Every finding on record at Harris Health Center LLC

Based on surveyor observation, record review, and staff interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen, 1 of 1 ice machine, 1 of 3 freezers, and 1 of 1 kitchenette.Findings are as follows:1. Review of the U.S. Food and Drug Administration (FDA), Food Code 2022 Edition, section 4.602.11 (E)(4)(b), states in part, .surfaces of UTENSILS and EQUIPMENT contacting FOOD.shall be cleaned.In EQUIPMENT such as ice bins and.ice makers.at a frequency necessary to preclude accumulation of soil or mold.During a surveyor observation on the initial tour of the main kitchen on 1/27/2026 at approximately 10:08 AM of the ice machine, revealed a white colored component within the ice machine with small flecks of a pink colored matter that was able to be removed by wiping it with a paper towel.During a surveyor interview immediately following the above observation with the Cook, Staff C, she acknowledged the pink wipeable matter within the ice machine and on the paper towel after it was used to wipe the substance off the component.2. Review of the FDA Food Code 2022 edition, section 6-305.11, states in part, .lockers or other suitable facilities shall be provided for the storage of employees possessions .During a surveyor observation on the initial tour of the main kitchen on 1/27/2026 at approximately 10:08 AM, a cell phone and two beverage cups were noted to be lying on a worktable in the main kitchen.During a surveyor interview immediately following the above observation with Staff C, she acknowledged the cell phone and two cups on top of the worktable. Additionally, she revealed that the worktable is occasionally used as a food preparation area and indicated that the personal items should not be there.3. Review of the FDA, 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 below for a maximum of 7 days. The day of preparation shall be counted as Day 1 .a. During a surveyor observation on the initial tour of the main kitchen on 1/27/2026 at approximately 10:37 AM, revealed 1 of 3 freezers that contained the following:- a large zip lock style bag labeled with a resident's name and dated 7/21, that contained a frozen chicken breast that had an accumulation of ice crystals on the chicken breast. - seven unopened containers of Rich's On Top Soft Whip Sweet Cream with an expiration date of 9/19/2025.During a surveyor interview immediately following the above observation with Staff C, she acknowledged the seven expired food products and revealed they should be discarded. Additionally, she acknowledged the ice accumulation on the chicken breast and revealed the chicken breast should have been discarded three months after the date indicated on the bag.b. During a surveyor observation on 1/27/2026 at approximately 10:52 AM of the kitchenette's refrigerator, revealed an unlabeled and undated eight-ounce styrofoam cup filled with a white liquid.During a surveyor interview immediately following the above observation with Staff C, she acknowledged the unlabeled and undated cup with a white liquid and indicated that it should have been labeled and dated. Additionally, she revealed that it should be discarded.4. Review of the FDA Food Code, 2022 Edition, Section 4-501.11 (A) (B) states in part, EQUIPMENT shall be maintained in a state of repair and condition.EQUIPMENT components such as doors, seals.shall be kept intact, tight, and adjusted.During a surveyor observation on the initial tour of the main kitchen on 1/27/2026 at approximately 10:37 AM, revealed 1 of 3 freezers that had the rubber molding on the bottom portion of the door partially hanging off. Additionally, there was an accumulation of black matter and food particles behind the molding. Further, the freezer's interior white coated finish was scored at the bottom, was discolored, and was flaking off in various locations.During a surveyor interview immediately following the above observation with Staff C, she acknowledged the above observations.5. Review of an undated facility policy titled, POLICY ON FOOD BROUGHT IN BY VISITORS states in part Food or beverage that is brought in from the outside will be monitored by nursing staff for spoilage, contamination and safety.Foods or beverages [NAME] in from the outside will be labeled with resident's name, room number and dated by nursing with the current date the item(s) was brought to the facility for storage.food.will be dated when accepted for storage and discarded after 24 hours.During a surveyor observation on 1/27/2026 at approximately 10:52 AM of the kitchenette's refrigerator, revealed a brown bag labeled with a resident's name that contained three individually wrapped cheese sticks, an opened bag of pepperoni, an unlabeled and undated zip lock style bag containing a pickle, and an unlabeled and undated plastic container that contained unidentifiable cubed red and white food items that was covered with a patchy white film. Additionally, the brown bag failed to include a room number, a received-on date, or a discard by date.During a surveyor interview immediately following the above observation with Staff C, she acknowledged the undated brown bag and various undated food items and revealed that they should have been labeled and dated. Additionally, she acknowledged the patchy white film and revealed the food items should be discarded.

Based on clinical record review and staff interview, the facility failed to inform the resident or 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, psychotropic medications (a medication that affects brain activities associated with mental processes and behavior) for 3 of 5 residents reviewed for unnecessary medications, Resident ID #s 1, 5, and 12.Findings are as follows:Review of the facility policy titled, Medication Administration Safety; Psychotropic Medications and New Medication Orders effective 4/28/2025 states in part, Any and all psychotropic medications require resident or representative consent. Consent must include their awareness of the medication(s) ordered, the side effects to include black box warnings when applicable, and the risk/benefit (R/B) associated with the medications ordered.If verbal consent is received, the name of the representative giving consent shall be documented in the medical record. Consent is necessary prior to administration of these medications.Every effort must be made to attempt nonpharmacological intervention before receiving an order for a psychotropic medication.If/when a new medication is ordered.The resident/representative must be made aware of any new medications that have been ordered and/or any increase in dosage ordered for an existing medication.The progress notes.must show evidence of this notification.1a. Record review revealed Resident ID #5 was admitted to the facility in January of 2023 with a diagnosis including, but not limited to, dementia.Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 6 out of 15, indicating severe cognitive impairment.Review of a care plan focus area dated 8/26/2024 revealed the resident is at risk for experiencing adverse effects related to the daily usage of psychotropic medications.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-Rexulti 0.5 milligrams (mg) every morning-Rexulti 1 mg daily (dose increase from 0.5 mg)-Trazodone 25 mg twice daily-Rexulti 2 mg (dose increase from 1 mg) daily-Memantine 5 mg dailyRecord 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. Further, record review failed to reveal evidence that nonpharmacological interventions were attempted prior to initiating therapy for the above-mentioned psychotropic medications.During a surveyor interview on 1/30/2026 at 11:17 AM with the resident's primary representative, s/he revealed that s/he was unaware of the additions of new psychotropic medications or dose increases to existing psychotropic medications and would expect to have been notified.1b. Record review revealed Resident ID #12 was readmitted to the facility in December of 2024 with a diagnosis including, but not limited to, Alzheimer's disease.Review of an MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, indicating severe cognitive impairment.Review of a care plan focus area dated 3/15/2025 revealed the resident is at risk for experiencing adverse effects related to the daily usage of psychotropic medications.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-Seroquel 200 mg twice daily-Trazodone 25 mg three times daily-Mirtazapine 15 mg at bedtimeRecord review failed to reveal evidence that the resident's representative was informed, in advance, of the addition of new psychotropic medications to the resident's medication 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. Further, record review failed to reveal evidence that nonpharmacological interventions were attempted prior to initiating therapy for the above-mentioned psychotropic medications.1c. Record review revealed Resident ID #1 was readmitted to the facility in February of 2026 with a diagnosis including, but not limited to, schizoaffective disorder (a chronic mental health condition characterized by psychotic symptoms and mood disorders).Review of a care plan focus area dated 6/13/2022 revealed the resident is prescribed psychotropic medications for schizoaffective disorder.Review of a progress note dated 12/30/2025 at 1:52 PM revealed the resident was not sleeping well and the provider prescribed Seroquel 25 mg daily as needed for 14 days.Review of the December 2025 Medication Administration Record revealed the resident was administered Seroquel on 12/30 and 12/31.Record review failed to reveal evidence that the resident was informed, in advance, of the addition of the as needed Seroquel to his/her medication regimen prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident was informed of the risks and benefits, side effects, and/or treatment alternatives. Further, record review failed to reveal evidence that nonpharmacological interventions were attempted prior to prescribing the as needed Seroquel.During a surveyor interview on 1/30/2026 at 12:09 PM with Resident ID #s 1, 5, and 12's physician, he revealed that his expectation for the staff is to attempt nonpharmacological interventions prior to initiating drug therapy.During a surveyor interview on 1/30/2026 at 1:54 PM with the Director of Nursing Services, she revealed that the resident and/or their representatives should be informed of the risks and benefits, and side effects of psychotropic medications. Additionally, she indicated the facility attempts nonpharmacological interventions but was unable to provide evidence that any were attempted for the above-mentioned residents prior to initiating drug therapy. Cross reference F-605

Based on clinical record review and staff interview, the facility failed to ensure that each resident receives adequate monitoring for effectiveness and side effects for the use of psychotropic medications (a medication prescribed that affects brain activities associated with mental processes and behavior) for 5 of 5 residents reviewed for unnecessary medications, Resident #s 1, 5, 12, 13, and 18. Findings are as follows:Review of the facility policy titled, Medication Administration Safety; Psychotropic Medications and New Medication Orders effective 4/28/2025 states in part, .Every effort must be made to attempt nonpharmacological intervention before receiving an order for a psychotropic medication.New medications must be monitored for effectiveness, and ultimately to determine if the newly ordered medication should continue or be discontinued (wither [sic] due to ineffective or it is no longer needed). The IDT [interdisciplinary team] shall ensure there are systems in place to re-evaluate and monitored these newly ordered medications.Care plan interventions shall include monitoring effectiveness of medications on board as well as unwanted side effects of medication.1a. Record review revealed Resident ID #1 was readmitted to the facility in February of 2026 with a diagnosis including, but not limited to, schizoaffective disorder (a chronic mental health condition characterized by psychotic symptoms and mood disorders).Review of his/her care plan revealed the resident is prescribed psychotropic medications for schizoaffective disorder and to monitor and evaluate the medication's effectiveness and side effects and the resident's mood and behaviors.Record review revealed the resident is prescribed the following psychotropic medications:-Lithium carbonate 300 milligrams (mg) twice daily-Olanzapine 7.5 mg at bedtimeRecord review failed to reveal evidence of monitoring for effectiveness and side effects related to the above-mentioned psychotropic medications.1b. Record review revealed Resident ID #5 was admitted to the facility in January of 2023 with a diagnosis including, but not limited to, dementia.Review of a care plan focus area dated 8/26/2024 revealed the resident is at risk for experiencing adverse effects related to the daily usage of psychotropic medications with an intervention to monitor for changes in mood/behavior and to report adverse side effects or ineffectiveness to the provider as needed.Record review revealed the resident is prescribed the following psychotropic medications:-Memantine 5 milligrams (mg) daily-Rexulti 2 mg daily-Seroquel 75 mg daily-Trazodone 25 mg twice dailyRecord review failed to reveal evidence of monitoring for effectiveness and side effects related to the above-mentioned psychotropic medications.1c. Record review revealed Resident ID #12 was readmitted to the facility in December of 2024 with a diagnosis including, but not limited to, Alzheimer's disease.Review of a care plan focus area dated 3/15/2025 revealed the resident is at risk for experiencing adverse effects related to the daily usage of psychotropic medications with an intervention to monitor for changes in mood/behavior and to report adverse side effects or ineffectiveness to the provider as needed.Record review revealed the resident is prescribed the following psychotropic medications:-Seroquel 200 mg twice daily-Trazodone 25 mg three times daily-Mirtazapine 15 mg at bedtime-Olanzapine 2.5 mg twice dailyRecord review failed to reveal evidence of monitoring for effectiveness and side effects related to the above-mentioned psychotropic medications.1d. Record review revealed Resident ID #13 was readmitted to the facility in October of 2025 with a diagnosis including, but not limited to, major depressive disorder.Review of a care plan focus area dated 10/13/2025 revealed the resident is at risk for experiencing adverse effects related to the daily usage of psychotropic medications with an intervention to monitor for changes in mood/behavior and to report adverse side effects or ineffectiveness to the provider as needed.Record review revealed the resident is prescribed the following psychotropic medications:-Buspirone 7.5 mg at bedtime-Venlafaxine 37.5 mg dailyRecord review failed to reveal evidence of monitoring for effectiveness and side effects related to the above-mentioned psychotropic medications1e. Record review revealed Resident ID #18 was readmitted to the facility in October of 2025 with a diagnosis including, but not limited to, bipolar disorder (a chronic mental health condition characterized by manic and depressive episodes).Review of a care plan focus area dated 2/24/2025 revealed the resident is at risk for experiencing adverse effects related to the daily usage of psychotropic medications with an intervention to monitor for changes in mood/behavior and to report adverse side effects or ineffectiveness to the provider as needed.Record review revealed the resident is prescribed the following psychotropic medications:-Clozapine 137.5 mg twice daily-Divalproex 750 mg twice daily-Mirtazapine 15 mg daily-Sertraline 50 mg daily Record review failed to reveal evidence of monitoring for effectiveness and side effects related to the above-mentioned psychotropic medicationsDuring a surveyor interview on 1/30/2026 at 12:09 PM with Resident ID #s 1, 5, 12, 13, and 18's physician, he revealed that his expectation is for the staff to monitor the residents' behavior continuously. Additionally, he would expect nonpharmacological interventions to be attempted prior to initiating drug therapy.During a surveyor interview on 1/29/2026 at 2:22 PM with Registered Nurse, Staff B, she revealed that there is no system in place for documenting residents' behaviors, but if changes in behavior are noted, they are documented and the resident is seen by the psychiatric provider. During a surveyor interview on 1/30/2026 at 1:54 PM with the Director of Nursing Services, she revealed that she would expect behavior monitoring for effectiveness and side effects of the psychotropic medications to be completed but did not indicate how often it should be documented. Additionally, she revealed that an order for nonpharmacological interventions to have been in place and attempted prior to initiating drug therapy. She was unable to provide evidence that the facility ensured that each resident received adequate monitoring for effectiveness and side effects of the psychotropic medications for the above-mentioned residents.Cross reference F-552

Based on clinical record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs for 1 of 1 resident reviewed with a physician's order for a fluid restriction, Resident ID #13. Findings are as follows:Record review revealed that the resident was admitted to the facility in October of 2025 with diagnoses including, but not limited to, hypo-osmolality and hyponatremia (a condition where there is too much water and not enough salt in the blood, making the blood too watery).Record review revealed the following dietary physician's orders with a start date of 10/14/2025:- .THIN LIQUIDS NO FREE WATER 2/2 [secondary to] FLUID RESTRICTION AT THIS TIME.- .Diet.regular texture ***FLUID RESTRICTION***With Meals.Further record review failed to reveal evidence that a comprehensive care plan was developed to address the fluid restriction. During a surveyor interview on 1/30/2026 at 1:45 PM with the Director of Nursing Services, she revealed that she would expect the physician's order for the fluid restriction to be included in the resident's comprehensive care plan.

Based on clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program (IPCP) that includes, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic are prescribed the appropriate antibiotic for 2 of 5 residents reviewed for antibiotic use, Resident ID #s 11 and 22. Findings are as follows:According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Perform antibiotic 'time outs.' .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions:Does this resident have a bacterial infection that will respond to antibiotics?If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration?Can the spectrum of the antibiotic be narrowed or the duration of therapy shortened (i.e., de-escalation)?Would the resident benefit from additional infectious disease/antibiotic expertise to ensure optimal treatment of the suspected or confirmed infection . 1. Record review revealed that Resident ID #11 was readmitted to the facility in June of 2025 with diagnoses including, but not limited to, pneumonia, acute respiratory disease, and dysphagia (trouble swallowing). Record review revealed the following physician's orders:-mupirocin 2% (a topical antibiotic used on the skin to treat or prevent bacterial infections) Cleanse left great toe with normal saline, pat dry and apply mupirocin ointment and cover with a Band-Aid from 1/3/2026 through 1/8/2026. -mupirocin 2% (a topical antibiotic used on the skin to treat or prevent bacterial infections) Cleanse left great toe with normal saline, pat dry, apply skin prep, apply mupirocin ointment and cover with a bordered gauze from 1/8/2026 through 1/22/2026. Additional record review failed to reveal evidence that an antibiotic time out or a review at day two or three was conducted for the mupirocin. 2. Record review revealed that Resident ID #22 was readmitted to the facility in June of 2025 with diagnoses including, but not limited to, pneumonia, acute respiratory failure, epilepsy (a seizure disorder), and repeated falls. Record review revealed the following physician's orders:- azithromycin (an antibiotic) 250 milligrams (mg)- Take two tablets once daily on 12/23/2025- azithromycin 250 mg- Take one tablet daily for four days 12/24/2025 through 12/27/2025ceftriaxone (an antibiotic)- One gram daily from 12/24/2025 to 12/30/2025Additional record review failed to reveal evidence that an antibiotic time out or a review at day two or three was conducted for the azithromycin and ceftriaxone. During a surveyor interview conducted on 1/30/2026 at 11:41 AM with the Director of Nursing Services (DNS), she was unable to provide evidence that antibiotic timeouts or antibiotic reviews had been completed. The DNS further acknowledged that she was unfamiliar with the antibiotic timeout process but stated she would discuss this with the Infection Preventionist and initiate completion of antibiotic timeouts moving forward.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 resident reviewed with a physician's order for staff assistance with meals at all times, Resident ID #7.Findings are as follows:Record review revealed the resident was readmitted to the facility in December of 2021 with a diagnosis including, but not limited to, food in respiratory tract causing injury.Review of a Minimum Data Set assessment dated [DATE] revealed that the resident required partial/moderate assistance of one staff member for eating.Review of a physician's order dated 11/25/2025 revealed to assist the resident with meals at all times twice daily between 7:00 AM through 3:00 PM and 3:00 PM through 11:00 PM.Surveyor observations revealed the resident was eating independently in a common area without staff assistance on the following dates and times:-1/27/2026 at 12:50 PM-1/28/2026 continuous surveyor observation from 12:48 PM to 1:14 PMReview of the January 2026 Treatment Administration Record revealed the above-mentioned physician's order was documented as completed on the following dates and times:-1/27/2026 7:00 AM - 3:00 PM shift-1/28/2026 7:00 AM - 3:00 PM shift documented as completed by Registered Nurse, Staff F.During a surveyor interview on 1/28/2026 at 2:37 PM with Staff F, he revealed that he documented the physician's order to provide the resident assistance with meals at all times on 1/28/2026 7:00 AM - 3:00 PM as completed, however he acknowledged that he did not provide the resident with assistance when eating. He further revealed that the task is delegated to the Nursing Assistants (NA). When the surveyor inquired further, Staff F revealed that he was unaware of what NA had assisted the resident with eating for the lunch meal and acknowledged that he documented the physician's order to assist with meals at all times as completed although he was unaware of who, if anyone, assisted the resident with eating during that time.During a surveyor interview on 1/29/2026 at approximately 3:06 PM with the Director of Nursing Services, she revealed that that she would expect staff to have followed the physician's order and documented accurately in the resident's record.

Based on surveyor observations, clinical record review, and staff interview, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 3 medication carts reviewed.Findings are as follows:Record review of the facility policy titled, Medication Administration Safety Program (MASP) - Medication Cart states in part, .The cart is to be checked periodically for expired medications. If an expired medication is noted during medication administration, the medication should not be given and removed from the cart and replaced.Medication labels are not to be altered, modified or marked in any way other than for noting the date that the product was opened.Inhalers shall be labeled accordingly and stored per manufacturer's guidelines.During a surveyor observation on 1/28/2026 at 10:24 AM, of the first-floor Certified Medication Technician (CMT) medication cart, in the presence of CMT, Staff E, revealed the following:-Wixela inhalation device opened and out of the foil package, with the dose counter reading of 57. Additionally, the device was not labeled with the date it was opened.-Wixela inhalation device opened and out of the foil pouch, with the dose counter reading of 5, labeled with the date opened as 10/23/2025.Review of the manufacturer's guidance revealed that the device should be discarded one month after removal from the foil pouch or when the dose counter reads zero. -Fluticasone propionate inhalation device opened and out of the foil pouch, with the dose counter reading of 45, labeled with the date opened as 10/23/2025.Review of the manufacturer's guidance revealed that the device should be discarded two months after opening the foil pouch or when the dose counter reads zero.-One opened bottle of Allergy Relief fexofenadine hydrochloride 180 milligrams, labeled without a visible expiration date. During a surveyor interview with Staff E immediately following the above-mentioned observations, she acknowledged the findings. Additionally, she stated that the Allergy Relief is house stock and a resident is currently prescribed this medication.During a surveyor interview on 1/28/2026 at approximately 3:00 PM, with the Director of Nursing Services, she was unable to provide evidence that the facility stored and labeled drugs accordingly per the facility's policy and professional principles.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed with a physician's order to obtain a urine specimen, Resident ID #5, for 2 of 5 residents reviewed for unnecessary medications, Resident ID #s 6 and 24, for 1 of 1 resident reviewed with a physician's order for a fluid restriction, Resident ID #13, and for 1 of 1 resident reviewed with a suprapubic catheter (SP tube, a flexible rubber tube inserted through the abdomen into the bladder to drain urine), Resident ID #11. 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.1. Record review revealed Resident ID #5 was admitted to the facility in January of 2023 with a diagnosis including, but not limited to, dementia.Review of a progress note dated 1/13/2026 at 4:36 PM revealed Resident ID #5 was experiencing increased periods of agitation and confusion, and the provider was notified. Additionally, the provider ordered blood work and a urine specimen to be obtained to rule out an acute medical condition. Review of a physician's order dated 1/14/2026 revealed to obtain a urine specimen for culture and analysis.Review of the progress notes revealed the following:-1/14/2026 at 5:13 AM: The resident refused to provide a urine sample-1/15/2026 at 10:14 AM authored by Registered Nurse, Staff B: Unable to obtain a urine specimenRecord review failed to reveal evidence that the urine specimen was obtained as ordered, or that the provider was notified the urine specimen was unable to be obtained.During a surveyor interview on 1/29/2026 at 1:23 PM with Staff B, she revealed that the urine specimen was not obtained and could not recall if the provider was notified. Additionally, she indicated that the provider should be informed and notification should be documented in the progress notes.During a surveyor interview on 1/30/2026 at 12:09 PM with the resident's physician, he could not recall if he was informed that the resident's urine specimen was unable to be obtained and would expect to have been notified.During a surveyor interview on 1/30/2026 at 1:54 PM with the Director of Nursing Services (DNS), she revealed that she would have expected the resident's urine specimen to be obtained as ordered, and for staff to have notified the provider if the urine specimen was unable to obtained. Additionally, she would expect staff to document notification in the progress notes.2. Record review revealed Resident ID #11 was readmitted to the facility in June of 2025 with a diagnosis including, but not limited to, neuromuscular dysfunction of the bladder (the loss of normal bladder control due to nerve damage).Review of a care plan focus area dated 12/3/2025 revealed the resident requires Enhanced Barrier Precautions (EBP, wearing personal protective equipment that includes a gown and gloves when performing high contact care activities such as assisting with washing and personal hygiene) due to the resident having an SP tube.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident requires substantial/maximum assistance for personal hygiene.Review of a physician's order dated 9/12/2025 revealed to follow EBP every shift and for staff to comply with the signage posted for EBP.Review of the EBP signage posted on the resident's door throughout the survey process from 1/27/2026 through 1/30/2026 revealed to wear a gown and gloves for high-contact care activities including, but not limited to, dressing, bathing, providing hygiene, and changing briefs.During a surveyor observation on 1/27/2026 at 11:36 AM, Nursing Assistant, Staff D, was observed in the resident's room adjusting the bed linens while wearing only one glove and was not wearing a gown. Staff D then closed the resident's door.During a surveyor interview immediately following the above-mentioned observation with Staff D, she revealed that she had completed personal care for the resident but did not wear a gown. Additionally, she acknowledged the EBP signage posted on the resident's door but indicated that she was told by staff that a gown was not required for personal care.During a surveyor interview on 1/28/2026 at 11:38 AM with the Infection Preventionist, Staff B, she revealed that she would expect staff to have worn a gown when assisting the resident with his/her personal care.3a. Record review revealed Resident ID #6 was admitted to the facility in September of 2023 with diagnoses including, but not limited to, stroke and seizures.Record review revealed the following physician's medication orders:-Gabapentin (a medication prescribed to help control seizures) 300 milligrams (mg) three times daily-Systane Nighttime ointment (an ointment prescribed to treat dry eye) apply a small amount to each eye at bedtime-TheraTears eye drops (lubricating eye drops for dry eye) apply one drop to each eye twice daily and twice daily as neededReview of the January 2026 Medication Administration Record (MAR) revealed the resident refused the above-mentioned medications on the following dates:-Gabapentin: 1/1, 1/2, 1/3, 1/4, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/13, 1/14, 1/15, 1/16, 1/17, 1/18, 1/19, 1/20, 1/21, 1/22, 1/23, 1/24, 1/25, 1/26, 1/27-Systane ointment: 1/1, 1/2, 1/3, 1/4, 1/5, 1/6, 1/7, 1/9, 1/10, 1/11, 1/12, 1/13, 1/16, 1/17, 1/19, 1/20, 1/21, 1/22, 1/24, 1/25-TheraTears: 1/1,1/2 (both), 1/3 (both), 1/4 (both), 1/5 (both), 1/7 (both), 1/9 (both), 1/11 (both), 1/12 (both), 1/14 (both), 1/16 (both), 1/17, 1/18 (both), 1/19, 1/21, 1/22 (both) 1/23 (both), 1/24, 1/25 (both), 1/26 (both)Record review failed to reveal evidence that a provider was notified that the resident was not receiving the above-mentioned medications as ordered due to the resident's frequent refusals.During a surveyor interview on 1/28/2026 at 12:47 PM with Medication Technician, Staff E, she revealed that the resident refuses his/her medications often and she marks it as refused. She failed to indicate that she would and/or should have notified the nurse and/or provider of the resident's frequent refusals for the above-mentioned medications.During a surveyor interview on 1/28/2026 at 2:06 PM with the DNS, she revealed that she would expect the resident's frequent medication refusals to be communicated to the nurse and addressed with the provider, and for staff to document it in the progress notes.3b. Record review revealed Resident ID #24 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, dementia.Review of a physician's order revealed to administer hydroxyzine pamoate (a medication prescribed to help treat anxiety and mood disorders) 25 mg three times daily.Review of the January 2026 MAR revealed the resident did not receive his/her hydroxyzine as ordered on the following dates and times:-1/4 1:00 PM and 6:00 PM-1/5 8:00 AM, 1:00 PM, and 6:00 PM-1/7 8:00 AM, 1:00 PM, and 6:00 PM-1/11 8:00 AM, 1:00 PM, and 6:00 PM-1/14 8:00 AM, 1:00 PM, and 6:00 PMRecord review failed to reveal evidence that a provider was notified that the resident was not receiving his/her hydroxyzine as ordered on the above-mentioned dates and times.During a surveyor interview on 1/28/2026 at 2:09 PM with the DNS, she was unable to provide evidence that the resident received his/her hydroxyzine as ordered.4. Record review revealed Resident ID #13 was admitted to the facility from an acute care hospital in October of 2025 with diagnoses including, but not limited to, hypo-osmolality and hyponatremia (a condition where there is too much water and not enough salt in the blood, making the blood too watery).Record review revealed the following dietary physician's orders with a start date of 10/14/2025:- .THIN LIQUIDS NO FREE WATER 2/2 [secondary to] FLUID RESTRICTION AT THIS TIME.- .Diet regular texture ***FLUID RESTRICTION***With Meals.Further record review failed to reveal evidence of the amount of fluids to be restricted to per the above order Record review of a progress note dated 10/29/2025 at 2:53 PM authored by Registered Nurse Staff B, states in part, .MD [medical doctor] also contacted regarding resident's fluid restriction. Information regarding the limitation is unclear but was due to low sodium.Further record review failed to reveal evidence that the physician's order for fluid restrictions was clarified after the provider was notified on 10/29/2025.During a surveyor interview on 1/28/2026 at 12:58 PM, with Medication Technician (MT) Staff E, she stated she was aware that the resident is on fluid restrictions but was unable to state the specifics of the restriction. During a surveyor interview on 1/30/2026 at 12:16 PM, with the resident's physician, he acknowledged that the order for fluid restrictions did not include specific limitations and stated the order should include a specific amount of fluid to be restricted in a specified amount of time.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that the resident's legally authorized representative (guardian) was invited to and allowed to participate in the care planning process for 1 of 1 resident reviewed with a court-appointed guardian, Resident ID #12. Additionally, the facility failed to ensure that the required comprehensive care plan was reviewed and revised by the interdisciplinary team after an incident of resident-to-resident abuse occurred for 2 of 2 residents reviewed, Resident ID #s 24 and 28. Findings are as follows:1. Record review revealed Resident ID #12 was readmitted to the facility in December of 2024 with a diagnosis including, but not limited to, Alzheimer's disease.Record review of a Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 3 out of 15, indicating severely impaired cognition.Further record review revealed that the resident's primary representative is his/her legally appointed guardian.During a telephone interview on 1/28/2026 at 9:31 AM with the resident's guardian, it was revealed that s/he had not been invited to any meetings to discuss the resident's care in over a year.Record review revealed that 2025 care conferences were held on the following dates:-2/10/2025-6/5/2025-9/17/2025-12/16/2025Further record review revealed that the resident's guardian was only involved in the meeting that was held on 2/10/2025. Additionally, there is no evidence that s/he was invited to or allowed to participate in the three out of four care conferences that were held.During a surveyor interview on 1/30/2026 at 9:00 AM with the Social Worker, she was unable to provide evidence of attempts to notify or involve the resident's guardian in the care planning process, thus limiting his/her ability to participate in the development, review, and revision of the resident's person-centered care plans.2. Record review of a facility policy titled, Abuse prohibition dated August of 2020 states in part, .PROCEDURE.Investigation It is the DNS [Director of Nursing]/designee's responsibility to act immediately to.Carry out proper staff interventions and include all interventions in the Resident's care plan.Review of a facility reported incident submitted to the Rhode Island Department of Health on 11/9/2025 revealed that Resident ID #28 struck Resident ID #24 with his/her fist causing an abrasion to his/her forehead.2a. Record review revealed that the victim, Resident ID #24, was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, dementia.Record review revealed a progress note dated 11/9/2025 at 8:36 PM which indicated that the resident was involved in an altercation with another resident (Resident ID #28). Record review of a care plan initiated on 12/16/2024, revealed a problem area indicating s/he has had increased episodes of sexually inappropriate behavior towards other residents. Interventions include but are not limited to, when the resident is in the dining room s/he should be seated away from residents of the opposite gender.During a surveyor observation on 1/28/2026 at approximately 2:30 PM of surveillance video still footage, in the presence of another surveyor, the DNS, and the Administrator revealed the following:- On 11/9/2025 at 2:05 PM Resident ID #24 was observed to be seated in the middle of two residents of the opposite gender, one being Resident ID #28. Additionally, two staff members were observed to be in the area and did not intervene and assist Resident ID #24 with seating away from the residents of the opposite gender as indicated in his/her care plan.During a surveyor interview on 1/28/2026 at approximately 2:55 PM, with the DNS in the presence of another surveyor, the social worker, and the Administrator, the DNS acknowledged that Resident ID #24 was seated between two residents of the opposite gender while two staff members were present. Additionally, they were unable to provide evidence that Resident ID #24's care plan was followed as indicated when s/he was seated next to Resident ID #28, a resident of the opposite gender, which resulted in a resident-to-resident abuse incident between them.2b. Record review revealed that the perpetrator, Resident ID #28, was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, dementia with mood and behavioral disturbance and unspecified psychosis not due to a substance or known physiological condition. Record review revealed a care plan with a start date of 1/29/2024 edited on 1/27/2026, with a problem area indicating his/her mood has resulted in a resident-to-resident incident. Further record review failed to reveal evidence that the care plan was revised to include interventions relative to the resident-to-resident abuse incident that occurred on 11/9/2025.During a surveyor interview on 1/29/2026 at 11:01 AM with the DNS, she revealed that she would expect the resident's care plan to have been updated with new interventions. Cross reference F-600

Based on surveyor observation, clinical record review, and staff interview, the facility failed to protect the residents' right to be free from abuse for 1 of 1 resident reviewed for abuse, relative to a physical altercation between Resident ID #s 24 and 28. Findings are as follows:Review of a facility policy titled, Abuse prohibition dated August of 2020 states in part, .It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are to be free from abuse.DEFINITIONS.Abuse: Willful infliction of injury.resulting in physical harm.Examples of abuse.Physical-Hitting.Review of a facility reported incident submitted to the Rhode Island Department of Health on 11/9/2025 revealed that Resident ID #28 struck Resident ID #24 with his/her fist causing an abrasion to his/her forehead.Record review revealed that the victim, Resident ID #24, was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, dementia.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. Review of a care plan focus area dated 12/16/2024 revealed the resident has had increased episodes of sexually inappropriate behavior towards other residents. Additionally, interventions include, but are not limited to, seat the resident away from residents of the opposite gender when s/he is in the dining room. Record review revealed that the perpetrator, Resident ID #28, was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, dementia with mood and behavioral disturbance and unspecified psychosis not due to a substance or known physiological condition. Review of an MDS assessment dated [DATE] revealed a BIMS score of 1 out of 15, indicating severe cognitive impairment. Additionally, it revealed s/he has verbal behavioral symptoms directed towards others that occurred 1 to 3 days of a 7-day review period.Record review of a progress note dated 11/9/2025 at 8:36 PM revealed that Resident ID #24 was involved in an altercation with Resident ID #28.Review of an Event Report dated 11/9/2025 revealed that Resident ID #s 24 and 28 were sitting in the community room. Resident ID #24 attempted to touch Resident ID #28's genital area and in response was struck in the eye and forehead by Resident ID #28. Additionally, Resident ID #24 sustained a small laceration to his/her left forehead and a scratch under his/her right eye that was bleeding. During a surveyor observation on 1/28/2026 at approximately 2:30 PM of surveillance video footage, in the presence of another surveyor, the Director of Nursing Services (DNS), and the Administrator, revealed the following:-11/9/2025 at 2:05 PM: Resident ID #24 was observed to be seated in the middle of two residents of the opposite gender, one being Resident ID #28. Additionally, two staff members were observed to be present in the area and failed to separate Resident ID #24 from the residents of the opposite gender as indicated in his/her care plan.During a surveyor interview on 1/28/2026 at approximately 2:55 PM, with the DNS in the presence of another surveyor, the Social Worker, and the Administrator, the DNS acknowledged that Resident ID #24 was seated between two residents of the opposite gender while two staff members were present. Additionally, they were unable to provide evidence that Resident ID #24's care plan was followed thus resulting in Resident ID #28 striking and injuring Resident ID #24.During a surveyor interview on 1/28/2026 at approximately 2:10 PM with Nursing Assistant, Staff A, she revealed that she was working the day the altercation occurred. She further revealed that she did not witness the altercation between the residents, however, she did observe Resident ID #24 with a cut to his/her forehead that was bleeding. Additionally, she revealed that she was told that Resident ID #24 attempted to touch Resident ID #28's groin, but after the facility staff had reviewed the surveillance video footage, it was determined that Resident ID #24 did not attempt to touch Resident ID #28 at all.During a surveyor interview on 1/29/2026 at 10:25 AM with Registered Nurse, Staff B, she revealed that Resident ID #s 24 and 28 don't mix. She revealed that staff try to keep both residents separated. Additionally, she revealed that Resident ID #24 is to be kept away from residents of the opposite gender which has been in effect for a long time.During a surveyor interview on 1/29/2026 at 9:53 AM with the Administrator, he was unable to provide evidence that Resident ID #24 was kept free from physical abuse.Cross reference F-657

Based on clinical record review and staff interview, the facility failed to provide notice of the bed-hold policy to a resident in writing when a resident is hospitalized and return to the facility is anticipated for 1 out of 1 resident reviewed for a hospital transfer, Resident ID #1. Findings are as follows:Record review of an undated facility document titled RESIDENT BED HOLD NOTICE states in part, .BED HOLD POLICY Whenever a resident is transferred from this facility for the purposes of hospitalization.the resident and / or representative must be informed of the facility's policy concerning holding the bed.Record review revealed that the resident was readmitted to the facility in November of 2025 with a diagnosis including, but not limited to, acute respiratory failure with hypoxia (a condition of low oxygen in the blood). Record review of a Discharge Minimum Data Set Assessment revealed that the resident had an unplanned discharge from the facility and was transferred to an acute care hospital on 1/3/2026 and s/he was anticipated to return to the facility. Further record review failed to reveal evidence that the facility provided the resident with written notice of the bed-hold policy at the time of his/her transfer to the hospital on 1/3/2026.During a surveyor interview on 1/30/2026 at 12:08 PM with the Social Worker, she was unable to provide evidence that the resident was notified in writing of the bed-hold policy when s/he was transferred to the hospital on 1/3/2026.

Based on clinical record review and staff interview, the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually.Findings are as follows:Record review revealed a document titled, Facility Assessment last updated 9/30/2025, which revealed the following participants were involved in the completion of the Facility Assessment:- Administrator- Director of Nursing Services- Social Worker- Medical Director- A residentFurther review of the Facility Assessment failed to reveal evidence that the facility solicited and considered input from a resident representatives and family members, as required per the regulation.During a surveyor interview on 1/30/2026 at 9:44 AM with the Administrator, he was unable to provide evidence that the Facility Assessment included input from a resident representative and or a family member and indicated that he was unaware it was a requirement.

Based on surveyor observation, record review, staff, and resident interviews, it has been determined that the facility failed to ensure that a resident received adequate supervision to prevent an elopement for 1 of 3 residents reviewed Resident ID #1.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 9/14/2025 reveals that Resident ID #1 left the facility without following the leave of absence policy and procedure. Record review revealed the resident was admitted to the facility in March of 2023 with diagnoses including, not limited to, bipolar disorder and epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures).Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 14 out of 15 indicating the resident's cognition is intact. Additional review of the MDS revealed the resident ambulates independently.Record review revealed a progress note dated 9/13/2025 at 10:38 PM, revealed the resident left the facility and went to the hospital to visit with his/her relative. Record review of a care plan revised on 9/13/2025 after the resident retuned to the facility from visiting his/her relative, revealed the resident is at risk for elopement and staff interventions including, but not limited to, ensuring staff awareness of the resident's wander risk and ensuring that the LOA policy and procedure is being followed. Record review revealed the following nursing progress notes from 9/14/2025, the day after the resident left the facility without following the LOA policy: 9:00 AM- the facility received a call from a police department that was approximately 12 miles from the facility across the state line. The police indicated to the facility that Resident ID #1 was at their station, and they would be accompanying him/her back to the facility.11:53 AM, revealed the resident left the facility without following the LOA policy and procedure, s/he returned to the facility accompanied by the police on 9/14/2025 at approximately 9:20 AM, and the resident was sent to a local hospital for evaluation.A surveyor observation on 9/17/2025 at 10:28 AM of the staff desk area adjacent to the front door revealed a key attached to a wooden pad visible on a shelf that was accessible to the residents. During a simultaneous surveyor observation and interview on 9/17/2025 at 12:45 PM with Staff A, she acknowledged the key on the shelf and that the key is accessible to the residents. She indicated it was the key for the rear door on the first floor. Additionally, she revealed that the key for the rear door is kept either in the desk drawer, at the staff desk, or on the shelf as observed. Staff A revealed that the last time she had seen the resident ambulating in the hall was on 9/15/2025 at approximately 7:50 AM and indicated that this may have been the key the resident used on 9/14/2025 to exit the facility and that the location of the key had not changed since the resident eloped from the facility on 9/14/2025. During a surveyor interview with the resident on 9/17/2025 at 10:40 AM, s/he revealed that on 9/13/2025 s/he had signed the LOA log to go out to see his/her relative at a hospital accompanied by a family member. S/he revealed that they returned to the facility on the night of 9/13/2025 and s/he did not call the facility to notify them that s/he would be out for an extended period. The resident revealed that on 9/14/2025 at approximately 8:10 AM, s/he removed the key from the staff desk, unlocked the rear door, and left the facility via a bus to see his/her relative at the hospital. S/he indicated that after visiting with his/her relative, s/he went to the police station that was approximately a block from the hospital and asked for a ride back to the facility. The resident indicated that s/he was out of the facility for less than two hours and returned to the facility accompanied by the police and is aware that s/he did not follow the facility's LOA policy. Additionally, the resident indicated that since this incident, s/he is not allowed to leave the facility without being accompanied by a family or staff member.During a surveyor interview on 9/17/2025 at 11:00 AM with Registered Nurse, Staff B, she acknowledged that the above-mentioned LOA log entries were not completed in its entirety, as required. Additionally, Staff B acknowledged that the LOA log should have been signed off by the nurse on duty prior to the resident leaving the facility and upon his/her return.Surveyor review of the facility's video surveillance footage on 9/17/2025 at 1:25 PM in the presence of the Administrator, revealed the resident was walking toward the staff desk area adjacent to the front entrance on 9/14/2025 at 8:12 AM and walked back with the key in his/her hand. The resident then opened the exit door at the rear end of the hall on the first floor, left the key in the door, and exited the facility on 9/14/2025 at 8:14 AM. During a surveyor interview on 9/17/2025 at 1:35 PM with the Director of Nursing Services (DNS), she indicated that the resident had been made aware on the evening of 9/13/2025 that s/he was no longer allowed to leave the facility unaccompanied because of his/her non-compliance to the facility's LOA policy. The DNS indicated that on 9/14/2025 the resident left the facility unknown to the staff until they were notified by the police department. She indicated that the resident had used the key that was at the staff desk area to unlock the door. The DNS acknowledged that the location of the key had not been changed after this incident and that it remained at the same location where the resident had removed it on the date of the incident.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 3 of 4 residents reviewed for side rails, Resident ID #s 11, 21, and 25. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Last revised 8/8/2024, states in part, .Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body .Facilities must also conduct routine preventive maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair . 1. Record review revealed that Resident ID #11 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, osteoarthritis, and joint disorders. During surveyor observations on the following dates and times the resident was observed with 2 half side rails on his/her bed: -10/1/2024 at 9:59 AM -10/2/2024 at 11:05 AM -10/3/2024 at 8:45 AM 2. Record review revealed that Resident ID #21 was readmitted to the facility in August of 2023 with diagnoses including, but not limited to, hemiplegia (one sided paralysis or weakness) affecting the right dominant side. During surveyor observations on the following dates and times the resident was observed with 2 half side rails on his/her bed: 10/1/2024 at 8:48 AM and 11:40 AM 10/2/2024 at 9:49 AM 10/3/2024 at 9:26 AM 3. Record review revealed that Resident ID #25 was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, spinal stenosis (narrowing of the space inside of the spinal column) and a burst fracture (a serious spinal injury that occurs when a vertebra breaks into multiple pieces after being crushed by a strong force) of T9-T10 vertebrae. During surveyor observations on the following dates and times the resident was observed with 2 half side rails on his/her bed: 10/1/2024 at 8:40 AM and 10:44 AM 10/3/2024 at 8:47 AM, 9:12 AM and 11:59 AM During a surveyor interview with the resident on 10/1/2024 at 10:44 AM, s/he revealed that s/he uses the bed rails for turning and repositioning in bed. Record review failed to reveal evidence that entrapment assessments were completed for the above-mentioned residents. During a surveyor interview on 10/3/2024 at 1:38 PM with the Director of Nursing Services, she could not provide evidence that the entrapment assessments were completed.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight for 1 of 4 residents reviewed for significant weight loss and/or gain, Resident ID #9. Findings are as follows: Record review of the facility's policy titled, Weight Monitoring and Weight Loss/Gain Protocol states in part, .Procedure: Residents who are at risk for a nutritional decline are to be weighed weekly .How to weigh the resident .6. Weights that are + [plus] or minus 3 pounds from the last reading must be reported to the nurse who will then be required to supervise an immediate re-weigh to double check the accuracy of the reading. The nurse is to initial the supervised reading to verify accuracy .a significant weight loss/gain is defined as a difference of 3 pounds or more in one week (if resident on weekly weights); a loss/gain of 5% or greater within one month .WHEN A SIGNIFICANT WEIGHT LOSS IS NOTED, THE FOLLOWING INTERVENTIONS MUST OCCUR:1 Reweigh the residents who are reported to have a significant weight loss in order to assess the accuracy of the weight. The reweight shall be done within 24 hours .If the re-weigh is accurate and there has been a significant weight loss/gain, nursing must notify: physician, dietician, DNS [Director of Nursing Services] . Record review revealed the resident was admitted to the facility in December of 2011 with diagnoses including, but not limited to, diabetes (a chronic disease that occurs when the body has too much glucose, or blood sugar, in the blood) and dementia. Review of a care plan dated 12/6/2023 revealed, the resident is a nutritional risk due to dysphagia (difficulty in swallowing) and requires a mechanical soft diet. Staff interventions include, but are not limited to, monitoring the resident's weights as ordered. Review of a physician's order dated 7/12/2024 revealed an order to obtain weekly weights on Tuesdays and if the weight is plus or minus 3 pounds (lbs.) from their previous weight, the resident should be re-weighed. Review of a document titled Vital signs: Weight revealed the following weights were obtained: - 8/20/2024: 166 lbs. - 8/27/2024: 150 lbs. - 9/3/2024: 166 lbs. - 9/10/2024: 183 lbs. - 9/17/2024: 164 lbs. Record review revealed the resident had the following documented significant weight losses: - 8/20/2024 to 8/27/2024: 16 lb. weight loss, which is 9.64% in one week. - 9/10/2024 to 9/17/2024: 19 lb. weight loss, which is 10.38% in one week. Record review revealed the resident had the following documented significant weight gains: - 8/27/2024 to 9/3/2024: 16 lb. weight gain, which is 9.64% in one week. - 9/3/2024 to 9/10/2024: 17 lb. weight gain, which is 10.24% in one week. Record review failed to reveal evidence the resident was re-weighed within 24 hours of the above-mentioned dates when s/he had a documented significant weight loss or weight gain, as indicated in the facility's policy and per the physician's order. Record review revealed the resident was last evaluated by the dietician on 7/15/2024 and has not been revaluated since the above weight discrepancies . Additional record review failed to reveal evidence that the physician, the dietician, and the Director of Nursing Services (DNS) were notified of the significant weight losses or weight gains, as indicated in the facility's policy. During a surveyor interview on 10/3/2024 at 1:29 PM with the primary physician, he acknowledged the weights documented were indicative of significant weight loss and weight gain. However, he could not provide evidence of being notified by the staff of the resident's significant weight losses or gains. The physician further indicated that he would expect the nurse to re-weigh the resident to ensure the weights were accurate. During a surveyor interview on 10/3/2024 at 1:42 PM with the DNS, she indicated that she would expect the staff to re-weigh the resident if the weights were up or down 3 lbs. from the previous weight obtained. Additionally, the DNS could not provide evidence that the physician was notified of the documented significant weight losses or gains, as indicated in the facility's policy. During a subsequent interview on 10/3/2024 at 1:50 PM with the Registered Dietician, she acknowledged that she was not aware of the resident's significant weight losses or weight gains. Additionally, the dietician further indicated that she has recently been hired and has not assessed this resident since she began working at the facility.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms, and 1 of 2 medication carts observed. Findings are as follows: Review of a facility policy titled, .Storage and expiration dating of medication and biological's last revised on [DATE] states in part, .Facility should ensure that medications and biological's that .have an expired date on the label .have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier .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 . 1. During a surveyor observation of the 1st floor medication storage room on [DATE] at 9:10 AM, in the presence of Registered Nurse, Staff A, the following was revealed: - A 10 dose box of Fluzone (a flu vaccination) vaccine; with 5 doses remaining in the box, with a manufacturer's expiration date of ,d+[DATE] - A 10 dose box of High Dose Fluzone vaccine; with 5 doses remaining in the box, with a manufacturer's expiration date of ,d+[DATE] During a surveyor interview immediately following the observation with Staff A, she acknowledged that the above-mentioned vaccinations were expired. 2. During a surveyor observation of the 1st floor Certified Medication Technician medication cart on [DATE] at 1:30 PM, in the presence of Staff A, the following was revealed: -2 bottles of Latanoprost Solution (an eye drop used to treat glaucoma) 0.005% opened and undated. Manufacturer's instructions indicate to discard the eye drops 6 weeks after opening. -1 Wixela (an inhaler used to treat asthma),d+[DATE] micrograms (mcg), opened (not in a foil pouch) and undated. Manufacturer's instructions indicated to discard 1 month after removal from the foil pouch. -2 Trelegy Ellipta (an inhaler used to treat asthma) ,d+[DATE].5 mcg inhalers, opened and undated. Manufacturer's instructions indicate to discard 6 weeks after opening. During a surveyor interview immediately following the above observations with Staff A, she acknowledged that the above-mentioned medications were opened and undated and that they should be dated when opened. During a surveyor interview on [DATE] at 1:52 PM with the Director of Nursing Services, she acknowledged that the Fluzone vaccines were expired. She further revealed that she would expect the staff to date medications when opening them and discard them appropriately based on the manufacturer's instructions.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 2 residents reviewed with physician orders for quarterly fall assessments, Resident ID #s 7 and 9, and 2 of 5 residents reviewed with psychiatric recommendations, Resident ID #s 9 and 21. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1a. Record review revealed Resident ID #9 was admitted to the facility in December of 2011 with diagnoses including, but not limited to, dementia with mood disturbance and major depressive disorder. Review of a physician's order dated 1/30/2024 revealed an order for fall assessments to be completed quarterly and documented in the resident's record. Record review failed to reveal evidence that fall assessments had been completed quarterly as ordered, the last fall assessment was documented on 12/26/2023. 1b. Record review revealed Resident ID #7 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, polyarthritis (arthritis in five or more joints at the same time), fibromyalgia (a chronic condition that causes widespread pain and tenderness in the body), muscle weakness, and a history of falling. Review of a physician's order dated 3/13/2024 revealed an order for fall assessments to be completed quarterly and documented in the resident's record. Record review revealed that a fall assessment was completed on admission in March of 2024. Additional record review failed to reveal evidence that a quarterly fall assessment was completed in June 2024, as ordered. 2a. Review of a document titled, Psychiatric Evaluation & Consultation dated 9/11/2024 revealed, Resident ID #9 was seen by a practitioner on this date for a follow up visit related to agitation and behavioral disturbance. Additional review of this consultation revealed a recommendation to restart Quetiapine (an antipsychotic medication that is used to treat mental and mood disorders) 25 milligrams (mg) daily, as needed for agitation, for 14 days. Record review failed to reveal evidence the physician was notified of the psychiatric recommendation to restart the resident on Quetiapine 25 mg daily, as needed. 2b. Record review revealed Resident ID #21 was readmitted to the facility in August of 2023 with diagnoses including, but not limited to, schizophrenia and generalized anxiety disorder. Review of a document titled, Psychiatric Evaluation & Consultation dated 9/2/2024 revealed, Resident ID #21 was seen by a practitioner on this date for a follow up and routine psychiatric evaluation related to complaints of depression. Additional review of this consultation revealed a recommendation for melatonin (a medication used to treat insomnia). Record review failed to reveal evidence the physician was notified of the psychiatric recommendation for melatonin. During a surveyor interview on 10/4/2024 at 1:58 PM with the residents' primary care physician, he indicated that he would expect the staff to notify him of any psychiatric recommendations. He further stated, I have no recollection of these recommendations. Additionally, he indicated that he would expect Resident ID #9's quarterly fall assessments to be completed, as ordered. During a surveyor interview on 10/4/2024 at 2:18 PM with a Psychiatric Nurse Practitioner, Staff B, he indicated that he made the above-mentioned psychiatric recommendations after his visit with Resident ID #'s 9 and 21. Staff B indicated that after his visits with the residents, he notifies the staff of all recommendations including medication recommendations. Those recommendations are then uploaded into the electronic medical record within 48 hours of his visit. Additionally, Staff B indicated that the staff has access to his recommendations that are uploaded in the residents' electronic medical records. During a surveyor interview on 10/4/2024 at approximately 1:15 PM and a subsequent interview on 10/4/2024 at approximately 2:50 PM with the Director of Nursing Services (DNS), she acknowledged that Resident ID #7 did not have a quarterly fall assessment completed as ordered, in June of 2024. Additionally, she acknowledged that Resident ID #9 did not have a fall assessment completed quarterly as ordered, since 12/26/2023. Furthermore, the DNS could not provide evidence the physician was notified of the psychiatric recommendations for Resident ID #s 9 and 21 after Staff B assessed the residents. 42399

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for falls for 1 of 1 resident reviewed who had actual falls, Resident ID #16. Findings are as follows: Record review revealed the resident was readmitted to the facility in December of 2023 with a diagnosis including, but not limited to, schizoaffective disorder. Record review of a facility document titled, Fall Prevention Program last revised 12/2010, states in part, .Fall risk assessments are performed as a part of the admission assessment, as part of the quarterly review, and as an annual and/or significant change of condition process of care plan review .Whenever a resident has a history of falls and/or scores high on the fall risk assessment form, or actually has a fall their record is to be reviewed .and a careplan is to be developed which establishes preventative measures or interventions to be taken to lower or eliminate the risk .any and all immediate fall prevention interventions are to be added to the resident's care plan at that time . Review of the resident's progress notes, dated 7/1/2024 through 10/3/2024, revealed that the resident had experienced falls on the following dates: -7/9/2024 -8/14/2024 Further record review failed to reveal evidence of a fall related care plan that identifies preventative measures or interventions to be implemented relative to the above falls. During a surveyor interview on 10/3/2024 at 1:11 PM with Registered Nurse, Staff A, she acknowledged that the resident did not have a care plan in place related to falls. During a surveyor interview on 8/21/2024 at approximately 3:00 PM, with the Director of Nursing Services, she was unable to provide evidence that a comprehensive person-centered care plan was developed and implemented to address the resident's falls. 41729

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a safe environment relative to smoking, smoking areas, and smoking safety. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 2/27/2024 alleges that smoking has been observed outside of the door of the nursing facility. There have been observations of cigarette butts littered all over the property and a smoldering ashtray. Review of a policy and procedure titled Smoking Policy states in part, .residents that wish to smoke must be in a designated area and may be limited to specific times . During a surveyor observation on arrival at the facility on 2/28/2024 at approximately 8:05 AM revealed the following: -Approximately 100 cigarette butts littered on the ground at the North and East entrances - An ashtray tower leaning against the North exterior wall of the facility with folding chairs - An ashtray observed in the mulch at the South bulkhead entrance; 5 feet from building During a surveyor observation on 2/28/2024 at 11:00 AM, Resident ID #4 was in a wheelchair and was observed smoking approximately 10 feet from the door near the handicapped ramp. During a surveyor interview on 2/28/2024 at 11:02 AM with Resident ID #4, s/he revealed that s/he always smokes in this spot. During a surveyor observation of the outside areas of the facility in the presence of the Administrator on 2/28/2024 at 12:45 PM, he acknowledged that the facility had an ashtray leaning against the exterior of the building, another ashtray on the ground in the mulch and had multiple cigarette butts littered on the ground. Additionally, he indicated that he would expect the staff and residents who smoke to follow policy and state law.

47279 Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections relative to disinfecting glucometers (a device used to monitor blood glucose) for 3 of 3 residents observed who require blood glucose monitoring, Resident ID #s 8, 9, and 14; and 2 of 2 residents reviewed relative to contact precautions, Resident ID #s 14 and 18; and the handling of soiled linen for 1 of 1 laundry room observed. Findings are as follows: 1. According to the facility's policy last revised March of 2015 titled, diabetes - care of equipment states in part, .5. If a glucometer is to be used for one resident and then reused for another, the device must be cleaned and disinfected between uses .Follow the glucometer manufacturer's recommendations for cleaning . Review of the glucometer manufacturer's QA/QC (Quality Assurance/Quality Control) Reference Manual titled, ASSURE PLATINUM BLOOD GLUCOSE MONITORING SYSTEM, states in part, GUIDELINES FOR CLEANING AND DISINFECTING THE ASSURE PLATINUM METER. To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below .The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens .Clean and disinfect the meter following step-by-step instructions .Option 1 Obtain a commercially available EPA [Environmental Protection Agency]-registered disinfectant detergent or germicide wipe .CLEANING AND DISINFECTING PROCEDURES. NOTE Two disposable wipes are needed for each cleaning and disinfecting procedure; one wipe for cleaning and a second wipe for disinfecting .CLEANING .Step 3 Wipe surface of the meter to clean blood and other body fluids .Step 4 Dispose of the used towelette in a trash bin. The meter should be cleaned prior to each disinfection step. DISINFECTING STEP 5 Pull out 1 new towelette and wipe the entire surface of the meter horizontally and vertically to remove bloodborne pathogens . Review of a document dated 8/18/2023 addressed from the EPA to a Clorox representative regarding the Clorox product with EPA Registration Number 5813-79, states in part, .DIRECTIONS FOR USE .TO CLEAN [HARD, NONPOROUS SURFACES] .Wipe surface clean with this product. Let air dry .TO DISINFECT .[Use to disinfect] hard, nonporous surfaces: For visibly soiled surfaces, clean first .Special instructions for Use Against .HCV [Hepatitis C Virus] .This product kills HCV .on a precleaned hard, nonporous surfaces/objects previously soiled with blood/body fluids in health care settings .Cleaning Procedure: Blood and other bodily fluids must be thoroughly cleaned from surfaces and other objects before applying this product . a) Record review revealed Resident ID #14 was readmitted to the facility in September of 2023 with diagnoses including, but not limited to, chronic viral hepatitis C and type II diabetes. Additionally, his/her blood sugars are monitored four times a day. b) Record review revealed Resident ID #8 was readmitted to the facility in February of 2022 with a diagnosis including, but not limited to, type II diabetes. Additionally, his/her blood sugars are monitored four times a day. c) Record review revealed Resident ID #9 was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, type II diabetes. Additionally, his/her blood sugars are monitored four times a day. During surveyor observations on 11/9/2023 at 11:39 AM during the medication administration task with Registered Nurse (RN), Staff B, the following observations were made: - Staff B obtained Resident ID #9's blood sugar. Staff B then used one Clorox wipe to clean the glucometer. Staff B did not utilize a second Clorox wipe to disinfect the glucometer as per the manufacturer's guidelines, prior to proceeding to the next resident. - Staff B obtained Resident ID #8's blood sugar with the same glucometer used for Resident ID #9. Staff B was observed using his gloved hands to remove the used test strip, which was contaminated with blood, from the glucometer. At this point, the surveyor informed Staff B, that there was a test strip release button on the glucometer that allows the strip to be ejected without having to manually remove it. Staff B returned to the nursing cart located at the nurses' station and proceeded to use one Clorox wipe to clean the glucometer. Staff B did not utilize a second Clorox wipe to disinfect the glucometer as per the manufacturer's guidelines and proceeded to the next resident. - Staff B obtained Resident ID #14's blood sugar using the same glucometer that was previously used on Resident ID #s 8 and 9. Staff B exited the room, and was noted to be holding the uncleaned, non-disinfected glucometer with the contaminated test strip still in the glucometer, which was observed to be in direct contact with the clean, unused blood glucose monitoring supplies which were contained in a small basket used for multiple residents. Staff B proceeded to walk through the facility passing the common area and dining room with several residents present, until he returned to the nurses' station where he placed the basket atop the nursing cart. Again, it was noted the glucometer and contaminated test strip were in direct contact with the basket of clean blood glucose monitoring supplies. With a gloved hand, he manually removed the contaminated test strip from the glucometer and disposed of it in the sharps container. Without changing gloves, he grabbed the Clorox wipes cannister and removed a wipe, and proceeded to wipe the glucometer with the now contaminated wipe using the same gloves that were used to manually remove the contaminated test strip, which had just been used to obtain a blood sugar from Resident ID #14, who is positive for Hepatitis C. After using the one contaminated Clorox wipe, he set down the glucometer. Staff B was not observed to utilize a second Clorox wipe to disinfect the glucometer as per the manufacturer's guidelines. Additionally, a surveyor observation on 11/9/2023 at 1:37 PM revealed the glucometer that was used to assess the above-mentioned resident's blood sugars, after having already been cleaned with one Clorox wipe, revealed an accumulation of dark colored debris in 4 separate areas of the battery cover latch. During a surveyor interview on 11/9/2023 at 1:54 PM with the Director of Nursing Services (DNS), in the presence of 3 additional surveyors, she revealed that Staff B had used the wrong wipes for cleaning and disinfecting the glucometer. She further revealed that PDI wipes, which contain bleach, should've been used. Additionally, she was unsure if the Clorox wipes used by Staff B are effective at killing blood borne pathogens. During a surveyor interview on 11/9/2023 at 2:52 PM with Staff B, he acknowledged that he manually removed the contaminated test strip from the glucometer and without changing his gloves, proceeded to use a Clorox wipe to clean the glucometer. He further revealed he was unsure if the Clorox product was effective at killing blood borne pathogens. Additionally, he revealed he had utilized the same Clorox product to wipe the glucometer when assessing multiple resident's blood sugars earlier that day. During a follow up surveyor interview on 11/10/2023 at 1:59 PM with the DNS, she revealed that test strips should be disposed of immediately after use and that dirty items should not be mixed with clean supplies. She was unable to provide evidence that staff provided a safe and sanitary environment to help prevent the transmission of infection and blood borne pathogens. As a result of the facility's failure to follow its own diabetic equipment cleaning and disinfection policy relative to glucometers, and more specifically, the glucometer's reference manual specific to the cleaning and disinfection process, placed all residents who require blood glucose monitoring at increased risk for the transmission of blood borne pathogens. Furthermore, Staff B's multiple failures including improperly cleaning and disinfecting the multi-use glucometer by not utilizing two wipes as indicated, mixing dirty and clean supplies, and utilizing a contaminated wipe to clean and disinfect the glucometer, placed these residents at increased risk for contracting blood borne pathogens. 2. Review of a facility policy titled, guideline for Management of MDROs [Multidrug resistant organism] dated 1/18, states in part, .discontinuing Contact Precautions [wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment] .Contact Precautions should be used for the duration of the stay in the setting in which they were first implemented .In general it is reasonable to discontinue contact precautions when three or more surveillance cultures for the target MDRO are repeatedly negative over the course of week or two in a patient who has not received antimicrobial therapy for several week . Further review of the facility policy titled, guidelines for Management of MDROs states in part, .MRSA [Methicillin resistant Staphylococcus aureus infection; an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics] - RIDOH [Rhode Island Department of Health] recommends that Contact precautions may be discontinued when: There is documentation of 2 consecutive negative MRSA screens from previously positive sites .Screens are to be obtained no sooner than 72 hours after the completion of decolonization and/or treatment has been completed . a. Record review revealed Resident ID #18 was admitted to the facility in March of 2023 with a diagnosis including, but not limited to, MRSA. Review of a hospital discharge summary dated 3/8/2023 revealed the resident was positive for MRSA in a right lower extremity wound and was being treated with Bactrim (antibiotic). Review of a progress note dated 3/14/2023 states in part, .also, resident tested positive for MRSA of the nares while in the hospital and treatment was not offered/completed. Dr [doctor] .aware and resident with new order for Bactroban [a medication to treat/decolonize a resident with MRSA in the nares or decolonized MRSA] to nares BID [twice daily] topically for 5 days . Review of a care plan dated 3/8/2023 and updated 6/27/2023 revealed the resident has MRSA in the nares with interventions that include, but are not limited to, standard universal precautions in place. Review of the March 2023 Medication Administration Record revealed the following orders: - Bactrim, twice daily, with a start date of 3/8/2023 and an end date of 3/11/2023. - Bactroban, apply to nares two times daily, for 5 days, with a start date of 3/15/2023 and an end date of 3/19/2023. Record review failed to reveal evidence that at least two negative MRSA screens were obtained for the nares. Record review failed to reveal evidence that at least two negative MRSA screens were obtained for the right lower extremity wound. During surveyor observations on the following dates and times revealed the resident had no signage posted outside his/her room indicating s/he was on contact precautions and did not have an isolation bin containing personal protective equipment (PPE) supplies outside his/her room: - 11/7/2023 at 9:13 AM - 11/8/2023 at 8:07 AM - 11/9/2023 at 10:42 AM Review of the CENTER FOR EPIDEMIOLOGY & INFECTIOUS DISEASES Guidelines for the Management of Methicillin Resistant Staphylococcus Aureus in Rhode Island Long-Term-Care Facilities (2007) revealed that routine decolonization for MRSA in the nares is not recommended for long term care facility residents. It further revealed that decolonization attempts would be appropriate for residents admitted from the hospital with decolonization procedures already underway. Additionally, to remove a resident from contact precaution following decolonization would require the following criteria to be met: Contact precautions may be discontinued when there is documentation of two (2) consecutive negative MRSA screens from previously positive sites. Screens should be obtained no sooner than 72 hours after completion of decolonization and/or treatment of infection and screens should be at least five days apart. During a surveyor interview on 11/10/2023 at 11:17 AM with the DNS, she acknowledged that the resident's lower extremity wound, and nares were not re-cultured following the completion of the antibiotic treatment, per facility policy and Center for Epidemiology and Infectious Disease guidelines. Further, she was unable to provide evidence that the resident's lower leg extremity wound, or nares were re-cultured following the completion of antibiotic treatment. b. Review of a facility policy titled, Isolation states in part, .Contact precautions .use Contact Precautions for residents known or suspected to be infected with microorganism that can be easily transmitted by direct or indirect contact .The above includes organisms such as MRSA .Contact Precaution Procedure .require the use of appropriate PPE [Personal Protective Equipment], including a gown and gloves upon entering the contact precaution room . Record review revealed Resident ID #14 was readmitted to the facility in September of 2023 with a diagnosis including, but not limited to, non-pressure chronic ulcer of the right foot. Record review of a progress note dated 10/9/2023 at 10:56 AM revealed in part that the resident's right foot wound was cultured and tested positive for MRSA and s/he was placed on contact precautions. Record review revealed the following physician orders: - 10/9/2023 contact precautions every shift due to MRSA of the right foot wound. - 11/2/2023 cleanse right foot wound with Dakins (wound cleanser), pat dry, apply a thin layer of Silver Silvadene (antimicrobial wound cream) to the wound bed followed by calcium alginate (wound treatment), and apply a clean dressing and wrap with kling once a day. Multiple surveyor observations from 11/7/2023 through 11/8/2023 revealed that the resident had no signage posted outside his/her room indicating s/he was on contact precautions and did not have an isolation bin containing PPE supplies outside his/her room. Multiple observations on these dates were made of staff entering and exiting the resident's room without wearing the required PPE, which includes gloves and a gown. During an additional surveyor observation on 11/7/2023 at 12:17 PM of RN, Staff A, she was observed completing the above-mentioned treatment to the resident's right foot wound. Staff A completed the wound treatment without having donned a gown. Additionally, the wound was observed to be opened and was noted to have a scant amount of sanguineous (bloody) drainage on the existing dressing. During a surveyor interview immediately following the above observation with Staff A, she revealed Resident ID #14 was not on any isolation precautions. When informed by the surveyor of the active physician order for contact precautions, she revealed only gloves would be required for contact precautions. During a surveyor interview on 11/8/2023 at 3:08 PM with the DNS, she was unaware that Resident ID #14 had an order to be on contact precautions for MRSA in his/her right foot wound. She further revealed that a resident on contact precautions would have signage posted outside the door as well as a bin of PPE. Furthermore, she indicated that after the resident completed his/her antibiotic course, s/he was removed from contact precautions. She was unable to provide evidence that the wound was re-cultured as per policy prior to discontinuing the contact precautions. 3. Review of a facility policy titled Laundry Guidelines dated 10/18 states in part, POLICY: It is the policy of this facility to handle, store, process, and transport linen so as to prevent the spread of infection .Laundry Handling .All laundry will be handled as if it is potentially infectious and/or capable of transmitting infectious disease . According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 2/3/2023 states in part, .Handling Laundry .The facility staff should handle all used laundry as potentially contaminated and use standard precautions (e.g., gloves, gowns when sorting and rinsing) . During a surveyor observation on 11/9/2023 at 11:56 AM with the DNS, a walk through of the laundry room was completed. No PPE, e.g gowns, was observed. During a surveyor observation on 11/10/2023 at 8:49 AM with Nursing Assistant, Staff D, she was observed in the laundry room loading the washing machine wearing only gloves. She failed to don a gown when sorting and loading the soiled laundry. When Staff D was asked to show the surveyor how laundry is processed, Staff D proceeded to open the door to the clean side of the laundry room with the same pair of dirty gloves on, she then opened the dryer, removed the lint trap, and then replaced it. She then opened the cleaned stored linen rack still wearing the same pair of dirty gloves and pushed the cleaned linen back in to the storage rack. During a surveyor interview on 11/10/2023 at 11:18 AM with the DNS she was unable to provide evidence that the facility stored, process and transported linen to prevent the spread of infection.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 4 residents reviewed for accident hazards, Resident ID #1. Findings are as follows: Record for Resident ID #1 revealed s/he was admitted to the facility in December of 2021 from a geriatric psychiatric unit of an acute care hospital. Review of the Continuity of Care (COC) form provided to the facility from the acute care hospital, upon the resident's admission revealed a form titled, PATIENT REGISTRATION RECORD. Review of the PATIENT REGISTRATION RECORD revealed the resident's admission diagnosis for that hospitalization was listed as, TRIED TO JUMP OUT WINDOW. Additional record review revealed an admission history and physical of the resident was performed by the facility's Medical Director (MD), who ordered an intervention for the resident to be followed up by psychiatric services related to his/her previous hospitalization . Further review of the resident's record failed to reveal evidence that the resident had received any follow up psychiatric services while at the facility. During an interview with the MD on 3/18/2022 at 1:25 PM, he indicated that he would have expected the resident to have been evaluated by psychiatry as ordered. During an interview with Registered Nurse (RN), Staff A on 3/16/2022 at approximately 1:00 PM, she revealed that she was informed in a verbal report from the acute care hospital, that the resident was found, while standing in front of an open window, at his/her previous facility, stating that s/he wanted to go home but did not want to break his/her leg. A facility reported incident was received by the Department of Health on 3/14/2022 indicating that at approximately 6:45 PM on 3/12/2022, Resident ID #1 was unable to be located inside of the facility. At 7:30 PM the resident was located outside, next to the facility, after an apparent slip and fall. This document also reveals that the resident was assisted inside and then it was decided by staff, to send him/her to an acute care hospital for an evaluation. Review of the resident's hospital records following this incident revealed s/he was found outside of the facility in the ice and snow with obvious signs of trauma. The resident sustained fractures to his/her cheek, temporal bone, and shoulder blade. Additionally, the resident was found to have two subarachnoid hemorrhages, (brain bleeds). Review of the facility's camera footage in the presence of the Nursing Home Administrator (NHA) on 3/18/2022 at approximately 9:30 AM, revealed that the resident was seen on 3/12/2022 at 5:52 PM in his/her room. The resident is seen next at 6:08 PM, exiting his/her room with his/her hat and coat on, and a cane in his/her hand. The resident is then seen walking behind the nurse's station, where no staff are present, and turns around to face a window. S/he is then seen bending down and reaching out. The Nursing Home Administrator (NHA) revealed that this is where the Resident pulled up the window and climbed out onto the facility's roof. He then indicated that the angle of the camera prevented this from being captured on film. Additionally, the NHA revealed that it was when a staff member went into the resident's room to give him/her their medication, at 6:35 PM, s/he was noted to be missing. The NHA further indicated that he found the resident behind the facility at approximately 7:30 PM, and that s/he was transferred to an acute care hospital for evaluation of his/her injuries at approximately 8:00 PM. During an interview with the Lead Nurse Manager on 3/16/2022 at 8:30 AM, she revealed that she and was not aware that the resident attempted to leave his/her previous facility through a window. Additionally, she indicated that she would expect this critical information to be communicated clearly to all staff. During an interview with the NHA on 3/17/2022 at approximately 4:00 PM, he was unable to provide evidence that the facility provided adequate supervision and assistance to prevent an accident hazard for Resident ID #1.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to properly quarantine 3 of 3 sampled residents (Residents ID #'s 6, 8, and 11), and properly utilize Personal Protective Equipment (PPE) according to professional standards to prevent the spread of COVID-19. Additionally, the facility failed to implement a surveillance plan for tracking, monitoring and/or reporting of fever, respiratory illness, and/or other signs/symptoms of COVID-19 for all residents and staff. Findings are as follows: I. According to the Center for Disease Control and Prevention (CDC) guidance, Responding to Coronavirus (COVID-19) in Nursing Homes Considerations for the Public Health Response to COVID-19 in Nursing Homes updated Apr. 30, 2020 states in part, Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Further review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 07/15/2020 states in part, .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Patient Placement . , place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room .The patient should have a dedicated bathroom . During the entrance conference on 11/17/2020 at 9:00 AM, the Director of Nursing (DON) revealed that the residents at the facility have never tested positive for COVID-19 prior to their current COVID-19 outbreak. She stated that residents in the facility were tested for COVID-19 starting 11/2/2020 due to a staff member testing positive for COVID-19 on 10/29/2020. She stated that all residents tested negative for COVID-19 on 11/2/2020. She further revealed that all residents were tested for COVID-19 between 11/9/2020 and 11/11/2020. There were 9 residents who tested positive for COVID-19 (Resident ID #'s 1, 4, 7, 9, 13, 14, 15, 16 and 17). Additionally, the DON revealed that 6 residents were sent to the hospital, (Resident ID #'s 1, 7, 13, 15, 16 and 17) of which 1 passed away at the hospital (Resident #16). 1. Record review revealed Resident ID #'s 8 and Resident ID #7 shared a room. Record review revealed that Resident ID #8 tested negative for COVID-19 on a test with a collection date of 11/11/2020. Resident ID #7 was found to have a temperature of 102.5 degrees Fahrenheit on 11/11/2020 (a normal human body temperature is typically between 97.7- 99.5 degrees Fahrenheit). Pulse oximetry was 88 % on room air (measurement of oxygen levels in the blood, a normal value is between 95 and 100 %), and coarse lung sounds. Record review revealed Resident ID #7 tested positive for COVID-19 on the test with a collection date of 11/11/2020. Further record review revealed that on 11/12/2020, Resident ID #7's pulse oximetry was 88% while on 2 liters of oxygen, his/her temperature was 101.7 degrees Fahrenheit, s/he was congested and coughing, was agitated and shaky, and had poor skin color. As a result, 911 was called and Resident ID #7 was sent to the hospital. Record review and surveyor interview with the DON on 11/17/2020 at 1:55 PM, revealed Resident ID #8 was never placed on quarantine after being exposed to Resident ID #7. Subsequently, on 11/12/2020, the facility moved Resident ID #10 into the room with Resident ID #8. During a surveyor interview on 11/18/2020 at 8:10 AM, the Administrator and the DON revealed that both Resident ID #'s 8 and 10 tested positive for COVID-19 on the test with a collection date of 11/16/2020. 2. Record review revealed Resident ID #'s 11 and Resident ID #1 shared a room. Record review revealed that on 11/11/2020 Resident ID #1 had a Temp low grade = 99.5 . and subsequently tested positive for COVID-19 on the test with a collection date of 11/11/2020. Record review revealed Resident ID #11 was never placed on quarantine after sharing a room with Resident ID #1. Further record review revealed that Resident ID #12, was moved into Resident ID #11's room on 11/12/2020. During a surveyor interview with the DON on 11/17/2020 at approximately 3:00 PM, she revealed Resident ID #11 was never placed on quarantine after sharing a room with Resident ID #1. The DON revealed that on 11/12/2020, the facility was made aware that Resident ID #1 tested positive for COVID-19 in the morning, they moved Resident ID #12 into Resident ID #11's room that evening. Record review revealed that Resident ID #11 subsequently tested positive for COVID-19 on the test with a collection date of 11/16/2020. 3. Record review revealed Resident ID #'s 6 and Resident ID #9 shared a room. Resident ID #9 tested positive for COVID-19 on the test with a collection date of 11/11/2020. Record review failed to revealed that Resident ID #6 was placed on quarantine after sharing a room with Resident ID #9. Record review revealed that Resident ID #6 subsequently tested positive for COVID-19 on the test with a collection date of 11/16/2020. During a surveyor interview with the DON on 11/17/2020 at approximately 3:00 PM, she revealed Resident ID #6 was never placed on quarantine after sharing a room with Resident ID #9. The CDC guidance titled Responding to Coronavirus (COVID-19) in Nursing homes, updated April 30, 2020 states in parts all recommended COVID-19 PPE (Personal Protective Equipment) should be worn during care of the residents under observation, which includes the use of an N95 or higher level respirator, eye protection, gloves and gown. The following surveyor observations were made between 8:15 AM and 9:30 AM on 11/17/2020 failed to reveal signage indicating quarantine status and what PPE staff is required to wear when they enter the rooms of Residents ID #'s 6, 8 and 11. Additionally, surveyor observation between 9:30 AM and 2:40 PM on 11/17/2020 revealed Staff A and Staff B were in Resident ID #8's room not wearing eye protection or a gown. During a surveyor interview with Staff A on 11/17/2020 at 2:15 PM, she revealed she was in Resident ID #6 and 8's room on this day to administer their morning and lunch time medications. Staff A stated that she did not wear eye protection or a gown while in the rooms. During a surveyor interview on 11/17/2020 at 3:00 PM with the Administrator and the DON, they acknowledged that staff was not wearing the required PPE (eye protection and gown) when they enter the rooms of Resident ID's #6 and 8. II. According to the CDC publication titled, Using Personal Protective Equipment (PPE), updated August 19, 2020 states in part, . Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap) . Surveyor observations on 11/17/2020 at 9:45 AM revealed Staff A and Staff C, wearing their N95 masks improperly. Both staff failed to place the top strap of the respirators on the crown of their heads. They placed both straps of the respirator at the base of their necks. Surveyor observation on 11/17/2020 at 1:00 PM, revealed both Staff A and Staff C again wearing their N95 masks improperly. Immediately following this observation an interview was conducted with Staff A, she acknowledged she was wearing her N95 mask incorrectly. III. The CDC document titled, Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings states in part, Identification and Management of ill Residents .The facility has criteria and a protocol for initiating active surveillance for respiratory infection among residents and healthcare personnel . During the survey, the facility failed to provide accurate information regarding COVID-19 testing, which includes the facility logs of residents and staff who were confirmed or suspected of COVID-19. Record review failed to provide evidence of information regarding a surveillance plan for tracking, monitoring and/or reporting of fever, respiratory illness, and/or other signs/symptoms of COVID-19 for all staff and residents. During the interview on 11/17/2020 at 3:00 PM, the DON was unable to provide information regarding a surveillance plan for tracking, monitoring and/or reporting of fever, respiratory illness, and/or other signs/symptoms of COVID-19 for all staff and residents.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards as possible, and that residents are provided with adequate supervision to prevent elopement for 3 of 3 sampled residents at risk for elopement (ID's #1, 2 and 3). Findings are as follows: The facility's policy titled Elopement Procedure, reveals in part, It is the policy of this facility to provide a safe and secure environment for all residents. In order to achieve this goal, residents are to be monitored at all times . DEFINITIONS: .Elopement- leaving the facility without permission and/or notification to the facility . The Administrator/Designee will: 1. Notify the resident's legal guardian or designated person as well as the primary physician . 1) Resident ID #1 was admitted to the facility in May 2019 with [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating the resident has severe cognitive impairment. On admission s/he was assessed as confused. The admission fall risk assessment revealed s/he had a score of 10 indicating high risk and revealed his/her mental status as intermittent confusion, poor recall, judgement or safety awareness. The admission assessment also revealed s/he was an elopement risk and had psych consult, social services consult and 15-minute check interventions to be initiated. Review of Resident ID #1's current care plan revealed a problem start date of 9/12/2019, stating that the resident is an elopement risk due to [DIAGNOSES REDACTED].Notify md of any changes in mood, behavior or wandering/elopement attempts . On 7/9/2020, the facility reported an incident of elopement by Resident ID #1, that occurred on 7/8/2020 at approximately 9 PM. The facility is in an urban setting, along the North side of the building is a one-way street, along the front of the build is a heavily traveled main street. Surveyor interview on 7/14/2020 at approximately 10:50 AM with the Director of Nursing (DNS) and the Administrator, revealed that a Certified Nursing Assistant (CNA) notified the nurse that the resident, last seen sleeping in his/her bed at 8:30 PM, was unable to be located. While the staff was searching the facility, the local police called the facility and informed them that this resident has been located at a nearby Chiropractic office. Following this telephone call a CNA walked to the chiropractic office to retrieve the resident. Additionally, the Administrator revealed they had not identified the door that the resident used to exit the facility, nor had they viewed the camera footage. He then stated that it was believed the resident exited the facility through a door that leads to a wheelchair ramp. He then indicated that they customarily rely on staff statements rather than the camera footage. Staff statements were requested by this surveyor. Neither the Administrator nor the DNS could provide staff statements. The DNS revealed staff statements regarding this elopement were never collected. Surveyor observation of the camera footage (requested by surveyor) on 7/14/2020 at approximately 1:00 PM, in the presence of the Administrator and DNS revealed the following: -7/8/2020 at 9:12:01 PM - resident turns corner on the first-floor hallway and walks toward the elevator. S/he is wearing pajamas, shoes and is carrying a bag. -7/8/2020 at 9:13:45 PM - resident comes out of basement elevator. (this elevator does not have any codes or alarms) Resident then walks down a hallway that ends in an exit. (There are no internal cameras directed towards this exit) -7/8/2020 at 9:17:21 PM - resident is seen exiting the basement door through a camera located outside. Ambulating in the direction of Wheldon Avenue. -7/8/2020 at 9:19:20 PM -resident is seen rounding the corner from Wheldon Avenue to the sidewalk on Broadway. -7/8/2020 at 9:20:19 PM- resident is seen walking past the front of the facility on the sidewalk. -7/8/2020 at 9:51:08 PM- resident and CNA are seen ambulating back toward the facility. The route the resident took to the Chiropractor's office was noted to be a walking distance of approximately 500 feet. During a surveyor observation on 7/14/2020 at 1:30 PM of the basement door (which was exited by the resident) in the presence of the DNS, revealed that the alarm was set to a quiet doorbell like ring. It rings twice then stops even if the door remains open. During an interview with the DNS immediately following the above observation, she indicated that this alarm would not be heard by the staff upstairs which is where the resident rooms are located. Surveyor observation of the facilities door alarms on 7/14/2020 at approximately 3:30 PM with the Administrator revealed that the exit doors were set to alarm in different manners, they were as follows: 1.) Basement door that resident exited from was set to ring twice (soft rings) when opened and then stops. 2.) Basement door near business office was not alarmed, however there is an internal door which is locked to prevent access to this area, which is alarmed. 3.) The two doors in the nurse's station hallway, had loud blaring alarms that needed to be shut off with a key. 4.) The door leading to the wheelchair ramp had an alarm set to ring when the door was opened, a code must be entered to stop this alarm. 5.) Main entrance door, at the front of building, was set to ring twice (soft rings) when opened. However, the alarm would stop even if the door remained open. 6.) An exit door located on the first-floor unit of the facility, down the hall around a corner out of view from the nursing station, that rings once when opened and then stops. Surveyor interview on 7/14/2020 at 10:35AM with the Activities Director revealed that Resident ID #1 had made it out the door unattended 2 or 3 times that she had witnessed in the past year. Surveyor interview on 7/15/2020 at 11:41 AM with Staff C revealed that Resident ID #1 is a wanderer and she goes to the doors to exit, the alarms go off and staff go retrieve her. She further revealed that when this happens the nurse is notified. Review of a Safety Events- Elopement form dated 7/8/2020 revealed the attending was not faxed, the Physician was not notified, and the resident representative was not notified. Surveyor interview on 7/15/2020 at 12:02 PM with Staff Nurse A, revealed that she had not notified the Physician or the resident's emergency contact of the elopement. She further revealed that no written statements were taken from staff and an interview of the resident was not conducted as s/he is not a reliable reporter. She further reported that no alarms went off. During a surveyor interview on 7/15/2020 at 12:31 PM with the DNS, she revealed that she was unaware that the Physician and emergency contact were not notified about the resident's elopement. She acknowledged that they should have been notified and statements should have been obtained. Additionally, she was only able to provide 15 minute checks for 7/8/2020 and 7/9/2020. 2) Resident ID #2 was admitted to the facility in December 2019 with [DIAGNOSES REDACTED]. A quarterly ((MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score was unable to be conducted, indicating the resident has severe cognitive impairment. On admission s/he was assessed as confused, disoriented x 3 and had diminished safety awareness. The admission assessment revealed s/he was an elopement risk. A surveyor observation on 7/14/2020 at 11:53 AM made in the presence of the DNS, of Resident ID #2 revealed s/he was attempting to exit the building unsupervised. The alarm activated and the DNS retrieved the resident and brought him/her back inside and closed the door. Record review of the resident's progress notes revealed the following: -12/28/2019 at 3:46 PM- .resident made multiple attempts to elope this morning . -1/2/2020 at 3:05 PM- Resident was found attempting to exit the front door, where there is a steep staircase. Shortly after was attempting to exit the ramp door . -1/14/2020 at 6:14 PM- Resident noted to be ambulating down ramp wearing no coat and shoes, required re-direction by staff . -1/16/2020 at 12:20 AM (late entry 7a-7p 1/15/20)- Resident with 15-20 elopement attempts throughout shift, making it outside the facility side door (by ramp) at least 10 times. - 7/8/2020 at 6:46 PM- Exit seeking, found outside on porch x 3. Grab a CNA forcefully .when she tried to stop (him/her) from going outside (DNS aware) . -7/9/2020 at 3:41 PM- .Exit seeking, found outside on porch x 2 this shift before lunch . -7/10/2020 at 5:36 PM- Resident found on front porch at 8:30 AM .exit seeking through back door onto deck .difficult to get back into facility .DNS was notified and stayed with resident through dinner . Record review of an elopement risk evaluation dated 1/20/2020, revealed that the resident is an elopement risk. It further revealed the interventions that were initiated were 15-minute checks. A copy of the 15-minute checks of this resident were requested by the surveyor for review on 7/14/2020 at approximately 10:00 AM. The DNS was unable to locate the 15-minute checks. On 7/14/2020 at 3:30PM the DNS was only able to locate the 15-minute checks sheets for 7/8/2020 and 7/9/2020 for Resident ID #2. 3) Resident ID #3 was admitted to the facility in December 2011 with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicates a BIMS score of 10 of 15, indicating the resident has moderate cognitive impairment. Review of resident's elopement assessments dated 6/4/2019 and 7/14/2020 both revealed the resident to be an elopement risk. They further reveal that 15-minute checks were to be initiated. Record review of Resident ID #3's record lacked evidence of a care plan related to elopement. Record review of progress notes revealed the following: - 9/6/2019 at 11:27 PM- SW (social worker) made aware that .left the facility without making staff aware. SW and nursing contacted resident's friend .who reported resident had walked to her house .SW met with (him/her) .to remind .that (s/he) is not to leave the building on (his/her) own for safety reasons . -1/23/2020 at 4:55 PM- .has been leaving the facility unaccompanied and walking to Dunkin Donuts . SW and staff member explained .(s/he) cannot leave the building unaccompanied . During a surveyor interview on 7/17/2020 at approximately 3:45 PM with the DNS, she revealed that they are not doing 15-minute checks on Resident ID #3. She was unable to produce any evidence that 15-minute checks had ever been completed or that a care plan related to elopement was developed. The facility failed to ensure that cognitively impaired residents are provided with adequate supervision to prevent elopement. Furthermore, they failed to perform interventions for the supervision of residents found to be at risk for elopement such as 15-minute checks and development of a care plan. Additionally, they failed to assure all door alarms were able to be heard by staff, which put the residents at risk for serious injury or harm.