Every finding on record at Avalon Nursing Home INC

Based on record review and staff interview, the facility failed to complete an annual performance review for every nurse aide (NA), at least once every 12 months, for 5 of 5 NA personnel records reviewed, Staff A, B, C, D, and E. Findings are as follows:Record review of the personnel records failed to reveal evidence that a 2025 annual performance evaluation was completed for the following NAs:-Staff A, hired in July of 2009-Staff B, hired in March of 2022-Staff C, hired in October of 2021-Staff D, hired in November of 2023-Staff E, hired in August of 2008During a surveyor interview with the Director of Nursing Services on 7/13/2026 at 3:34 PM, he acknowledged that the performance evaluations were not completed as required for Staff A, B, C, D and E within the last 12 months.

Based on surveyor observation, record review, and staff interview, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 medication room and for 1 of 1 resident observed with medication stored on his/her nightstand, Resident ID #10.Findings are as follows:1. During surveyor observation of the medication room in the presence of Registered Nurse (RN), Staff F, on 7/13/2026 at approximately 12:30 PM, revealed the medication room refrigerator was unlocked. Upon the surveyor and Staff F exiting the medication room, Staff F left the medication room door partially open and then assisted a resident in his/her room. Review of the medication room refrigerator contents revealed the following medications:One insulin kit that contained the following: -1 Lantus Solostar insulin vial-8 Lispro insulin vials-2 Glargine insulin vials -2 Dupixent (a prescription drug that treats various moderate-to-severe inflammatory conditions) injectable pens-4 Lorazepam bottles (a controlled medication requiring double lock system)-2 Latanoprost Ophthalmic eye drop bottles-1 Tubersol (a purified protein derivative (PPD) used in the tuberculin skin test to detect tuberculosis (TB) infection) vial-2 Trulicity injectable penDuring a surveyor interview immediately following the above observation with Staff F, she acknowledged that the refrigerator was left unlocked and that she had left the door open. She further revealed that she should have locked the refrigerator and closed medication room the door.A subsequent observation of the medication room on 7/14/2026 at 12:44 PM, revealed that the medication room door was left open.During a surveyor interview on 7/14/2026 at 12:47 PM with Staff F, she closed the medication room door and acknowledged that the door to the medication room should remain closed and locked when unattended.2. During the medication observation task on 7/14/2026 at 8:27 AM with RN, Staff F, Resident ID #10 was observed in his/her room with the medication Zoryve Roflumilast 0.3% topical foam (a medication prescribed to treat skin conditions) located on the top of his/her nightstand.During a surveyor interview immediately following the above observation with Staff F, she revealed that the Zoryve Roflumilast is a prescription that the resident uses daily. Additionally, she acknowledged that the medication should not have been stored in the resident's room and should have been stored in the treatment cart.Record review failed to reveal evidence that the resident had a self-administration assessment completed for medications.During surveyor interviews on 7/13/2026 at 3:46 PM and 7/14/2026 at 11:20 AM with the Director of Nursing Services, he revealed that he would expect the medication refrigerator to be kept locked and that the medication room door kept closed and locked. Additionally, he revealed that the prescribed medication for Resident ID #10 should have been kept in the nursing treatment cart unless s/he was assessed to self-administer his/her own medications.

Based on surveyor observation, clinical record review, 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; maintaining standards of practice during a wound care treatment for 1 of 1 resident reviewed, Resident ID #9, and the use of Enhanced Barrier Precautions (EBP, use of gown and gloves for high contact activities) for 1 of 1 resident reviewed, Resident ID #22.Findings are as follows:1. Record review revealed Resident ID #9 was re-admitted to the facility in May of 2026 with diagnoses including, but not limited to, dementia and a fracture of the right femur. Record review revealed a physician's order to cleanse the slit to the coccyx (the tailbone) with wound wash, followed by Medi honey (a medical grade honey used to treat wounds) and cover with an Allevyn (a foam dressing used to manage wound drainage and to prevent pressure injuries) dressing daily.During a surveyor observation on 7/15/2026 at 1:45 PM of Registered Nurse (RN), Staff G, completing the treatment to the resident's coccyx wound, she failed to establish a clean field and placed all of the wound supplies, including the tube of Medi Honey, directly on the resident's bed and then placed the wound cleanser on the resident's nightstand. Staff G removed the old dressing from the resident's coccyx, then failed to remove her dirty gloves, perform hand hygiene or put on new gloves prior to cleansing the wound and applying the new wound treatment. Additionally, with her soiled gloves she removed the supplies from the resident's bed and nightstand, brought them to the sink, removed her gloves, and washed her hands. Finally, she retrieved the supplies from the counter and placed them into the treatment cart.During a surveyor interview with Staff G immediately following the above observations, she acknowledged that she placed the wound supplies, including the Medi honey tube on the resident's bed and revealed that this is her typical practice when performing wound care. She further acknowledged that she did not change her gloves or perform hand hygiene after removing the soiled dressing or prior to cleansing the wound and applying the new wound treatment. Additionally, she revealed that the wound supplies were returned to the treatment cart for multi-resident use. 2. Record review revealed Resident ID #22 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, malnutrition.Record review revealed the resident has a non-pressure wound to his/her coccyx. Record review revealed the resident is on EBP due to his/her wound.Surveyor observations from 7/13/2026 through 7/15/2026 revealed signage posted outside of Resident ID #22's room indicating s/he is on EBP.Review of the facility signage titled Enhanced Barrier Precautions states in part, .Wear Gown and Gloves prior to these activities .Dressing .bathing .transferring .providing hygiene.Clean their hands, including before entering and when leaving the room .During a surveyor observation on 7/15/2026 at 9:19 AM, Resident ID #22 was in his/her bathroom when Nursing Assistant (NA), Staff H completed toileting, hygiene, and transferred the resident off the toilet. During this observation Staff H, was not wearing the appropriate Personal Protective Equipment (PPE), including a gown.During a surveyor observation on 7/15/2026 at 9:23 AM, Resident ID #22 was in his/her bathroom, Registered Nurse (RN), Staff G was observed performing wound care to the resident's coccyx. During this observation Staff G, was not wearing the appropriate PPE, including a gown.During a surveyor interview immediately following the above observations, Staff G acknowledged that she and Staff H were not wearing the correct PPE, including a gown, while performing toileting, hygiene, transferring the resident, and providing wound care.During surveyor interviews on 7/15/2026 at approximately 9:45 AM and 2:30 PM, with the Director of Nursing Services, he revealed that he would expect the nurse to set up a clean field for her supplies, change gloves and cleanse her hands after removing the soiled dressing and prior to cleaning the wound and placing a new dressing. Additionally, it would be his expectation that staff wear the appropriate PPE when performing toileting, hygiene, transferring, and providing a wound treatment.

Based on record review and staff interview, the facility failed to develop, implement, and maintain an effective training program for existing staff consistent with their expected roles, relative to the required training based on the facility assessment for 8 of 8 staff reviewed, Staff A, B, C, D, E, I, J, K.Findings are as follows:Record review of the Facility Assessment, revised in April of 2026, titled, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies states in part, .Staff training/education and competencies: The following are training topics; Communication.Resident's rights.Abuse, neglect, misappropriation &exploitation.Infection Control.Culture change.Required in service training for nurse aides including ensuring the continuing competencies are no less than 12 hours per year and including dementia management and resident abuse prevention.Disaster planning and procedures.Caring for the resident with Alzheimer's or other dementia and psychological disorders as residents with trauma and /or PTSD [Post Traumatic Stress Disorder], and implementing non pharmacological interventions, Trauma Informed Care, Compliance and Ethics, Pandemic policies and QAPI [Quality Assurance and Performance Improvement.Record review of the facility's staff education files revealed the following trainings were not completed, as required:-Nursing Assistant (NA), Staff A, hired on 7/29/2009, record failed to reveal evidence that she completed the mandatory trainings for culture change, caring for a resident with mental and psychosocial disorders, trauma-informed care, and pandemic policies.-NA, Staff B, hired on 3/1/2022, record failed to reveal evidence she completed the mandatory trainings, for communication, resident rights, abuse, neglect, misappropriation and exploitation, infection control, culture change, disaster planning and procedures, caring for a resident with mental and psychosocial disorders, trauma-informed care, and pandemic policies-NA, Staff C, hired on 10/29/2021, record failed to reveal evidence she completed the mandatory trainings, for culture change, disaster planning and procedures, caring for a resident with mental and psychosocial disorders, trauma-informed care, and pandemic policies-NA, Staff D, hired on 11/20/2023, record failed to reveal evidence she completed the mandatory required trainings, including culture change, disaster planning and procedures, caring for a resident with mental and psychosocial disorders, trauma-informed care, and pandemic policies-NA, Staff E, hired on 8/18/2008, record failed to reveal evidence she completed the mandatory trainings for culture change, care for a resident with mental illness, and pandemic policies.-Dietary Aid, Staff I, hired on 10/31/2023 failed to reveal evidence she completed the mandatory training for cultural change.-Dietary Aid, Staff J, hired on 10/15/2025 failed to reveal evidence he completed the mandatory training for cultural change.-Janitor, Staff K, hired on 2/11/2022 failed to reveal evidence he completed the mandatory training for communication, residents' rights, infection control and culture change.During surveyor interviews on 7/14/2026 at 11:15 AM and 2:30 PM with the Director of Nursing Services, he was unable to provide evidence that the required trainings were completed based on the facility assessment for 8 of 8 staff reviewed Staff A, B, C, D, E, I, J, K.

Based on record review and staff interview, the facility failed to provide training to their staff, that at a minimum educates staff on, abuse and neglect.Findings are as follows:Record review of the most recent abuse in-service training sign-in sheet, dated 1/5/2025, titled Staff Sign Off Sheet for Abuse and Neglect, along with a folder containing abuse post-tests provided by the Director of Nursing Services (DNS), revealed that only 13 of the 28 listed nursing staff had signed indicating attendance at the abuse training. Further review of the post-tests revealed that only three had been completed by staff. Additionally, the in-service sign-in sheet did not include the Social Worker, dietary staff, housekeeping staff, or maintenance staff.During a surveyor interview on 3/10/2026 at 2:07 PM with the housekeeping/dietary aide, Staff E, she stated that she had never received training related to abuse at the facility.During a surveyor interview on 3/11/2026 at 9:30 AM with Nursing Assistant, Staff B, she stated that she had never received training related to abuse at the facility.During a surveyor interview on 3/10/2026 at 3:20 PM with the DNS, he was unable to explain why 10 staff members who had signed the in-service sheet indicating attendance at the abuse training did not have a completed post-test. The DNS was also unable to provide evidence of a completed post-test for Staff B, despite her signature on the in-service sheet indicating attendance at the training. Additionally, the DNS stated he was unaware that abuse training was required for all facility staff, not solely nursing staff, until this requirement was brought to his attention by the surveyor.

Based on clinical record review and staff interview, the facility failed to ensure that alleged violations involving abuse are reported immediately, but not later than 2 hours, after the allegation was made, relative to 1 of 2 residents reviewed for abuse who had a bruise to his/her outer thigh, Resident ID# 1.Findings are as follows:Record review of the facility policy dated 8/2020, titled, Reporting Patient Abuse states in part, .any person that has reason to believe that a patient has been abused.should contact the charge nurse, DNS [Director of Nursing Services] and/or Administrator at the time of the incident .the incident will be reported to the Department of Health.within 2 hours.Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 3/5/2026, alleges that on 3/4/2026, Resident ID #1 reported to the 11:00 PM to 7:00 AM shift nurse that a Nursing Assistant (NA) Staff B, was too rough with him/her on the previous shift, 3:00 PM to 11:00 PM. Upon interview with Resident ID #1, s/he stated that the NA hurried him/her to bed and twisted his/her arms when pivoting him/her from his/her chair to the bed. Additionally, when a skin check was completed on 3/5/2026, a small, blue mark was noted to his/her right outer thigh with an unknown etiology and that the NA will no longer be assigned to care for Resident ID #1. Further review revealed that the incident report was submitted to the RIDOH on 3/5/2026 at 1:39 PM, indicating that the report was not submitted within the required two-hour timeframe from when the allegation was made.Record review of a nursing progress note dated 3/4/2026 at 6:22 AM, authored by Registered Nurse (RN), Staff A, revealed that Resident ID #1 complained that Staff B was being too rough with him/her on the 3:00 PM to 11:00 PM shift. The note further indicated that Staff A would speak to the DNS about the allegation. During a surveyor interview on 3/11/2026 at 8:52 AM with Staff A, she revealed that the resident revealed to her on 3/4/2026 at approximately 1:30 AM, that s/he did not want Staff B, to take care of him/her any longer and that she is just too rough. Additionally, Staff A revealed that she did not report the allegation of abuse to the DNS.During a surveyor interview on 3/10/2026 at 12:23 PM with RN, Staff C, she stated that she had been off from work for several days and returned to the facility on 3/5/2026. Staff C further stated that after being away from the facility for a few days, she typically reviews residents' progress notes for updates. Staff C reported that after reviewing Staff A's progress note regarding the abuse allegation made by Resident ID #1, she then reported the allegation to RIDOH.During a surveyor interview on 3/10/2026 at 3:20 PM with the Administrator, he was unable to provide evidence that the facility reported the allegation of abuse immediately, or within 2 hours, after the allegation of abuse was made.

Based on clinical record review and staff interview, the facility failed to ensure that an allegation of abuse was thoroughly investigated for 1 of 2 residents reviewed, who had a bruise to his/her outer thigh, Resident ID #1. Additionally, the facility failed to prevent further potential abuse while the investigation was in progress. Findings are as follows:Record review of the facility policy titled, Reporting Patient Abuse dated 8/2020 states in part, .any person that has reason to believe that a patient has been abused.should contact the charge nurse, DNS [Director of Nursing Services] and/or Administrator at the time of the incident .A full investigation will be conducted which may include written statements from witnesses as well as the resident.Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 3/5/2026, alleges that on 3/4/2026, Resident ID #1 reported to the 11:00 PM to 7:00 AM shift nurse that a Nursing Assistant (NA), Staff B, was too rough with him/her on 3/3/2026, the previous shift, 3:00 PM to 11:00 PM. Upon interview with Resident ID #1, s/he stated that Staff B hurried him/her to bed and twisted his/her arms when pivoting him/her from the chair to the bed. Additionally, when a skin check was completed on 3/5/2026, a small, blue mark was noted to his/her right outer thigh with an unknown etiology and that Staff B will no longer be assigned to care for Resident ID #1. Record review revealed the resident was admitted to the facility in June of 2022 with diagnoses including, but not limited to, bipolar disorder (a chronic mental health condition that causes extreme mood swings), anxiety, and insomnia.Record review of the resident's Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 14 out 15, indicating s/he is cognitively intact. A. Record review of a nursing progress note, dated 3/4/2026 authored by Registered Nurse (RN), Staff A, revealed that Resident ID #1 complained to her that Staff B was being too rough with him/her on the 3:00 PM to 11:00 PM shift and that she would speak to the DNS about the allegation.During a surveyor interview on 3/10/2026 at 12:23 PM with RN, Staff C, she stated that she had been off from work for several days and returned to the facility on 3/5/2026. Staff C further stated that after being away from the facility for a few days, she typically reviews residents' progress notes for updates. Staff C reported that after reviewing Staff A's progress note regarding the abuse allegation made by Resident ID #1, she then initiated the investigation. Record review of the investigation failed to reveal evidence of Staff A's statement relative to the abuse allegation and failed to reveal evidence of a statement relative to the abuse allegation from RN, Staff D, who was assigned to the resident on 3/3/2026 during the 3-11 PM shift. Record review of a statement written by the alleged perpetrator, NA, Staff B, revealed that the allegation is false, and she denied twisting the resident's arm and leg. Additionally, there is nothing further written in the NA's statement related to the events of that night.B. Record review of the facility schedule revealed that Staff B worked on the evening of 3/4/2026 and 3/5/2026, indicating that the NA was allowed to work after the allegation of abuse was made by the resident.During a surveyor interview on 3/10/2026 at 1:37 PM with the Administrator, he acknowledged that the facility failed to obtain statements from key staff members involved in the incident, including RNs Staff A and Staff D, and failed to obtain a detailed statement from the alleged perpetrator regarding the events in question. Additionally, the Administrator confirmed that although Staff B was removed from providing care to Resident ID #1, she was permitted to continue working in the facility on 3/4/2026 and 3/5/2026, providing care to other residents after the allegation of abuse had been reported.

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 1 of 1 resident reviewed, who experienced actual weight loss, Resident ID #3. Findings are as follows: Review of a facility policy and procedure titled WEIGHT, last revised in May of 2023, states in part, .It is the policy of this home to monitor the weight of every resident on a regular basis and to carry out the appropriate interventions when necessary to assure the optimum level of health possible for the individual resident .the facility will ensure that each resident maintains acceptable parameters of body weight unless the resident's clinical condition demonstrates that this is not possible .The Director of Nursing will .Ensure that all residents with unplanned weight loss are monitored by the physician and dietician .Calculate weight loss/gains above or below 5 lbs. [pounds] and notify the resident's physician, dietician and DNS [Director of Nursing Services] if there is a discrepancy . Review of a facility policy titled Weighing and Measuring the Resident states in part, .1. Report significant weight loss/weight gain to the nurse supervisor. 2. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria .1 month- 5% weight loss is significant; greater that 5 % is severe .3. Notify the Nurse Supervisor if the resident refuses the procedure. 4. Report other information in accordance with facility policy and professional standards of practice. Record review revealed the resident was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, bipolar disorder and depression. Further record review revealed the s/he was recently hospitalized from 3/6/2025-3/27/2025, related to behaviors and a diagnosis of a urinary tract infection. Review of a care plan dated 4/1/2025 revealed that the resident is at nutritional risk related to a weight loss, reduced appetite, and possible medication changes. Further review of the care plan revealed interventions to monitor weights, administer an appetite stimulant, and consult with a Registered Dietician (RD) as needed. Record review revealed the following weights were obtained: - 3/5/2025: 118 lbs. - 4/2/2025: 118.6 lbs. - 5/7/2025: 110 lbs. - 5/28/2025: 110 lbs. Record review revealed the resident experienced a 7.82% (8.6 lbs.) severe weight loss in one month, from 4/2/2025 to 5/7/2025. Record review of the Registered Dietician Assessments on the dates below revealed the following: - 5/13/2025: Will request reweigh to confirm weight. Will continue to follow . - 5/20/2025: Will request reweigh to confirm weight. Will continue to follow . - 5/27/2025: Reweigh needed to confirm current weight. will continue to follow . Record review failed to reveal evidence that a reweigh was obtained on or after 5/13 and 5/20/2025 per the RD's recommendations. Record review failed to reveal evidence that a reweigh was obtained. Additionally the record revealed that a weight was obtained on 5/28/2025, 21 days after weight of 110 lbs. was obtained on 5/7/2025, which confirmed the resident experienced a weight loss in one month. Record review failed to reveal evidence that the Dietician or the Physician were notified of the weight loss that was greater than 5% from 4/2 to 5/7/2025, per the facility's policy. During a surveyor interview on 5/29/2025 at 12:49 PM with the RD, she revealed that when she requests a reweigh on a resident, she documents it in the assessment and gives the DNS and the Charge Nurse a handwritten note to obtain it. She stated that she was unaware that the reweigh was completed on 5/28/2025 that confirmed the resident had a severe weight loss of 8.6% in one month. She further revealed that she would have expected the reweigh to be completed no more than 2 days after the weight was initially identified. Additionally, she revealed that had she been notified that the reweigh had been obtained, she would have provided further recommendations. During surveyor interviews on 5/29/2025 at 1:28 PM and 2:55 PM with the Nurse Practitioner (NP), she revealed that she was not aware of the extent of the resident's weight loss, and she would not confirm if she was or was not made aware of the resident's severe weight loss. Record review of a note authored by the NP dated 5/29/2025 at 10:10 PM, states in part, Plan: Updated labs due on June 4th which will include pre alb/albumin [an abnormal amount of albumin may suggest a problem with a nutrient deficiency] .If decreased in combination with wt [weight] loss, would add Remeron [a medication prescribed to stimulate your appetite] .Add HDS [house dietary supplement] 240 cc TID [three times a day]. During a surveyor interview on 5/29/2025 at 3:25 PM with the Director of Nursing Services, he revealed that his expectation is that a reweigh should be obtained on the same day or the next morning. Additionally, he was unable to provide evidence that the Dietician or the Physician were notified of the resident's severe weight loss, per the facility's policy.

Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to continuous oxygen administration for 2 of 2 residents reviewed, Resident ID #s 18 and 30, for 1 of 1 resident reviewed who had an order to offload their heels, Resident ID #6 and for 1 of 1 resident reviewed for a hand splint, Resident ID #20. 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. 1a. Record review revealed Resident ID #18 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (COPD, a lung condition that restricts your breathing) and dependence on supplemental oxygen. Record review revealed a physician's order dated 4/21/2025 for oxygen at 2 liters per minute via nasal cannula (medical device used to provide supplemental oxygen therapy) continuously. During surveyor observations the resident was observed with oxygen at 4 liters per minute via nasal cannula on the following dates and times: - 5/27/2025 at 10:16 AM - 5/28/2025 at 11:37 AM - 5/29/2025 at 8:58 AM - 5/30/2025 at 9:06 AM During a surveyor interview on 5/30/2025 at 9:06 AM with Registered Nurse (RN), Staff A, she acknowledged that the resident was not being administered oxygen at 2 liters continuously, as ordered. During a surveyor interview on 5/30/2025 at 9:17 AM with the Director of Nursing Services (DNS), he indicated it would be his expectation that the resident's order would be followed relative to oxygen liter flow. 1b. Record review revealed Resident ID #30 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, COPD, pneumonia, acute respiratory failure, and dyspnea (shortness of breath). Record review revealed a physician's order dated 3/11/2025 for oxygen at one liter per minute continuously via nasal cannula. During surveyor observations the resident was observed with oxygen at 2.5 liters per minute via nasal cannula on the following dates and times: - 5/27/2025 at 9:42 AM - 5/27/2025 at 11:45 AM - 5/28/2025 at 11:44 AM - 5/28/2025 at 1:10 PM During a surveyor interview on 5/30/2025 at approximately 12:17 PM with the DNS, he was unable to provide evidence that the oxygen order was followed. 2. Record review revealed Resident ID #6 was admitted to the facility in January of 2016 with a diagnosis including, but not limited to, transient ischemic attack (a temporary change in the nerve function caused by disruption of blood flow to an area of the brain or spinal cord). Record review revealed a physician's order dated 3/4/2025 to off load both of the resident's heels when in bed as tolerated. During surveyor observations the resident's heels were lying directly on the mattress and not off loaded on the following dates and times: - 5/27/2025 at 9:55 AM - 5/27/2025 at 11:24 AM - 5/28/2025 at 9:59 AM - 5/28/2025 at 10:17 AM - 5/30/2025 at approximately 8:20 AM Record review failed to reveal evidence that the resident could not tolerate his/her heels being offloaded while in bed. During a surveyor interview on 5/30/2025 at 8:26 AM with RN, Staff A, she acknowledged that the resident's heels were not offloaded. During a surveyor interview on 5/30/2025 at 9:37 AM with the DNS, he revealed it would be his expectation for the order to be followed. 3. Record review revealed Resident ID #20 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, left hand muscle wasting and atrophy (a wasting or thinning of muscle mass). Record review of a physician's order dated 3/6/2025 revealed to apply a left-hand splint after morning care and to remove it during the afternoon rounds During surveyor observations on the following dates and times the resident was observed not wearing his/her left-hand splint: - 5/27/2025 at approximately 9:50 AM - 5/27/2025 at 11:21 PM - 5/28/2025 at 10:00 AM - 5/28/2025 at 11:36 AM During a surveyor interview on 5/29/2025 at approximately 1:18 PM with RN, Staff A, she acknowledged that the resident was not wearing his/her left hand splint as ordered. During a surveyor interview on 5/30/2025 at 9:10 AM with the DNS, he indicated it would be his expectation that the resident would be wearing his/her left-hand splint as ordered. 47939

Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the influenza or pneumococcal vaccination or did not receive the vaccinations due to medical contraindications or refusal, for 3 of 5 residents reviewed for the influenza vaccination, Residents ID #s 11, 16, and 21 and for 2 of 5 residents reviewed for the pneumococcal vaccination, Resident ID #s 16 and 30. Findings are as follows: 1a. Record review of Resident ID #11 revealed the resident was admitted to the facility in September of 2021. Record review of the resident's immunization record failed to reveal evidence that the influenza vaccine was offered, received, or declined for the 2024-2025 flu season. 1b. Record review of Resident ID #16 revealed the resident was admitted to the facility in March of 2021. Record review of the resident's immunization record failed to reveal evidence that the influenza vaccine was offered, received, or declined for the 2024-2025 flu season. 1c. Record review of Resident ID #21 revealed the resident was admitted to the facility in January of 2020. Record review of the resident's immunization record failed to reveal evidence that the influenza vaccine was offered, received, or declined for the 2024-2025 flu season. 2a. Record review of Resident ID #16 revealed the resident was admitted to the facility in March of 2021. Record review of the resident's immunization record failed to reveal evidence that the pneumococcal vaccine was offered, received, or declined. 2b. Record review of Resident ID #30 revealed the resident was admitted to the facility in March of 2025. Record review of the resident's immunization record failed to reveal evidence that the pneumococcal vaccine was offered, received, or declined. During a surveyor interview on 5/30/2025 at 8:47 AM with the Director of Nursing Services, he was unable to provide evidence that the above-mentioned residents had received or declined the influenza and pneumococcal vaccines, as required.

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment relative to window air conditioning units, for 4 of 4 air conditioning units observed. Findings are as follows: During surveyor observations on the following dates and times the window air conditioning units in occupied resident rooms were observed to have an accumulation of visible black matter on the adjustable louvers (adjustable flaps) and beyond the louvers within the air conditioners: -5/28/2025 at 10:46 AM and 5/30/2025 at 8:40 AM rooms [ROOM NUMBERS]. -5/28/2025 at 11:05 AM and 12:34 PM rooms 13 (C/D) and 14. During a subsequent surveyor observation and simultaneous interview on 5/30/2025 at 8:40 AM with the Director of Nursing Services of rooms 8, 13 (C/D), 14, and 17, he acknowledged that an accumulation of black matter was visible on the adjustable louvers and beyond the louvers within the air conditioners. Additionally, he revealed that the air conditioning units should be cleaned. During a surveyor interview on 5/30/2025 at 9:59 AM with the Administrator, he was unable to provide evidence that the facility maintained a safe, functional, and comfortable environment. 47939

Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective in-service training program including no less than 12 hours per year, to ensure competence of nurse aides (NAs) with their expected roles for 2 of 4 NAs reviewed, Staff D and E. Findings are as follows: Record review revealed that NA, Staff D, was hired on 2/3/2017. Additional review revealed that Staff D did not receive at least 12 hours of training in 2024. Record review revealed that NA, Staff E was hired on 3/1/2022. Additional review revealed that Staff E did not receive at least 12 hours of training in 2024. During a surveyor interview on 5/30/2025 at 10:03 AM with the Director of Nursing Services, he was unable to provide evidence of at least 12 hours of training for 2024 for Staff D and E.

Based on record review and staff interview, it has been determined that the facility failed to protect identifying information for 3 of 4 current residents residing in the facility, who were identified in the survey results binder, Resident ID #s 3, 4 and 17. Findings are as follows: During an observation of the facility's surveyor results binder the survey dated 5-16-2024 and the Resident/Staff Roster were revealed. The roster identified Resident ID #s 3, 4, and 17. Further review of the above survey contained information including, but not limited to, the resident's diagnoses and their physician orders. During a surveyor interview with the Administrator on 5/29/2025 at approximately 10:45 AM, following the above observation, he revealed that he was unaware that the Resident/Staff Roster was in the survey binder and that it should not have been. The Administrator was unable to provide evidence that the facility protected the identifying information of the residents listed in the survey results binder.

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 and the 1 of 1 medication storage room observed. Findings are as follows: Review of a facility policy titled Medication Labeling and Storage with a revision date of February 2023 states in part, .Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding .destroying these items . 1. During the medication storage and labeling task on [DATE] at approximately 9:00 AM through 10:15 AM, in the presence of Registered Nurse (RN), Staff A, observation of the treatment cart and the medication room revealed the following: -One vial of tuberculin purified protein derivative (tuberculin skin test solution) opened and not dated. Additionally, the manufacturer's instructions indicate to discard the vial after 30 days of opening. -One Insulin lispro injectable pen (a medication prescribed to treat high blood sugar) 100 units per milliliter (ml) with an open date of [DATE] and an expiration date of [DATE]. Additionally, manufacturer's instructions indicate to discard the vial after 28 days of opening. -One lorazepam intensol oral suspension (a medication prescribed to treat anxiety) 2 milligrams (mg) per ml with an open date of [DATE]. Additionally, the manufacturer's instructions indicate to discard it after 90 days of opening. During a simultaneous interview with Staff A, she acknowledged the opened date for the lorazepam was greater than 90 days and the medication should be discarded, Additionally, she acknowledged that the insulin was expired and in use, and that the tuberculin purified protein derivative vial should have been dated when opened. 2. During a surveyor observation of the medication cart on [DATE] at 12:17 PM in the presence of Certified Medication Technician (CMT), Staff B, a medication prescription card was observed with twenty-two tablets of lorazepam 0.5 mg. Further observation revealed this medication had been discontinued in March of 2025. During a subsequent interview immediately following the above observation with Staff B, she acknowledged that the order for the lorazepam tablets had been discontinued and the medication should have been discarded per the facility policy. During a surveyor interview with the Director of Nursing Services on [DATE] at 11:20 AM and 1:06 PM, he revealed that he would expect that the medication bottles would be dated once opened, and that the lorazepam intensol, lispro and tuberculin purified protein derivative vial should be discarded.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: Review of the Rhode Island Food Code, 2022 Edition, section ,d+[DATE].17 (B) states in part, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED .shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . 1. During the initial tour of the main kitchen on [DATE] at 9:40 AM, with the Food Service Manager (FSM), the following was observed in the reach-in refrigerator: -One, 5 pound (lb.) container of ricotta cheese approximately ,d+[DATE] full, opened, with a manufacturer's use by date of [DATE]. -One, 2.5lb. sealed package of cooked sliced roast beef with a use or freeze by date of [DATE]. -One, 6.11lb. bag of nacho cheese sauce without a use by date or a manufacturer's expiration date. -Three, 1lb. sealed packages of bologna with a use by date of [DATE]. 2. Observation during the initial tour, of the reach-in freezer, the following was observed: -One, frozen, rectangular block of split pea soup with the occlusive packaging unsealed, the contents were exposed, discolored, and covered in ice crystals. 3. Observations during the initial tour of the dry storage room, the following was observed: -One, 6.6lb. can of mandarin oranges with a manufacturer's date of [DATE] and without an expiration date. -One 2.5lb. box of Nabisco Entertainment Crackers, opened, with a use by date of [DATE]. During a surveyor interview with the FSM immediately following the above observations, she revealed that she would expect food and beverages to be labeled and dated when opened. She further acknowledged that the expired items, undated items and the exposed pea soup should have been discarded.

Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or, no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Rhode Island Department of Health- RIDOH), in accordance with State law, for 2 of 2 residents reviewed for allegations of abuse, Resident ID #s 1 and 2. Findings are as follows: Record review of a facility policy last revised in January of 2024 titled, Reporting Patient Abuse states in part, This facility will report all cases of suspected or actual abuse or neglect to the Department of Health .Any person that has reason to believe that a .resident has been abused, neglected or mistreated should contact the .DNS [Director of Nursing Services .at the time of the incident. In turn, the incident will be reported to the Department of Health .in written format within 2 hours of the suspicion and/or incident . 1. Record review of a facility reported incident submitted to the RIDOH on 8/22/2024 at 3:54 PM, alleges that on 8/21/2024 at 12:45 PM, Resident ID #1 was in tears and alleged Staff A of inappropriate sexual behaviors with him/her. Record review failed to reveal evidence that this allegation of sexual abuse was reported to the RIDOH within 2 hours as required. Record review revealed Resident #1 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, heart failure and myocardial infarction (heart attack). Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 out of 15, indicating moderately impaired cognition. During a surveyor interview on 8/29/2024 at 12:25 PM with the Minimum Data Set Assessment Coordinator, she revealed that on 8/21/2024 Resident ID #1 had revealed that Staff A, had touched Resident ID #1 in all the right places while in the shower. Additionally, she revealed she informed the DNS immediately. 2. Record review of a facility reported incident submitted to the RIDOH on 8/14/2024, alleges that on 8/4/2024 Staff B squeezed Resident ID #2's left leg causing him/her pain. Record review failed to reveal evidence that this allegation of staff to resident abuse was reported to the RIDOH within 2 hours as required. Record review revealed Resident ID #2 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, acute kidney failure and acquired absence of the right foot and other toes of the left foot. Record review of a Quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. During a surveyor interview on 8/29/2024 at 11:56 AM with the resident s/he revealed that this incident occurred a few weeks ago with Staff B. Resident ID #2 stated that Staff B squeezed his/her left leg causing him/her pain. During a surveyor interview on 8/29/2024 at 12:52 PM, with the DNS, he acknowledged that he was made aware of Resident ID #1's sexual abuse allegation on 8/21/2024 and Resident ID #2's allegation of staff to resident abuse on 8/4/2024. Additionally, he acknowledged that he did not report the allegations to the RIDOH or other officials within 2 hours as required.

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. Findings are as follows: 1. Record review of the Rhode Island Food Code, 2018 Edition, section 4-601.11 states in part, .(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT .shall be kept free of encrusted grease deposits and other soil accumulations. (C) NON-FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . During the initial tour of the main kitchen on 5/29/2024 at 8:55 AM and 9:15 AM in the presence of the Administrator, the following was observed: - A microwave on the back counter was noted to have dried food particles, orange and brown in color, on the inside of the door, walls, ceiling and glass turning plate. - In the refrigerator labeled as the Defrosting Fridge in the basement, there were two wrapped pieces of red meat resting directly on the shelves. The bottom of the refrigerator was covered in red liquid, both stained and wet. 2. Record review of the Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, Ready-to Eat, Time/Temperature Control for Safety, Date Marking .(B) .(1) The day the original container is opened in the Food establishment shall be counted as Day 1 . During the initial tour of the main kitchen on 5/29/2024 at 8:55 AM in the presence of Cook, Staff B, the following was observed in the refrigerator labeled [NAME] Fridge/Freezer: - One 46 ounce (oz) nectar thickened apple juice opened and not dated. Manufacturer's instructions indicate to use the product within 10 days upon opening. - One 46 oz nectar thickened sugar free peach mango juice opened and not dated. Manufacturer's instructions indicate to use the product within 10 days upon opening. - One 46 oz nectar thickened cranberry juice opened and not dated. Manufacturer's instructions indicate to use the product within 10 days upon opening. During a surveyor interview with Staff B at the time of the above observation, she acknowledged that the nectar thickened juices should have been dated when opened. During a surveyor interview with the Administrator on 5/29/2024 at approximately 9:15 AM, he acknowledged that the microwave and refrigerator were dirty and needed to be cleaned and that the nectar thickened juices should have been dated when opened.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program (IPCP) to help prevent the transmission of communicable diseases and infections for 2 of 3 residents reviewed for multidrug-resistant Organisms (MDRO), Resident ID #s 6 and 28. Additionally, the facility failed to conduct appropriate infection control practices relative to personal protective equipment during foley catheter (a flexible tube that is inserted through the urethra to help drain urine from the bladder) removal for 1 of 1 resident observed, Resident ID #3. The facility further failed to implement a water management program based upon industry standards and/or the Centers for Disease Control and Prevention (CDC) toolkit and to perform and document specified testing for the prevention of Legionella disease (a very serious type of lung infection caused by the bacteria called Legionella which can be found in water). This deficient practice could impact 31 of 31 residents, as well as an indeterminable number of staff and visitors. Findings are as follows: Review of the Centers for Disease Control and Prevention's (CDC) document titled, Multidrug-resistant organisms management states in part, .For ill residents (e.g. those totally dependent upon healthcare personnel for healthcare and activities of daily living) .use Contact Precautions [use of gown and gloves when entering a resident's room] in addition to Standard Precautions . Review of a facility policy titled Isolation - Categories of Transmission-Based Precautions states in part, .Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environment contamination and risk of transmission of a pathogen, even before specific organism has been identified .Contact precautions are used for residents infected or colonized [If you are colonized with an MDRO, these germs are living on or in your body. You may not be sick with an infection, but you can still spread the infection] with MDROs in the following situations .when a resident has wounds, secretions, or excretions that are unable to be covered or contained .the individual on contact precautions is placed in a private room if possible . Review of a policy title Enhanced Barrier Precautions last revised on 1/8/2024 states in part, Post the appropriate Enhanced Barrier Precautions (EBP) sign on the patient's room door .Enhanced Barrier Precautions (EBP) are to be utilized for the duration of the patients stay .All patients with any of the following: Infection or colonization with an MDRO when Contact Precautions do not apply .PPE Used for These Situations .During high contact patient care activities: Dressing .bathing/showering .transferring .providing hygiene .changing linens .changing briefs or assisting with toileting .device care or use, central line, urinary catheter, enteral feeding . 1 a. Record review revealed that Resident ID #6 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, Vancomycin-resistant Enterococci (VRE, a type of bacteria present in the gastrointestinal tract that develop resistance to many antibiotics, especially vancomycin.) Review of a care plan dated 5/21/2024 revealed s/he tested positive for VRE. Interventions include, but are not limited to, contact precautions. Review of a hospital continuity of care form dated 5/6/2024-5/15/2024 revealed, Isolation Status s/he was on infection control precautions for VRE. During a surveyor observation on 5/29/2024 at 9:00 AM of the resident's room revealed a sign for contact precautions. The sign states in part, Everyone must put on gloves before room entry .put on a gown before room entry . During a surveyor observation on 5/29/2024 at 9:52 AM of Registered Nurse, Staff C, she obtained the resident's vital signs without wearing a gown or gloves. During a surveyor interview immediately following the above observation on 5/29/2024 with Staff C, she acknowledged that she should have worn a gown and gloves as required. Additionally, she acknowledged the resident was on contact precautions related to VRE. During a surveyor observation on 5/29/2024 at 12:24 PM of the Director of Nursing Services (DNS), he entered the resident's room and lifted the residents blanket up to assess his/her legs without wearing a gown or gloves. During a surveyor interview immediately following the above observation with the DNS, he acknowledged that he should have worn a gown and gloves to enter the resident's room as required. Additionally, he acknowledged the resident was on contact precautions for VRE. During a surveyor observation on 5/29/2024 at 2:10 PM of Physical Therapist Assistant, Staff D, entered the resident's room without wearing a gown or gloves and performed therapeutic exercises with the resident for approximately 20 minutes. During a surveyor interview immediately following the above observation with Staff D, she acknowledged that she should have worn a gown and gloves to enter the room per the signage on the resident's door but was unaware of why the resident was on contact precautions. During a surveyor interview on 5/30/2024 at 10:06 AM with the DNS, he revealed that the resident was on contact precautions for VRE and would expect staff to wear a gown and gloves when entering the resident's room. 1 b. Record review revealed that Resident ID #28 was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, cerebral infarction (stroke). Review of a urine culture dated 4/29/2024 revealed that s/he is positive for extended-spectrum beta-lactamase (ESBL, infection resistant to common antibiotics and may require complex treatments). Review of a urine culture dated 5/18/2024 revealed that s/he is positive for ESBL and was treated with antibiotics from 5/20/2024 through 5/27/2024. Record review failed to reveal evidence of a re-culture to determine if the resident remained positive for ESBL. During surveyor observations from 5/29/2024 through 5/31/2024 revealed the resident was not on contact precautions. During a surveyor interview on 5/31/2024 at approximately 9:00 AM with Registered Nurse, Staff A, she revealed that the resident was not on any precautions after completing his/her antibiotic treatment for ESBL. During a surveyor interview on 5/31/2024 at 11:17 AM with the DNS, he acknowledged that Resident ID #28 was not on contact precautions or EBP per the CDC, Rhode Island Department of Health and the facility policy. Additionally, he was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to MDROs. 2. Record review revealed that Resident ID #3 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, acute kidney failure. Review of a physician's order dated 5/24/2024 states in part, Insert 16 Fr [French] 3-way foley .for irrigation .(Foley to be removed immediately following treatment) . During a surveyor observation on 5/30/2024 at approximately 8:30 AM of the resident's room failed to reveal evidence that s/he was on EBP. Further observation revealed Registered Nurse, Staff A, removing the resident's foley catheter while wearing only gloves. She was not observed to be wearing a gown relative to enhanced barrier precautions. During a surveyor interview immediately following the above observation with Staff A, she indicated that she only needs gloves to remove the foley catheter and no other precautions were necessary. During a surveyor interview on 5/30/2024 at 10:06 AM with the DNS, he revealed that the resident should be on enhanced barrier precautions and the nurse should be wearing a gown and gloves during foley catheter insertion and removal. 3. Record review of the CDC document titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated June 2021, version 1.1 states in part, .The key to preventing Legionnaires' disease is maintenance of the water systems in which Legionella may grow .Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant. Common issues that contribute to water stagnation include .reduced building occupancy .Stagnation can also occur when fixtures go unused, like a rarely used shower . During a surveyor interview with the Administrator on 5/29/2024 at approximately 8:00 AM he revealed that the facility has not been flushing any empty rooms as they are at full capacity. Additionally, he revealed that there were no unused sinks in the facility. Surveyor observation of a shower room on 5/30/2024 at 9:15 AM located in a housekeeping room, revealed there was a shower that was not in use. Further observation of the facility revealed a utility room with two sinks that were not in use. During a surveyor interview at the time of the above-mentioned observations with the Administrator, he indicated that the shower and the two sinks were not being utilized by anyone in the facility. Record review of the facility's water management binder failed to reveal evidence that the water flow assessment was filled out in its entirety to indicate how many sinks, toilets, and water reservoirs were in place. Further review of the water management binder failed to reveal evidence that the facility conducted flushing maintenance of the unused shower and sinks that were identified on 5/30/2024. During a surveyor interview with the Administrator on 5/30/2024 at 11:50 AM, he was unable to provide evidence that the facility maintained or implemented a water management program based upon industry standards and the CDC toolkit for the prevention of Legionella, as required. During a surveyor interview on 5/31/2024 at 9:14 AM with the DNS he was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of communicable diseases and infections. 47279 46715 50004

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a blood purifying treatment given when kidney function is not optimum) receive such services consistent with professional standards of practice for 1 of 1 resident reviewed for dialysis, Resident ID #19. Findings are as follows: Record review revealed the resident was admitted to the facility in March of 2021 with a diagnosis including, but not limited to, end stage renal disease (ESRD, when your kidneys can no longer support your body's needs). Record review of the resident's comprehensive care plan revealed that the resident receives dialysis three days a week on Tuesdays, Thursdays, and Saturdays at 9:45 AM. a) Record review failed to reveal evidence of a physician's order for dialysis to include the name of the center, the type of dialysis, and the scheduled days the resident is to receive dialysis. During a surveyor interview on 5/31/2024 at 10:23 AM with Registered Nurse, Staff A, she acknowledged that there was no order in place relative to dialysis that includes the above-mentioned information. b) Review of a facility policy titled, End-Stage Renal Disease, Care of a Resident with, states in part, .Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed . Record review revealed a document titled, Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement that states in part, This Agreement is made by and between [Facility] and [Dialysis Center], expressly for the purpose of care coordination .and is effective upon the date of last signature . Further review of the above-mentioned document failed to reveal evidence that it was signed and dated by either the dialysis center or the nursing facility. During a surveyor interview on 5/31/2024 at 11:17 AM with the Director of Nursing Services, he acknowledged that the dialysis service agreement lacked a signature and date from either party and was unable to explain why the facility nor dialysis center signed or dated the dialysis service agreement. He further revealed that it should be signed and dated by both parties. Additionally, he revealed that he was unaware that a physician's order relative to dialysis was required.

Based on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program, which includes but is not limited to communication, residents rights, abuse, quality assurance and performance improvement, infection control and behavioral health, for all new and existing staff consistent with their expected roles for 4 of 4 staff members reviewed, Staff C, E, F and G. Findings are as follows: Record review revealed that Registered Nurse, Staff C, was hired on 3/27/2019. Additional review revealed that Staff C did not receive any mandatory education in 2023. Record review revealed that Registered Nurse, Staff E was hired on 2/15/2022. Additional review revealed that Staff E did not receive any mandatory education in 2023. Record review revealed that Certified Medication Technician (CMT), Staff F was hired on 2/17/2014. Additional review revealed that Staff F did not receive any mandatory education for all of 2023. Further review revealed that she has not received an annual performance evaluation or 12 hours of mandatory in-services as required. Record review revealed that Nursing Assistant, Staff G was hired on 7/5/2017. Additional review revealed that Staff G did not receive any mandatory education for all of 2023. Further review revealed that he has not received an annual performance evaluation or 12 hours of mandatory in-services as required. During a surveyor interview on 5/30/2024 at 12:03 PM with the Director of Nursing Services, he was unable to provide evidence of any mandatory education for 2023 for any of the above mentioned staff. Additionally, he was unable to provide evidence of annual performance reviews or proof of 12 hours of inservice training for the Staff F and G.