Every finding on record at Apple Rehab Clipper

Based on clinical record review and staff interview, the facility failed to inform the resident's appointed representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering of, and administration of, antipsychotic medications for 2 of 5 residents reviewed, Resident ID #s 25 and 35.Findings are as follows:1. Record review revealed Resident ID #25 was admitted to the facility in September of 2025 with diagnoses including, but not limited to, Alzheimer's disease, unspecified psychosis (a collection of symptoms that affect the mind, causing a temporary but profound loss of contact with reality) and major depressive disorder.Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating the resident has moderate cognitive impairment.Review of a care plan focus area dated 8/12/2025 revealed the resident is receiving psychotropic medications related to psychosis. Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-Trazodone 25 milligrams (mg) daily with a start date of 3/26/2026-Valproic Acid 500 mg/10 milliliter (ml) give 15 ml twice a day with a start date of 4/14/2026-Rexulti 1 mg daily with a start date of 4/28/2026-Seroquel 150 mg daily at bedtime with a start date of 5/2/2026-Seroquel 75 mg twice daily with a start date of 5/2/2026-Lorazepam 0.5 ml three times a day with a start date of 5/13/2026Record review failed to reveal evidence that the resident's representative was informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident representative was informed of the risks and benefits, side effects, and/or treatment alternatives.2. Record review revealed Resident ID #35 was admitted to the facility in January of 2026 with diagnoses including, but not limited to, Alzheimer's disease, unspecified psychosis and anxiety disorder.Record review of a Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 indicating the resident has moderate cognitive impairment.Review of a care plan focus area dated 5/11/2026 revealed the resident is receiving psychotropic medications related to psychosis, hallucinations, and delusions.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-Escitalopram Oxalate 10 mg daily with a start date of 3/10/2026-Trazodone 50 mg daily at bedtime with a start date of 4/13/2026 through 5/4/2026-Trazodone 50 mg twice a day with a start date of 5/4/2026 Record review failed to reveal evidence that the resident's representative was informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident representative was informed of the risks and benefits, side effects, and/or treatment alternatives.During a surveyor interview on 5/28/2026 at 11:50 AM with the Staff Developer/Infection Preventionist, she acknowledged Resident ID #s 25 and 35 are receiving the above-mentioned psychotropic medications. Additionally, she was unable to provide evidence that the residents' representatives were informed in advance of psychotropic medications the residents were being administered, as required.During a surveyor interview on 5/29/2026 at 9:31 AM with the Administrator, she was unable to provide evidence Resident ID #s 25 and 35's representatives were informed in advance of the psychotropic medications that were being administered to the residents, as required.

Based on clinical record review and staff interview, 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, including initial goals based on admission orders, for 1 of 1 resident reviewed who was newly admitted to the facility with a Prevena wound vac (a portable, disposable negative pressure therapy system designed to protect and manage surgical incisions by applying continuous suction to promote healing and reduce complications), Resident ID #54.Findings are as follows:Review of an undated facility policy titled Baseline Care Plans, states in part, A baseline care plan will be developed and implemented for each resident within 48 hours of admission in accordance with applicable regulatory requirements. The baseline care plan will include the minimum healthcare information necessary to provide appropriate care and services until the comprehensive care plan is completed. PROCEDURE.The interdisciplinary team will develop a baseline care plan within 48 hours of admission.The baseline care plan may include: Initial goals of care.Physician orders.Dietary orders.Therapy services.Social service needs.other immediate care needs and interventions.Record review revealed the resident was admitted to the facility in May of 2026 with diagnoses including, but not limited to, type 2 diabetes mellitus and viral hepatitis c.Record review failed to reveal evidence of a completed baseline care plan, initiated within 48 hours after admission, including initial goals based on admission orders.During a surveyor interview on 5/27/2026 at 12:05 PM, with Registered Nurse, Staff B, she revealed that the Minimum Data Set (MDS) Coordinator was responsible for completing resident care plans, and was unable to provide evidence of a completed baseline care plan, initiated within 48 hours after the resident's admission, stating, I don't know what you mean by baseline care plan.During a surveyor interview on 5/27/2026 at 12:26 PM, with the MDS Coordinator, she revealed that she is responsible for completing baseline care plans and indicated that they are completed on paper and kept in the resident's chart. She acknowledged that the resident's baseline care plan had not been completed 48 hours after his/her admission, per regulation and facility policy, as she was not at the facility when the resident was admitted and no other responsible party completed it.During a surveyor interview on 5/27/2026 at 12:42 PM, with the Staff Developer/Infection Preventionist, she revealed that she would expect baseline care plans to be completed 48 hours after the resident's admission, per regulation and facility policy.

Based on clinical record review and staff interview, the facility failed to meet professional standards of practice for 1 of 1 resident reviewed with a midline catheter (a type of intravenous catheter inserted into a vein in the upper arm often used to deliver antibiotics), Resident ID #59.Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2026 with diagnoses including, but not limited to, sepsis due to enterococcus (an infection caused by bacteria entering the bloodstream requiring the use of intravenous antibiotics) and pneumonia.a. Record review revealed a physician's order dated 5/14/2026 to change the midline dressing on admission and once weekly, and as needed every night shift on Tuesday.Record review of the May 2026 Treatment Administration Record (TAR) revealed the above order was not signed off as completed on 5/14/2026.Additional record review failed to reveal evidence that the midline dressing change was completed as ordered on admission.b. Record review revealed a physician's order dated 5/19/2026 to measure external catheter length on admission, every 7 days with dressing changes and as needed every night shift on Tuesday.Record review of the May 2026 TAR revealed that it was signed off as completed on 5/19 and 5/26/2026. Additional record review failed to reveal evidence of documented measurements on the above mentioned dates and that measurements were completed on admission per the physician's order.c. Record review revealed a physician's order dated 5/19/2026 to measure upper arm circumference 6 inches above insertion site on admission, every 7 days with dressing changes and as needed every night shift on Tuesday.Record review of the May 2026 TAR revealed that it was signed off as completed on 5/19/2026 and 5/26/2026. Additional record review failed to reveal evidence of documented measurements on 5/26/2026 and that measurements were completed on admission per the physician's order.During a surveyor interview with Registered Nurse, Staff C on 5/29/2026 at 12:08 PM, she revealed that the measurements for the resident's midline catheter are done during third shift and signed off as completed in the TAR. Additionally, she was unable to locate where the arm circumference and external catheter length measurements were documented.During a surveyor interview with the Staff Developer/Infection Preventionist on 5/29/2026 at 12:19 PM, she was unable to provide evidence that the resident's midline external catheter length and his/her arm circumference were measured on admission and weekly per the physician's orders. Additionally, she was unable to provide evidence that the resident's dressing was changed on admission, as ordered.

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 enhanced barrier precautions (EBP; refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities), for 1 of 1 resident reviewed with a Prevena wound vac (a portable, disposable negative pressure therapy system designed to protect and manage surgical incisions by applying continuous suction to promote healing and reduce complications), Resident ID #54.Findings are as follows:Review of a facility policy, last revised 5/5/2024, titled, Enhanced Barrier Precautions, states in part, It is the policy.to adhere to the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS) guidelines related to.EBP.to prevent the transmission of.MDROs.This facility will implement.EBP.during high-contact resident care activities for.indwelling medical devices. Examples of high-contact resident care activities: Dressing.Bathing/showering/providing hygiene.transferring.changing linens.changing briefs or assisting with toileting.device care or use.wound care.The facility will implement enhanced barrier precautions to include any resident with an indwelling device.regardless of MDRO colonization or infection status.Enhanced barrier precautions will remain in effect for the duration of the resident's stay at the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.Appropriate signage for EBP will be visible.Appropriate PPE [personal protective equipment] and hand sanitizer will be readily accessible for use.Record review revealed the resident was admitted to the facility in May of 2026 with diagnoses including, but not limited to, type 2 diabetes mellitus and viral hepatitis c. Further record review revealed the resident was admitted to the facility with a Prevena wound vac.Review of a physician's order dated 5/22/2026 states, [Right] hip-Wound drainage system-leave in place until follow up on 6/11. Do not remove dressing system. Monitor area for [signs and symptoms of] infection and report to [provider] as needed.Review of the May 2026 Treatment Administration Record revealed the above order was signed off each shift as completed.During surveyor observations on the following dates and times, EBP signage and appropriate PPE were not observed at the resident's doorway:5/26/2026 at 10:16 AM5/26/2026 at 11:47 AM5/27/2026 at 9:15 AM5/27/2026 at 11:05 AMDuring a surveyor interview on 5/27/2026 at 12:05 PM with Registered Nurse, Staff B, she revealed the resident was admitted with a wound vac and has a physician's order in place for the device and to monitor for signs and symptoms of infection. She further revealed that she monitors the device to ensure it is functioning, which includes checking the tubing and the dressing/surgical site.During a surveyor interview on 5/28/2026 at 9:00 AM, with the Infection Preventionist, she acknowledged that the resident was admitted to the facility with a wound vac and is not on EBP. She was unable to provide evidence why the resident was not placed on EBP and revealed that she is going to put the resident on EBP, after this concern was identified by the surveyor.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 2 of 5 residents reviewed for medication administration, Resident ID #s 3 and 5.Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 2 of 5 residents reviewed for medication administration, Resident ID #s 3 and 5.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/25/2025, alleges in part, that there were concerns with nursing errors.Record review of an undated facility policy titled, Medication Administration, states in part, .To ensure safe, accurate, and effective administration of medication to the residents, promoting optimal health outcomes while minimizing medication errors .All medication shall be administered safely and accurately in accordance with physician orders . 1. Record review revealed Resident ID #3 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, chronic kidney disease (progressive damage and loss of function of the kidneys).Record review of a hospital document titled, Discharge summary dated [DATE], revealed a physician's order for Aranesp (a medication prescribed to treat anemia caused by chronic kidney disease) 25 micrograms (mcg) every 7 days, related to acute kidney injury (an abrupt decrease in kidney function) upon discharge from the hospital. Record review failed to reveal evidence that the above-mentioned order was entered into the resident's record upon his/her admission to the facility. Record review of a pharmacy Consultation Report dated 5/8/2025 states in part, CLINICAL PRIORITY RECOMMENDATION: PROMPT RESPONSE REQUESTED .medication review process revealed the following medication dosing discrepancies on the admission orders .Aranesp inject 25 mcg .every 7 days listed on the dc [discharge] summary report reviewed in PCC [point click care-electronic medical record] as Aranesp .every 28 days .please consider clarifying these medication orders .Record review revealed that the Nurse Practitioner provided an on 5/20/2025 to administer Aranesp 25 mcg every 7 days. Additionally, the order indicates to hold the medication if the resident's hemoglobin (hgb- the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues) is greater than 10.9 grams per deciliter (g/dl). (The normal range for hgb is 14.0-18.0).Review of the May, June and July 2025 Medication Administration Records (MAR) failed to reveal evidence that the Aranesp was administered as ordered on the following dates: -5/21/2025 -5/28/2025 -6/5/2025-6/13/2025-6/27/2025-7/4/2025 Record review failed to reveal evidence that the provider was notified of the above-mentioned missed medication administrations.Record review revealed a physician's order was provided to obtain a complete blood count (CBC- a blood test to obtain the levels of red blood cells and hemoglobin) on the following dates and times:-5/7/2025-5/13/2025-5/16/2025-6/14/2025Record review of the clinical laboratory results report for the above-mentioned orders revealed the following: -5/7/2025 hgb 9.3 (g/dl) -5/13/2025 hgb 9.3 (g/dl) -5/16/2025 hgb 9.4 (g/dl) -6/14/2025 hgb 10.6 (g/dl)These results indicate that the resident should have been administered the Aranesp per the physician's order. During a surveyor interview on 7/8/2025 at 9:00 AM with the physician, he indicated that he was aware of the above mentioned hgb values and that he would have expected the Aranesp to be administered as ordered. Additionally, he indicated that he was not notified that the resident had not received the medication as ordered.2. Record review revealed Resident ID #5 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia and displaced fracture of the first and second vertebrae.Record review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 6/24/2025, revealed the following physician's orders:- Heparin 5,000 units/milliliter (ml) inject 1 ml every 8 hours - Trazodone 50 milligrams (mg) once daily at bedtimeRecord review of the June 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received the above-mentioned medications on 6/24/2025.Record review failed to reveal evidence that the provider was notified of the above-mentioned missed medication administrations.During surveyor interviews on 7/7/2025 at 4:11 PM and 7/8/2025 at 11:41 AM and 2:13 PM, with the Director of Nursing Services, she indicated it would be her expectation that the physician's orders for Resident ID #s 3 and 5 to have been followed. Additionally, she was unable to provide evidence that Resident ID #s 3 and 5 were kept free from significant medication errors.

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician, relative to the providers failure to reconcile the resident's post and pre hospitalization orders relative to the administration of Aranesp (a medication prescribed to treat anemia caused by chronic kidney disease), for 1 of 1 resident reviewed, Resident ID #3. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/25/2025 alleges in part, there are concerns related to medication errors.Record review of an undated facility policy titled, Medication Administration, states in part, .To ensure safe, accurate, and effective administration of medication to the residents, promoting optimal health outcomes while minimizing medication errors .All medication shall be administered safely and accurately in accordance with physician orders . 1a. Record review revealed Resident ID #3 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, chronic kidney disease (progressive damage and loss of function of the kidneys). Record review revealed a physician's order dated 4/23/2025 for Aranesp 40 micrograms (mcg) to be administered every 28 days. Additionally, the order indicates that the resident's hemoglobin (hgb-the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues) is to be checked prior to administration and if the results are greater than 10.9 grams per deciliter (gm/dL), the medication is to be held. Additional record review revealed that the resident was re-hospitalized in April of 2025 and readmitted to the facility in May of 2025.Record review of a hospital document titled, Discharge summary dated [DATE], revealed a physician's order for Aranesp 25 mcg every 7 days, to be administered upon discharge from the hospital. Record review failed to reveal evidence that the above-mentioned order was reconciled by the nurse with the physician upon the resident's readmission to the facility on 5/6/2025.Record review of a progress note dated 5/7/2025, authored by the resident's physician states in part, .Visit Type: History and Physical .Medication List: medications review and reconciled, please see MARS [Medication Administration Records] .PCC [point click care-electronic medical record] and nursing notes and orders reviewed .Record review failed to reveal evidence that the physician's order for Aranesp 25 mcg every 7 days was reconciled by the physician from the hospital's Discharge summary dated [DATE].Record review of a progress note dated 5/8/2025, authored by the Nurse Practitioner states in part, .Medication List: medications review and reconciled, please see MARS .Record review failed to reveal evidence that the physician's order for Aranesp 25 mcg every 7 days was reconciled by the Nurse Practitioner from the hospital's Discharge summary dated [DATE].Record review of a pharmacy Consultation Report dated 5/8/2025 states in part, CLINICAL PRIORITY RECOMMENDATION: PROMPT RESPONSE REQUESTED .medication review process revealed the following medication dosing discrepancies on the admission orders . Aranesp inject 25 mcg .every 7 days listed on the dc [discharge] summary report reviewed in PCC as Aranesp .every 28 days .please consider clarifying these medication orders .During a surveyor interview on 7/8/2025 at 1:21 PM with the Nurse Practitioner, she indicated that it is her practice to compare the hospital's orders on the discharge summary with the current orders in PCC. Additionally, she revealed she was not aware that the order listed on the discharge summary was not transcribed into the resident's record and should have been. Additionally, she revealed that she did not recall reviewing the hospital discharge summary for Resident ID #3 when s/he was readmitted . Furthermore, she acknowledged that she provided and order on 5/20/2025 to administer Aranesp 25 mcg every 7 days with a with a parameter to hold the Aranesp if the resident's hgb is greater than 10.9 gm/dL. 1b. Record review failed to reveal evidence that a physician's order was in place to obtain a weekly hemoglobin value to determine if the Aranesp should be administered to Resident ID #3 or held.During a surveyor interview on 7/8/2025 at 9:00 AM with the physician, he revealed it is his practice to compare the hospital discharge summary with the current orders that are in Point Click Care (PCC- healthcare software). He acknowledged that he failed to reconcile the Aranesp order on the hospital discharge summary with the Aranesp order that was listed in PCC. Additionally, he revealed that he was not aware that Resident ID #3 did not have an order to routinely monitor his/her hgb, as the previous Aransep order from 4/23/2025 indicated to do so. He revealed that he would have expected an order to be in place. During a surveyor interview on 7/7/2025 at 4:11 PM, with the Director of Nursing Services, she indicated it would be her expectation that Resident ID #3's Aranesp order would have been reconciled by a provider and an order to monitor the resident's hgb weekly would have been implemented upon readmission to the facility.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with a nephrostomy receives care, consistent with professional standards of practice relative to physician's orders, for 1 of 1 resident who has a percutaneous nephrostomy tube (PCN- an artificial opening created between the kidney and the skin which allows for urinary drainage), Resident ID #4.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/25/2025 alleges in part, that there were concerns with facility staffing and nursing medications errors.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 June of 2025, with a diagnosis including, but not limited to, an artificial opening of urinary tract.1a. Review of a physician's order dated 6/11/2025 to empty Nephrostomy drain and record output every shift.Record review of the June 2025 Medication Administration Record (MAR) record failed to reveal evidence that the drain output was recorded as ordered on the following dates and times:-6/13/2025, 3:00 PM to 11:00 PM-6/14/2025, 7:00 AM to 3:00 PM-6/16/2025, 7:00 AM to 3:00 PM-6/17/2025, 7:00 AM to 3:00 PM-6/23/2025, 7:00 AM to 3:00 PM-6/24/2025, 3:00 PM to 11:00 PM1b. Additional review revealed a physician's order dated 6/12/2025 to use 10 milliliters of Normal Saline (NS) to flush the PCN every day and evening shift to maintain patency. Additional review of the June 2025 MAR failed to reveal evidence that the PCN was flushed as ordered on the following dates and times:-6/13/2025, 3:00 PM to 11:00 PM-6/16/2025, 3:00 PM to 11:00 PM-6/17/2025, 7:00 AM to 3:00 PM1c. Further record review revealed a physician's order dated 6/12/2025 to complete PCN care, remove old dressing, cleanse with normal saline and pat dry, cover with a split sponge gauze and secure with tape, every evening shift every two days. Further review of the June 2025 MAR failed to reveal evidence the above-mentioned treatment was completed on 6/16/2025 as ordered.During a surveyor interview with the Director of Nursing Services on 7/9/2025 at 2:13 PM, she indicated it would be her expectation for the resident's PCN orders to be completed as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 2 of 2 units observed during meal service. Findings are as follows: 1. Record review of the United States (U.S.) Food and Drug Administration (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 . Record review of the U.S. FDA Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . During the initial tour of the main kitchen with the Food Service Director (FSD) on 5/5/2025 at 9:24 AM, the following was observed in the walk-in refrigerator: - One 46 ounce (oz.) bottle of nectar thickened orange juice, opened and not dated. Manufacturer's instructions indicate to use the product within 10 days once opened. - One 46 oz. bottle of nectar thickened apple juice, opened and dated 4/6. Manufacturer's instructions indicate to use the product within 10 days once opened. Additional observations of the main kitchen during the initial tour revealed the ceiling of the microwave had clumps of yellow food matter stuck to it. During a surveyor interview immediately following the above observations with the FSD, he acknowledged that the juices should be marked with the date they are opened and discarded after 10 days. Additionally, he acknowledged that the microwave had food debris inside. 2. Record review of the U.S. FDA Food Code, 2022 Edition, section 3-301 states in part, .Food employees shall minimize bare hand and arm contact with exposed food that is not in a ready-to-eat form . During a follow up visit to the kitchen during lunch preparation on 5/6/2025 at 11:47 AM, Cook, Staff F, was observed handling two slices of white bread and sliced cheese, assembling a sandwich without using gloves. During a surveyor interview with the FSD immediately following the observation, he acknowledged that Staff F should have been wearing gloves prior to handling food and discarded the sandwich. 3. Record review of the U.S. FDA Food Code, 2022 Edition, section 3-307.11 states in part, .Food shall be protected from contamination . During surveyor observations of the breakfast meal service on 5/6/2025 at 8:00 AM, a steam table cart was stationed at the beginning of the Portside Unit. Breakfast plates containing hot food were carried from the steam table to resident rooms, up to approximately 50 feet away. During surveyor observations of the lunch meal service on 5/7/2025 at 11:59 AM, a steam table cart was stationed adjacent to the clean linen closet on the Portside Unit. Uncovered lunch plates containing hot food were carried from the steam table to room [ROOM NUMBER] (the furthest resident room from the steam table) approximately 42 feet from the right, and to rooms approximately 37 feet away from the left by Dietary Aides, Staff L and M. During surveyor observations of the lunch meal service on 5/7/2025 at 12:45 PM, a steam table cart was stationed adjacent to room [ROOM NUMBER] on the Starboard Unit. Uncovered lunch plates containing hot food were carried from the steam table down to rooms approximately 68 feet down the hallway to room [ROOM NUMBER] (the furthest resident room from the steam table) by Staff L and M. During a surveyor interview with Staff L and M, immediately following the above observations, they acknowledged that they were carrying uncovered plates of hot food down the hall to serve residents. Additionally they reavealed that plates of food are only covered if the residents aren't going to be eating their meals right away. During a surveyor interview with the FSD on 5/7/2025 at 12:57 PM, he indicated that carrying uncovered meals down the halls has been the facility's practice. He was unable to provide evidence that the meals were being protected from potential contamination.

Based on record review and staff interview, it has been determined that the facility failed to provide a dietary menu that meets the nutritional needs of residents in accordance with established national guidelines. Findings are as follows: 1. Record review of the facility's diet manual titled, Maryland Department of Health and Mental Hygiene Diet Manual for Long Term Care Residents 2014 Revision, failed to meet the current established national guidelines (the United States Department of Agriculture (USDA) establishes and reviewes national guidelines every 5 years, to promote health, meet nutrient needs and provide guidance for healthy dietary patterns by life stages). The diet manual provided to the surveyor by the facility was from 2005 to 2010, indicating the guidelines were outdated as the current national guidelines were revised in 2020 with new recommendations. During a surveyor interview with Registered Dietitians, Staff D and E on 5/8/2025 at 10:03 AM, they revealed that the facility's menus are generated from corporate each month and each facility's dietitian is responsible for reviewing the menu for nutritional adequacy. Additionally, they indicated they use the Maryland Diet Manual, 2014 Revision as a standard to review menus each month. 2. Record review of a document published by the USDA, revealed that a standardized recipe is utilized in a food service establishment to ensure the nutritional values per serving are valid and consistent, as the same products and quantities are being used every time the recipe is produced. Record review of the menu served from 5/4/2025 through 5/10/2025 failed to reveal evidence that standardized recipes were on file. Further record review revealed a binder titled, Apple Rehab Recipes Spring/Summer Menus 2016, containing several recipes from Allrecipes.com and other internet sources, which did not contain caloric or nutrient information. During a surveyor interview with the Food Service Director on 5/8/2025 at 11:50 AM, he revealed that he does not use standardized recipes when preparing meals for residents. During a surveyor interview via telephone with the Director of Nutrition Services on 5/8/2025 at 12:36 PM, she revealed that she would expect the dietitian at each facility to follow the company's diet manual, Maryland Department of Health and Mental Hygiene Diet Manual for Long Term Care Residents 2014 Revision, to review menus for nutritional adequacy. She was unaware that the facility's diet manual was out of date. Additionally, she indicated that standardized recipes are not used in the facility. Further, she was unable to provide evidence that the facility's menus met the nutritional needs of residents in accordance with established national guidelines.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 2 medication carts observed. Findings are as follows: Review of a facility's policy titled Storage and Expiration Dating of Medications and Biologicals dated [DATE], states in part, .Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened . 1a. During a surveyor observation on [DATE] at 9:40 AM of the Portside Unit medication cart, in the presence of Registered Nurse (RN), Staff A, revealed the following: - One Breo Ellipta Inhaler, opened with a date of 3/22. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. During a surveyor interview with Staff A immediately following the above observation, she acknowledged that the inhaler had a date of 3/22, and that the inhaler was expired. 1b. During a surveyor observation on [DATE] at 8:57 AM of the Starboard Unit medication cart, in the presence of RN, Staff C, revealed the following: -One Treligy Ellipta inhaler, opened and not dated. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. -One Breyna Inhaler, opened and not dated. Review of the manufacturer's instructions indicate to discard the inhaler 3 months after opening. -One Flovent inhaler, opened and not dated. Review of the facility policy indicates medications should be dated when opened. - One Fluticasone propionate nasal spray, opened and not dated. Review of the manufacturer's instructions indicate to discard the nasal spray after using 120 sprays. - Two Albuterol Inhalers, opened and not dated. Review of the facility policy indicates medications should be dated when opened. During a surveyor interview with Staff C immediately following the above observation, she acknowledged that the above-mentioned medications were opened and not dated. During a surveyor interview on [DATE] at approximately 4:00 PM with the Director of Nursing Services (DNS), she was unable to provide evidence the expired Breo Ellipta inhaler was not removed from the Portside Unit medication cart. Additionally, the DNS was unable to provide evidence the above-mentioned medications were dated when opened.

Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 2 of 6 resident reviewed, who experienced actual weight loss, Resident ID #s 17 and 23. Additionally, the facility failed to follow it's own policy relative to weight monitoring, for 3 of 6 residents reviewed, Resident ID #s 17, 22, and 23. Findings are as follows: Review of a facility policy titled Weight Monitoring states in part, .Accurate and timely measurement of weight changes in all residents is an important tool in assessing their nutritional status .Residents will be weighed weekly for 4 weeks, upon admission and readmission, then monthly .If there is a 5 lbs. [pounds] weight discrepancy (plus or minus) a reweight should be obtained .Significant weight changes will be reported to a physician . 1A. Record review revealed Resident ID #23 was re-admitted to the facility in January of 2025 with a diagnosis including, but not limited to, dementia. Review of a care plan dated 1/20/2025 revealed the resident has a potential for nutritional decline with an intervention including, but not limited to, weigh as ordered. Record review of hospital discharge paperwork dated 1/16/2025 revealed the resident weighed 179.1 pounds on 1/14/2025. Additional record review revealed the resident weighed 179.0 lbs. on re-admission to the facility on 1/16/2025. Record review revealed the following weights were obtained for Resident ID #23: - 1/16/2025: 179 lbs. - 2/6/2025: 163.8 lbs. - 4/3/2025: 161.8 lbs. - 5/2/2025: 154.6 lbs. Record review revealed the resident experienced an 8.5% (15.2 lbs.) severe weight loss in less than one month from 1/16/2025 to 2/6/2025. Record review revealed a progress note authored by Registered Dietitian (RD), Staff D which indicated that he had assessed the resident on 2/7/2025 following the above-mentioned severe weight loss. Further review of his note revealed that he believed the resident's weight of 179 lbs. obtained on 1/16/2025 was an error and did not implement any interventions. Additional record review failed to reveal evidence that the physician was notified of Resident ID #23's severe weight loss, as indicated per the facility's policy. Further record review revealed the resident continued to lose weight and had experienced an additional weight loss of 7.2 lbs. in one month, from 4/3/2025 to 5/2/2025, without the facility implementing any interventions. Additional record review revealed a progress note dated 5/5/2025, authored by Staff D, that states in part, Weight: 154.6 lbs (5/2/25). No significant 1 or 6 month change. Slightly below recent usual body weight range. Tolerating meals with good intake. Appears adequately nourished. Monitor for restart of scheduled supplement. During a surveyor interview with Staff D, on 5/8/2025 at 10:03 AM, he revealed that he assessed the resident on 2/7/2025 and did not implement any interventions at that time. He indicated that he felt s/he appeared adequately nourished and that the weight that was obtained on 1/16/2025 was an error. However, he was unable to provide evidence that Resident ID #23 was reweighed to verify the accuracy of the weight that was obtained on 1/16/2025, or to determine if interventions should have been implemented following the resident's documented severe weight loss on 2/6/2025. Additionally, he acknowledged he did not implement any interventions following his/her weight loss on 5/2/2025. B. Record review revealed Resident ID #17 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, type 2 diabetes. Record review of a care plan dated 4/14/2025 revealed the resident has the potential for a nutritional decline and a history of weight loss. Staff interventions include to obtain weights as ordered. Record review of a physician's order for Resident ID #17 dated 4/14/2025 revealed to obtain weekly weights every Monday for 4 weeks. Record review revealed the following weights were obtained for Resident ID #17: - 4/14/2025: 155.0 lbs. - 4/28/2025: 143.6 lbs. - 5/2/2025: 143.0 lbs. - 5/4/2025: 148.2 lbs. - 5/5/2025: 143.0 lbs. Record review revealed the resident experienced a 7.74% (12 lbs.) severe weight loss in less than one month from 4/14/2025 to 5/5/2025. Record review failed to reveal evidence that any interventions were implemented by the facility after the resident's 7.74% severe weight loss, in less than one month. Additional record review failed to reveal evidence that the physician was notified of the severe weight loss, per the facility's policy. 2A. Record review failed to reveal evidence that Resident ID #23's weights were obtained weekly on 1/23/2025 and 1/30/2025 as indicated in the facility's policy. Additional record review failed to reveal evidence that the facility reweighed the resident for a 5 lbs. weight discrepancy on 2/6/2025. B. Record review failed to reveal evidence that Resident ID #17's weight was obtained upon admission on [DATE], as indicated in the facility's policy. The first weight was obtained two days after admission, on 4/14/2025. Additional record review failed to reveal evidence that a weekly weight was obtained on 4/21/2025, as ordered. C. Record review revealed Resident ID #22 was admitted to the facility in June of 2021 with diagnoses including, but not limited to [NAME]-[NAME] disease (a rare progressive inherited neurogenerative disorder that primarily affects the brain), adult failure to thrive and dysphagia (difficulty swallowing). Record review revealed the following weights were obtained for Resident ID #22: - 1/16/2025: 90.8 lbs. - 2/6/2025: 85.8 lbs. - 2/16/2025: 85.8 lbs. - 2/24/2025: 83.6 lbs. - 3/7/2025: 81.2 lbs. - 3/24/2025: 87.0 lbs. Record review revealed the resident experienced a weight loss of 5 lbs. (5.5%) on 2/6/2025 from the previous weight that was obtained on 1/16/2025. Record review failed to reveal evidence that the resident was reweighed after a 5 lbs. weight discrepancy was observed, until 2/16/2025, one month later. Record review revealed a physician's order dated 2/16/2025 for weekly weights x 4. Record review failed to reveal evidence that a weekly weight was obtained on 3/16/2025, as ordered. During a surveyor interview on 5/8/2025 at 1:33 PM with Registered Nurse, Staff B, she was unable to provide evidence of the above-mentioned missing weights. During surveyor interviews on 5/7/2025 at 1:18 PM and at 1:42 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that interventions had been implemented to address Resident ID #s 17 and 23's severe weight losses. Additionally, the DNS was unable to provide evidence that Resident ID #s 17, 22, and 23's weekly weights were obtained as ordered, or that the facility's Weight Monitoring policy was followed. During a surveyor interview on 5/8/2025 at 9:00 AM and at 9:15 AM with the Medical Director, he indicated that he was not made aware of Resident ID #s 17 and 23's severe weight loss, but would have expected to have been notified, as per the facility's policy. Additionally, the Medical Director indicated that he would expect the residents' weights to be obtained as ordered and per the facility's policy. As the facility's Registered Dietitian failed to identify severe weight losses, no interventions were put in place to maintain acceptable parameters of nutritional status, such as usual body weight, for two residents, Resident ID #s 17 and 23.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with a pressure ulcer (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence) 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 2 residents reviewed with wounds, Resident ID #31. Findings are as follows: Review of a facility policy titled, Dressing, Dry Clean (NON-STERILE) states in part, Procedure .Put on gloves .remove soiled dressings, remove gloves, wash or sanitize hands with sanitizer and apply gloves .Apply dressing and secure . Record review revealed the resident was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to a stage 4 pressure ulcer (the most severe type of pressure ulcer characterized by full-thickness tissue loss with exposed bone, tendon, or muscle) to the sacral region (located at the base of the spine). Review of a physician's order dated 5/1/2025 revealed an order to clean the stage 4 pressure ulcer with vashe wash (a wound cleanser), pack with alginate AG (silver; an absorbent wound treatment) then apply a collagen sheet (a wound dressing that promotes wound healing by supporting a moist environment and stimulates new tissue growth) daily and as needed. During a surveyor observation of Registered Nurse, Staff A, completing a dressing change of the resident's wound, on 5/7/2025 at 11:00 AM, Staff A put on a pair of gloves, removed the soiled dressing from the resident's wound and did not remove the soiled gloves or perform hand hygiene before applying the clean dressing to the resident's wound. Additionally, Staff A applied a collagen sheet that contained silver; not the collagen sheet that was ordered. During a surveyor interview immediately following the above-mentioned observation, Staff A acknowledged that she did not remove the soiled gloves and did not perform hand hygiene after removing the soiled dressing. She further acknowledged she was wearing the same dirty gloves to apply the clean dressing to the resident's wound. Additionally, Staff A acknowledged that she did not apply the collagen sheet to the resident's wound that was ordered. During a surveyor interview on 5/7/2025 at 1:10 PM with the Director of Nursing Services (DNS), she indicated that she would have expected Staff A to change her gloves, perform hand hygiene, and put on clean gloves before applying the clean dressing to the resident's wound. The DNS was unable to provide evidence that the physician's order for the wound dressing was followed.

Based on record review, and resident and staff interviews, it has been determined that the facility failed to obtain written authorization for residents whom the facility is holding personal funds for 2 of 5 residents reviewed, Resident ID #s 4 and 12. Findings are as follows: 1. Record review of Resident ID #4 revealed a personal funds balance report dated 5/5/2025 indicating the personal funds account had a balance of $1.86. Review of the Personal Needs Fund Authorization document revealed the resident had signed the document and it was witnessed on 9/26/2024, directing that his/her personal needs funds be given to him/her. Further record review failed to reveal evidence of a Resident Personal Needs Authorization form authorizing the facility to hold the resident's funds. 2. Record review of Resident ID #12 revealed a personal funds balance report dated 5/5/2025 indicating the personal funds account had a balance of $138.13. Review of the Personal Needs Fund Authorization document revealed the resident had signed the document and it was witnessed on 7/21/2021 directing that his/her personal needs funds be given directly to him/her. Further record review failed to reveal evidence of a Resident Personal Needs Authorization form authorizing the facility to hold the resident's funds. During a surveyor interview with the Business Office Manager on 5/6/2025 at 1:05 PM, she was unable to provide evidence that the Resident Personal Needs Authorization forms were followed for Resident ID #s 4 and 12.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight and weight monitoring for 7 of 8 residents reviewed, Resident ID #s 4, 10, 12, 17, 38, 41 and 44. Findings are as follows: Review of the facility's undated policy titled, Weight Monitoring, states in part, PURPOSE: To establish a reference for a resident's body weight that is realistic and individually appropriate and to effectively monitor and communicate weight changes. CLINICAL POLICY: .Accurate and timely measurement of weight changes in all residents is an important tool in assessing their nutritional status. Residents will be weighed weekly for 4 weeks on admission and readmission then monthly, unless otherwise indicated by the MD [Medical Doctor] order and/or recommended by the RD [Registered Dietitian]. The following procedure is intended to assure that weight changes are identified and assessed as needed. PROCEDURE: .2. Residents will be weighed during the first seven days of the month and upon admission every week x 4 weeks. It is the responsibility of the charge nurse to assure that weights are taken. 3. Weights will be taken ad recorded on the weight sheet .or in Point Click Care. If there is a 5 lb. [pound] weight discrepancy (plus or minus) a reweight should be obtained. The Charge Nurse should then review the weight and compare this to the previous weights to determine a 5% weight change in 30 days or 10% change in 180 days. 4. Significant weight changes will be reported to: a. Physician/APRN [Advance Practice Registered Nurse] b. Responsible party c. RD d. DNS [Director of Nursing] . e. Care Plan Coordinator 5. Residents who have experienced significant weight loss will be reviewed by the RD to evaluate the need for changes in the plan of care. The resident's care plan will be updated accordingly. During a surveyor interview with Registered Nurse Practitioner (RNP), Staff E, on 5/22/2024 at 9:29 AM, she revealed her expectation is that weights will be obtained upon admission and then weekly for 4 weeks. Staff E also revealed her expectation is that if those weekly weights are stable, staff will then obtain monthly weights, unless there is a specific physician's order that states otherwise. During a surveyor interview with the Staff Development Coordinator, Registered Nurse, Staff D, on 5/21/2024 at 2:59 PM, she revealed if residents do not have a physician's order for obtaining weights, staff are to follow the facility's policy and procedure. During a surveyor interview with the DNS on 5/22/2024 at 9:02 AM, she revealed if there is a 5 lb. weight discrepancy (plus or minus), a reweigh should be obtained within 1 day. Additionally, she revealed if the resident is unavailable or refusing to be reweighed, staff should try to reweigh the resident on the following day. 1. Record review revealed Resident ID #12 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, Parkinson's disease (a chronic and progressive movement disorder that initially causes tremors, stiffness or slowing of movement) dementia and dysphagia (difficulty swallowing), and s/he has a gastrostomy tube (G-tube, a tube that delivers nutrition directly into the stomach). Record review revealed the resident has a physician's order dated 4/17/2024 for, NPO [nothing by mouth] diet . Further record review revealed the resident has a physician's order dated 4/18/2024 for, Jevity 1.5 Cal/Fiber Oral Liquid (Nutritional Supplement) give 474 ml [milliliter] via G-Tube three times a day for nutrition flush with 250ml water post jevity . Review of care plan revealed a focus dated 4/22/2024 which states in part, I have the potential for a nutritional decline R/T [related to] multiple problems .dysphagia, need for tube feeding . with interventions including, but not limited to, .weigh me as ordered . Record review of the resident's weights revealed the following: 4/17/2024 179 lbs. 4/24/2024 176.3 lbs. 4/26/2024 153.9 lbs. 5/2/2024 168 lbs. Record review of the resident's weight record revealed the resident experienced a weight loss of 22.4 lbs. (12.7%) on 4/26/2024 from his/her previous weight obtained on 4/24/2024. Record review revealed the resident experienced a weight gain of 14.1 lbs. (9.6%) on 5/2/2024 from his/her previous weight obtained on 4/26/2024. Record review revealed the resident experienced a weight loss of 14.7 lbs. (8.7%) on 5/21/2024 from his/her previous weight obtained on 5/2/2024. Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy on 4/26/2024 and 5/2/2024. Subsequently, on 5/21/2024 at approximately 4:00 PM, the facility staff was asked to provide a weight for Resident ID #12, which was 153.3 lbs. Further review of the weight record revealed that the resident experienced an overall weight loss of 25.7 lbs. (14.3%) from his/her admission weight of 179 lbs. on 4/17/2024 to his/her current weight obtained on 5/21/2024 of 153.3 lbs., (approximately 1 month). Record review of the care plan, failed to reveal evidence of any new interventions implemented to prevent the resident from further weight loss. During a surveyor interview with the RD on 5/21/2024 at 11:15 AM, he revealed that he reviewed the resident's weight record on 4/26/2024 and asked staff to obtain a reweigh. The RD further revealed there was no reweigh documented and he did not push them to obtain a reweigh to verify the weight change. Additionally, he did not add any interventions as the resident is receiving nutrition via the G-Tube. Further, the RD revealed that the facility's policy is to obtain weights upon admission and weekly for 4 weeks and if the weight is stable, staff will obtain monthly weights thereafter. During a surveyor interview with the Minimum Data Set Coordinator on 5/21/2024 at 12:31 PM, she revealed she was unaware of the above-mentioned weight loss. Additionally, she was unable to provide evidence of any new interventions added to the resident's care plan for nutrition. During a surveyor interview with the RNP, Staff E, on 5/21/2024 at 12:35 PM, she revealed she is aware of the resident's weight loss and is waiting for the RD to assess the resident and make any recommendations. Staff E further revealed when a weight loss is identified, she will usually communicate with staff to have the RD assess the resident or she will ask staff to enter the weight loss in the Dietitian Communication log for the RD to review. Additionally, Staff E revealed due to Resident ID #12 having a G-tube, she wants to ensure the resident is receiving enough nutrition/calories. Further, she expects staff to continue to monitor the resident's weight, especially for a recently admitted resident or a resident with a weight discrepancy. During a surveyor interview with the DNS on 5/22/2024 at 4:00 PM, she was unable to provide evidence that the resident was reweighed per the facility policy or that any new interventions were implemented to prevent the resident from having further weight loss. 2. Record review revealed Resident ID #4 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (chronic lung disease) and atrial fibrillation (an irregular and often very rapid heart rhythm). Review of a care plan dated 12/11/2023, .I have the potential for a nutritional decline R/T multiple medical problems . with interventions including, but not limited to, .weigh me as ordered . Record review of the resident's weights revealed the following: 1/16/2024 141.6 lbs. 2/19/2024 154.9 lbs. Record review of the resident's weight record revealed the resident experienced a weight gain of 13.3 lbs. on 2/19/2024 from his/her previous weight obtained on 1/16/2024. Further, the record failed to reveal evidence of a reweigh when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy. Additionally, the record failed to reveal evidence of a weight after 2/19/2024, as per the facility policy which indicates monthly weights will be obtained in the first 7 days of the month, until it was brought to the facility's attention on 5/21/2024. Subsequently, the resident was weighed on 5/21/2024 at approximately 3:30 PM with a weight of 153.4 lbs. During a surveyor interview with the DNS on 5/22/2024 at 10:04 AM, she revealed the resident was admitted on hospice services and that staff usually do not obtain monthly weights for hospice residents, although, the facility's policy does not specify. Additionally, the DNS was unable to provide evidence of a physician's order to discontinue the resident's weights and she was unable to provide his/her monthly weights, after February of 2024. 3. Record review revealed Resident ID #10 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, Alzheimer's Disease, paraplegia (paralysis of the legs and lower body), unstageable pressure ulcer (a full-thickness injury with a wound base covered by a layer of dead tissue) to the left buttocks and hypothyroidism (abnormally low activity of the thyroid gland). Record review of the care plan revised on 4/8/2024, revealed the resident has the potential for a nutritional decline related to a history of multiple medical problems, including recent hospitalization with interventions including, but not limited to, weigh him/her as ordered. Review of the resident's weights revealed the following: -3/23/2024 130.0 lbs. -3/25/2024 124.4 lbs. -4/1/2024 117.6 lbs. -4/1/2024 117.8 lbs. -4/2/2024 117.6 lbs. -4/8/2024 120.2 lbs. -4/15/2024 122.2 lbs. Record review of the resident's weight record revealed the resident experienced a weight loss of 5.6 lbs. on 3/25/2024 from his/her previous weight obtained on 3/23/2024. Additionally, the record failed to reveal evidence of a reweigh when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy. Further review failed to reveal evidence of a monthly weight for May 2024, per the facility policy, which indicates monthly weights will be obtained in the first 7 days of the month. During a surveyor interview with the DNS on 5/23/2024 at approximately 8:30 AM, she was asked to provide a weight for Resident ID #10. Subsequently, the resident was weighed that morning with a weight of 119 lbs. During an interview with the DNS on 5/22/2024 at 11:30 AM, she was unable to explain why the resident was not reweighed after s/he lost 5.6 lbs. and she would expect a reweigh to be obtained within 24 hours. Additionally, she was unable to explain why there was no weight obtained in May of 2024 and she further revealed she would expect the weight policy to be followed. 4. Record review revealed Resident ID #17 was admitted to the facility in June of 2021 with diagnoses including, but not limited to, vascular dementia and high cholesterol. Record review of the care plan initiated on 6/14/2021 revealed the resident has the potential for a nutritional decline related to a history of multiple medical problems, including dementia and weight loss, with interventions including, but not limited to, weigh him/her as ordered. Record review of the resident's weight record revealed the following: -1/4/2024 182.2 lbs. -2/2/2024 163.8 lbs. -2/5/2024 182.2 lbs. -4/2/2024 162.5 lbs. -4/8/2024 171.9 lbs. -5/13/2024 177.2 lbs. Record review of the resident's weight record revealed the resident experienced a weight loss of 18.4 lbs. on 2/2/2024 from his/her previous weight obtained on 1/4/2024. Record review revealed the resident experienced a weight loss of 19.7 lbs. (10.8%) on 4/2/2024 from his/her previous weight obtained on 2/5/2024. Record review revealed the resident experienced a weight gain of 9.4 lbs. (5.78%) on 4/8/2024 from his/her previous weight obtained on 4/2/2024. Record review revealed the resident experienced a weight gain of 5.3 lbs. (3%) on 5/13/2024 from his/her previous weight obtained on 4/8/2024. Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy on 4/2/2024, 4/8/2024 and 5/13/2024. Additionally, the record failed to reveal evidence of a monthly weight obtained in March 2024. During a surveyor interview on 5/22/2024 at 9:31 AM with RNP, Staff E, she reviewed the above-mentioned weights and revealed there were large fluctuations in the resident's weights and indicated the resident should have been reweighed the day the weight fluctuations were identified. During a surveyor interview on 5/22/2024 at 10:53 AM with the DNS, she could not explain why a reweigh was not obtained when the resident had a 5 lb. or greater weight loss/gain and she further revealed she would expect the reweigh to be obtained within 24 hours. Additionally, she acknowledged that there was no weight obtained in March 2024 and would expect the policy to be followed. 5. Record review revealed Resident ID #38 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and hypertension (high blood pressure). Record review revealed a care plan dated 4/8/2024 for .I have the potential for a nutritional decline R/T multiple medical problems ., with interventions including but not limited to .weight me as ordered . Further review of the care plan revealed s/he is at risk for cardiac compensation related to hypertension with interventions including but not limited to .Encourage weight loss and/or maintaining a healthy weight in accordance with height . Record review of the resident's weight record revealed the following: 4/21/2024 127.1 lbs. 4/28/2024 133.0 lbs. Record review revealed the resident experienced a weight gain of 5.9 lbs. on 4/28/2024 from his/her previous weight obtained on 4/21/2024. Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy. Further record review failed to reveal evidence that a monthly weight was obtained in May 2024. Record review failed to reveal evidence of new interventions implemented to prevent the resident from further weight gain. During a surveyor observation of Resident ID #38 in the presence of Registered Nurse, Staff C, on 5/22/2024 at 1:25 PM, she acknowledged the resident had bilateral lower leg edema (swelling). During a surveyor interview with the DNS on 5/22/2024 at 10:00 AM, she was unable to provide evidence that the reweigh was obtained when the resident had a weight loss/gain of 5 lbs. or more per the facility's policy. Additionally, the DNS was unable to provide evidence that the monthly weight for May 2024 was obtained within the first seven days of the month per the facility's policy. Furthermore, the DNS was unable to provide evidence that new interventions were implemented to prevent the resident from further weight gain. 6. Record review revealed Resident ID #41 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (chronic lung disease) and hypertension. Record review of the physician's orders revealed an order dated 4/13/2024 for weekly weights for 4 weeks, then monthly. Record review of the resident's weight record revealed the following: -4/6/2024 141.8 lbs. -4/15/2024 135.0 lbs. -4/21/2024 140.6 lbs. -5/13/2024 133.2 lbs. Record review of the resident's weights failed to reveal evidence that the weekly weights were obtained for 2 of 4 opportunities, on 4/28/2024 and 5/5/2024: Record review revealed the resident experienced a weight loss of 6.8 lbs. on 4/15/2024 from his/her previous weight obtained on 4/6/2024. Record review revealed the resident experienced a weight gain of 5.6 lbs. on 4/21/2024 from his/her previous weight obtained on 4/15/2024. Record review revealed the resident experienced a weight gain of 7.4 lbs. on 5/13/2024 from his/her previous weight obtained on 4/21/2024. Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy on 4/15/2024, 4/21/2024 and 5/13/2024. During a surveyor interview on 5/22/2024 at 9:45 AM with the DNS, she acknowledged that a reweigh was not obtained when the resident had a weight loss/gain of 5 lbs. or more per the facility's policy. 7. Record review revealed Resident ID #44 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, hypertension, gastroesophageal reflux disease (GERD, a condition where the stomach acid repeatedly flows back up into the esophagus, causing irritation and discomfort) and chronic kidney disease. Record review revealed the resident has a care plan initialed on 11/29/2023 for .I have the potential for a nutritional decline R/T multiple medical problems ., with interventions including, but not limited to, .weigh me as ordered . Record review of the resident's weight record revealed the following: 11/18/2023 135.0 lbs. 12/12/2023 131.1 lbs. 1/4/2024 125.6 lbs. 3/1/2024 128.6 lbs. 4/2/2024 123.4 lbs. 4/11/2024 123.4 lbs. Record review revealed the resident experienced a weight loss of 5.5 lbs. on 1/4/2024 from his/her previous weight obtained on 12/12/2023. Record review revealed the resident experienced a weight gain of 5.2 lbs. on 4/2/2024 from his/her previous weight obtained on 3/1/2024. Additionally, the record failed to reveal evidence that the resident was reweighed when s/he had a weight loss/gain of 5 lbs. or more, per the facility's policy on 1/4/2024 and 4/2/2024. Further record review failed to reveal evidence that a monthly weight was not obtained in May 2024. Record review failed to reveal evidence of any new interventions implemented to prevent the resident from further weight loss. During a surveyor interview with the DNS on 5/22/2024 at 4:00 PM, she was unable to provide evidence that the reweighs were obtained or that a monthly weight for May 2024 was obtained per the facility policy. Additionally, the DNS was unable to provide evidence that new interventions were implemented to prevent the resident from further weight loss.

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (nursing assistant), at least once every 12 months, for 3 of 3 nursing assistants personnel records reviewed, Staff F, G, and H. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following nursing assistants: -Staff F, Date of hire 11/23/2022 -Staff G, Date of hire 7/17/2007 -Staff H, Date of hire 12/4/2000 During a surveyor interview on 5/22/2024 at 3:25 PM with the Director of Nursing Services, she was unable to provide evidence of a completed performance evaluation wihtin the last 12 months for the above-mentioned employees. 45855

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #4. 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). 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 revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (chronic lung disease) and atrial fibrillation (an irregular and often very rapid heart rhythm). Review of a care plan dated 1/6/2024, revealed the resident requires an SP (supra-pubic, a drainage tube that is inserted into the bladder through the abdominal wall to continuously drain urine from the bladder) tube related to urinary retention unresolved by other interventions. Further review of the care plan failed to reveal evidence of an intervention that includes measuring and recording the urinary output every shift. Record review of the documented urinary output from 5/9/2024 through 5/21/2024, failed to reveal evidence that the output was measured and recorded each shift and only revealed documentation for 9 of 39 opportunities on the following dates and times: -5/9/2024 at 2:36 PM, 0 milliliter (ml) -5/10/2014 at 2:17 PM, 0 ml -5/15/2024 at 6:39 AM, 100 ml -5/15/2024 at 2:03 PM, 1450 ml -5/17/2024 at 1:44 PM, 150 ml -5/18/2024 at 2:00 PM, 0 ml -5/19/2024 at 2:49 PM, 0 ml -5/20/2024 at 1:59 PM, 0 ml -5/21/2024 at 2:16 PM, 150 ml During a surveyor interview with the Staff Development Coordinator, Staff D, on 5/22/2024 at 12:09 PM, she acknowledged that the resident's urinary output was not documented every shift. During a surveyor interview with the Director of Nursing Services on 5/23/2024 at 8:51 AM, she was unable to provide evidence that the facility provided appropriate treatment and services for a resident with a urinary catheter, including documenting the urinary output to assess for adequacy of renal function.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 2 of 2 residents reviewed, Resident ID #s 10 and 12. Findings are as follows: 1. Record review for Resident ID #10 revealed a physician's order dated 5/3/2024 for Seroquel (an antipsychotic medication that treats several kinds of mental health conditions) 25 mg (milligrams) daily in the morning, Seroquel 50 mg daily in the evening. Additional review revealed a physician's order dated 5/20/204 for Seroquel 25 mg PRN (as needed) once daily for anxiety. Record review of the pharmacist's Consultation Report dated 4/19/2024 states in part, Recommendation: Please include the following guidance for Seroquel in the interdisciplinary care plan and ensure the following are monitored and documented in the medical record: - Identify common behavioral expressions and describe how the behaviors impact the resident and others (e.g., increases resident distress, dangerous to the resident or others) .Implement and periodically reassess appropriate, individualized, person centered interventions, documenting the results. - Communicate to the interdisciplinary team anything that may contribute to the observed behaviors (e.g., noise, hearing deficit) . - Perform ongoing monitoring for neuroleptic malignant syndrome (e.g., fever, muscle cramps, tremors, unstable blood pressure, delirium) . - Monitor for metabolic complications such as weight gain, hyperlipidemia, and hyperglycemia. - Monitor routinely for other medication specific side effects (e.g., anticholinergic effects, irregular heartbeat, falls, drowsiness, signs/symptoms of trans ischemic attack [a brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain]. or stroke). Response required. Record review for Resident ID #10 failed to reveal evidence that the Consultation Report, with noted irregularities, was reviewed and acted upon by the resident's provider. Additionally, the record failed to reveal evidence of ongoing monitoring for neuroleptic malignant syndrome, evidence of monitoring for metabolic complications, evidence of monitoring routinely for medication specific side effects or that the resident's behaviors were monitored and documented. 2. Record review for Resident ID #12 revealed a physician's order dated 4/27/2024 for Haloperidol (antipsychotic medication) 2 ml (milliliter) via peg tube (a feeding tube that is inserted into the stomach) twice daily. Additional review revealed a physician's order dated 5/16/2024 for Haloperidol 1 ml via peg tube every 8 hours PRN for increased restlessness. Record review of the pharmacist's Consultation Report dated 4/19/2024 states in part, Recommendation: Please include the following guidance for Haloperidol in the interdisciplinary care plan and ensure the following are monitored and documented in the medical record: - Identify common behavioral expressions and describe how the behaviors impact the resident and others (e.g., increases resident distress, dangerous to the resident or others). - Implement and periodically reassess appropriate, individualized, person centered interventions, documenting the results. - Communicate to the interdisciplinary team anything that may contribute to the observed behaviors (e.g., noise, hearing deficit). - Discuss with the prescriber the clinical appropriateness of a gradual dose reduction (at least quarterly) - Perform ongoing monitoring for neuroleptic malignant syndrome (e.g., fever, muscle cramps, tremors, unstable blood pressure, delirium) . - Monitor for metabolic complications such as weight gain, hyperlipidemia, and hyperglycemia. - Monitor routinely for other medication specific side effects (e.g., anticholinergic effects, irregular heartbeat, falls, drowsiness, signs/symptoms of trans ischemic attack or stroke). Response required. Record review of Resident ID #12's care plan failed to reveal evidence that a care plan was developed relative to mood or behavior. Further record review failed to reveal evidence that the Consultation Report, with noted irregularities, was reviewed and acted upon by the resident's provider. Additionally, the record failed to reveal evidence of ongoing monitoring for neuroleptic malignant syndrome, evidence of monitoring for metabolic complications, monitoring routinely for medication specific side effects or that the resident's behaviors were monitored and documented. During a surveyor interview on 5/21/2024 at 12:40 PM and again on 5/22/2024 at 9:10 AM with the residents' provider, Registered Nurse Practitioner (RNP), Staff E, she was unsure if she had reviewed the above-mentioned consultation reports with the recommendations. Additionally, Staff E revealed she would expect that the pharmacist's recommendations would be followed. Lastly, she was unable to provide evidence that she reviewed the Consultation Reports. During a surveyor interview on 5/22/2024 at 12:34 PM with the Director of Nursing Services, she was unable to provide evidence that the pharmacy consultation reports were reviewed by the provider and revealed the pharmacy medication irregularity reports are placed in the provider's folder for review.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 medication room observed. Findings are as follows: Review of a facility policy titled, Storage and Expiration Dating of Medications, Biological's revealed in part, .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened . Surveyor observation on [DATE] at 12:20 PM of the medication storage room in the presence of Registered Nurse, Staff C, revealed the following: -1 vial of tuberculin purified protein derivative (used to test for the diagnosis of tuberculosis) opened and undated. Manufacturer's instructions states, vial once entered should be discarded after 30 days. -1 bottle of lorazepam intensol (a medication used to treat anxiety) 2 milligram/milliliter (mg/ml) unopened with a manufacturer expiration date of [DATE]. -1 bottle of lorazepam intensol 2 mg/ml unopened with a manufacturer expiration date of [DATE]. -1 bottle of lorazepam intensol 2 mg/ml opened, with the open date of [DATE] documented on the box. Manufacturer's instructions states, discard opened bottle after 90 days. During a surveyor interview immediately following the above observation, Staff C acknowledged that the vial of tuberculin purified protein derivative was open and undated. She further revealed that the above lorazepam intensol bottles were expired and could not explain why they were not discarded. 21613

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and services in accordance with professional standards of practice, relative to following physician's orders for weekly body audits for 1 of 7 residents reviewed, Resident ID #12. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, Parkinson's disease ( a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and dementia. Further record review revealed a physician's order dated 4/17/2024 for Body Audit on Admission and Q [every] week by Licensed Nurse on Shower Day. Document on Body Audit Form . Record review of the Body Audit form failed to reveal evidence that the weekly body audits were completed and documented on the Body Audit forms for 4 out of 5 opportunities, between 4/17/2024 through 5/21/2024. During a surveyor interview with Registered Nurse, Staff C, on 5/22/2024 at 8:37 AM, she acknowledged the weekly body audits were not completed and documented on the Body Audit Forms, per the physician's order. During a surveyor interview with the Director of Nursing Services on 5/23/2024 at 8:49 AM, she was unable to provide evidence that the weekly body audits were completed and documented on the Body Audit forms, as ordered.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical and nursing needs that are identified in the comprehensive assessment for 1 of 1 resident reviewed with lower leg edema (swelling), Resident ID #38. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, Alzheimer's disease and hypertension (high blood pressure). Review of the care plan initiated on 4/8/2024, revealed the resident experienced lower extremity edema, with interventions including, but not limited to, apply ACE wraps (compression bandage) to both lower legs in the morning and remove the ACE wraps at bedtime. Surveyor observations of the resident on 5/20/2024 at 1:16 PM and 5/22/2024 at 12:40 PM, failed to reveal evidence that the resident was wearing his/her ACE wraps, instead s/he was observed wearing non skid socks. During a surveyor interview with the resident on 5/22/2024 at approximately 12:45 PM, the resident revealed s/he has been wearing the non skid socks since s/he has been admitted to the facility. The resident further revealed if s/he was provided the ACE wraps, s/he would wear them. During a surveyor interview with Nursing Assistant (NA), Staff B, on 5/22/2024 at 12:46 PM, she revealed that she is the resident's primary NA and that the resident has been wearing the non skid socks since s/he was admitted to the facility in April of 2024. Additionally, she was unaware that the resident had a care plan for ACE wraps. During a surveyor interview with Registered Nurse, Staff C, on 5/22/2024 at 1:18 PM, she revealed that she was unaware of the resident's care plan for bilateral leg edema to apply the ACE wraps every morning and to remove them at bedtime. During a surveyor interview with the Director of Nursing Services on 5/22/2024 at 4:31 PM, she acknowledged that the above care plan for the resident's lower leg edema had not been implemented.

Based on record review and resident and staff interviews, it has been determined that the facility failed to protect a resident's right to be free from physical and psychological abuse for 3 of 3 residents reviewed for staff to resident abuse, Resident ID #s 1, 2, and 3. Findings are as follows: Record review of a facility incident report submitted to the Rhode Island Department of Health (RIDOH), dated 11/16/2023, revealed allegations of physical abuse by Nursing Assistant (NA), Staff B, on behalf of Resident ID #s 1 and 2 and psychological abuse of Resident ID #3. The incident report indicated that the Administrator received the complaint on 11/16/2023. The report alleges during the second shift on 11/15/2023 Nursing Assistant (NA), Staff A, and Agency NA, Staff B, were providing care together to two residents; Staff A witnessed Staff B put a pillow on Resident ID #1's face and bend Resident ID #2's legs incorrectly. Additionally, Resident ID #3 revealed Staff B purposefully and loudly banged utensils on the bedside table while s/he was asleep causing him/her to startle, and wake; Staff B allegedly laughed at the resident. Record review of the facility policy updated on 7/23/2023 and titled, ABUSE/RESIDENT states in part, .abuse or mistreatment of any kind toward a resident is strictly prohibited .Abuse shall be defined as: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. 1. Record review of Resident ID #1 revealed s/he was admitted to the facility in November of 2023, with diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, open wound of the right foot, and type 2 diabetes. Review of a Brief Interview for Mental Status (BIMS) dated 11/10/2023 revealed a score of 3 out of 15, indicating severely impaired cognition. Further record review revealed a care plan dated 11/17/2023 which states in part, .resident allegedly abused by a staff member .resident will not experience trauma related to alleged incident. 2. Record review of Resident ID #2 revealed s/he was readmitted to the facility in July of 2022 with diagnoses including, but not limited to, dementia, depression, and osteoarthritis. Review of a BIMS dated 6/17/2023 revealed a score of 12 out of 15, indicating moderately impaired cognition. 3. Record review for Resident ID #3 revealed s/he was admitted to the facility in September of 2023 with diagnoses including, but not limited to, congestive heart failure, depression, and anxiety. Review of a BIMS dated 10/4/2023 revealed a score of 15 out of 15 indicating intact cognition. Further review of Resident ID #3's record revealed a progress note dated 11/16/2023 at 12:23 PM, authored by the social worker, which states in part, .resident stated [s/he] was shook up after the incident last night .stated [s/he] was dosing[SIC] off around dinner time and agency staff member, Staff B, entered [his/her] room and slammed [his/her] silverware on the bedside table extremely loudly and purposefully which woke [him/her] up .Staff B laughed .resident stated it triggered a past trauma .resident felt scared and angry that this had happened .resident then overheard another resident screaming and later overheard gossip that Staff B had hit the resident in the face with a pillow . During a surveyor interview with the resident on 11/17/2023 at 12:15 PM, s/he revealed after speaking with the social worker, s/he is relieved in knowing that Staff B is not returning to the facility. The resident revealed a past history of trauma which includes physical and sexual abuse. Review of the resident's record revealed a social work assessment that revealed the resident was physically and sexually abused as a child by a family member and when s/he hears loud noises, it triggers his/her past abuse. During a surveyor interview on 11/17/2023 at 11:02 AM with Staff A, she revealed when she entered Resident ID #3's room on 11/15/2023 at approximately 5:45 PM, to collect the dinner trays, the resident revealed what Staff B had done and confirmed what is documented in the above progress note written by the social worker. Additionally, Staff A revealed while she and Staff B were providing Resident ID #1 with evening care at approximately 7:30 PM, she witnessed Staff B hit the resident in the face with the bed pillows. Staff A further revealed that around 10:20 PM while walking by Resident ID #2's, room she witnessed Staff B inappropriately stretching the resident's legs upward which caused the resident to scream out in pain. Staff A indicated that Staff B exited the resident's room when she arrived. Staff A indicted that she immediately notified Registered Nurse, Staff C, after each incident involving Staff B and the above-mentioned residents. During a surveyor interview with Staff C, on 11/17/2023 at 10:24 AM, she acknowledged that she was made aware of the abuse allegations by Staff A. Staff C acknowledged that she failed to call the DNS or Administrator upon learning of the abuse allegations and indicated that she left a handwritten note under the Administrators door. Additionally, Staff C failed to remove the alleged perpetrator from the schedule upon learning of the abuse allegations nor did she report the abuse allegations within 2 hours, as required. Review of a facility document titled 5-day Investigation Report states in part, RN that received the initial complaint on 11/15/2023 was educated and warned on immediate notification of any abuse directly to the Administrator and DNS and removing the suspected abuser immediately from the facility .facility started abuse in-servicing and reporting requirements with staff emphasizing the need for immediate action. During a surveyor interview with the Administrator on 11/17/2023 at 9:45 AM, she revealed that Staff B will not be returning to the facility and the agency to which she is employed with was notified of the suspected abuse allegations. The Administrator further revealed that her expectation is that Staff C would have removed Staff B upon receiving the report of suspected abuse and was unable to provide evidence that the facility kept Resident ID #s 1, 2, and 3 free from abuse.

Based on record review, resident, and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 5 reviewed, Resident ID #1. Findings are as follows: Record review of the facility's discharge policy titled, Discharge/Community states in part, Nursing will complete .interdisciplinary form and medication list .a review of medication regime, medication and treatments with the resident and/or family is conducted prior to discharge . Record review of a community complaint reported to the Rhode Island Department of Health on 1/23/2023, alleges Resident ID #1 was sent home with another resident's medications, (Resident ID #2). Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with diagnoses including but are not limited to, after care following joint replacement and presence of left artificial knee joint. During a surveyor interview with Resident ID #1 on 1/25/2023 at approximately 1:25 PM, s/he revealed s/he was discharged home on 1/20/2023 with 9 bubble packs of medication that belonged to another resident, in addition to her/his own medications. The resident further revealed that s/he did not receive discharge instructions or education by the nurse. The resident further revealed that s/he called the facility to inform them that s/he has someone else medications. Review of a facility document titled Continuity of Care Discharge/Transfer of Patient Form indicated that the resident's medication list was attached to this document. Further review of this document failed to reveal a list of discharge medications, or that it was signed as completed by the discharging nurse, Registered Nurse, Staff A, or that it was signed off as reviewed by the resident. During a surveyor interview with Staff A on 1/26/2023 at 1:20 PM she acknowledged that she mistakenly provided Resident ID #2's medications to Resident ID #1 upon his/her discharge. She further revealed that she failed to reconcile the medication list as indicated on the Continuity of Care Form per the facility's discharge policy with the resident or the family member during the discharge. During a surveyor interview with the Administrator on 1/26/2023 at approximately 11:00 AM she was unable to provide evidence that all pre-discharge medications were reconciled with the resident's post-discharge medications prior to Resident ID #1 being discharged home from the facility. Please refer to F 726, F 761, and F 835.

Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through the plan of care for 1 of 5 residents reviewed for discharge services, Resident ID #1. Findings are as follows: Record review of a community complaint reported to the Rhode Island Department of Health on 1/23/2023, alleges that Resident ID #1 was sent home with another resident's medications (Resident ID #2). Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with the diagnoses including but are not limited to, after care following joint replacement and presence of left artificial knee joint. During a surveyor interview with Resident ID #1 on 1/25/2023 at approximately 1:25 PM, s/he revealed s/he was discharged home on 1/20/2023 with 9 bubble packs of medication that belonged to another resident, in addition to her/his own medications. The resident further revealed that s/he did not receive discharge instructions or education pertaining to medication administration by the discharging nurse, Registered Nurse, Staff A. The resident further revealed that s/he called the facility to inform them that s/he had someone else's medications. Record review of Staff A's personnel file failed to reveal any competencies or skill sets relative to medication reconciliation prior to or after this incident was brought to the facility's attention by Resident ID #1 on 1/20/2023. During a surveyor interview with Staff A on 1/26/2023 at 1:20 PM, she acknowledged that she mistakenly provided Resident ID #2's medications to Resident ID #1 upon discharge. She further revealed that she failed to reconcile Resident #1 's pre-discharge medications with the resident's post-discharge medications. Additionally, she stated that she needed to acclimate herself to long term care and on how to properly conduct a discharge. During a surveyor interview with the Administrator on 1/26/2023 at approximately 11:00 AM, she acknowledged that the nurse should have reviewed and reconciled all medications prior to discharging the resident. Additionally, she was unable to provide evidence that Staff A had the competencies or skill sets relative to medication reconciliation as she discharged Resident ID #1 home with Resident ID #2's medications. Please refer to F 661, F 761, and F 835. 46338

Based on record review and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles for 1 of 10 residents reviewed relative to breaking the chain of custody of medications and administering them to a resident, Resident ID #2. Findings are as follows: According to U.S. Pharmacist article, published June 11, 2021 titled Uncovering the Impact of Storage on Generic Medications, states in part .Storage conditions are vitally important to the overall integrity and quality of medications, and the United States Pharmacopeial Convention, the FDA(Federal Drug Administration), and drug manufacturers provide guidelines for proper storage .From the point of manufacture to the distribution of a medication to a patient, many factors can directly impact the integrity of a drug product, which may result in an avoidable decrease in treatment efficacy or even cause harm. One of the most easily overlooked factors that can directly impact the quality of a drug product is the condition in which medications are stored. From fluctuating temperatures to improper sealing to potential contamination during transportation from place to place, medications are often subjected to conditions that are less than optimal. Most drugs require specific storage conditions to ensure that their integrity remains intact . Record review of a community complaint reported to the Rhode Island Department of Health on 1/23/2023, alleges that Resident ID #1 was sent home with another resident's medications (Resident ID #2). Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with diagnoses including but are not limited to, after care following joint replacement and presence of left artificial knee joint. Record review reveals Resident ID #2 is a current resident at the facility. Record review for Resident ID #2 revealed s/he was admitted to the facility in July of 2020 with diagnoses including, but are not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness of the body), aphasia (disorder that affect your communication), and back pain. During a surveyor interview with Resident ID #1 on 1/25/2023 at approximately 1:25 PM, s/he revealed s/he was discharged home on 1/20/2023 with 9 bubble packs of medication that belonged to another resident (Resident ID #2), in addition to her/his own medications. The resident further revealed that s/he called the facility to inform them that s/he had someone else's medications. Resident ID #1 then indicated that the Administrator came to his/her home to retrieve Resident ID # 2's medications. During a surveyor interview with the Administrator on 1/26/2023 at 11:00 AM, she acknowledged that Resident ID #1 was discharged with Resident ID # 2's medications. She further indicated that she retrieved the medications from Resident ID #1's home and returned them to Registered Nurse, Staff A. The Administrator was unable to recall or provide evidence of which medications she retrieved from Resident ID #1's home. She further indicated that because the facility lost the chain of custody for Resident ID #2's medications they should have been destroyed and re-ordered. During a surveyor interview with Staff A, on 1/26/2023 at 1:20 PM, she revealed she received the medications from the Administrator and placed them back in the medications cart. Additionally, she revealed that those medications were administered to Resident ID #2 that day. During a surveyor interview with the Nurse Practitioner on 1/30/2023 at 12:00 PM, she revealed that the medications should not have been administered to the resident once they were taken out of the facility. Please refer to F 661, F 726, F 835 47808

Based on record review, resident, and staff interview, it has been determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 5 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community complaint reported to the Rhode Island Department of Health on 1/23/2023, alleges that Resident ID #1 was sent home with another resident's medications (Resident ID #2). Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with the diagnoses including but are not limited to, after care following joint replacement and presence of left artificial knee joint. During a surveyor interview with Resident ID #1 on 1/25/2023 at approximately 1:25 PM, s/he revealed s/he was discharged home on 1/20/2023 with 9 bubble packs of medication that belonged to another resident (Resident ID #2), in addition to her/his own medications. The resident further revealed that s/he did not receive discharge instructions or education pertaining to medication administration by the nurse. The resident further revealed that s/he called the facility to inform them that s/he had someone else's medications. The facility asked the resident is s/he could return Resident ID #2's medications. The resident explained that s/he could not drive as s/he was recovering from knee surgery, therefore the Administrator elected to pick up the medications from Resident ID #1's home. During a surveyor interview with the Administrator on 1/26/2023 at 11:00 AM, she acknowledged that Resident ID #1 was discharged with Resident ID # 2's medications. She further indicated that she retrieved the medications from Resident ID #1's home and returned them to Registered Nurse, Staff A. The Administrator was unable to recall or provide evidence of which medications she retrieved from Resident ID #1's home. She further indicated that the medications should have been destroyed and re-ordered for Resident ID #2 Please refer to F661, F761, and F835. 47808

Based on record review and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and failed to follow the policy related to weight monitoring for 9 of 12 sample residents reviewed for nutrition, Resident ID #'s 4, 5, 7, 12, 15, 18, 22, 23, and 307 Findings are as follows: The facility's policy for WEIGHT MONITORING states in part, .Accurate and timely measurement of weight changes in all resident is an important tool in assessing their nutritional status. Resident will be weighed weekly for 4 weeks on admission and readmission then monthly . The following procedure is intended to assure that weight changes are identified and assessed as needed. Procedure: . 2. Resident will be weighed during the first seven days of the month and upon admission every week x 4 weeks. It Is the responsibility of the charge nurse to assure that weights are taken. 3. Weights will be taken and recorded on the weight sheet . or Point Click Care. If there is a 5 lbs [pounds] weight discrepancy (plus or minus) a reweigh should be obtained. The Charge Nurse should then review the weight and compare this to the previous weights to determine a 5% weight change in 30 days or 10% change in 180 days. 4. Significant weight changes will be reported to: a. Physician/APRN [Advanced Practice Registered Nurse] b. Responsible party c. RD [Registered Dietician] d. DNS [Director of Nursing Services]/ADNS [Assistant Director of Nursing Services] e. Care Plan Coordinator 5. Resident who have experiences significant weight loss will be reviewed by the RD to evaluate the need for changes in the plan of care. The resident's care plan will be updated accordingly. Record review revealed the following: 1. Record review for Resident ID #4 revealed the resident was admitted to the facility in November of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's weight record revealed the resident's weight was 116.2 lbs. (pounds) on 1/1/2022 and 132.8 lbs. on 2/11/2022, indicating weight gain of 16.6 lbs. (14.29%) from the previous weight. Further record review revealed the resident's weight was 132.8 lbs on 2/11/2022, and 151.2 lbs. on 3/1/2022, indicating severe weight gain of 18.4 lbs. (13.86%) from the previous weight. The record failed to reveal evidence that the resident was reweigh when s/he had a weight discrepancy of 5 lbs. or more per the facility's policy. Additionally, record review failed to reveal evidence of any new interventions relative to the resident's severe weight gain (33.8 % weight gain in 3 months). 2. Record review for Resident ID #5 revealed the resident was admitted to the facility in June of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's weight record revealed an admission weight of 143.2 lbs. on 6/12/2021. Further review of the monthly weights revealed a weight of 127.6 lbs. on 9/14/2021. The resident was reweighed on 9/14/2021 and the weight obtained was 121.4 lbs., indicating a severe weight loss of 21.8 lbs in 3 months. Further record review revealed the resident's weight was 126.2 lbs. on 9/24/2021 and his/her weight was 110.7 lbs on 3/1/2022 which indicated a further weight loss of 15.5 lbs. (12.28%) from September 2021 (total weight loss of 32.5 lbs. since admission). Record review of the resident's care plan initiated on 6/14/2021 states in part, I have the potential for a nutritional decline R/T [related to] need for altered consistency diet, weight loss . Further record review failed to reveal evidence of any new interventions with the exception of a supplement started on September 22, 2021 that was implemented to prevent the resident from further weight loss. 3. Record review for Resident ID #7 revealed the resident was admitted to the facility in June of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review failed to reveal evidence of documentation of the percentage of supplement taken. Further review of the resident's weight record revealed the resident's weight was 102.9 lbs. on 1/1/2022 and on 2/11/2022 the resident weighed 92.2 lbs. which indicated a severe weight loss of 10.7 lbs. (10.4 %) in 1 month. The record failed to reveal evidence that a reweigh was obtained when the resident had a weight discrepancy of 10.7 lbs. Record review of the resident's care plan initiated on 6/14/2021 states in part, I have the potential for a nutritional decline R/T history of dementia, underweight, weight loss . The care plan failed to reveal evidence of new interventions relative to the resident's severe weight loss, other than changing the resident's diet from carbohydrate control with regular consistency to regular diet and mechanical soft consistency. 4. Record review for Resident ID #12 revealed the resident was admitted to the facility in June of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan initiated on 6/21/2021 states in part, I have the potential for a nutritional decline R/T multiple medical problems, weight loss . The care plan failed to reveal evidence of any new interventions relative to the resident's severe weight loss. Record review of the resident's weight record revealed an admission weight of 127.8 lbs. on 6/15/2021. Further record review revealed the resident's weight obtained on 3/8/2022 of 100.7 lbs. which indicated a severe weight loss of 27.1 lbs. (21.21%) in 9 months. Further record review failed to reveal evidence of new interventions to prevent the resident from further weight loss. 5. Record review for Resident ID #15 revealed the resident was admitted to the facility in December of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Further record review revealed the resident's weight was 268 lbs. on 12/15/2021 and 210 lbs. on 12/27/2021. which indicated a severe weight loss of 58 lbs. (21.6 %) in 11 days. The record failed to reveal evidence that a reweigh was obtained when the resident had a weight discrepancy of 58 lbs. Further record review revealed the resident's weight was 211.5 lbs. on 1/11/2022, and 221 lbs. on 2/11/2022, which indicated a 9.5 lbs. weight gain in one month. The record failed to reveal evidence that a reweigh was obtained when the resident had a weight discrepancy of 9.5 lbs. Additionally, record review revealed the resident's weight was 268 lbs. on 12/15/2021 and 222.4 lbs. on 3/2/2022, which indicated a severe weight loss of 45.6 lbs. (17.01%) in less than 3 months. The resident has a care plan dated 12/20/2021 which states in part, I have potential for a nutritional decline R/T multiple medical problems. Need for a therapeutic diet, Recent hospitalization , recent surgery, interventions include, Encourage fluids, provide my diet as ordered, weigh me as ordered. Record review failed to reveal evidence that new interventions were implemented to address the resident's weight loss of 45.6 lbs (17.01%) in less than 3 months. 6. Record review for Resident ID #18 revealed the resident was readmitted to the facility in June of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's weight record revealed a weight of 170.2 lbs. on 6/15/2021 and a weight of 147.1 lbs. on 3/8/2022, which indicated a weight loss of 23.1 lbs. (13.57%) in 9 months. Record review of the resident's care plan initiated on 12/03/2018 and last revised on 11/23/2020 states in part, I have the potential for a nutritional decline R/T multiple medical problems, need for a therapeutic diet, history of weight loss, weight gain . Further record review failed to reveal evidence of new interventions implemented to prevent the resident from further weight loss. 7. Record review for Resident ID #22 revealed the resident was readmitted to the facility in June of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's weight record revealed a weight of 147.7 lbs. on 12/4/2021 and a weight of 136 lbs. on 3/1/2022, which indicated a weight loss of 11.7 lbs. (7.92 %) in 3 months. Record review of the resident's care plan initiated on 4/14/2021 and last revised on 3/7/2022 states in part, I have the potential for a nutritional decline R/T multiple medical problems, need for a therapeutic diet, weight loss . Further record review failed to reveal evidence of new interventions implemented to prevent the resident from further weight loss. 8. Record review for Resident ID #23 revealed the resident was admitted to the facility in December of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review failed to reveal evidence that the admission weight was obtained per the facility's policy. Record review of the resident's weight record revealed the resident's weight was 130 lbs. on 1/14/2022 and 119.2 lbs. on 2/11/2022, which indicated a severe weight loss of 10.8 lbs. (8.3 %) in 1 month. Further record review failed to reveal evidence that a reweigh was obtained per the facility's policy. Additionally, record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan dated 12/27/2021 for I have potential for a nutritional decline R/T multiple medical problems . with intervention to include .2 handled sip cup with straw . Additionally, review of the resident's diet slip revealed .2 handled sip cup with straw. During a surveyor observation of the resident during meals revealed the resident did not have a 2 handled cup with a lid/straw on the following dates and times: -3/8/2022 at 9:20 AM -3/8/2022 at 12:51 PM -3/9/2022 at 8:52 AM During a surveyor interview with the nursing assistant (NA), Staff H on 3/9/2022 at approximately 9:00 AM, she acknowledged that she did not provide the 2 handled cup with lid/straw for drinks. 9. Record review for Resident ID #307 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review failed to reveal evidence that an admission weight was obtained per the facility's policy and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a surveyor interview with the Director of Nursing Services (DNS) on 3/8/2022 at 3:45 PM, she was unable to provide evidence that the admission weight was obtained per the facility's policy. Additionally, she revealed a reweigh should be obtained within 1-2 days of when the weight discrepancy is identified. Additionally, during an interview with the DNS on 3/9/2022 at 9:11 AM, she was unable to provide evidence that weights were obtained per the facility policy. During a surveyor interview with the Registered Dietitian on 3/9/2022 at 2:15 PM, he was unable to provide evidence that the care plans for nutrition were updated to address the residents' weight loss or weight gain. During a surveyor interview with the Staff Development Coordinator on 3/10/2022 at 1:01 PM, she revealed she has not provided in-services to nursing staff relative to the facility's policy for weight monitoring.

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 necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 3 of 3 residents reviewed with pressure ulcers, Resident ID #s 20, 38, 293. Findings are as follows: The facility's policy entitled, Documentation, states in part: 4. A complete wound assessment and documentation will be done weekly on each area until healed utilizing the skin/wound tracking record . a. Site/Location b. Stage - this applies only to pressure ulcers, including Stage I, deep tissue injury .Wound healing is to be described by changes in the wound appearance and size . c. Size - length, width, and depth measured in centimeters (cm) . d. Appearance of the wound bed - this describes the tissue present in the wound bed including color, drainage, odor, and periphery (the outer edge of an area). e. Undermining (tissue destruction underlying intact skin along the wound margins)/tunneling (narrow corridors of tissue destruction that extend from the wound base into the tissue) .If present, measure depth of area in centimeters . f. Surrounding skin - describe the condition of the surrounding skin noting if it is intact, [DIAGNOSES REDACTED]tous (redness of the skin surface), indurated (abnormal hardening of the tissue), [MEDICAL CONDITION] (excessive amount of fluid), macerated (softening of tissue) and the temperature if abnormal. g. Drainage/exudate (accumulation of fluids within the wound bed) - describe the amount, color, consistency and odor . 1. Resident ID #20 was readmitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), dated [DATE], reveals that the resident is at risk for pressure ulcers and had a stage 2 pressure ulcer upon re-admission. Review of the facility policy, titled Wound and Skin Care Definitions, defines stage 2, in part, as partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (loose, stringy necrotic tissue) . Review of the care plan, initiated 1/4/2021, reveals that the resident had a stage 2 pressure ulcer upon re-admission. A care plan intervention indicates, consult with wound care nurse specialist as ordered/needed. Record review failed to reveal evidence of a full assessment of the resident's pressure ulcer upon re-admission and 4 consecutive weeks thereafter (1/4/2021- 2/7/2021): - Review of the re-admission assessment, dated 1/4/2021, reveals that the resident has a stage 2 pressure ulcer to the coccyx. - Review of the weekly body audit assessment, dated 1/15/2021, indicates pressure on the right buttock, left buttock, and sacrum. The assessment states, Same wound as when in hospital/ It does breech all areas in the text above. Escsar(sic) (thick, leathery skin) in the center and edges . - Review of the weekly body audit assessment, dated 1/22/2021, indicates pressure on the sacrum and left gluteal fold. The assessment states, Same wound as when in hospital. Escsar (sic) in the center and edges . -Review of the weekly body audit assessment, dated 2/07/2021, indicates pressure on the sacrum. The assessment states, Eschar has partially detached from wound edges, full wound now viable. Wound measure 7cm wide, 4cm tall, and 2.5cm deep. The documentation of the pressure ulcer failed to reveal evidence of a full assessment of the resident's pressure ulcer weekly which includes all of the following: location, stage, size, appearance of the wound bed, undermining/tunneling, surrounding skin, and drainage/exudate. Record review revealed a telephone order, dated 2/8/2021, for a wound care evaluation. There is no evidence that an order for [REDACTED]. Review of the initial wound care evaluation from an outside consultant, dated 2/10/2021, revealed the following: - Wound location: coccyx - Measurements: 18.0 cm length x 5.0 cm width x 2.0 cm depth - Undermining: 3 cm at 9-3 o'clock - Stage 4 - Eschar: partial coverage - Slough, [MEDICATION NAME] (fibrous mesh that impedes the flow of blood), Necrotic Tissue (non-viable tissue): Minimal - Wound Base Color: pale pink - Granulation Tissue: Pale/Gray - Odor: none - Drainage Amount: Large - Drainage Color: Purulent (thick and milky drainage from a wound, typically indicating infection) - Epithellum (regeneration of new skin): None - Periwound (tissue surrounding wound) Integrity: [DIAGNOSES REDACTED] Further review of the above wound consult revealed that the wound was debrided (removal of devitalized/necrotic tissue and foreign matter from the wound) at this time. Review of the facility policy, titled Wound and Skin Care Definitions, defines stage 4, in part, as full thickness skin loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling . Review of the wound tracking document, dated 2/18/2020, revealed an assessment of the wound (after the lack of weekly assessments were brought to the facility's attention) which revealed the following: - Wound Location: Sacrum: Noted as large stage 4 pressure ulcer, macerated skin surrounding - Measurement: 6.8 cm height x 8.6 cm width x 2.5 cm depth - Color: Red - Odor present - Undermining present - Progress = declined During a surveyor observation of the wound on 2/18/2021 at 11:44 AM, in the presence of the nurse, Staff B, it was observed to be consistent with a stage 4 pressure ulcer. The wound was noted to have tunneling and the wound bed was noted to be black with eschar. During a surveyor interview with the nurse, Staff A, on 2/17/2021 at 11:58 AM, she acknowledged that there was no full assessment done upon admission or weekly thereafter. Additionally, she acknowledged that the wound was originally a stage 2 and has declined to a stage 4. During a surveyor interview with the Director of Nursing Services (DNS) on 2/18/2021 at 10:05 AM, she could not provide evidence that weekly assessments were done for the pressure ulcer. During a surveyor interview with the Medical Director on 2/18/2021 at 10:23 AM, he indicated that he would expect the facility to follow their policy on wound care. 2. Resident ID #38 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the facility policy, titled Wound and Skin Care Definitions, defines stage 2, in part, as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister or sero-sanginous filled blister . Review of the admission assessment, dated 1/30/2021, states left toe blister. Review of the admission MDS, dated [DATE], reveals that the resident is at risk for pressure. The MDS failed to assess the resident's blister as a pressure ulcer. Review of the care plan, initiated on 2/2/2021, reveals that the resident is at risk for skin breakdown due to decreased mobility. Review of a nursing progress note, dated 2/3/2021, revealed that the resident had an intact fluid filled blister on the top of the left foot, with a small amount of serous drainage noted. The area measured 0.2 cm by 3 cm. Review of a nursing progress note, dated 2/17/2021, states in part, Resident has a blister that has deflated, no longer filled with fluid. Further record review from 1/30/2021 until 2/17/2021 failed to reveal evidence of a full weekly wound assessment upon admission and 2 consecutive weeks thereafter, including all of the following: location, stage, size, appearance of the wound bed, undermining/tunneling, surrounding skin, and drainage/exudate. During a surveyor observation of the resident's left toe on 2/18/2021 at 12:02 PM, in the presence of the nurse, Staff B, the area appeared red and the blister had opened. During a surveyor interview with the nurse, Staff B, on 2/18/2021 at 12:14 PM, she indicated that the area on the left foot is approximately 6 cm x 4 cm and further described it as a collapsed blister. During a surveyor interview with the DNS on 2/18/2021 at 12:08 PM, she acknowledged that the blister would be considered a stage 2 pressure ulcer and could not provide evidence of full weekly wound assessments. 3. Resident ID #38 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the hospital's Continuity of Care Form, dated 2/6/2021, reveals that the resident has a stage 2 pressure ulcer to the right buttocks and a wound to the left lower extremity (LLE). The wound to the LLE measured 9 cm by 1.3 cm by 0.3 cm. Review of the Braden Scale for Predicting Pressure Ulcer Risk assessment, dated 2/7/2021, reveals that the resident is at high risk for pressure. Review of the care plan, revised on 2/11/2021, reveals that the resident was admitted to the facility with areas to the left lower extremity, right buttock, and sacrum. Review of the skin conditions section of the admission assessment, dated 2/7/2021, reveals the following: - Right buttock - stage 2 pressure (no measurements) - Left lower leg (rear) - stage 2 pressure; measures: 9.0 cm length x 1.3 cm width x 0.3 cm depth - Left heel - suspected Deep Tissue Injury (DTI) (injury to the soft tissue under the skin due to pressure) - Sacrum - stage 2 (no measurements) Further review of this assessment reveals a comment indicating that the resident has moisture-associated skin damage (MASD) to both the buttock and coccyx with a stage 2. Record review from 2/7/2021 until 2/17/2021 (when resident was discharged ) failed to reveal evidence of a full weekly wound assessment upon admission and 1 week thereafter, including all of the following: location, stage, size, appearance of the wound bed, undermining/tunneling, surrounding skin, and drainage/exudate. During a surveyor interview with the nurse, Staff A, on 2/17/2021, she acknowledged that the admission assessment documented wounds to the right buttock, left lower leg, left heel, and sacrum. Additionally, she acknowledged that a full wound assessment was not completed upon admission or the following week. During a surveyor interview with the DNS on 2/18/2021 at 10:05 AM, she was unable to provide evidence that a full wound assessment was completed upon admission or weekly thereafter.