025- Milk of Magnesia (MOM)- administer 30 milliliters orally as needed if no BM for three days.-5/7/2025- Dulcolax (Bisacodyl) Suppository- administer 10 milligrams rectally as needed if no BM from MOM.-5/7/2025- Fleet Enema- administer 1 enema rectally as needed if no results from Dulcolax suppository, give fleet enema on the 4th day.Record review failed to reveal evidence that MOM was administered after three days without a BM. Further review revealed MOM was administered on the fifth day without a BM on 12/17/2025. Additional review failed to reveal that any additional medications were administered as ordered or that the provider was notified per the facility's policy. During a surveyor interview on 12/18/2025 at 12:00 PM with Registered Nurse, Staff F, she indicated that she did not have a bowel list printed at that time and was unaware if anyone was on the bowel list. After requested by the surveyor, she was unaware how to print the bowel list and required assistance from another staff member. She acknowledged that Resident ID #11 had not had a bowel movement recorded in five days and no interventions were implemented as ordered. During a surveyor interview on 12/19/2025 at 2:29 PM with the DNS, she could not provide evidence that the bowel protocol had been followed as ordered. Cross Reference F 684

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure the residents' environment remains as free of accident hazards as possible, related to securing medications and hazardous equipment (razor) for 1 of 1 treatment cart observed on a secured unit in close proximity to Resident ID #s 9 and 14, and for 1 of 2 smokers reviewed without a smoking assessment, Resident ID #21.Findings are as follows:1. During a continuous surveyor observation on 12/16/2025 of the third-floor (the secure unit) nursing treatment cart located in the hallway, it was observed to be unlocked while unattended by staff for seventeen minutes from 10:37 AM to 10:54 AM.Record review revealed Resident ID #9 was admitted to the facility with a diagnosis of dementia. Further record review revealed a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating a severely impaired cognition.During a surveyor observation on 12/16/2025 at approximately 10:00 AM revealed Resident ID #9 wandering in the hallways, self-propelling in his/her wheelchair.Record review revealed Resident ID #14 was admitted to the facility with a diagnosis of Alzheimer's disease. Further record review revealed a BIMS score of 0 of 15, indicating severely impaired cognition.During a surveyor observation on 12/16/2025 at approximately 10:00 AM revealed Resident ID #14 walking around the hallways independently.During a surveyor observation on 12/16/2025 at 11:03 AM of the treatment cart with Licensed Practical Nurse (LPN) Staff B, treatment medications such as diclofenac gel, antifungal creams, hemorrhoidal cream, and a box of clean razors were being stored in the treatment cart.During a surveyor interview with Staff B, following the above observation, she acknowledged that the cart was left open and would expect it to be locked when unattended. During a surveyor interview on 12/18/2025 at 1:17 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the residents' environment in the secured unit was maintained as free of accident hazards as possible, as required.2. Record review of the smoking policy states in part, .Residents who smoke will be evaluated for their ability to smoke safely upon admission, quarterly and . to ensure that they continue to be capable of smoking and use smoking materials without presenting a danger to themselves or others.Clinical record review revealed Resident ID #21's Occasional/Former Smoker Evaluation dated 3/14/2025, revealed that s/he wishes to smoke, and continued to be on the facility's list of smokers provided to the surveyor on 12/16/2025.Record review failed to reveal evidence that the resident was evaluated for his/her smoking capabilities quarterly on 6/14/2025 and 9/14/2025.During a surveyor interview on 12/19/2025 at approximately 1:00 PM with the DNS, she acknowledged that the resident failed to be re-evaluated for his/her smoking capabilities quarterly, as required.

Based on surveyor observation, clinical record review, staff and resident interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for resident's relative to 1 of 1 privacy curtain observed with staining, and for 2 of 3 units reviewed without an assigned housekeeper.Findings are as follows:1.Record review revealed Resident ID #94 was admitted to the facility in March of 2024 with a diagnosis including, but not limited to, dementia.During a surveyor observation of the resident's room on 12/16/2025 at 10:35 AM, the privacy curtain between the resident's bed and his/her roommate was observed to have large, brown stains that were splattered across the length of the curtain.A subsequent observation of the resident's room on 12/19/2025 at 12:54 PM revealed that the privacy curtain still had the staining and had not been changed.During a surveyor interview with Nursing Assistant, Staff Q, immediately following the above observation, she acknowledged that the resident's privacy curtain had scattered brown staining and was dirty.During a surveyor interview with Licensed Practical Nurse, Staff B on 12/19/2025 at 1:38 PM, she acknowledged that the privacy curtain was dirty and would expect that it would be cleaned by laundry and housekeeping.During a surveyor interview with the Director of Nursing Services on 12/19/2025 at 1:31 PM, she revealed that the privacy curtain should have been removed and cleaned by the housekeeping staff.2.During surveyor observations on the following dates and times, flies were observed in common areas and in occupied residents' rooms:- 12/16/2025 at 10:22 AM, inside room [ROOM NUMBER]- 12/16/2025 at approximately 11:00 AM, second floor outside the nurses' station- 12/16/2025 at 2:54 PM, inside room [ROOM NUMBER]Record review of the October and November 2025 resident council meeting minutes revealed that there were flies in resident rooms and in the common areas. During the resident council interview task on 12/17/2025 at 1:42 PM, several residents indicated that housekeeping is a problem, with only one housekeeper on duty most of the time. They indicated the second floor often goes a week or longer without bathrooms being cleaned, floors swept, trash emptied, or paper products refilled.Record review of the Resident Bed List Report dated 12/16/2025 revealed the following census by floor:- First floor: 25 residents- Second floor: 41 residents- Third floor: 35 residentsRecord review of the staffing schedule for housekeeping from 12/7 through 12/20/2025 revealed there was one housekeeper scheduled for the entire building on 12/7, 12/8, 12/9, 12/10, 12/13, 12/15, and 12/16, and this housekeeper was scheduled to work only on the first floor.Additional record review revealed there were only two housekeepers scheduled to work in the facility on 12/11 and 12/18/2025. These housekeepers were assigned on the first and third floors.During a surveyor interview with the Director of Maintenance on 12/19/2025 at approximately 10:01 AM, he indicated that he was aware of the residents' concerns related to housekeeping services. However, he was unable to provide evidence that there were more than one housekeeping staff scheduled on the dates mentioned above, to maintain a clean, sanitary, and comfortable environment for the residents.During a surveyor interview with Housekeeper, Staff R, on 12/19/2025 at 10:01 AM, she indicated that when she is on schedule, she only cleans the first floor and does not clean second and third floors.During a surveyor interview with Housekeeper, Staff S, on 12/19/2025 at 10:20 AM, she revealed she works part time on the third floor and does not work on the first and second floors.During a surveyor interview with the Regional Director of Nursing on 12/19/2025 at 10:30 AM, she acknowledged that the facility does not have sufficient housekeeping staff to provide residents with a safe, functional, sanitary and comfortable environment.

Based on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to physician's orders for 1 of 3 residents reviewed who receives Eliquis (a medication prescribed to prevent and treat blood clots), Resident ID #64.Findings are as follows:According to 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's orders unless they believe that the orders are in error or would harm the clients.Record review revealed the resident was admitted to the facility in July of 2023 with a diagnosis including, but not limited to, acute embolism and thrombosis of unspecified deep veins of the right lower extremity (a health condition when blood clots form in the vessels blocking blood flow).Record review of the Electronic Medical Record (EMR) revealed a physician's order dated 12/12/2025 for Eliquis 5 milligrams twice daily.Record review of the paper Medication Administration Record (MAR) revealed that the Eliquis order was written as discontinued on 12/16/2025.Record review failed to reveal evidence that the order was discontinued by the provider on 12/16/2025.During a surveyor interview on 12/19/2025 at 9:40 AM with Licensed Practical Nurse, Staff D, she acknowledged that the resident's Eliquis order is still active in the EMR.Record review of the paper MAR failed to reveal evidence that the Eliquis was administered for 5 opportunities from 12/16/2025 through 12/19/2025.During a surveyor interview on 12/19/2025 at 11:30 AM with the Director of Nursing Services, she was unable to provide evidence that the Eliquis administered as ordered. She acknowledged that the order should not have been discontinued on 12/16/2025.

Based on surveyor observation, clinical record review, staff, and resident interview, the facility failed to provide activities of daily living (ADL) care for 1 of 1 resident reviewed for who receives hospice services, Resident ID #78.Findings are as follows:Record review revealed Resident ID #78 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, severe protein-calorie malnutrition, major depressive disorder, cataracts (a condition which includes the clouding of the eye's lens which can lead to blurred vision and blindness), and adult failure to thrive. Further review revealed this resident was receiving hospice services. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. Further review revealed the resident required maximum assistance with ADLs including personal hygiene, bathing and toileting due to incontinence of bowel and bladder. During a surveyor interview on 12/16/2025 at approximately 11:15 AM with Resident ID #78, the resident stated that s/he was very uncomfortable because s/he had not had ADL care provided that morning or the day before (12/15/2025 and 12/16/2025). The resident indicated that a hospice aide usually comes in but had not been there in two days and the facility staff had not provided ADL care to him/her. Additionally, the resident indicated that s/he was angry because s/he should have been cleaned and dressed by the time of the interview. During a surveyor interview on 12/16/2025 at 11:39 AM with Nursing Assistant (NA), Staff A, she indicated that she thought that a hospice aide usually provides ADL care for the resident, but they had not been into the facility yet. She further acknowledged that the resident had not had ADL care provided at the time of the interview. Record review of the ADL documentation failed to reveal evidence that the resident had received ADL care on the day shift of 12/15/2025 and 12/16/2025, which includes toileting hygiene, bathing, and dressing. During a surveyor interview on 12/17/2025 at 3:08 PM with Registered Nurse, Staff E, she indicated that a hospice NA comes to the facility once a week to provide care for the resident, not daily. She could not provide evidence that the resident received care on the 1st shift of 12/15/2025 and on the morning of 12/16/2025, prior to the surveyor bringing it to the staff's attention. During a surveyor interview on 12/19/2025 at 2:29 PM with the Director of Nursing Services, she indicated that she would expect staff to document when ADL care is provided. Additionally, she could not provide evidence that Resident ID #78 received ADL care on the 1st shift of 12/15/2025 and 12/16/2025, prior to the surveyor bringing it to staff's attention. Cross Reference: F 684

Based on clinical record review and staff interview, the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling foley catheter (a flexible tube that collects urine from the bladder and empties into a drainage bag) related to urine output monitoring, Resident ID #10.Findings are as follows:According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Volume 2, 10th Edition, page 252 states, .the usual daily urine volume in the adult is 1-2 Liters or 1000-2000 cubic centimeters (cc) [milliliters] . Additionally, 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 policy titled URINARY CATHETER CARE dated April of 2015 states in part, .empty drainage bag at least every 8 hours and as necessary.Record review revealed the resident was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, urinary retention.Record review revealed a physician's order dated 10/3/2025 to monitor catheter drainage every shift.Record review of a document titled, Vital Reports from 11/18/2025 through 12/18/2025 failed to reveal evidence that the resident's urine output was recorded for 36 of 90 opportunities. Additional review failed to reveal evidence that the resident's urine output was recorded in milliliters to accurately monitor his/her output every shift for 21 of 90 opportunities.During a surveyor interview on 12/19/2025 at 1:27 PM with Nursing Assistant (NA), Staff G, she acknowledged that they are required to empty the resident's urinary catheter bag, measure the amount of urine in the bag, and document the amount in milliliters in the resident's record every shift.During surveyor interview on 12/19/2025 at 1:31 PM with the Director of Nursing Services, she acknowledged that the NAs are responsible for emptying the urinary catheter bags, measuring the amount of urine in the bag, and documenting the amount of urine in milliliters in the resident's record every shift.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure residents who are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for a continuous feeding via a jejunal tube (J-tube, a surgically placed device used to give direct access to the small intestine for supplemental feeding, hydration or medicine), Resident ID #13. Findings are as follows: According to Lippincott Nursing Procedures Nineth Edition dated 2023, states in part, .Managing Enteral Tube Feeding Problems.Aspiration of gastric secretions.Elevate the head of the bed a minimum of 30 degrees.Review of a facility policy dated April 2015 titled Enteral Feeding [feeding provided through an alternative method via a J-tube] states in part, .Elevate head of bed 30-45 degrees.Label formula and administration set with date, time, resident's name and nurse initials.Always keep HOB [head of bed] elevated to prevent aspiration.Record review revealed that Resident ID #13 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, adult failure to thrive and gastroesophageal reflux disease (a chronic digestive condition where the stomach acid frequently flows back up into the canal that connects the throat to the stomach). Record review revealed physician's orders dated 8/1/2024 to elevate the resident's head of bed at 30 degrees continuously and to change the enteral feeding bag once a day. During surveyor observations on 12/16/2025 at 10:30 AM, 11:15 AM, and at 12:52 PM, the resident was observed lying flat while receiving enteral feeding via the J-tube and the head of the bed was not elevated at 30 degrees, as ordered. Additional surveyor observations on 12/18/2025 at 9:25 AM and at 9:30 AM, the resident was observed lying flat while receiving content from a bag via the J-tube that was not labeled with the content or dated, as per the facility's policy. During a surveyor observation and interview on 12/18/2025 at 9:32 AM and at 9:52 AM with Registered Nurse, Staff H, she acknowledged the resident was lying flat while receiving his/her enteral feeding via the J-tube. Staff H then exited the room during the observation on 12/18/2025 at 9:32 AM without elevating the head of the bed after it was brought to her attention by the surveyor. Additionally, Staff H, acknowledged the enteral feeding bag was not labeled and dated, as required. During a surveyor interview on 12/18/2025 at 9:56 AM with the Director of Nursing Services (DNS), she indicated that she would expect the head of the bed to be elevated to at least 30 degrees when s/he is receiving his/her enteral feeding via the J-tube. Additionally, the DNS indicated that the bag containing the enteral feeding should have been labeled and dated.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to enhanced barrier precautions (EBP; refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO], for 4 of 4 residents observed on EBP, Resident ID #s 12, 13, 22 and 65. Findings are as follows: Review of the facility signage titled Enhanced Barrier Precautions states in part, .Wear Gown and Gloves prior to these activities .Dressing .bathing .transferring .providing hygiene . Device care or use of a device.feeding tubes.Clean their hands, including before entering and when leaving the room .1. Record review revealed Resident ID #22 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, a wound on the right hand. During a surveyor observation on 12/16/2025 at approximately 10:30 AM revealed signage posted outside of Resident ID #22's room indicating s/he is on EBP. During a surveyor observation on 12/16/2025 at 10:46 AM, Nursing Assistant, Staff L, was observed dressing Resident ID #22 without wearing a gown per the facility's signage. Staff L then exited the room, went into the hallway, acquired a wheelchair and went back into the resident's room, then transferred the resident from the bed to the wheelchair without wearing a gown.During a surveyor interview immediately following the above observation with Staff L, he acknowledged that he had assisted the resident with dressing and transferring and failed to wear a gown as per the facility's signage. 2. Record review revealed Resident ID #13 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, an artificial opening of the gastrointestinal track status J-tube insertion (a surgically placed device used to give direct access to the small intestine for supplemental feeding, hydration or medicine). During a surveyor observation on 12/16/2025 at approximately 11:00 AM revealed signage posted outside of Resident ID #13's room indicating s/he is on EBP. During a surveyor observation on 12/16/2025 at 11:04 AM, Nursing Assistant, Staff L, was observed providing a bed bath for Resident ID #13 without wearing a gown as per the facility's signage.During a surveyor interview immediately following the above observation with Staff L, he acknowledged that he had given the resident a bed bath and failed to wear a gown. During a surveyor interview on 12/19/2025 at 12:03 PM with the Director of Nursing Services (DNS), she acknowledged that both Resident ID #s 13 and 22 are on EBP. The DNS further indicated that she would expect the staff to wear a gown and gloves when giving a bed bath, dressing, and transferring the residents as indicated on the signage.3. During a surveyor observation on 12/16/2025 at 10:56 AM with Laundry Aide, Staff P, she failed to sanitize her hands while dropping off clean laundry in between resident rooms who were on EBP. She was first observed going into Resident ID #12's room to drop off clean laundry, touched the cabinet in the room, then exited the room without sanitizing her hand. She then went back to the clean laundry cart, grabbed another set of clean clothing, went into Resident ID #65's room to drop off the clothing, she exited the room and did not sanitize her hands.During a surveyor interview following the above observation, Staff P initially indicated that she had utilized the hand sanitizers in Resident ID #s 12 and 65 rooms, however, the hand sanitizer dispensers in both rooms had been checked by the surveyor prior to this observation and both dispensers were empty. Staff P then acknowledged that she should have sanitized her hand between rooms, before and after dropping off laundry in resident rooms.During a surveyor interview on 12/18/2025 at 1:08 PM with the DNS, she was unable to provide evidence that the laundry aide maintained an infection prevention practice to help prevent the transmission of communicable diseases and infections.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for errors observed during the medication administration task, there were four errors resulting in an error rate of 16% affecting Resident ID #s 43, 81, 62 and 101.Findings are as follows: 1. Record review revealed Resident ID #43 has a physician's order for Carvedilol (a medication prescribed to treat several heart and blood vessel conditions by relaxing blood vessels and slowing the heart rate) 3.125 milligrams (mg) twice a day with parameters to hold for a heart rate less 60. During a surveyor observation on 12/18/2025 at 8:53 AM with Certified Medication Technician (CMT), Staff I, she was observed obtaining the resident's heart rate which was 42. Staff I then administered the Carvedilol to the resident. During a surveyor interview with Staff I, immediately following the above observation, she acknowledged the resident's heart rate was 42 and had administered the Carvedilol instead of holding it, as ordered. 2. Record review revealed Resident ID #81 has a physician's order for Humalog Kwik Pen insulin (a medication prescribed to treat diabetes) 100 unit/milliliter (ml) three times a day per sliding scale (a method of determining the dose of insulin to be administered based on a person's current blood sugar level). During a surveyor observation on 12/18/2025 at 11:36 AM with Registered Nurse (RN), Staff H, she was observed placing a needle on the insulin pen without sanitizing the hub (a rubber seal on the top of the insulin pen where the needle is inserted). Additionally, Staff H did not prime the needle and proceeded to administer the insulin to the resident. Manufacturer's instruction on the One-Care safety pen needles box revealed to prime the needle prior to administering insulin. During a surveyor interview with Staff H immediately following the above observation, she acknowledged that she did not sanitize the insulin pen hub prior to attaching the needle and she did not prime the insulin needle prior to administering the insulin to the resident, as required. 3. Record review revealed Resident ID #62 has a physician's order for Lispro insulin pen (a medication prescribed to treat diabetes) 100 units/milliliter (ml) 20 units daily.During a surveyor observation on 12/18/2025 at 11:45 AM RN, Staff J, was administering the resident insulin without priming the needle. Manufacturer's instruction on the One-Care safety pen needles box revealed to prime the needle prior to administering insulin. During a surveyor interview with Staff J immediately following the above observation, she acknowledged that she did not prime the insulin needle prior to administering the insulin to the resident, as required. 4. Record review of the December 2025 Medication Administration Record revealed Resident ID #101 received 10 units of Lispro via an insulin pen on 12/18/2025 at 11:45 AM. During a surveyor observation on 12/18/2025 at 11:45 AM with RN, Staff K administering the insulin to Resident ID #101 he did not prime the needle to the insulin pen. Manufacturer's instruction on the One-Care safety pen needles box revealed to prime the needle prior to administering insulin. During a surveyor interview with Staff K immediately following the above observation, he acknowledged that he did not prime the insulin needle prior to administering the insulin to the resident, as required. During a surveyor interview on 12/18/2025 at 1:27 PM with the Director of Nursing Services (DNS), she acknowledged Resident ID #43's Carvedilol should have been held for a heart rate of 42, as ordered. The DNS further indicated that would expect Staff H to have sanitized the insulin pen hub and primed the insulin needle prior to administering insulin to Resident ID #81. Additionally, she indicated that Staff J and Staff K should have also primed the insulin needle prior to administering the insulin.

Based on surveyor observation and record review, the facility failed to protect identifying information for 7 current residents listed in the facility's survey results binder for 2 of 4 surveys reviewed.Findings are as follows:During a surveyor observation on 12/17/2025 at approximately 1:45 PM of the first floor, a black binder with a title of State Survey Results was stored on a wall in the entrance to the facility, facing the public.Record review of the survey binder revealed resident rosters (a list provided to a facility that corresponds to a number identifier utilized in a survey to protect privacy) included with the statement of deficiencies for the following surveys:- Survey results for exit date 9/18/2025, identifying Resident ID #s 74 and 99- Survey results for exit date 9/6/2024, identifying Resident ID #s 12, 32, 60, 61, and 74Further record review of the above surveys with the attached rosters contained information including, but not limited to, physician's orders and medical diagnoses.During a surveyor interview on 12/17/2025 at 2:05 PM with the Administrator, he acknowledged that the residents' names along with their corresponding number identifiers were in the binder and should not be available to view.

Based on surveyor observation and staff interview, it has been determined that the facility failed to properly store and serve food under sanitary conditions relative to serving temperatures of a potentially hazardous food item, improper cooling procedures, sanitation of the main kitchen, and infection control practices.Findings are as follows: 1. Record review of the 2022 Food Code published by the U.S Food and Drug Administration Section 4-601.11 (C) reads in part, .non-contact surfaces of equipment shall be free of an accumulation of .dirt, FOOD residue, and other debris . During a surveyor observation on 11/19/2025 at approximately 10:30 AM of the main kitchen, the following was revealed:- a grease accumulation over hood of 6 burner stove- a grease and grime accumulation in corners of the tilt skillet- black sheeting on the shelves of three worktables with an accumulation of debris and food crumbs- a rusted bottom shelf of a worktable that the meat slicer was stored on 2. Record review of the 2022 Food Code published by the U.S. Food and Drug Administration Section 5-501.113 states in part, receptables and waste handling units for refuse .shall be kept covered . During a surveyor observation on 11/19/2025 at approximately 10:30 AM of the main kitchen, the following was revealed:-a trash container was uncovered at the entrance of the dish room entrance while not in use3. Record review of the 2022 Food Code published by the U.S. Food and Drug Administration Section 3-501.14(A) states in part,.Cooked Time/Temperature control for safety food shall be cooled within 2 hours from 57 degrees C. [135 degrees F] to 21 degrees C and within a total of 6 hours from 57 degrees C to 5 degrees [41 degrees F or less].During a surveyor observation on 11/19/2025 at approximately 10:15 AM, 6 whole cooked chicken breasts were sitting on a worktable and with an internal temperature reading of 98.1 F. During a surveyor interview with the Food Service Director (FSD) immediately following the above-mentioned observation, she revealed that the chicken was to be used for chicken salad. During a surveyor observation on 11/19/2025 at approximately 11:30 AM in the walk-in refrigerator, a pan of chicken salad was stored, with an internal temperature of 68.7 degrees F.During a surveyor interview with the FSD immediately following the above-mentioned observation, she acknowledged a cooling log was not in place for the preparation of the chicken salad. 4. Record review of the 2022 Food Code published by the U.S Food and Drug Administration Section 3-501.16 Time Temperature Control for Safety Food Hot or Cold Holding states in part, .time/temperature control for safety food shall be maintained . (2) .at 5 degrees C (41 degrees F) or less. During a surveyor observation on 11/19/2025 at approximately 11:45 AM of the lunch meal service, a 4-ounce carton of 1% milk had an internal temperature of 45.5 degrees F. 5. Record review of the 2022 Food Code published by the U.S Food and Drug Administration Section 3-501.11 states, Stored frozen foods shall be maintained frozen.During a surveyor observation on 11/19/2025 at approximately 10:30 AM in the walk-in refrigerator, 14 containers of Magic Cup (a frozen nutritional supplement option for adding nutrition, calories, and protein for those experiencing swallowing difficulties or involuntary weight loss) were stored. The manufacturers label reads store frozen.6. Record review of the 2022 Food Code published by the U.S. Food and Drug Administration Section 4-501.110(B) states, .the temperature of the wash solution in a spray type dishwasher that use chemicals to sanitize may not be less than 49 degrees C (120 degrees F).During a surveyor observation on 11/19/2025 at 11:30 AM, the wash temperature was not registering because the dish machine's Printed Circuit Board (PCB-the critical function of the PCB is to regulate water temperatures) was in disrepair and not functioning. 7. Record review of the 2022 Food Code published by the U.S Food and Drug Administration Section 2-301.14(E) states, When to wash.food employees shall clean their hands and exposed portions of their arms .after handling soiled equipment or utensils.During a surveyor observation on 11/19/2025 at 10:30 AM of the dish room, Dietary Aide, Staff A, was observed donning (putting on) gloves without washing his hands. Further observation revealed that he lifted the dirty door handle of the dish machine to push a rack of dishes through. Additional observation revealed he did not take his gloves off or wash his hands prior to unloading the clean dishes from the dishrack.During a surveyor interview on 11/19/2025 at 2:30 PM with the FSD, she acknowledged that the above mentioned equipment was in need of cleaning, that the trash receptable was uncovered when not in use, that the milk was not served at an acceptable temperature parameter, that the Magic Cups were not stored frozen, that handwashing was not performed by the dietary staff member prior to donning gloves and when handling soiled equipment, and that the dish machine was malfunctioning.

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 for 1 of 3 nursing unit kitchenettes. Findings are as follows: 1a. The Rhode Island Food Code 2018 Edition 4-501.114, states in part, .a chemical sanitizer for a manual or mechanical operation at contact times .shall be used as follows: (A) A chlorine solution shall have a minimum concentration range 50-99 . 4-501.116 Ware washing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device . 1b. According to the State Operational Manual, Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 8/8/2024, states in part, .The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift . During a surveyor observation on 9/3/2024 at approximately 8:30 AM of the main kitchen, revealed the dish machine was in use. During a surveyor interview on 9/3/2024 at approximately 8:50 AM with Dietary Aide, Staff L, she revealed that the dish machine was converted from a high temperature sanitizing dish machine to a chlorine-based sanitizing dish machine. Additionally, when asked for a test strip to test the concentration of the chlorine-based sanitizing solution, Staff L provided the surveyor with a test strip that is used to test quaternary ammonium (a chemical solution used for sanitizing) sanitizer, not a chlorine-based sanitizer test strip. During a surveyor interview with the Food Service Director (FSD) immediately following the above observation, he revealed the dish machine was changed from a high temperature sanitizing dish machine, which used hot water to sanitize, to a chemical sanitizer, using a chlorine-based solution to sanitize. Upon further interview he was unable to reveal when the conversion took place. Additionally, he was unable to provide evidence that the dish machine was being monitored to ensure the chemical sanitizing solution was at the appropriate concentration or that the appropriate test strips were available. During surveyor interviews on 9/3/2024 at approximately 9:30 AM and 11:30 AM with the FSD, he revealed the service company for the dish machine had not yet been contacted to obtain the appropriate test strips or to check the functionality of the machine. During a surveyor interview on 9/3/2024 at approximately 2:00 PM with the Administrator, he revealed that the service company was just contacted and would be at the facility before the days end. During a surveyor observation and interview on 9/3/2024 at approximately 3:00 PM, with the facility's service technician, he revealed he had the appropriate test strips with him. Additionally, when he tested the chlorine-based sanitizer in the dish machine twice. The test stripa read less than 50 PPM (parts per million), indicating the dish machine was not sanitizing (the required level is 50 - 99 PPM). The facility's failure to ensure that dishes and utensils were properly sanitized had the potential to cause more than minimal harm or death due to the risk of foodborne illness. 2. The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .Nonfood contact surfaces shall be kept free of an accumulation of dirt, dust food residue and other debris . During a surveyor observation on 9/3/2024 at approximately 8:45 AM of the main kitchen revealed the following: - Three utility carts with heavy staining and scoring - [NAME] colored food spills under the steam table - Reach in refrigerator had a moderate amount of food crumbs on the bottom surface - Baker's rack (rack that holds pans) with a buildup of grime on the ridges along the back side of the rack - Grease build up along the sides and the corners of the stove - Third floor kitchenette refrigerator had a moderate number of brown spills along the back sides of the second and third shelves - Storage area under the tilt skillet with a moderate amount of grease and grime build up - Bottom of the plate holder had an accumulation of a black crumb-like substance - The floor mixer had a significant accumulation of rust During a surveyor interview on 9/4/2024 at approximately 2:30 PM with the FSD, he was unable to provide evidence of a cleaning schedule for the above mentioned observations. 3. The Rhode Island Food Code 2018 Edition 4-501.12 states in part, .Surfaces that are subject to scratching and scoring shall be .discarded if they can no longer be effectively cleaned and sanitized . During a surveyor observation on 9/3/2024 at approximately 9:50 AM, revealed 22 red lip plates with heavy scoring and deep scratches to the surface. During a surveyor interview on 9/4/2024 at approximately 2:30 PM with the FSD, he was unable to provide evidence of purchase orders for the replacement of the red lip plates. 4. The Rhode Island Food Code 2018 Edition 3-501.13 states in part, .Thawing . (A) Under refrigeration that maintains food temperature at .41 degrees F [Fahrenheit] or less; or (B) Completely submerged under running water: (1) At a water temperature of .(70 degrees F) or below . (C) Thawed in a microwave oven . During a surveyor observation on 9/4/2024 at approximately 1:52 PM, 3 packages of beef stew meat were sitting in a pan, thawing at room temperature. During a surveyor interview immediately following this observation with the FSD, he was unable to explain why the beef stew meat was thawing at room temperature. 5. 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 (41 degrees F) or less . During a surveyor observation on 9/3/2024 at approximately 11:30 AM during the lunch meal service in the main kitchen, [NAME] slaw, egg salad and ham salad sandwiches were observed on a tray in front of the steam table. The following temperatures were obtained: - Cold holding temperature reading of the egg salad was 49.1 degrees F. - Cold holding temperature reading of the ham salad was 48.9 degrees F. Additionally, record review failed to reveal evidence of a recorded cold holding temperature for the [NAME] slaw that was being served as a vegetable. During a surveyor observation on 9/4/2024 at approximately 11:40 AM, revealed 12 seafood salad sandwiches on a tray in front of the steam table. When the temperature was checked, the internal cold holding temperature was 50 degrees F. During a surveyor interview on 9/4/2024 at approximately 11:45 AM with the FSD, he acknowledged that the cold holding temperatures for the seafood, egg and ham salads were not within the acceptable temperature parameters for potentially cold hazardous foods. Additionally, he revealed the cold holding temperature for the coleslaw was not taken prior to the onset of the lunch meal. 6. The Rhode Island Food Code 2018 Edition 4-901.11 states in part, .Equipment and Utensils, Air-Drying Required .After cleaning and SANITIZING, EQUIPMENT and UTENSILS . (B) May not be cloth dried . During a surveyor observation on 9/3/2024 at approximately 9:30 AM and on 9/4/2024 at 9:45 AM, of the Dietary Aide, Staff Q, she was observed drying wet meal trays with a napkin. During a surveyor interview on 9/4/2024 at approximately 2:30 PM with the FSD, he was unable to explain why Staff Q was drying the meal trays with a napkin. 7. The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .food contact surfaces shall be cleaned to sight . During a surveyor observation on 9/4/2024 at approximately 1:50 PM of the ice machine, revealed the lower portion of the ice chute had an accumulation of a black and pink substance. During a surveyor interview on 9/4/2024 at approximately 2:30 PM with the Regional Clinical Nurse, she acknowledged the ice machine was in need of cleaning and service.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure a resident who is at risk for pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents reviewed with an actual pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), Resident ID #67. Findings are as follows: Record review revealed the resident was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, diabetes, Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) and a stage 3 pressure ulcer (a wound that involves full-thickness skin loss that extends into the subcutaneous tissue) of the sacral region. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact. Additionally, it revealed the resident requires extensive assistance of 2 staff members for bed mobility. Record review of a document dated 7/28/2024 titled, Braden Scale for Prediction of Pressure Score Risk, revealed a score of 16, indicating the resident is at risk for developing pressure ulcers. Record review of a care plan revised on 8/6/2024, revealed the resident is at risk for potential alterations in skin integrity related to decreased and impaired mobility, with interventions including, but not limited to, skin condition checks weekly, inspect feet daily with care, and assess skin under footwear. Record review of a physician's order dated 6/16/2024, revealed an order for weekly body checks on Thursdays. Review of the August 2024 Treatment Administration Record (TAR) revealed the last body check for the resident was completed on 8/22/2024. Additional review failed to reveal evidence that the weekly body check was completed on 8/29/2024, as ordered. During a surveyor interview with the resident on 9/5/2024 at 2:54 PM, s/he revealed that s/he has pain to his/her right heel periodically and receives pain medication from the staff. Additionally, the resident indicated that s/he was told by staff that s/he has an open wound to his/her right heel and that the wound has been there since late August of this year. During a surveyor observation on 9/5/2024 at 2:52 PM of the resident's right heel, revealed an open wound to the resident's right heel, without a treatment or covered by a dressing. During a surveyor observation of the resident's right heel on 9/5/2024 at 3:12 PM, in the presence of a Registered Nurse, Staff B, revealed an open wound to the resident's right heel. During a surveyor interview immediately following the above observation with Staff B, he acknowledged that the resident has an open wound to his/her right heel. Staff B could not provide evidence as to when the resident's right heel was first observed to be open, but he indicated that the resident's right heel has remained unchanged over the last few days. Staff B further indicated that he had applied skin prep (a skin protectant that should not be applied directly to an open wound) to the resident's right heel on the morning of 9/5/2024 and that he did not notify the physician of the open wound to the resident's right heel. After the wound was brought to the facility's attention, record review revealed a progress note titled, Wound Note dated 9/5/2024 at 7:51 PM, revealing the resident had a right heel deep tissue pressure injury which was resolved on 8/26/2024 but has reopened. Additionally, the note revealed the wound to the resident's right heel was measured as 3 centimeters (cm) in width by 2 cm in length by 0.2 cm in depth. During a surveyor observation and simultaneous interview on 9/5/2024 at 3:34 PM with the Director of Nursing Services (DNS), she acknowledged that the resident had an open wound to his/her right heel. Additionally, the DNS indicated that the wound did not have a dressing or treatment order and further indicated that the wound did not appear to have just opened as of today. The DNS acknowledged that the facility was not aware of the resident's right heel wound until it was brought to their attention by the surveyor on 9/5/2024. The DNS further indicated that she would expect the staff to notify the physician of changes to the resident's skin condition and obtain an appropriate treatment for the wound.