Every finding on record at John Clarke Senior Living

Based on clinical record review, resident interview, and staff interview, the facility failed to ensure that residents were free from significant medication errors for 1 of 1 resident reviewed, Resident ID #1. Specifically, the facility administered 50 units of short-acting insulin to the resident instead of the prescribed 50 units of long-acting insulin. This medication error resulted in the resident receiving a medication with a substantially different onset, peak, and duration of action than ordered. The facility's failure to administer the medication as prescribed placed the resident at immediate risk for serious hypoglycemia, loss of consciousness, hospitalization, or death. The deficient practice created a situation in which serious injury, serious harm, serious impairment, or death was likely to occur and therefore constituted Immediate Jeopardy to resident health and safety. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/4/2026, alleging that Resident ID #1 was administered the wrong insulin.Review of the facility policy titled, Medication Administration states in part, .Ensure that the six rights of medication administration are followed: Right resident, Right drug, Right dosage.Right route.Right time.Right documentation.Review MAR [Medication Administration Record] to identify medication to be administered.Compare medication with MAR to verify resident name, medication name.dose.Record review revealed the resident was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, type 2 diabetes mellitus (a metabolic condition when the body cannot use insulin correctly and sugar builds up in the blood).Record review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13 out of 15 indicating the resident's cognition is intact.Record review revealed the following physician orders:- NovoLog (a short-acting insulin used to control mealtime blood sugar spikes and begins working within 5-10 minutes) pen-injector 100 unit/milliliter (U/ML) Inject as per sliding scale: if 200 - 249 = 2; 250 - 299 = 4; 300 - 349 = 6; 350 - 399 = 8; 400 - 449 = 10, given before meals for diabetes with a start date of 3/18/2026. - Novolog pen-injector 100U/ML, inject 6 units one time a day in the morning with a start date of 5/23/2026.- Tresiba (a long-acting insulin that is taken once a day that starts to work several hours after administration and works evenly for 24 hours to lower sugar in the blood) 200 U/ML, inject 50 units at bedtime for type 2 diabetes with a start date of 5/22/2026.Record review of the June 2026 MAR revealed on 6/2/2026 the Tresiba insulin order was signed off with a chart code of 5 indicating the insulin was held and to reference the progress notes.Record review of a nursing progress note dated 6/2/2026 at 9:50 PM revealed a medication error had occurred at 8:15 PM resulting in the resident receiving 50 units of Novolog instead of the scheduled 50 units of Tresiba, as ordered. Further review of the progress notes revealed the attending physician was notified of the error, and new orders were obtained to monitor for signs and symptoms of hypoglycemia (low blood sugar) check his/her blood sugar every 20 minutes for 3 hours and hourly thereafter. Additionally, the resident was administered 240 ML of orange juice for prevention of hypoglycemia and cookies.Additional record review of a nursing progress note dated 6/2/2026 at 10:28 PM revealed the physician had called the facility to check on the resident and was informed that the resident's blood sugar was 175 at that time after s/he had been given 240 ML of orange juice and a cookie.Additional record review of an incident report dated 6/2/2026 at 8:15 PM states in part, Incident Description: nurse reported administering Novolog 50 units vs [versus] scheduled Tresiba 50 units.immediately reported to MD [Medical Doctor].error reported to resident at time of occurrence.During a surveyor interview on 6/17/2026 at 10:55 AM with Registered Nurse, Staff A, she stated that on 6/2/2026 she had worked on the unit as one of the nurses with Registered Nurse, Staff B. She stated that Staff B had alerted her on the evening of 6/2/2026 that she had administered Resident ID #1 the wrong insulin. Staff A stated that Staff B had acknowledged that she had administered 50 units of Novolog instead of 50 units of Tresiba to the resident. Staff A further stated that she assisted Staff B in monitoring the resident's blood sugar and gave him/her orange juice while Staff B contacted the physician, Nurse Practitioner (NP), Staff C.During a surveyor interview on 6/17/2026 at 12:55 PM with the resident, s/he acknowledged that the staff had indicated to him/her on 6/2/2026 that s/he had been administered the wrong does of insulin.During a surveyor interview on 6/17/2026 at 1:07 PM with NP, Staff C, she acknowledged that she had been notified by the facility on 6/2/2026 of a medication error involving the administration of the wrong insulin to Resident ID #1. She further stated that she expects staff to adhere to all established medication administration policies and procedures, including verifying the resident's identity and confirming the correct medication prior to administering any medication.During a surveyor interview on 6/17/2026 at 10:47 AM and at 11:40 AM with the Director of Nursing Services (DNS), she acknowledged that on the evening of 6/2/2026 she was notified by Staff B that she had administered the wrong insulin to the resident. Additionally, the DNS acknowledged that Staff B had notified her that the resident had been administered 50 units of Novolog in error instead of 50 units of Tresiba, as ordered.During a surveyor interview on 6/18/2026 at 9:13 AM with Staff B, she acknowledged that on the evening of 6/2/2026 she administered 50 units of Novolog to the resident instead of the prescribed 50 units of Tresiba. Staff B stated that she realized the error after administering the insulin and immediately notified Staff A and NP, Staff C. She further acknowledged that she did not verify the type of insulin prior to administration.As a result of the facility's failure to ensure that medications were administered in accordance with facility policy and accepted standards of practice, Resident ID #1 received the wrong medication. Specifically, the facility failed to confirm the correct medication prior to administration, resulting in Resident ID #1 receiving 50 units of a short-acting insulin (Novolog) instead of the prescribed 50 units of a long-acting insulin (Tresiba). Consequently, the resident required continuous monitoring for hypoglycemia following the medication error. This deficient practice placed the resident at risk for serious injury, harm, impairment, or death and had the potential for such outcomes to occur.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to maintain an infection control program to help prevent the transmission of infections related to contact precautions (an infection control intervention designed to reduce the transmission of multidrug-resistant organisms in nursing homes) and standard precautions (the minimum infection prevention practices applied to all patients in all healthcare settings, at all times, to protect healthcare workers and patients from the transmission of infectious agents, regardless of the patient's infection status) for 2 of 2 residents reviewed, Resident ID #'s 61 and 19.Findings are as follows: 1. Record review of an undated facility policy titled Transmission-Based (Isolation) Precautions states in part .It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission.'Contact precautions' refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident environment.The facility will use standards approaches as defined by the CDC[Centers for Disease Control and Prevention], for transmission-based precautions.contact.If sharing noncritical equipment between residents, the equipment will be cleaned and disinfected following manufacturer's instructions .According to Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings.Wound Care Facilitator Guide from the Centers for Disease Control and Prevention, last revised on 1/27/2023, states in part, .Maintain separation between clean and soiled equipment to prevent cross contamination .Any unused disposable supplies that enter the patient/resident's care area should remain dedicated to that patient/resident or be discarded. They should not be returned to the clean supply area. If supplies are dedicated to an individual patient/resident, they should be properly labeled and stored in a manner to prevent cross-contamination or use on another patient/resident (e.g., in a designated cabinet in the patient/resident's room) .Multidose topical wound care medications, such as creams, sprays and ointments, should be dedicated to an individual patient/resident.Containers entering patient/resident care areas should be dedicated for single-patient /resident use or discarded after use .Record review revealed that Resident ID #61 was admitted to the facility in April 2026 with diagnoses including, but not limited to, Methicillin-resistant Staphylococcus aureus (MRSA, a strain of Staphylococcus aureus resistant to methicillin and related beta-lactam antibiotics) and an infection of the left knee prosthesis (an artificial knee joint).Further record review revealed a physician's order dated 4/5/2026 for contact precautions to be implemented every shift due to MRSA involving the left lower extremity (LLE) and nares. Additional record review reveaaled the resident receives daily wound care treatment to the buttocks and LLE.During a continuous surveyor observation on 4/9/2026 from 10:10 AM to 10:29 AM, Registered Nurse, Staff A, was observed providing care in the resident's room. Upon exiting, Staff A placed the following items on top of the medication cart without cleaning and disinfecting them per manufacturer's instructions:-A case containing a stethoscope, blood pressure cuff, and pulse oximeter (used to measure heart rate and oxygen saturation)-One eight-ounce bottle of wound cleanser spray-One roll of white tapeDuring a surveyor interview at 10:37 AM on 4/9/2026, Staff A acknowledged that Resident ID #61 is positive for MRSA in both the wound and nares and acknowledged the physician's order for contact precautions.A subsequent observation at 10:48 AM revealed Staff A placed the wound cleanser and tape into the medication cart and then entered another resident's room (who was not on contact precautions) with the same vital signs equipment case. The case was placed on that resident's bedside table. The surveyor intervened prior to Staff A obtaining vital signs using the contaminated equipment.During a follow-up interview immediately after the observation, Staff A acknowledged that the vital signs equipment had been taken from a contact precautions room into another resident's room without prior disinfection and confirmed it should have been cleaned before reuse. Staff A also acknowledged placing wound care supplies used for Resident ID #61 into the general wound care supply within the medication cart, which is utilized for multiple residents.During an interview at 12:16 PM on 4/9/2026, the Director of Nursing Services (DNS) stated that equipment used for residents on contact precautions should be dedicated to single-resident use or appropriately disinfected prior to use with other residents. The DNS further stated that wound care supplies for residents on contact precautions are expected to be designated for individual use.2. Record review of the Center for a Disease Control and Prevention guideline titled Clinical Safety: Hand Hygiene for Healthcare Workers dated February 27, 2024, states in part, .If your task requires gloves.change gloves and clean hands.before exiting a patient [resident] room.Record review revealed Resident ID #19 was admitted to the facility in March 2026 with a diagnosis including, but not limited to, type 2 diabetes mellitus (a condition in which the body is unable to properly use or produce sufficient insulin, resulting in elevated blood glucose levels). Further review revealed a physician's order dated 3/18/2026 for NovoLog insulin to be administered subcutaneously (under the skin) via a pen injector in accordance with a sliding scale (a method of insulin dosing based on pre-meal blood glucose levels).During a surveyor observation of Registered Nurse, Staff A, was administering medications on 4/9/2026 at 11:51 AM. She donned (applied) gloves and obtained the resident's blood glucose using a lancet. After applying a drop of blood to the test strip and obtaining the reading, Staff A placed a 2x2 gauze on the resident's finger and exited the room without removing gloves or performing hand hygiene. Staff A then disposed of the lancet and test strip in a sharp's container, reached into her pocket to retrieve keys, touched the top and second drawers of the medication cart, and handled a container of multi-use disinfectant wipes prior to removing gloves or performing hand hygiene.Staff A subsequently applied new gloves and administered NovoLog insulin via injection. She then stepped into the doorway without removing gloves or performing hand hygiene and disposed of the used needle in the sharp's container. Staff A again reached into her pocket for keys, touched the medication cart drawer, and returned the insulin pen to the cart prior to removing gloves or performing hand hygiene.During a surveyor interview immediately following the observation, Staff A acknowledged failing to remove her gloves and performing hand hygiene after obtaining the blood glucose reading and administering the insulin, prior to touching her keys and the medication cart. She further stated that it is her usual practice not to remove gloves during these tasks, revealing that disinfectant wipes are stored in a locked medication cart.During surveyor interviews conducted on 4/9/2026 at 2:39 PM and 4/10/2026 at approximately 12:45 PM, the Director of Nursing Services stated that staff are expected to remove gloves and perform hand hygiene after disposing of the lancet and test strip and prior to exiting the resident's room.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide adequate supervision for one of one resident reviewed, Resident ID #1. This resident successfully eloped from the facility on two separate occasions and later entered an unsecured area within the facility, where they sustained a fall that required a hospital transfer for evaluation.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 9/21/2025 alleges that Resident ID #1 has eloped out of the facility multiple times, and indicated the resident is not appropriate for the facility.Review of an undated facility policy titled, Elopement of Resident, states in part, .All residents will be assessed for potential elopement risk at admission and with a significant change in status.For residents identified as at risk, an interdisciplinary elopement prevention care plan will be developed.Staff witnessing a confused resident or an identified elopement risk resident attempting to leave the Center will intervene as appropriate to redirect the resident to a safe area and prevent elopement.Record review revealed the resident was admitted to the facility in March of 2025, with a diagnosis including, but not limited to, dementia.Review of a Significant Change Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating the resident has severely impaired cognition. Further review revealed the resident displayed wandering behaviors, one to three days, during the seven-day look back period and utilized a wander guard (a device designed to prevent individuals from wandering away by alerting caregivers when a resident breaches a designated perimeter) daily. Review of a Wandering Assessment dated 7/20/2025 revealed a score of 11, indicating s/he is at high risk for wandering. Record review failed to reveal evidence that an Elopement Assessment was completed, after the resident's significant change in status on 7/18/2025, per the facility policy.Review of a care plan focus area initiated on 6/16/2025 revealed the resident has exit seeking behaviors due to his/her diagnosis of dementia. Interventions include, distract resident from wandering by offering pleasant diversions, food, or conversation and to utilize a wander guard, as ordered. Record review revealed the following physician's orders dated 6/14/2025:- Check functional status of wander guard to right wrist, each shift- Check placement of wander guard on right wrist, each shiftReview of a progress note dated 8/26/2025 revealed the resident successfully eloped from the facility and was found by nursing staff outside of the front door. Further review states, additional safety measures implemented.Record review failed to reveal evidence that additional safety measures were identified and implemented, following the resident's successful elopement on 8/26/2025. Record review revealed a progress note dated 9/20/2025, authored by Registered Nurse (RN), Staff A, which states, at 17:25 [5:25 PM] resident was found by RN outside of building in facility parking lot. Wander guards functioning properly on wheelchair and wrist, wander guard system did not activate. On call supervisor notified and made aware.Record review failed to reveal evidence that additional safety measures were identified and implemented, following the resident's successful elopement on 9/20/2025. Record review revealed a progress note dated 9/21/2025, one day after the resident's successful elopement, which states in part, Resident unable to be located, CNA [Certified Nursing Assistant] found resident lying on the floor in dark therapy room on [his/her] back with difficulty to arouse. Resident responded yes when RN called out [his/her] name multiple times in a delayed response. Resident unable to verbalize any pain and gave a blank stare when asked questions. Resident lethargic on assessment, then became alert with 0 orientation. able to move all 4 [extremities] unable to grasp hands to determine hand strength, pupils unequal at baseline with sluggish response to light accommodation .On call provider.notified with new orders to send resident to [NAME] ED [Emergency Department] for treatment and evaluation via EMS [Emergency Medical Services] .Resident transferred off therapy room floor onto stretcher via EMS personnel.Record review revealed the resident retuned to the facility on 9/22/2025 with a diagnosis of a urinary tract infection. During a surveyor observation on 9/24/2025 at 9:29 AM, Resident ID #1 was noted to have a wander guard on his/her right wrist and 2 additional wander guards located on the back of his/her wheelchair. Record review failed to reveal evidence of a physician's orders to check for functionality or placement of the two wander guards located on the resident's wheelchair. During surveyor interviews on 9/24/2025 at 10:39 AM and 12:35 PM, with RN, Staff A, she indicated that she was one of the nurses on duty on 9/20/2025. She acknowledged that Resident ID #1 successfully eloped from the facility on 9/20/2025, through the main entrance door, and was found in the parking lot, in his/her wheelchair. She revealed that when she was unable to locate the resident in the facility and initiated a facility search. She indicated that RN, Staff B found the resident outside in the parking lot. She further revealed that based on surveillance footage, the resident eloped after a visitor had opened the door the resident was able to self-propel outside. She revealed that there is a wander guard system at the front door but indicated the alarm did not go off when the resident exited the facility. Additionally, she revealed that Resident ID #1 frequently wanders around the facility, indicating that staff are constantly questioning his/her whereabouts. Furthermore, she revealed that the resident was found the next day on 9/21/2025, lying on the floor of the therapy room, where s/he should not have been able to enter, indicating the room should have been locked. She further revealed that the resident has previously been found in other rooms, such as a storage room due to his/her wandering behaviors. During a surveyor interview on 9/24/2025 at 10:53 AM, with RN, Staff B, she indicated that she was one of the nurses on duty on 9/20/2025. She revealed that on 9/20/2025 at approximately 5:25 PM, she saw Resident ID #1 self-propelling towards the front doors and indicated that she was following behind him/her. She further revealed that she had stopped to assist another resident, by the time she approached the front doors she observed Resident ID #1 outside in the parking lot with another resident, who was holding his/her wheelchair to prevent the resident from self-propelling further into the parking lot. Additionally, she revealed that Resident ID #1 has previously eloped from the facility. Furthermore, she revealed that the wander guard alarm did not alert when the resident left the faciity on 9/20/2025. Surveyor observation on 9/24/2025 of the facility parking lot reveals, the flat parking lot slopes toward a hill that descends to a highly traveled main road and ultimately ending at a large body of water. During surveyor interviews on 9/24/2025 at 9:46 AM with the Director of Nursing Services (DNS) and the Administrator, they acknowledged that Resident ID #1 successfully eloped from the facility on 8/26/2025 and 9/20/2025. During a surveyor interview on 9/24/2025 at 10:24 AM, with the DNS, she revealed that after the resident's successful elopement on 9/20/2025 and after the incident on 9/21/2025 where the resident was found in the therapy room, the social worker was attempting to find the resident placement on a secured unit at another facility, however, she was unable to provide evidence that any additional interventions or safety measures were in place to prevent the resident from wandering into areas of the facility where s/he should not be and eloping again while s/he was still a resident at the facility. A surveyor observation on 9/24/2025 at 11:19 AM, of the surveillance footage from 9/20/2025, revealed Resident ID #1 self-propelled in his/her wheelchair to the front door and was noted to be sitting at the front door, without the doors opening. Further review revealed a visitor entered the facility, causing the main doors to open, the resident was then able to self-propel outside and elope from the facility. Additionally, no staff were present in the video, when the resident successfully eloped from the facility. During a surveyor interview on 9/24/2025 at 12:23 PM, with the Administrator and DNS, the Administrator acknowledged that the wander guard system did not alarm on 9/20/2025, when the resident exited through the front door perimeter. The Administrator further revealed that she had placed one of the two wander guards on the back of the resident's wheelchair but was unable to recall when she had placed it. Additionally, they were unable to provide evidence that Resident ID #1 received adequate supervision to prevent him/her from eloping from the facility, twice, once on 8/26/2025 and again on 9/20/2025, also they failed to prevent him/her from wandering into an unsecured area of the facility on 9/21/2025.The facility failed to reassess the resident's risk for elopement following a significant change in condition and did not implement adequate supervision interventions. As a result, a cognitively impaired resident previously identified as a wander risk was able to exit the facility through the main doors on two occasions, 8/26/2025 and 9/20/2025. During the second incident, the resident was found in the parking lot, having been stopped by another resident. The facility's continued failure to provide adequate supervision led to the resident being found on the floor of the therapy room on 9/21/2025, following an unwitnessed fall one day after the most recent elopement. This incident required the resident to be transferred to the hospital for further evaluation. These systemic failures placed Resident ID #1 at risk for more than minimal harm, serious injury, or death.

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #30. Findings are as follows: According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 252 states the usual daily urine volume in the adult is 1-2 Liters or 1000-2000 cubic centimeters (cc). According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage. According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1284 states, To reduce the risk of bacterial proliferation [rapid increase in numbers] empty the collection bag at least every 8 hours through the drainage spout - more frequently if there is a large volume of urine. Record review revealed that the resident was readmitted to the facility in March of 2024 with diagnoses including, but not limited to, influenza and Alzheimer's disease. Review of a physician's order dated 3/2/2024 revealed the resident has a foley catheter for urinary retention. Review of the resident's care plan revealed a focus that states in part, Foley Catheter r/t [related to] urinary retention . Additional review revealed an intervention including, but not limited to, Foley Catheter Care QS [every shift] - Empty Bag and record amount. Record review revealed the following documented urine output: 3/1/2024 no output is documented. 3/2/2024 at 8:48 PM - 250 cc 3/3/2024 at 12:00 PM - 100 cc and at 9:18 PM - 200 cc 3/4/2024 at 6:59 AM - 300 cc 3/5/2024 at 9:13 PM - 100 cc During a surveyor interview on 3/6/2024 at 11:26 AM with Registered Nurse, Staff A, in the presence of the Director of Nursing Services (DNS), she acknowledged that the resident's urinary output was not documented every shift and that she was unsure what the resident's output was every day. Additionally, she revealed that the physician was not notified regarding minimal output due to staff being unaware of the resident's accurate urine output. During a surveyor interview on 3/6/2024 at 12:31 PM with the DNS, she acknowledged that the resident's output was not recorded accurately for the above dates. Additionally, the DNS was unable to provide evidence that the facility provided appropriate treatment and services for a resident with a urinary catheter including emptying and documenting the urinary output to assess for adequacy of renal function.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a sanitary environment for residents, staff and the public relative to 1 of 2 ice machines. Findings are as follows: During a surveyor observation on 3/4/2024 at 8:45 AM of the main kitchen ice machine, revealed black matter on the inside shield of the ice dispenser. Additionally, the left upper front quarter of the shield revealed a linear pattern of black spots. During a surveyor interview immediately following the above observation with the Kitchen Supervisor, Staff B, he acknowledged the above-mentioned black matter. Additionally, he was unable to provide evidence of the facility-initiated cleaning schedule. Record review of a document titled; Ice Machine Cleaning Schedule indicated a monthly cleaning schedule is conducted on the 10th day of each month. Further, it revealed the last time the ice machine was cleaned was 2/10/2024. Record review of the ice machine service documents from an outside company, revealed the ice machine was cleaned and sanitized every 6 months, with the most recent cleaning completed on 12/13/2023. During a surveyor observation and simultaneous interview on 3/5/2024 at approximately 9:15 AM with the Food Service Director, he acknowledged the presence of the above-mentioned black matter and indicated that the ice machine needed to be emptied and cleaned that day.

Based on record review and staff interview, it has been determined that the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents, for 1 of 1 residents reviewed for falls, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health dated [DATE] states in part, [DATE] Rolled off bed sustained 2 femur fracture, hit head on cabinet XXX[DATE] died in facility. Record review revealed the resident was admitted to the facility in September of 2019 with diagnoses including, but not limited to, neurocognitive disorder with Lewy Bodies (also known as Lewy body dementia), and senile degeneration of the brain. Review of a quarterly MDS (Minimum Data Set) Assessment, dated [DATE] reveals that the resident requires two or more staff for assistance with bed mobility, transfer, and toileting. Record review of a document titled MORSE FALL SCALE (method of assessing a patient's likelihood of falling) dated [DATE] revealed a score of 55 which indicates that the resident was at High Risk for Falling. Record review of a document titled Quarterly Safe Patient Handling assessment dated ,d+[DATE]//2022 states in part, .1.Patients Level of Assistance .Dependent .4.Level of Cooperation and Comprehension .unpredictable or varies, not cooperative, or unable to follow simple direction .9a.Reposition in bed .drawsheet .Number of Staff .Two Staff . Further review of the clinical record revealed that the resident was admitted to Hospice services on [DATE]. In addition, a review of the hospice admission documentation revealed the resident was not receiving any scheduled comfort measure medications. Further review of the hospice record revealed a document titled HOSPICE CARE COORDINATION NOTE dated [DATE] that states in part, .routine visit .Pt. [patient] is non-verbal .Pain is 0 . Review of a written statement dated [DATE] by Staff C, revealed in part, On the morning of [DATE], CNA [Certified Nursing Assistant] called this writer stating resident fallen out of bed. Resident was found on the ground on [his/her] back on the far side of the room lying next to the heater with [his/her] head lying against the bedside cabinet . Record review of a written statement dated [DATE] by Nursing Assistant (NA), Staff A states in part, .[S/he] was on [his/her] right side [NA, Staff B] had stepped out to get a clean soaker pad .and [the resident] rolled off the bed . During a surveyor interview with Staff A on [DATE] at approximately 1:20 PM, she revealed that she and Staff B were providing care to the resident. Staff B went to get additional supplies. Staff A acknowledged that she was by herself with the resident. She further acknowledged that the resident was positioned on his/her side when the resident fell out of bed onto the floor. Record review of a radiology report dated [DATE] states in part, .Acute left proximal femoral fracture [Broken hip] with moderate displacement with varus angulation (bowing) .Acute moderately displaced fracture of proximal shaft of femur (joint of the hip). [Femoral shaft fractures are high energy impact injuries to the femur] . Record review of the resident's progress notes dated [DATE] states in part, 9am [morning] found without resp[respiration]/pulse . Record review revealed the following physician's orders and start dates: -On [DATE],Acetaminophen Tablet (medication used to treat mild to moderate pain) 650 MG (milligrams) every 6 hours as needed for mild pain. -On [DATE], Acetaminophen 1000 mg 3 times per day for pain management. Additionally, on [DATE] and order for Ibuprofen (anti-inflammatory drug used for treating pain, fever, and inflammation) PRN [as needed] 400 mg every 6 hours as needed for pain. -On [DATE], Morphine Sulfate(opioid pain reliever used to manage moderate-to-severe pain) 20 MG/ML(Milliliter) 2.5mg every 1 hours as needed for pain. -On [DATE], the order for the above-mentioned medication was increase to Morphine Sulfate 20mg/ml 4 times per day. -On [DATE], Lorazepam[sedative medication use to treat anxiety] 2 MG/ML every 8 hours for end of life. Further review of the Medication Administration Record (MAR) from [DATE] through [DATE] failed to revealed evidence that the resident received any pain medication or that was experiencing any pain prior to the fall on [DATE]. During a surveyor interview on [DATE] at approximately 3:00 PM with the Director of Nursing Services she was unable to provide evidence that on [DATE] Resident ID #1 was provided with adequate assistance to prevent accidents. Additionally, she acknowledged the resident sustained fractures and declined rapidly after the fall out of bed.

Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan to meet resident's needs relative to obtaining weights for 1 of 5 sample residents, Resident ID #36. Findings are as follows: Record review revealed the resident was readmitted to the facility in December of 2020 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a care plan, last revised 3/16/2021, for .has nutritional problem r/t hx of wt [weight] loss/gain trends, [CONDITION(S)] trends, . with interventions including, but are not limited to, Monitor/record/report to [physician as needed] .significant weight loss: 3 lbs [pounds] in 1 week . Additionally, record review revealed a care plan, last revised 4/13/2021, for .has hx [history] of unplanned/unexpected weight gain/loss r/t [related to] [CONDITION(S)] . with interventions including, but are not limited to, .Weekly weighs. Review of the Weights and Vitals Summary from May 2021 to January 2022, revealed that the weights were not obtained 27 of 39 opportunities. During a surveyor interview with the Director of Nursing Services on 2/7/2022 at approximately 2:30 PM, she was unable to provide evidence that the above weekly weights were obtained according the plan of care.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents receive necessary treatment and services consistent with professional standards of practice to prevent new ulcers from developing for 2 of 7 sampled residents, Resident ID #'s13 and 15. Findings are as follows: 1. Record review revealed Resident #13 was admitted to the facility in September of 2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of a Braden Skin Assessment (a tool used to determine pressure sore risk) dated 11/18/2021 revealed the resident is at a high risk for developing pressure ulcers. An additional record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed s/he is at risk for developing a pressure ulcer. Record review of a care plan with revision dates of 11/24/2021 and 12/6/2021 revealed s/he has the potential for developing a pressure ulcer related to impaired mobility. Further record review revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .off load heels when in bed . During a surveyor observation on 2/3/2022 at 9:28 AM and on 2/7/2022 at 9:08 AM revealed s/he was observed lying in bed with his/her heels resting directly on the mattress and not off loaded as ordered. During a surveyor interview on 2/7/2022 at 9:08 AM with Nursing Assistant, Staff A, she acknowledged that the resident's heels should have been off loaded and they were not. 2. Record review revealed Resident #15 was admitted to the facility in October of 2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Braden Skin assessment dated [DATE] revealed s/he is at moderate risk for developing pressure ulcers. Further record review of a MDS assessment dated [DATE] revealed s/he is at risk for developing pressure ulcers. Record review revealed a care plan dated 12/5/2021 that revealed s/he is at risk for pressure ulcers related to impaired mobility and lower extremity [CONDITION(S)]. Further record review revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .heels off loaded q (every) shift as tolerated . During a surveyor observation of Resident ID #15 on the following dates and times revealed s/he lying in bed with his/her heels resting directly on the mattress and not off loaded as ordered: - 2/3/2022 at 8:55 AM - 2/4/2022 at 2:17 PM - 2/7/2022 at 9:30 AM During a subsequent observation on 2/7/2022 at approximately 11:00 AM after the above observations were brought to the facility's attention Resident ID #15's heels were offloaded on a pillow. The resident was not observed to be in any discomfort and was able to tolerate the offloading. During a surveyor interview with the Director of Nursing Service on 2/7/2022 at approximately 11:14 AM she was unable to explain why the heels were not off loaded as ordered.

Based on surveyor record review and staff interview, it has been determined that the facility has failed to meet professional standards of quality related to 1 of 8 residents reviewed for following appropriate bowel regimen (ID #37). Findings are as follows: Surveyor record review revealed a facility policy titled, Bowel Protocol which states in part, .The 3-11 charge nurse will review the BM list daily. Any resident who has not had a BM in three days will receive 30 cc of milk of magnesia and 4 oz prune juice at HS, if no results will receive a [MEDICATION NAME] suppository at 6 am then a Fleet enema on 3-11 if necessary . All bowel medications will not be administered without a doctor's order. Additional record review revealed the following physician's orders [REDACTED].#37: - [MEDICATION NAME] Powder (Polyethylene [MEDICATION NAME] 3350) Give 17 gram by mouth every 24 hours as needed for Constipation. Dilute in 4-8oz fluid. - Milk of Magnesia Suspension 1200 MG/15ML (Magnesium [MEDICATION NAME]) Give 30 ml by mouth every 24 hours as needed for Constipation Per Bowel Protocol, Give after 2 full days with no bowel movement. - [MEDICATION NAME] Suppository 10 MG ([MEDICATION NAME]) Insert 1 suppository rectally every 24 hours as needed for Constipation PER BOWEL PROTOCOL IF NO RESULTS FROM MOM (Milk of Magnesia) - Fleet Enema Enema 7-19 GM/118ML (Sodium [MEDICATION NAME]) Insert 1 application rectally every 24 hours as needed for Constipation PER BOWEL PROTOCOL IF NO RESULTS FROM DOCULAX SUPPOSITORY. Further record review of Resident ID #37's Bowel Elimination Flow Sheet revealed that s/he did not have a bowel movement from 12/5/2020 through 12/11/2020 (6 days). It further revealed that the resident had a bowel movement on 12/12/2020 and 12/13/2020. Surveyor record review of Resident ID #37's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. During a surveyor interview with the Assistant Director of Nursing Services on 12/18/2020 at 10:27 AM, she acknowledged that interventions should have been put into place for the bowel protocol within two full days without a bowel movement. Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality related to not following physician's orders [REDACTED].#37. Findings are as follows: Record review revealed a facility policy titled, Bowel Protocol which states in part, 6. The 3-11 charge nurse will review the BM(bowel movement) list daily. Any resident who has not had a BM in three days will receive 30 cc (cubic centimeter) of milk of magnesia and 4 oz (ounces) prune juice at HS (hour of sleep), if no results will receive a [MEDICATION NAME] suppository at 6 am then a Fleet enema on 3-11 if necessary . 9. All bowel medications will not be administered without a doctor's order. Additional record review revealed the following physician's orders [REDACTED].>- [MEDICATION NAME] Powder (Polyethylene [MEDICATION NAME] 3350) Give 17 gram by mouth every 24 hours as needed for Constipation. Dilute in 4-8oz fluid. - Milk of Magnesia Suspension 1200 MG/15ML (Magnesium [MEDICATION NAME]) Give 30 ml by mouth every 24 hours as needed for Constipation Per Bowel Protocol, Give after 2 full days with no bowel movement. - [MEDICATION NAME] Suppository 10 MG ([MEDICATION NAME]) Insert 1 suppository rectally every 24 hours as needed for Constipation PER BOWEL PROTOCOL IF NO RESULTS FROM MOM (Milk of Magnesia) - Fleet Enema Enema 7-19 GM/118ML (Sodium [MEDICATION NAME]) Insert 1 application rectally every 24 hours as needed for Constipation PER BOWEL PROTOCOL IF NO RESULTS FROM [MEDICATION NAME] SUPPOSITORY. Further record review of the Bowel Elimination Flow Sheet revealed that s/he did not have a bowel movement from 12/5/2020 through 12/11/2020. This is a total of 6 days without a bowel movement. The record failed to reveal evidence that the facility followed their bowel protocol. During a surveyor interview with the Assistant Director of Nursing Services on 12/18/2020 at 10:27 AM, she acknowledged that interventions should have been put into place for the bowel protocol within two days without a bowel movement.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store medications in accordance with manufacturer's instructions for 1 of 1 medication storage room observed. Findings are as follows: Surveyor observation of the facility's medication room, in the presence of Staff Nurse A, on 12/15/2020 at 11:21 AM, revealed two opened and in use insulin pens belonging to Resident ID #18 stored in the medication refrigerator. The [MEDICATION NAME] FlexTouch (a long acting insulin, single patient, multiple use device) was labeled as opened on 12/10/2020. The Insulin [MEDICATION NAME] (a fast acting insulin, single patient, multiple use device) was labeled as opened on 12/7/2020. Review of the [MEDICATION NAME] FlexTouch manufacturer's instructions states, in part, .[MEDICATION NAME]® FlexTouch®: After initial use, the [MEDICATION NAME]® FlexTouch® must NOT be stored in a refrigerator .Keep the opened (in use) [MEDICATION NAME]® FlexTouch® away from direct heat and light at room temperature . Review of the Insulin [MEDICATION NAME] manufacturer's instructions states, in part, .3 mL single-patient-use Insulin [MEDICATION NAME]® .In-use (opened) Room Temperature .28 days (Do not refrigerate) . During a surveyor interview immediately after the observation with Staff A, she revealed that all insulins, opened and unopened, are stored in the refrigerator and they are removed approximately 10 minutes before administration to residents. During a surveyor interview with the Director of Nursing Services on 12/15/2020 at approximately 2:00 PM, she was unaware that the above-mentioned insulin devices were not supposed to be refrigerated after opening.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure a sanitary environment and to help prevent the development and transmission of communicable disease for 1 of 2 residents, Resident ID #30 observed relative to wound treatments. Findings are as follows: Review of the facility's policy, titled, Clean Dressing Technique states, .Establish a clean field, using clean linen or plastic .Open supplies onto the clean field .Cleanse wound with the solution ordered using the 'no touch' technique, i.e., do not directly touch any item that will come in contact with the wound . Record review revealed an admitted in 2013 and [DIAGNOSES REDACTED]. Further review revealed a physician's orders [REDACTED]. oval shape to fit ostomy and pouch, reinforce appliance edges with [MEDICATION NAME] tape (brand of adhesive tape). Surveyor observation on 12/15/2020 at 9:45 AM revealed Staff Nurse B performing the physician ordered treatment to Resident ID #30. Staff B was sitting, facing the resident, using a bedside table to hold treatment supplies. Staff B removed the resident's ostomy flange, pouch, and dressing materials; and cleansed the area with wound cleanser. Resident ID #30 was observed to have four open and bleeding areas surrounding the stoma. Staff B then took a sheet of alginate dressing material (equivalent to [MEDICATION NAME]) and cut a piece to fit one of the open areas of the skin. Staff B then placed the dressing material directly on her uniform pants, without a barrier, and then she placed the dressing material directly on the open wound. She repeated this process for each piece of dressing material used on the open areas, using the dressing material that she placed on her pants to place on the open wounds. During a surveyor interview with Staff B, following the observation, she revealed that she was unaware that she put the dressing material directly on her pants during the treatment. During a surveyor interview with the Director of Nursing Services on 12/15/2020 at 10:02 AM, she revealed that she would expect that nurses place dressing material on a clean field and not the nurse's clothing.

Based on surveyor observation, record review and staff interviews, it has been determined that the facility failed to provide the necessary treatment and services in order to promote healing of a pressure ulcer for 1 of 5 sample residents reviewed who currently have pressure ulcer (ID #1). Findings are as follows: National Pressure Ulcer Advisory Panel, published 2014, states in part; . If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less . Consult a seating specialist to prescribe an appropriate seating surface . . Select a support surface that provides enhanced pressure redistribution, shear reduction, and microclimate control for individual with Category/stage III, IV, and unstageable pressure ulcers . . Use alternate pressure seating devices judiciously for individuals with existing pressure ulcers . Record review revealed resident ID # 1 has severe cognitive impairment related to a [DIAGNOSES REDACTED]. A current care plan updated on 7/14/2016 indicates the resident has a pressure sore on his/her coccyx related to incontinence, variable nutritional intake and immobility. The approach includes OOB (out of bed) for short periods of time, . referral to wound Dr (doctor) . An 8/10/2016 Wound Care Specialist Evaluation indicates the resident currently has a pressure ulcer on the coccyx that measures approximately 2.0 cc (length) x 0.9 cc (width) x 0.1 (depth) which is characterized as unstageable necrosis (known but not stageable due to coverage of wound bed by slough and/or eschar) with moderate serous (drainage). The periwound radius is characterizes as excoriation, maceration (softening and breaking down of skin), surrounding deep tissue injury (purple /maroon). The recommendation includes Low air loss mattress (float the patient on air-filled cells while circulating air across the skin to reduce moisture and help maintain a constant skin interface pressure), limit sitting to 60 minutes, . Surveyor observations on 8/17/2016 at 8:15 AM, 9:00 AM, 11:30 AM and 1:30 PM, and on 8/18/2016 at 8:15 AM, 9:00 AM, 11:30 AM and 1:15 PM revealed the resident sitting in his/her wheelchair. Additional observation on 8/19/2016 between 8:05 AM to 9:00 AM revealed the resident sitting in his/her wheelchair. It was noted that the resident has a foam cushion in his/her wheelchair which is approximately 4 inches thick. Observation of the wound with the unit nurse (staff A) on 8/19/2016 at approximately 9:00 AM revealed an unstageable pressure ulcer that measures approximately 2.5 cc (length) x 2.5 cc (with) with necrotic tissue on the wound bed. The skin surrounding the wound is excoriated/macerated. It was noted that the resident has an overlay air mattress on his/her bed (parallel air tubes that can be inflated and deflated on a set schedule). During an interview on 8/18/2016 at 1:45 PM, with the nursing assistant (NA), staff B, who regularly cares for the resident revealed that the resident is assisted out of bed to the wheelchair on the 3rd shift (11:00 PM -7:00 AM) and remains sitting in the wheelchair until approximately 9:00 - 9:30 AM (approximately 150 to 210 minutes). Staff B further stated the resident is in bed after breakfast and again is assisted out of bed to the wheelchair at approximately 11:00 AM to 11:30 AM and remains sitting in the wheelchair until approximately 1:00 - 1:30 PM (approximately 90 minutes to 150 minutes). Staff B confirmed that the resident has a foam cushion while sitting in his/her wheelchair. During a subsequent interview with the unit nurse (staff A) on 8/19/2016 at 9:50 AM, she confirmed the above findings. When questioned during the phone interview on 8/19/2016 at 11:30 AM, the NA, staff C who works on the third shift stated the resident is assisted out of bed to his/her wheelchair between 6:00 AM to 6:30 AM. During an interview with the Assistant Director of Nursing Services (ADNS) on 8/19/2016 at approximately 10:30 AM, she was unable to provide evidence that the physician was informed that there is a new recommendation from the wound doctor. In addition, the ADNS disclosed that there is no recommendation relative to seating device. During a subsequent interview on 8/19/2016 at approximately 12:00 PM with the resident's primary physician, he stated he generally accepts the recommendations from the wound doctor and he was not informed of the above recommendations.

Based on record review and staff interview, it had been determined that the facility has failed to abide by the facility's Physician Services Agreement to inform the resident's primary care physician relative to recommendation by wound doctor for 1 of 5 sample residents (ID# 1). Findings are as follows: A review of the Physician Services Agreement between the Facility and the Provider (wound doctor) dated 2/11/2015 indicates the facility responsibility is to inform the resident's primary care provider of the clinician's recommendations within 24 hours. Record review revealed resident ID #1 currently has a pressure ulcer on the coccyx which is characterized as unstageable necrosis (known but not stageable due to coverage of wound bed by slough and/or eschar). Further record review revealed an 8/10/2016 Wound Care Specialist Evaluation with recommendations to include Low air loss mattress, limit sitting to 60 minutes, . There is no evidence the primary care physician was made aware of the recommendations. During an interview on 8/19/2016 at approximately 12:00 PM, the resident's primary care physician stated he was not informed of the recommendations. When questioned on 8/19/2016 at approximately 2:30 PM, the Director of Nursing Services was unable to produce evidence that the above recommendations were brought to the attention of the physician. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities they are deficiencies under State Regulations and grounds for licensure sanctions.

Based on surveyor observation, record review and staff interview, it was determined the facility failed to ensure a sanitary environment to help prevent the transmission of infections relative to housekeeping, cleaning of glucometers, and the proper disposal of laundry for 2 of 4 sample residents, ( ID # 6 and 10) and 1 of 1 non-sample resident ID # 15. The facilities Patient Room Disinfection Training Library Workbook states in part Sec 5b. Isolation Patient Rooms- Daily Cleaning. Immediately bag all cloths, wet mop heads, and dust mop heads used in the room as infectious waste. DO NOT use them in any other area. After cleaning the room, decontaminate any equipment that has been visibly soiled such as mop handles, buckets and castors with disinfectant. Thoroughly rinse out the mop bucket and wringer and replace with clean water and disinfectant before cleaning the next area. 1. On 8/18/2015 at 9:16 AM the surveyor observed a housekeeper (Staff B) entering a precautions room of resident ID # 6. Doning gloves but not wearing a gown. She proceeded to enter and clean the toilet with a cloth and spray bottle and then return the spray bottle to the housekeeping cart and placed the cloth in a bin on the housekeeping cart. With the same gloves she took the wet mop from the bucket of water on the cart and proceeded to enter and mop the floor in the residents room. Upon completion, she replaced the mop into the bucket of water on her cart. Still wearing the same gloves she took another spray bottle and a cloth and re-entered the resident's room. She wiped off the furniture, bed rails and table tops of both residents in the room. Upon completion, she returned the items to the housekeeping cart and removed her gloves and discarded them and proceed on to the next room to be cleaned. On 8/18/2015 at 9:25 AM, the surveyor interviewed the housekeeper (Staff B) when she completed the cleaning of the room. She stated that she did not need to wear the gown as she was not going to touch the resident that only the nursing assistants need to wear the gown. On 8/20/2015 at approximately 1:00PM the Director of Nurses and the Director of Housekeeping were interviewed. They stated that housekeeping should wear a gown and gloves when cleaning a precautions room. In addition, housekeeping should change cleaning equipment after completing a precautions room. Review of the User's Guide for the [MEDICATION NAME] EZ glucose monitor states in part: alcohol is not an approved product for cleaning environmental areas potentially contaminated with bloodborne pathogens. To disinfect glucose meters, use the EPA approved germicidal disinfectant labeled effective against TB or HBV or 1:10 bleach to water concentration solution. 2. On 8/18/2015 at 11:25 AM, the surveyor observed the Nurse (Staff A) use the glucometer to obtain a blood sugar for non-sample resident ID # 15. Staff A cleaned the glucometer with an alcohol wipe before and after obtaining the blood sugar. She then at 11:40 AM used the same glucometer to obtain a blood sugar on resident ID # 10. After completing the blood sugar for resident ID # 10, this nurse cleaned the glucometer with an alcohol wipe. During the surveyor interview with the Nurse (Staff A) on 8/21/2015 at 9:00 AM, this nurse indicated that she always uses alocohol wipes instead of the Sani Wipes. During the surveyor interview with the Director of Nursing on 8/19/2015 at 1:30 PM, she stated Sani Cloths are used to clean glucometers. 3) During surveyor observation of the bathing room on the Bath Row unit, on 8/19/2015 at 1:08 PM, two surveyors observed soiled clothing, pants, shirt, brief and a towel that were soiled with fecal material, and were left on a shelf in the bathing room. On 8/19/2015 at approximately 1:15 PM, a nursing assistant (Staff C) on the Bath Row Unit, was interviewed. She was unable to explain why the soiled items had not been placed in the laundry bin. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions.

Based on record review, observations and staff interview, it has been determined that the facility has failed to ensure that each resident receive and the facility provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for 1 of 1 sample residents, ( Resident ID # 3) relative to risk for aspiration. Findings are as follows: Resident ID #3 has current [DIAGNOSES REDACTED]. The resident was readmitted to the facility after a hospitalization on [DATE] with a [DIAGNOSES REDACTED]. Record review includes a 8/6/2015 physicians order for 1:1 feed, upright centered position, small sips and bites. On 8/7/2015 a physician's telephone order states aspiration precautions every shift for aspiration risk. Record review revealed a nursing progress note dated 8/15/2015 that states appetite good, 1:1 feed aspiration precautions. A subsequent note dated 8/16/2015 revealed head of bed elevated and 1:1 feed. The resident had a speech language evaluation on 8/6/2015 that indicates severe oral/pharyngeal dysphagia. A review of resident's ID #3's current care plan has a focus area dated 8/6/2015 that states aspiration pneumonia. On 8/17/2015 at 12:07 PM the resident was observed by the surveyor upright in bed, eating a pureed lunch with the privacy curtain closed, there was no supervision observed. On 8/18/2015 at 8:50 AM the resident was observed by the surveyor in bed eating independently with no staff supervision. At this time,the head of bed was elevated and the privacy curtain was observed closed. At 12:00 PM, another surveyor observation of this resident revealed the resident eating lunch alone in his room with the head of bed elevated and the privacy curtain closed. During an interview with the DNS on 8/20/2015 at 9:45 AM, she stated the resident is supposed to be supervised by the nursing assistant (NA) for meals. The surveyor interviewed the speech therapist on 8/20/2015 at 12:30 PM. She told the surveyor that the resident did not need the 1 on 1 supervision but does require observations at least 3-4 times while eating. She further stated that she did not think supervision would be adequate if the curtain was closed while the resident was eating as he has a history of aspiration. The surveyor interviewed the nursing assistant (Staff D) on 8/20/2015 at 1:00 PM who told the surveyor that he checks on the resident during meals, at least every 15-20 minutes. The surveyor asked this nursing assistant why the curtain was closed and he stated that the resident's roommate does not like the bright light from the window. On 8/21/2015 at 10:00 AM the surveyor interviewed the MDS (Minimum Data Set) nurse regarding the resident's care plan, and questioned if something should be in the care plan regarding the supervision during meals and she was unable to explain why it was not in the care plan and added it. A review of resident's ID #3's current care plan on 8/21/2015 revealed an added intervention dated 8/21/2015 which states supervision with meals. The surveyor interviewed the resident's physician on 8/21/2015 at approximately 11:30 AM, who stated that the resident is a silent aspirator and that he should have a [DEVICE], but that is up to the resident.

Based on surveyor observation and staff interview, it was determined that the facility failed to provide maintenance services relative to ceilings throughout the nursing unit. Findings are as follows: Surveyor observation on 4/11/13 revealed that the drop-ceiling tiles throughout the facility are stained, cracked, broken and discolored. A partial count by the surveyor on 4/12/13 revealed at least 90 tiles that need to be replaced. Additionally, the metal framing which supports the ceiling tiles is bent, discolored and rusting in places. Virtually all of the tiles along the sides of the main corridor (rooms 1 - 10) are lifting at the corners, so that an unsightly dark edge is visible on each of the tiles when looking down the corridor. Closer observation of the drop ceiling on the morning of 4/15/13 revealed at least 4 places where marks/notes had been made in ink on the metal framing, e.g., near room 13 a note printed in ink on the framing said, "AC access," and arrows were drawn onto the framing near rooms 2 and 8. Observation of the therapy room on 4/12/13 revealed a 1/2 inch by 5 inch hole in the ceiling above the therapeutic stairs. There was a 4x3 foot area of light brown staining around the hole. During interview with the maintenance director on the afternoon of 4/11/13, a surveyor was told that ceiling tiles slated for replacement are marked with push pins and replaced on an as needed basis, however surveyor observation on the morning of 4/12/13 in the corridor between rooms 11 - 24 revealed 50 damaged tiles, but only 5 tiles marked with push pins/thumbtacks. Further interview with the maintenance director on 4/12/13 revealed that the tiles are singularly replaced on an as needed basis 2 or three times per year, but that the ceiling has not been totally redone in [AGE] years. He told surveyors, "It will never be completed - as soon as I replace one, another one gets damaged." Surveyor interview with the facility administrator on 4/12/13 at 4:30 PM revealed that there is no plan or budget to replace the ceiling. "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions."

Based on surveyor observation, record review and staff interview, it was determined that the facility failed to ensure the residents right to confidentiality of clinical medical treatment. This was evident by a review of the current nursing facility policy relative to Contact Precautions and or evident by the signs posted on the door frames during all days of the survey for 3 of 4 sample residents (ID #' 3, 7 and 10) who are identified by the facility with infectious conditions. Findings are as follows: A review of the current facility's policy relative to contact precautions states: "Place a "precaution bin" .....and an orange contact precaution sign that informs staff and family to check with the nurse before entering the room. Notify Environmental Services to set up trash and laundry bins inside room...." 1. On 2/21/2012 at 12:20 PM observation of room [ROOM NUMBER] (Fountain Unit) where resident ID # 3 resides revealed a sign posted on the door frame which identified Contact Precautions. The nurse indicated that the resident was on Contact Precautions [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). Upon entering the room the surveyor observed there were 2 covered containers with the top covers marked as "Contact Precautions Trash and Contact Precautions Laundry". The signage remained in place on all days of the survey. 2. Observation of resident ID #7 (Fountain Unit) 2/22/2012 at approximately 10:00 AM, during a dressing change, revealed a sign posted on the door frame of the resident's room which identified Contact Precautions. The nurse indicated the resident was on contact precautions [MEDICAL CONDITION] ([MEDICAL CONDITION] Rsistant Staphylococcus Aureus). 3. On 2/24/2012 at 12:00 PM observation of room [ROOM NUMBER] (New Wing) where resident ID # 10 resides revealed a sign posted on the doorframe which identified Contact Precautions. Additionally, inside the room there were 2 covered containers with the top covers marked as "Contact Precautions Trash and Contact Precautions Laundry". Interview on 2/24/2012 at 1:45PM with a staff nurse revealed that the resident is on Contact Precautions for VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]). Additionally, she indicated that these signs are for those residents who have infectious conditions and require precautions.

Based on surveyor observation, record review and staff interview it was determined the facility failed to ensure that services provided or arranged by the facility meet professional standards of quality for 2 of 13 sample residents (ID #'s 3 and 5) relative to the administration of oxygen. Findings are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.31, defines "Nursing", and states, in part: "It provides care and support of individuals and families during periods of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe." 1. Resident ID# 3 has a 2/6/2012 physician's orders [REDACTED]. Observation on 2/21/2012 at 12:20 PM, 2/22/2012 at 8:15 AM and at 3:00 PM, revealed the resident receiving oxygen at 1 liter per minute. In addition observations on 2/22/2012 at 8:50 AM revealed the oxygen was being administered at 1.5 liters per minute. On 2/23/2012 at 8:50 AM and 9:35 AM the resident was observed receiving oxygen between 0.5 and 1.0 liters per minute. When questioned on 2/23/2012 at 9:40 AM, the charge nurse indicated that the oxygen should not be administered below 2 liters per minute as per the physician's orders [REDACTED]. 2. Resident ID# 5 revealed a physician's orders [REDACTED]. Observations of the resident on 2/12/2012 at 10:00 AM and on 2/22/2012 at 8:22 AM and on 2/23/2012 at 8:15 AM, revealed that the resident was being administered oxygen at 2.5 liters per minute. When questioned on 2/23/2012 at 4:00 PM, the charge nurse confirmed that the physician's orders [REDACTED].

Based on surveyor observation and record review it was determined that the facility failed to ensure that a resident having pressure sores receives necessary treatment and services to promote healing and prevent infection from developing for 2 of 13 sample residents (ID #'s 3 and 7). Findings are as follows: 1. On 2/22/2012 at 9:15 AM, the surveyor entered resident ID # 3's room with the nurse for observation of wound care to the resident's Stage 2 Pressure Ulcer on her coccyx. At this time, the resident was found to be incontinent of a large amount of stool. The nurse donned her gloves and provided incontinent care to the resident. Immediately following this care and without a change in gloves or handwashing, the nurse proceeded to remove the resident's dressing and provide wound care. When questioned at 9:50 AM, the nurse stated that she always changes her gloves when soiled. However, she forgot to change her gloves this AM. 2. During surveyor observation on 2/22/2012 at 10:00 AM of wound care for resident ID # 7 who has a Stage 2 Pressure Ulcer on his right heel, the nurse was observed to remove her gloves after removing the resident's soiled dressings. The nurse then left the resident's room without washing her hands. Upon returning to the resident's room, the nurse donned a new set of gloves and proceeded to cleanse the resident's pressure ulcer. After cleaning the pressure ulcer, the nurse was observed placing one of her soiled gloved hands into the pocket of her pants, removed the gloved hand, and proceeded to do the dressing change.

Based on observation and interviews, it was determined that the facility failed to maintain an environment that remains free of accident hazards relative to an exposed metal heating element and protruding metal clamp to a baseboard heat cover located in room #28 for sample resident ID#12. Findings are as follows: During the initial tour on 2/21/2012 at approximately 9:15AM, the surveyor observed a 6 feet long baseboard heating cover lyning on the floor (exposed metal fin) adjacent to the bed (window side) of sample resident ID#12. In addition, a metal support clamp was protruding toward the lower section of this bed. This resident is transferred out of bed by hoyer lift by two staff members. On 2/23/2012 at approximately 2 PM, another surveyor entered the room of the aforementioned resident while the resident was being assisted by a nursing assistant. When the surveyor pointed to the exposed metal finned heating element and protruding metal clamp next to the bed of sample resident ID#12, this nursing aide disclosed to the surveyor that the baseboard cover had fallen off. On 2/24/2012, the surveyor informed the Environmental Service Manager at approximately 9:45 AM about the lack of a baseboard cover, the exposed metal fins and the protruding metal clamp. This manager revealed that he had not been made aware of this hazard.