Every finding on record at Jeanne Jugan Residence

Based on surveyor observation, record review, and staff interview, the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and visitors relative to 1 of 1 laundry room observed.Findings are as follows:Review of an undated facility policy titled, Dryer Care Policy states in part, .Lint screen is installed in the bottom compartment of all commercial dryers.These lint screens must be brushed and cleaned. If not the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperature in the basket and causing a potentially dangerous situation, ie fire.Lint screens must be brushed and cleaned every 2 or 3 loads to maintain proper airflow and prevent overheating.Staff will be present when dryers are in operation.During a surveyor observation and simultaneous interview on 4/1/2026 at 12:03 PM of the laundry room, in the presence of the District Manager, revealed two large Electrolux Professional dryers in operation without staff present. The District Manager indicated that the Housekeeper, Staff E, was on break.During a subsequent surveyor observation at approximately 12:10 PM in the presence of Staff E and the District Manager, revealed the lint traps for both dryers were noted to be covered in a thick blanket of white lint covering the entire mesh lint screen.Review of a DRYER TRAP CLEANING SCHEDULE document, which was reviewed at 12:11 PM, revealed the lint screens were documented as cleaned on 4/1/2026 at 8:00 AM, 10:00 AM, 12:00 PM, and 2:00 PM by Staff E.During a surveyor interview on 4/1/2026 at approximately 12:15 PM with Staff E, via the assistance of the District Manager as an interpreter, she revealed that she last cleaned the lint screens at 10:00 AM and acknowledged that she had not cleaned either lint screen at 12:00 PM, as documented. Additionally, she acknowledged that she prematurely documented that she cleaned the lint screen at 2:00 PM. Further, she revealed that she had dried three loads of laundry prior to the current load (fourth load) that was being dried since she last cleaned the lint screen at 10:00 AM.During a surveyor interview immediately following the above interview with the District Manager, he revealed that Staff E should not sign off the dryer trap cleaning log in advance and would have expected the lint screen to have been cleaned at 12:00 PM, as documented.During a surveyor interview on 4/2/2026 at 12:35 PM with the Maintenance Director, he revealed that he would expect that staff would follow the facility's policy relative to laundry services.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment for Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDROs] in nursing homes), for 1 of 1 resident observed being assisted with a transfer, Resident ID #5.Findings are as follows:Review of the facility policy titled, Enhanced Barrier Precautions Policy dated 1/2026 states in part, .Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of Multidrug Resistant Organisms .Residents in nursing facilities are particularly vulnerable to colonization and infection with MDROs, which can lead to limited treatment options and adverse health outcomes.Nursing staff initiates EBP for residents with.Wounds.even if the resident is not known to be infected or colonized with an MDRO.Record review revealed Resident ID #5 was admitted to the facility in June of 2021, with diagnoses including, but not limited to, dementia and a stage 4 pressure ulcer (the most severe form of a pressure ulcer, involving full-thickness tissue loss with exposure of the muscle, tendon, ligament, cartilage, or bone, primarily caused by prolonged pressure over a bony prominence) to his/her right ankle.During surveyor observations on all days of the survey, 3/30/2026 through 4/2/2026, a sign was posted by the resident's door indicating that the resident required EBP.Review of the EBP sign revealed that everyone must clean their hands, including before entering, and when leaving the room. Further review revealed providers, and staff must also wear a gown and gloves for high-contact activities, including transfers.During a surveyor observation on 3/31/2026 at 11:32 AM, Nursing Assistant (NA), Staff C, entered Resident ID #5's room without performing hand hygiene or putting on a gown or gloves. Staff C then applied a gait belt to the resident, assisted him/her with a transfer into a wheelchair, removed the gait belt, and positioned the resident with pillows behind his/her back. Staff C then entered the resident's bathroom, turned the water on and then immediately off, prior to exiting the room. Staff C failed to perform hand hygiene upon exiting the room. During a surveyor interview with Staff C, immediately following the above observations, she indicated that she does not usually put on a gown or gloves when assisting the resident with transfers. Additionally, she acknowledged that she failed to perform hand hygiene before entering or when exiting the resident's room. During a surveyor interview on 3/31/2026 at 11:54 AM with Licensed Practical Nurse, Staff D, she revealed that Resident ID #5 requires EBP due to having a wound on his/her ankle and that staff should follow the precaution signs that are posted. She further revealed that she would expect staff to perform hand hygiene when entering and exiting the resident's room, and to wear a gown and gloves when assisting the resident with transfers. During a surveyor interview on 4/1/2026 at 10:20 AM with the Infection Preventionist, she revealed that Resident ID #5 requires EBP related to his/her wound. Additionally, she indicated that she would expect staff to perform hand hygiene before entering and when exiting a resident's room, and to wear a gown and gloves for transfers when EBP is required. During a surveyor interview on 4/1/2026 at 12:53 PM with the Director of Nursing Services, she revealed that staff are expected to wear a gown and gloves when transferring a resident who requires EBP.

Based on record review and staff interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by the Facility Assessment, for 2 of 5 nurses reviewed for wound care competencies. Findings are as follows:Review of the Facility Assessment last revised in January of 2026 revealed that nursing competencies were verified upon orientation, annually at minimum, and as indicated for all staff as needed. The Facility Assessment further revealed that they provide care and services based on the needs of their resident population which includes residents who require wound care.Review of the resident roster revealed one resident, presently residing in the facility that requires daily wound care for a Stage IV pressure ulcer (the most severe form of a pressure ulcer, involving full-thickness tissue loss with exposure of the muscle, tendon, ligament, cartilage, or bone, primarily caused by prolonged pressure over a bony prominence).Review of the following nursing personnel files failed to reveal evidence that they had received training in wound care or that they were competent in providing wound care services: - Registered Nurse, Staff A with a hire date of April 24, 2015,- Licensed Practical Nurse, Staff B with a hire date of May 28, 2024.During a surveyor interview with the Director of Nursing Services on 4/1/2026 at 11:38 AM, she was unable to provide evidence that all nursing staff were competent in providing wound care.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: The Rhode Island Food Code 2018 Edition 3-501.19 Time as a Public Health Control reveals in part; .the food shall have an initial temperature of 5 degrees Celsius (41 degrees Fahrenheit) or less when removed from cold holding temperature control . Record review of the facility policy titled HOT & COLD FOOD HANDLING POLICY states in part, .It is the policy .to maintain food safety by proper .cold food holding .The food shall have an initial temperature control of 41 degrees or less if removed from cold holding temperature control .The temperature of cold food will be logged in the kitchen when removed from cold holding temperature . Additional record review of the facility policy titled FOOD PURCHASED & STORAGE states in part, .FOOD STORAGE .food is kept covered, labeled, dated and stored at a maximum of 41 degrees F [Fahrenheit] . 1. During the initial tour of the main kitchen in the presence of the Dietary Supervisor on 1/30/2023 at 8:30 AM revealed the following observations: In a reach-in freezer; - a one gallon resealable freezer bag with frozen blueberries covered with a thick layer of frost, not labeled, or dated - a one gallon resealable freezer bag with frozen peeled bananas, not labeled or dated - one unopened container of Cool Whip with an expiration date of 1/11/2023 In a walk-in dairy cooler/refrigerator; - one half block of sliced cheese, opened and not dated During a surveyor interview with the Dietary Supervisor on 1/30/2023 at approximately 8:35 AM she acknowledged the above findings. 2. During a surveyor observation in the main kitchen of the 2nd floor salad bar tray, in the presence of Dietary Staff D, on 01/30/2023 at 11:33 AM, revealed the following observations: - cottage cheese with an initial temperature of 41.9 degrees F when removed from cold holding temperature. - carrot raisin salad made with mayonnaise with an initial temperature of 44 degrees F when removed from cold holding temperature. During a subsequent surveyor observation of the temperatures for the 1st floor salad bar items on 1/30/2023 at 11:48 AM in the presence of Staff D revealed the following observations: - cottage cheese with an initial temperature of 46 degrees F when removed from cold holding temperature. - carrot raisin salad made with mayonnaise with an initial temperature of 47.6 degrees F when removed from cold holding temperature. During a surveyor interview with Staff D immediately following the above-mentioned observations, she acknowledged that the temperatures obtained were the initial temperatures when the food was removed from cold holding temperature. Additionally, she acknowledged that the temperatures were greater than 41 degrees and indicated the food was ready to be sent out and served for the lunch meal. During a surveyor interview with the Dietary Supervisor on 1/30/2023 at approximately 12:00 PM, she acknowledged that the initial temperatures of food should be 41 degrees or less if removed from cold holding temperature. 3. During a surveyor observation of the main kitchen on 1/31/2023 at 10:55 AM in the presence of Dietary Cook Staff E, revealed the following observations: - yogurt in an approximately one-quart sized plastic container retrieved from cold holding with a temperature of 46 degrees F obtained with the facility's thermometer and 46.9 degrees F with the surveyor's thermometer. - a small plastic container of yogurt with a temperature of 44.9 degrees F obtained with the facility's thermometer and 45 degrees F with the surveyor's thermometer when removed from cold holding temperature. - a container of carrot raisin salad made with mayonnaise that was stored in the back of the walk-in cooler/refrigerator with a temperature of 46.8 degrees F with the facility thermometer. - a sample of yogurt from a newly opened container with a temperature of 43.8 degrees F with the surveyor's thermometer when removed from cold holding temperature. - carrot raisin salad made with mayonnaise with a temperature of 46 degrees F with the facility's thermometer when removed from cold holding temperature. During a surveyor interview with Staff E at the time of the above-mentioned observations she acknowledged the findings and indicated that the items had not previously been removed from cold holding. During a surveyor interview with the Dietary Supervisor on 1/31/2023 at 11:10 AM, she indicated she would discard the items that did not have an initial temperature of 41 degrees or less when removed from cold holding. 4. During a surveyor observation of the main kitchen on 1/31/2023 at 11:35 AM in the presence of the Dietary Supervisor revealed the following observations: - carrot raisin salad made with mayonnaise that was retrieved from the dairy walk-in cooler with a temperature of 46.9 degrees F with the facility's thermometer and 47.1 degrees F with the surveyor's thermometer. - Oreo cream pie with a temperature of 46.0 degrees F with the facility's thermometer and 46.8 degrees F with the surveyor's thermometer. During a surveyor interview with the Dietary Supervisor immediately following the above-mentioned observations she acknowledged that the temperatures were greater than 41 degrees F when removed from cold holding and indicated she would discard the potentially hazardous food items and replace them with an alternate. During a surveyor observation of the main kitchen on 1/31/2023 at 2:09 PM in the presence of the dietary Supervisor revealed the following observations: - a container of facility prepared turkey salad made with mayonnaise that was retrieved from a walk-in cooler with a temperature of 50.7 degrees F when removed from cold holding. - a container of mayonnaise with a temperature of 44.9 when removed from cold holding. - a pan of cooked macaroni and cheese with a temperature of 42.9 degrees F when removed from cold holding. During a surveyor interview with the dietary supervisor immediately following the above-mentioned observations, she acknowledged the temperatures were above 41 degrees F. Additionally, she was unable to provide evidence that the facility ensured that food is stored, served, and distributed, in accordance with professional standards for food service safety.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents relative to falls for 1 of 2 residents reviewed, Resident ID #25 Findings are as follows: Review of the record revealed the resident was admitted to the facility in August of 2018 with diagnoses, including but not limited to, repeated falls, multiple fractures of ribs on the right side, fracture of upper end of left humerus (long bone in the upper arm), fracture of greater trochanter of left femur (upper part of the thigh), dementia and abnormalities of gait and mobility. Review of a document titled, Order Summary Report, revealed a current order dated 7/6/2022, for supervision on/off unit with rollator (a mobility device similar to a walker with 4 wheels) for all activity and ambulation. Review of the care plan, revised on 9/6/2022, revealed that s/he has interventions, including but not limited to, supervision on/off the unit with rollator for all activity and ambulation relative to potential falls and poor safety awareness. Review of a fall risk assessment, dated 12/29/2022, revealed that s/he is at high risk for falls. Surveyor observation of the resident on 1/30/2023 at 3:01 PM revealed the resident was ambulating in the hallway with his/her rollator without any staff present for supervision. Additional observations of this resident on 2/1/2023 revealed the following: - 10:52 AM: S/he was ambulating down the hallway without staff supervision then entered a room for church services. - Approximately 12:00 PM: S/he was observed ambulating in the hallway after exiting the church service, continued down to another hallway and then into a dining room without staff supervision. During an interview with Nursing Assistant's Staff A and B, on 2/1/2023 at approximately 2:00 PM, they revealed that the resident usually ambulates independently without staff supervision. Review of the January 2023 progress notes, revealed in part: - 1/17/2023 at 5:47 PM: Resident had an unwitnessed fall around 1505 [3:05 PM] .complained of pain to [his/her] left side/shoulder .did not recollect how [s/he] fell . Resident verbalized [s/he] will like to be sent to the hospital . During a surveyor interview with Licensed Practical Nurse Staff C, on 2/1/2023 at 2:22 PM, it was revealed that the unwitnessed fall on 1/17/2023 occurred in the hallway on the unit. She further revealed that her expectation would be that staff would either walk with the resident, or be within a short distance away to visualize him/her, when s/he is ambulating for supervision. During a surveyor interview with the Director of Nursing Services on 2/1/2023 at 4:28 PM, she was unable to provide evidence that the plan of care and the order for supervision were followed.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality relative to needle safety for contaminated needles for 1 resident observed, Resident ID #35. Findings are as follows: According to Occupational Safety and Health Standards 1910.1030(d)(2)(vii) Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed except as noted in paragraphs (d)(2)(vii)(A) and (d)(2)(vii)(B) below .Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure.1910.1030(d)(2)(vii)(B) Such bending, recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique. Record review revealed, Resident ID #35 was admitted to the facility in November 2021, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor observation of the medication administration task on 12/21/2021 at 10:43 AM with the nurse Staff A, she was observed administering [MEDICATION(S)] insulin pen subcutaneously in the resident's abdomen. Immediately following the observation, Staff A picked up the needle cap with her left hand and recapped the used needle while it was still connected to the insulin pen. During an interview with Staff A following the observation, she acknowledged the used needle should not have been recapped prior to disposal. During an interview on 12/21/2021 at 2:55 PM with the Director of Nursing Services, she acknowledged that it was not a standard of practice to recap a used needle.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles and with the expiration date when applicable, for 1 medication cart observed. Findings are as follows: Review of the facility's policy titled, LTC Facility's Pharmacy Services and Procedures Manual states in part, .5.3 If a multi-dose vial of an injectable medication has been opened or accessed [e.g., needle-punctured], the vial should be dated and discarded within 28 days unless the manufacturer specifies a different [shorter or longer] date for that opened vial . During the medication storage task on 12/21/2021 at 10:40 AM, a [MEDICATION(S)] insulin (a medication that lowers blood sugar) pen was present in the 3rd floor medication cart without a patient identifier or the date of when it was opened. During an interview immediately following the above observation, nurse Staff A acknowledged that the [MEDICATION(S)] insulin pen was currently in use for Resident ID #35. During an interview with the Director of Nursing Services on 12/21/2021, she was made aware that the insulin pen was not labeled with the resident's name and not dated when opened.

Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 of 3 sample residents reviewed (Resident ID #13). Findings are as follows: Record review for Resident ID #13 revealed the resident has [DIAGNOSES REDACTED]. The resident has a physician's orders [REDACTED]. Review of quarterly dietary progress notes dated 5/21/2020 and 8/13/2020 revealed the resident remains below ideal weight range. The note indicates the resident remains at risk related to swallowing issues and underweight status. Record review revealed a current care plan initiated on 1/17/2019 and revised on 8/19/2020 states in part, Underweight status. Used to weight (sic) @170's .Interventions/Tasks: Consume adequate calories at meals and snacks, and offer supplements 1-2 x day. Review of the weight documentation revealed the following: -10/21/2020 = 162.8 Lbs -10/14/2020 = 163.4 Lbs -10/7/2020 = 161.4 Lbs -9/30/2020 = 163.2 Lbs -9/23/2020 = 164.0 Lbs -9/16/2020 = 165.2 Lbs -9/9/2020 = 161.2 Lbs -9/2/2020 = 162.2 Lbs -8/26/2020 = 160.2 Lbs -8/19/2020 = 161.2 Lbs -8/13/2020 = 160.0 Lbs -8/12/2020 = 161.0 Lbs -7/29/2020 = 164.2 Lbs -7/29/2020 = 154.2 Lbs -7/22/2020 = 163.2 Lbs -7/15/2020 = 160.2 Lbs -7/8/2020 = 161.2 Lbs -7/1/2020 = 162.2 Lbs -6/24/2020 = 159.8 Lbs Review of the Treatment Administration Record failed to reveal evidence that the Ensure Compact was given between 6/21/2020 - 10/22/2020. During a surveyor interview on 10/23/2020 at 10:23 AM with Staff Nurse C, she was unable to provide evidence that Ensure Compact was given as ordered.

Based on record review and staff interview, it has been determined that the facility failed to purchase a surety bond, or otherwise provide assurance for the security of all personal funds of residents deposited with the facility. Findings are as follows: Review on 10/23/2020 at approximately 2:00 PM of the facility's Residence Nursing Facility Trust account balance as of 10/23/2020 revealed the total balance of resident funds held by the facility to be $17,575.09. Review on 10/23/2020 at approximately 2:00 PM of the facility's surety bond which has effective dates of 2/01/2020 through 2/01/2021 revealed the resident's funds are insured up to $13,000. During surveyor interview on 10/23/2020 at approximately 3:00 PM with the Administrator, she acknowledged that the surety bond did not cover the total balance of resident funds that were held by the facility.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's executed advance directive is documented in a prominent part of the medical record for 1 of 16 residents (Resident ID #39) reviewed for advance directives. Findings are as follows: Review of the facility policy, titled Advance Directives states in part, Document on admission, that Advance Directive exist and place a copy of the Advance Directives in the Resident Medical record. As Advance Directives are completed or modified, a current copy is kept within the Medical/Nursing Chart. Record review for Resident ID #39 revealed that s/he was admitted to the facility in September of 2020 for long-term care. Review of the record revealed a current physician order dated [DATE] in the electronic medical record for advance directive of DNR (do not resuscitate - instructing health care providers not to do cardiopulmonary resuscitation (CPR) if a resident's breathing stops or if the resident's heart stops beating). A review of the electronic and paper record lacked evidence of Resident ID #39's signed advance directive. During a surveyor interview with nurse, Staff A, on [DATE] at 10:52 AM, she revealed that there was not a copy of the resident's signed advance directive in the medical record.

Based on record review and staff interview, it has been determined that the facility failed to ensure that allegations of abuse are reported immediately, but not later than 2 hours after the allegation is made, to the administrator and to the State Survey Agency, and the results of the investigation are reported to the State Survey Agency within 5 working days, for 1 of 2 residents reviewed for abuse(Resident ID #1). Finding are as follows: Review of the facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property states in part, .The Home will ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to the administrator of the Home and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five (5) working days. According to Rhode Island state law, § 23-17.8-2. Duty to report, Telephone reports made pursuant to this section shall be followed-up within three (3) business days with a written report. Review of a community reported complaint dated 3/2/2020 states that Resident ID #1 was hallucinating in the middle of the night and tried to hit staff with (his/her) walker and ended up falling. The elder reported to the hospital that (s/he) was assaulted at the facility, so Police were sent out to get a statement. Review of facility nursing notes revealed the following entries from Staff Nurse B: 3/2/2020, 12:19 AM, assaulted staff multiple time with handsand (sic) walker.pt (patient) lost balance despite staff in attendece (sic) fell striking head. screaming help. 3/2/2020, 12:38 AM, pt. left with rescue. to be brought to (hospital) ER (emergency room ) for treatment and eval (evaluation). Alert disoriented yelling for help 3/2/2020, 4:30 AM, police arriving at unit approx (approximately) 0200 (2:00 AM), apparently pt. had made statements that she was assaulted . 3/2/2020, 5:04 AM, contacted (on-call manager, Assistant Director of Nursing Services (ADNS)) notified of fall but not accusations at present Further review of the record revealed a 3/2/2020, 9:57 AM, progress note from the current administrator stating, nurse reported that (city) police interviewed nurse on nights. Patient made accusation of alleged abuse .Telephone call to ombudsman (ABLTC) advised to take the resident back to facility and investigate the report and monitor the residents (sic) behavior. Telephone call to DPH (Department of Public Health) .Left voice mail. Review of emergency room notes obtained from the hospital states in part, Pt (patient) denies falling and states ?man punched (him/her) in stomach and then hit (him/her) in the head, +3inch lac (laceration) above left eyebrow. Bruising to bridge of nose +swelling. During a surveyor telephone interview on 10/26/2020 at 2:19 PM with Staff B, she revealed that she did not report the allegation of abuse to the administrator immediately or within 2 hours. Additionally, she was unable to explain why she did not notify the ADNS of the abuse allegation when she called to notify her of Resident ID #1's fall. During a surveyor interview with the ADNS on 10/26/2020 at 3:00 PM, she revealed that Staff B did call her on 3/2/2020 and notified her of Resident ID #1's fall but did not notify her of the abuse allegation made by the resident. During a surveyor interview with the Administrator on 10/26/2020 at 12:15 PM, she revealed that she did contact the State Agency by phone but she did not send in the Department of Health, Center for Health Facilities Regulation, Nursing Facility Required Reporting form for Certified Facilities or the Nursing Facility 5-day Investigation Report.

Based on record review and staff interview, it has been determined that the facility failed to ensure that allegations of abuse are thoroughly investigated and reported to the State Survey Agency within 5 working days of the incident for 1 of 2 residents reviewed for abuse (Resident ID #1). Finding are as follows: Review of a community reported complaint dated 3/2/2020 states that Resident ID #1 was hallucinating in the middle of the night and tried to hit staff with (his/ her) walker and ended up falling. The elder reported to the hospital that (s/he) was assaulted at the facility, so Police were sent out to get a statement. Review of facility nursing notes revealed the following entries from Staff Nurse B: 3/2/2020, 12:19 AM, assaulted staff multiple time with handsand (sic) walker.pt (patient) lost balance despite staff in attendece (sic) fell striking head. screaming help. 3/2/2020, 12:38 AM, pt. left with rescue. to be brought to (hospital) ER (emergency room ) for treatment and eval (evaluation). Alert disoriented yelling for help. 3/2/2020, 4:30 AM, police arriving at unit approx (approximately) 0200 (2:00 AM), apparently pt. had made statements that she was assaulted . 3/2/2020, 5:04 AM, contacted (on-call manager, Assistant Director of Nursing Services (ADNS)) notified of fall but not accusations at present. Review of emergency room notes obtained from the hospital states in part, Pt (patient) denies falling and states ?man punched (him/her) in stomach and then hit (him/her) in the head, +3inch lac (laceration) above left eyebrow. Bruising to bridge of nose + swelling. During a surveyor interview with the Administrator on 10/26/2020 at 12:15 PM, she was unable to provide evidence that the facility thoroughly investigated Resident ID #1's allegation of abuse or that investigative results were sent to the State Agency within 5 working days of facility staff being made aware of the allegation by the police.

Based on record review and staff interview, it has been determined the facility failed to ensure a resident's drug regimen is free from unnecessary [MEDICAL CONDITION] drugs related to as needed anti-psychotic drugs extended beyond 14 days without an evaluation for the appropriateness of the medication by the prescribing practitioner, for 1 of 6 sampled residents reviewed for unnecessary medications (Resident ID #26). Findings are as follows: Clinical record review for Resident ID #26 revealed a current physician's orders [REDACTED]. Record review of the Medical Administration Record revealed that between 9/28 and 10/26/2020 the resident received the [MEDICATION NAME] a total of 14 times, 8 of which were after the initial 14 days. It was documented as last received on 10/23/2020, this was 26 days after the initial order date. Further record review revealed a pharmacy consultation report dated 9/30/2020 which states in part, Please discontinue PRN [MEDICATION NAME] or add a stop date that does not exceed 14 days from initiation. If this PRN antipsychotic cannot be discontinued at that time, current regulations require that the prescriber directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated prior to issuing a new PRN order . The physician signed and dated the form on 10/21/2020, declining the recommendation and writing the patient has agitation and was evaluated by psych. During surveyor interview on 10/26/2020 at approximately 11:15 AM with the DNS she could not provide evidence of a stop date, or reassessment of the use of [MEDICATION NAME] by a physician every 14 days. During surveyor interview on 10/26/2020 at approximately 11:30 AM with the resident's physician, he revealed that he had not been assessing the resident every 14 days to assess for the need for the continued use of [MEDICATION NAME].

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 2 medication carts (2nd and 3rd floor nursing units). Findings are as follows: Surveyor observation of the 3rd floor medication cart on 11/15/2019 at approximately 8:15 AM, revealed an open bottle of Saline nasal spray (medication used to loosen mucous) which had an expiration date of 10/2019. Surveyor observation of the 2nd floor medication cart on 11/15/2019 at approximately 9:00 AM, revealed one opened bottle of [MEDICATION NAME] (a medication used to treat heartburn) with a manufacturer's expiration date of 10/22/2019 and one bottle of [MEDICATION NAME] with Tylenol (a medication used to treat pain) containing a label where the expiration date and pharmacy instructions were unreadable. During interview on 11/15/2019 at approximately 11:54 AM, the acting Director of Nursing Services acknowledged that the above medications should have been discarded and not made available for use.

Based on record review and staff and resident interviews, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice relative to 1 of 3 residents reviewed for activities of daily living (ID #1). Findings are as follows: According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Tenth Edition, 2004, page 965,Remove dentures at night and soak them in water or a denture product . Record review revealed Resident ID #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] revealed the resident required extensive assist with hygiene. Review of a progress noted dated 7/19/2019 at 6:53 AM, revealed, . Resident heard yelling out for the Nurse. [MEDICAL CONDITION] removed from face, resident stated he felt like he 'was choking' .Resident given a basin and spit a small amount of blood mixed with saliva .his throat hurt for which he gave a (pain) score of 8/10. Continuity of care form from the hospital for the period of 7/19/2019-7/22/2019 revealed, . Patient presented for evaluation of foreign body in airway. ENT performed bedside laryngoscopy (a procedure to view the inside of the throat) which showed partial plate (dentures) in the larynx. Patient was taken to the OR with successful removal of foreign body . Review of a statement dated 7/22/2019 written by Staff Nursing Assistant A, revealed that she came to work at 4 pm on the evening of (MONTH) 18, 2019, missing shift turnover report. It was the first time she put Resident ID #1 to bed and she was unaware that the resident had dentures. Surveyor interview on 7/29/2019 at 1:18 PM with Staff Nurse B, revealed that she was on duty on the evening of 7/18/2019 along with Nursing Assistant A, and she reported she did not check if dentures were in place prior to placing the [MEDICAL CONDITION] mask on the resident. During surveyor interview with the Director of Nursing (DNS) on 7/30/2019 at 10:00 AM, she acknowledged that Nursing Assistant A was new to the unit and did not remove the resident's dentures. Upon further interview with the DNS, she indicated that the following interventions were put into place after the incident: a) The facility implemented a physician's orders [REDACTED]. This order has been added to the Medication Administration Record [REDACTED]. b) The DNS implemented a protocol for Denture care dated 7/19/2019 which states, ALL RESIDENTS WITH DENTURES OR PARTIAL PLATES MUST RECEIVE NIGHTLY DENTURE CARE AND HAVE DENTURES REMOVED FROM THEIR MOUTH. IF THE RESIDENT REFUSES TO REMOVE THEIR DENTURES, PLEASE INFORM THE CHARGE NURSE IMMEDIATELY. c) The DNS revealed the facility is in the process of adding Denture insertion/removal into the task section of each residents' electronic record if applicable. d) The DNS revealed that if a Nursing Assistant must float to a different unit the Nurse now gives them a full report on all aspects of the resident's care including dentures and hearing aids.

Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility has failed to provide or obtain from an outside resource, dental services to meet the needs of 2 of 5 sampled residents investigated for dental services, (ID#s 26 & 35). Findings are as follows: 1) Clinical record review for Resident ID# 26 revealed s/he was last seen by the dentist on 10/5/2016 in which there was a recommendation for a tooth extraction. The record lacked evidence that the resident received any dental services since the 10/5/2016 visit. 2) Clinical record review for Resident ID# 35 revealed s/he was admitted to the facility on [DATE] and had not yet been seen by a dentist. During an interview with Resident ID#35 on 2/4/2019 at approximately 11:02 AM s/he revealed that s/he had some of his/her natural teeth and had not seen a dentist since admission and would like to see one. During an interview with the Director of Nursing on 2/7/2019 at 1:50 PM, she was unable to provide evidence that these residents had been provided with dental services to meet their needs.

Based on record review and staff interview, it has been determined that the facility failed to provide a written notice of transfer to the Office of the State Long-Term Care Ombudsman for 2 of 2 sample residents who were transferred to the hospital (Resident ID#s 31 & 48). Findings are as follows: 1) Medical record review for Resident ID# 31 revealed s/he was transferred from the facility to the hospital on [DATE]. 2) Medical record review for Resident ID# 48 revealed s/he was transferred from the facility to the hospital on [DATE]. When interviewed on 02/07/2019 at approximately 11:40 AM, the Medical Secretary was unable to produce evidence that Ombudsman's office was notified of the transfers.

Based on record review and staff and resident interviews, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 3 of 17 sample residents (Resident ID#'s 15, 20 & 34). Findings are as follows: 1) Clinical record review for Resident ID# 15 revealed an annual Minimum Data Set ((MDS) dated [DATE]. Under Section P, bed rails are coded as a restraint and used daily. Further record review revealed a bed rail assessment dated [DATE]. This assessment indicates the bedrails are used for positioning while in bed. The resident was interviewed on 1/6/2019 at 12:45 PM and stated that s/he uses the bedrails to reposition in bed but they do not prevent the resident from getting out of bed. 2) Clinical record review of Resident ID# 20 revealed a quarterly MDS dated [DATE]. Under section O, it is indicated that this resident does not utilize oxygen. Further record review revealed a physician's orders [REDACTED]. During a surveyor observation on 2/4/2019 at 10:52 AM an oxygen concentrator was observed in Resident ID# 20's room. An interview on 2/4/2019 at approximately 10:55 AM with Resident ID# 20 revealed she/he uses oxygen when needed. 3) Review of Resident ID#34's clinical record revealed he/she was admitted on [DATE] with an indwelling urinary catheter in place. Further record review revealed an Admission MDS dated [DATE] that indicates the resident is occasionally incontinent of urine. The Director of Nursing was interviewed on 1/6/2019 at 3:20 PM and was unable to explain why the above assessments were coded incorrectly.