Every finding on record at Kingston Center for Rehabilitation and Health Care

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for the ice machine located in the main kitchen. Findings are as follows: According to The Rhode Island Food Code 2018 Edition 5-202.13 reads in part, .an airgap between the water supply inlet and the flood level rim of the plumbing fixture equipment .shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) . A surveyor observation of the kitchen on 2/4/2024 at 8:15 AM revealed that the ice machine failed to have the required air gap. During a surveyor interview with the Food Service Director in the presence of the Administrator on 2/5/2024, they acknowledged that the ice machine failed to have an air gap.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of significant medication errors for 5 of 12 residents reviewed for medication administration, Resident ID #s 3, 15, 19, 27, and 37. Findings are as follows: Review of a facility policy titled, MEDICATION ADMINISTRATION, last revised December 2019, states in part, .For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR [Medication Administration Record] may be flagged. After completing the medication pass, the nurse returns to the missed resident to administer the medication .The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones . 1. Record review revealed Resident ID #3 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, hypotension and arthritis. Record review revealed a physician's order dated 7/6/2023 for gabapentin, 400 mg (milligrams), by mouth, every morning for nerve pain. Review of the February 2024 MAR revealed the above medication was not documented as being administered on 2/1/2024 and 2/4/2024. 2. Record review revealed Resident ID #15 was admitted to the facility in March of 2021 with a diagnosis including, but not limited to, hypothyroidism (a condition resulting from decreased production of thyroid hormones). Record review revealed a physician's order dated 6/18/2023 for Levothyroxine Sodium Oral Tablet, 200mg, by mouth, every morning, for hypothyroidism. Review of the February 2024 MAR revealed the above medication was not documented as being administered on 2/2/2024 and 2/4/2024. 3. Record review revealed Resident ID #19 was admitted to the facility in August of 2019 with a diagnosis including, but not limited to, diabetes mellitus, type two, with diabetic neuropathy. Record review revealed a physician's order dated 11/18/2023 for Novolog solution (insulin), 100 unit/ml, with instructions to inject per sliding scale, 4 times daily, before meals and at bedtime, for diabetes. Review of the February 2024 MAR revealed the above medication was not documented as being administered on 2/4/2024 at 9:00 PM. 4. Record review revealed Resident ID #27 was admitted to the facility in December of 2019 with a diagnosis including, but not limited to, diabetes mellitus, type two. Record review revealed a physician's order dated 5/15/2023 for insulin glargine solution, 100 unit/ml, with instructions to inject 48 units, subcutaneously (under the skin), at bedtime, for diabetes mellitus, type two. Review of the February 2024 MAR revealed the above medication was not documented as being administered on 2/2/2024 and 2/4/2024. 5. Record review revealed Resident ID #37 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, hyperlipidemia (high levels of fat in the blood) and heart disease. Record review revealed a physician's order dated 1/5/2024 for atorvastatin calcium, 40 mg, by mouth at bedtime, for hyperlipidemia and heart disease. Review of the February 2024 MAR revealed the above medication for atorvastatin calcium was not documented as being administered on 2/2/2024. Further record review revealed a physician's order dated 1/5/2024 for insulin glargline with instructions to inject 20 units subcutaneously, at bedtime, for diabetes mellitus, type two. Further review of the February 2024 MAR revealed the above medication for insulin glargline-yfgn (long-acting insulin that works slowly, over about 24 hours) was not documented as being administered on 2/4/2024. During a surveyor interview on 2/7/2024 at 8:41 AM, with Registered Nurse, Staff D, she revealed that after the concern was brought to the facility's attention by the surveyor, she went into the February 2024 MARs for Resident ID #s 27 and 37 and signed off on administering the medications, which was several days after the medications were to be administered. During a surveyor interview on 2/7/2024 at 2:01 PM, with the Director of Nursing Services, she revealed that her expectation is for the nurses to document immediately following administering medications. Further, she was unable to provide evidence the above-mentioned residents were free from significant medication errors.

Based on record review and staff interview, it has been determined that the facility failed to ensure the residents' medical record includes documentation that the residents were offered or received the pneumococcal vaccine, or did not receive the vaccination due to medical contraindications or refusal, for 5 of 11 residents reviewed, Resident ID #s 2, 12, 13, 17, & 20. Findings are follows: 1. Record review of Resident ID #2 revealed the resident was admitted to the facility in November of 2023 with diagnoses including, but not limited to, alcoholic cirrhosis of the liver and bipolar disorder. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia or flu vaccination. 2. Record review of Resident ID #12 revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, alcohol abuse, diabetes, and anxiety disorder. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia vaccine. 3. Record review of Resident ID #13 revealed the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, atherosclerotic heart disease of native vessels and acquired absence of both right and left leg above the knee. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia vaccine. 4. Record review of Resident ID #17 revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, malignant neoplasm of the liver, malignant neoplasm of the bladder, and pneumonitis due to inhalation of food. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia vaccine. 5. Record review of Resident ID #20 revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, lung cancer and adult failure to thrive. Record review failed to reveal evidence that this resident was offered, received, or declined the pneumonia vaccine. During a surveyor interview on 2/7/2024 at approximately 12:30 PM, with the Director of Nursing Services, she failed to provide evidence that the above residents were offered, had received, or had declined the pneumonia vaccine.

39496 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 1 resident reviewed for Multidrug-Resistant Organisms (MDRO), Resident ID #41. Findings are as follows: Review of the CDC's (Centers for Disease Control and Prevention) document titled, Multidrug-resistant organisms management (MDRO) states in part, .For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living .) .use Contact Precautions [use of gown and gloves when entering a resident's room] in addition to Standard Precautions .Implement Contact Precautions (CP) routinely for all patients colonized or infected with a target MDRO .modify CP to allow MDRO .colonized/infected patients whose site of colonization or infection can be appropriately contained and who can observe good hand hygiene practices to enter common areas and participate in group activities When active surveillance cultures are obtained as part of an intensified MDRO control program, implement CP until the surveillance culture is reported negative for the target MDRO. Record review revealed that Resident ID #41 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, vascular dementia and chronic kidney disease Stage 2. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed s/he requires moderate to maximum assistance to complete activities of daily living (ADLs). Additionally, the MDS Assessment revealed that the resident was frequently incontinent of bladder and always incontinent of bowels during the 7 day look back period. Review of a urine culture dated 1/20/2024 revealed s/he is positive for Extended- spectrum beta-lactamases (ESBL- a bacterial infection that is resistant to many antibiotics). Record review of the document titled Toilet Use: Self Performance revealed that between 1/25 and 2/5/2024, the resident required extensive assistance on 7 occasions and was totally dependant on 8 occasions. Review of the physician orders revealed an order for Ertapenem Sodium injection 1 gram (antibiotic) intramuscularly in the evening for urinary tract infection for 7 days. This order was started on 1/30/2024 and completed on 2/5/2024. Record review failed to reveal evidence of a re-culture for ESBL following the antibiotic treatment. Surveyor observations on 2/7/2024 failed to reveal evidence that the resident was on contact precautions. Record review failed to reveal evidence that the facility followed the CDC prevention documentation for removal of contact precautions for this resident who has a MDRO and was receiving an antibiotic treatment from 1/30/2024 through 2/5/2024 for an active infection. During a surveyor interview on 2/7/2024 at 12:25 PM with Registered Nurse, Staff B and Certified Medication Technician, Staff C, they revealed that the resident was not on contact precautions for ESBL. During a surveyor interview on 2/7/2024 at 12:46 PM with the Director of Nursing Services, she revealed that the provider did not re-culture for ESBL after completion of the antibiotic on 2/5/2024. Additionally, she acknowledged that the above resident was not on contact precautions. Furthermore, she was unable to provide evidence that the facility followed the CDC standard related to the removal of contact precautions to prevent the transmission of communicable diseases and infections for this resident.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 2 of 3 medication carts observed. Findings are as follows: Review of a policy titled, Medication-Storage states in part, To provide guidelines for proper storage of medications within the facility. The center will have Medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with Department of Health guidelines .Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy . Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities reveals in part, .Labeling of Drugs and Biological's .Labeling of medications and biological's dispensed by the pharmacy must be consistent with applicable federal and State requirements .Although medication delivery and labeling systems may vary the medication label at a minimum includes the medication name .prescribed dose, strength, the expiration date .the resident's name and route of administration .Additionally, to minimize contamination, facility staff should date the label of any multi-use vial when the vial is first accessed .If a multidose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days . 1) During a surveyor observation of the lower-level Certified Medication Technician (CMT) medication cart on [DATE] at 12:30 PM with CMT, Staff A the following was revealed: - A Trelegy Ellipta inhaler for Resident ID #27 open, in use and not dated. Manufacturer's instructions on the package state: Discard inhaler 6 weeks after opening. -A Trelegy Ellipta inhaler for Resident ID #25 open, in use and not dated. Manufacturer's instructions on the package state: Discard inhaler 6 weeks after opening. -A Spiriva Respimat inhaler for Resident ID #35 opened, in use and not dated. Manufacturers instruction on the box states, Discard 3 months after insertion of cartridge. During a surveyor interview with Staff A at the time of the above observation, she acknowledged that the above inhalers were open, in use and not dated. 2) During a surveyor observation of the lower-level Nurse's medication cart on [DATE] at 12:42 PM with Registered Nurse, Staff B, and the Director of Nursing Services (DNS) the following was revealed: - A lidocaine 1% (20 ml multidose vial) that was open, in use and not dated. Additionally, the vial did not have a label identifying which resident it was prescribed for. - A Humulin R 100 units/ml (3 ml multidose vial) open, and in use, that failed to identify a resident to whom is was prescribed. During a surveyor interview immediately following the above observation with the DNS, she acknowledged that the above medication vials failed to be labeled with a resident name. She further acknowledged that the lidocaine was not dated when opened. 50004

Based on record review and staff and resident interviews, it has been determined that the facility failed to protect the residents' right to be free from abuse relative to verbal abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident and a five-day investigation report, initially submitted to the Rhode Island Department of Health on 11/3/2023, revealed that Registered Nurse (RN), Staff A, was yelling and arguing with Resident ID #1. Record review of a facility policy titled ABUSE, last revised on 12/2022, states in part, POLICY: The facility prohibits the mistreatment, neglect, and abuse of resident/patients and misappropriation of resident/patient property by anyone including staff, family, friends, and residents of the facility .DEFINITIONS .Abuse .Willful infliction of injury, Unreasonable confinement, Intimidation resulting in physical harm, pain and/or mental anguish, Punishment resulting in physical harm or pain or mental anguish, Deprivation of goods and/or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing .DEFINITIONS . Mental/Emotional Abuse .Mental abuse is the use of verbal and nonverbal conduct which causes the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation included but not limited to harassing or yelling, intimidation, threatening or isolation and depravation of goods and services . Record review revealed that s/he was originally admitted to the facility in October of 2023 with diagnoses to include, but are not to, major depressive disorder, adjustment disorder with anxiety, anxiety disorder, bipolar II disorder and cognitive communication deficit. Additional record review revealed a Minimum Data Set Assessment, dated 10/25/2023 with a Brief Interview for Mental Status score of 13 out of 15, indicating that the resident is cognitively intact. During a surveyor interview with Resident ID #1 on 11/6/2023 at 10:40 AM, s/he revealed that s/he was having an argument with another resident when Staff A intervened and began to berate him/her. During a surveyor interview with the Administrator on 11/6/2023 at 11:10 AM, he revealed that he was made aware of the incident that occurred with Staff A and Resident ID #1; Staff A will not be allowed to return to the facility. During a surveyor interview with Nursing Assistant, Staff B, on 11/14/2023 at 11:45 AM, she indicated that she witnessed Staff A making the following comments to Resident ID #1 on 11/3/2023: 1. Telling Resident ID #1 to hit him 2. Telling Resident ID #1 to be a good doggie and stay in his/her place 3. Telling Resident ID #1 that he is like R. [NAME] (a pedophile) 4. Telling Resident ID #1 that he is going to get him/her a little doll because he knows s/he likes to play with little girls Additionally, Staff B revealed that she witnessed Staff A continuing to antagonize Resident ID #1 while following him/her back to his/her room.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents identified as an elopement risk received adequate supervision to prevent elopement from the facility for 1 of 1 residents reviewed, who successfully eloped from the facility, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 8/6/2023 indicated that on Sunday 8/6/2023 at approximately 3:30 PM, the resident was noted to be missing and was located at approximately 3:45 PM outside of the facility, at a neighboring property. According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards in the resident environment . Record review revealed the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 out of 15, indicating moderately impaired cognition. Further review of the MDS revealed the resident displayed wandering behaviors, 1 to 3 days, during the 7-day look back period. Additionally, the MDS revealed that the residents behaviors could put him/her at risk for wandering into potentially dangerous places, such as outside of the facility. Review of an Elopement Risk Evaluation dated 6/15/2023 revealed a score of 40, indicating the resident is at high risk for elopement. Review of the residents care plan revealed a focus area, initiated on 6/22/2023 and updated on 8/6/2023, which states, The resident is an elopement risk/wanderer [related to] Disoriented to place, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on the privacy or activities, actual elopement . Interventions include, but are not limited to, wander guard, check placement and functioning every day and distract resident from wandering by offering pleasant diversions. Review of the physician orders revealed an order dated 6/21/2023 to check wander guard placement to right ankle every shift and to test functionality daily. Review of the August 2023 Medication Administration Record failed to reveal evidence that the above order was documented as being completed on 8/6/2023, during the first shift. Review of a document titled Initial Event Documentation dated 8/6/2023 revealed the resident was last seen walking up and down the hallway of the facility around 2:30 PM. During a surveyor interview on 8/9/2023 at approximately 9:49 AM, with the Administrator and Director of Nursing Services (DNS), they indicated that they were unable to determine how the resident eloped from the facility and revealed that the resident has a wander guard located on his/her right ankle. They further revealed the main door and ambulance door are locked, alarmed, and have a wander guard system. Additionally, they revealed the four additional doors, located in the facility do not have a wander guard system but are locked and alarmed but will open if held for 15 seconds. During a surveyor interview on 8/9/2023 at 11:17 AM, with Certified Medication Technician, Staff A, she revealed around 2:30/2:45 PM she was sitting in the main dining room with another resident when she heard staff questioning the location of Resident ID #1. At this time, she revealed she began searching the facility for the resident but was unable to locate him/her. Additionally, she revealed she did not hear any door alarms going off during this time. During a surveyor interview on 8/9/2023 at 11:21 AM, with Certified Nursing Assistant, Staff B, he revealed Resident ID #1s roommate called him into his/her room and notified him that Resident ID #1 had walked past the window about 15 minutes before he entered the room. He indicated that at this time, he notified the nurse and began searching the facility. He further revealed that he did not hear any door alarms going off during this time. During a surveyor interview on 8/9/2023 at 11:28 AM, with Registered Nurse, Staff C, she revealed that after the resident was located and brought back to the facility, she tested his/her wander guards' functionality and revealed it lit up with 3 green zeros, indicating that it was working properly. Additionally, she revealed that she did not hear any door alarms go off during this time. During a surveyor observation on 8/9/2023 at 11:59 AM, revealed Resident ID #1 was wearing a wander guard to his/her right ankle. During a surveyor interview on 8/9/2023 at 12:30 PM, with Dietary Aid, Staff D, he revealed that he was in the main dining room, located near the main entrance, when he heard the main door alarm go off and overheard staff discussing the missing resident. At this time, he indicated he left the facility and began driving up the road to look for the resident but was unable to find him/her. Additional interviews conducted on 8/9/2023 failed to reveal evidence that additional staff scheduled on 8/6/2023 heard any door alarms going off, during the period when Resident ID #1 was missing. During a surveyor interview on 8/9/2023 at 2:30 PM, with the Administrator and DNS, they were unable to provide evidence that Resident ID #1 received adequate supervision to prevent him/her from eloping from the facility on 8/6/2023. Additionally, they were unable to identify how the resident eloped from the facility.

Based on surveyor observations and staff interview, it has been determined that the facility failed to maintain a sanitary and comfortable environment relative to 8 of 9 common bathroom/shower rooms and 3 of 28 resident rooms observed, Resident ID #s 17, 23 and 43. Findings are as follows: During surveyor observations from 12/11/2022 through 12/15/2022) of all communal bathrooms, shower/tub rooms and resident rooms, the following was revealed: 1. The floor drains were corroded/rusted in the lower level bathrooms #2 (shower and tub). The shower floor drain in lower level bathroom [ROOM NUMBER] had a heavy accumulation of hair, debris and residue. The upper level bathrooms #1 and #2 (showers), and the north end bathroom (tub) floor drains were corroded/rusted. 2. The sink drains and surfaces were corroded/rusted in lower level bathroom [ROOM NUMBER] and upper level bathroom [ROOM NUMBER], double sinks. 3. Portions of the walls had missing or chipped paint in upper level bathrooms #1 and #3, the north end bathroom and the window sill in Resident ID #23's room. 4. The upper level bathroom, #4 was observed with black matter to a portion of the shower stall grout. Additionally, 2 of the 4 legs to the shower chair were observed with black matter. 5. Portions of the tile floor were patched with cement in two separate areas in the upper level bathroom, #2. 6. Portions of the baseboards were rusted in upper level bathrooms #3 and #4 and the north end bathroom. 7. Window blinds had numerous broken/missing slats in the rooms of Resident ID #17 (10 slats) and 43 (5 slats). 8. The entire wooden shelf at the window of the upper level nursing station was heavily worn/stripped. 9. The hallway floor, adjacent to the resident's common sitting area, revealed a large patch of the flooring covered with black tape. During a surveyor interview on 12/15/2022 at 9:30 AM, with the Director of Operations and the Maintenance Director, they acknowledged all of the above findings and were in agreement that they were in need of repair/cleaning.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 medication storage rooms, including a refrigerator that contained 3 vials of Tuberculin Purified Protein Derivative (Tubersol-injectable medication to detect tuberculosis infection). Findings are as follows: During a surveyor observation of the medication storage room on [DATE] at 1:09 PM with Registered Nurse, Staff A, revealed a medication storage refrigerator with the following stored: -1 Tubersol vial open and not dated. -1 Tubersol vial opened with an expiration date of [DATE]. -1 Tubersol vial opened with an expiration date of [DATE]. Tubersol manufacturer's instructions states, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Do not use after expiration. Record review of the facility Resident Matrix revealed the facility had 2 re-admissions within the last 30 days, who were administered Tubersol injections, Resident ID #s 30 and 44. Additional record review of the above-mentioned residents' November and [DATE] Medication Administration Records revealed the following: -Resident ID #30 received a Tubersol injection upon re-admission on [DATE]. -Resident ID #44 received a Tubersol injection upon re-admission on [DATE]. During a surveyor interview following the observations with Staff A, she acknowledged that 2 of the above-mentioned vials were expired and 1 vial was open and not dated. Additionally, she revealed all 3 vials should be discarded.

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical records for each resident are maintained in accordance with professional standards and practices regarding accurate documentation between the controlled substances record and the Medication Administration Record (MAR) for 1 of 3 residents reviewed, Resident ID #2. Findings are as follows: Review of the facility policy titled, Medication Administration, states in part, .12. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones . Review of the resident's record revealed s/he was admitted to the facility in January of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Review of the resident's record revealed a physician order dated 1/21/2022 for [MEDICATION(S)] (medication used to help relieve moderate to severe pain) 5 mg (milligram), give 1 tablet by mouth every 6 hours for pain related to [CONDITION(S)]. Review of the controlled substance record revealed 1 tablet of [MEDICATION(S)] 5 mg was removed on the following dates and times: -4/3/2022 at 6:00 AM -4/4/2022 at 6:00 PM -4/5/2022 at 6:00 PM -4/6/2022 at 12:00 AM, 6:00 AM, and 6:00 PM -4/9/2022 at 6:00 PM -4/10/2022 at 12:00 AM and 6:00 AM Review of the resident's April 2022 MAR failed to reveal evidence that the medication was administered on the above dates and times. 2. Further review of the resident's record revealed a physician order dated 1/23/2022 for [MEDICATION(S)] (medication used to prevent and control seizures) 0.5 mg, give 0.5 mg by mouth two times a day related to anxiety disorder, unspecified. Review of the controlled substance record revealed 1 tablet of [MEDICATION(S)] 0.5 mg was removed on the following dates and times: -4/4/2022 at 5:00 PM -4/5/2022 at 5:00 PM -4/6/2022 at 5:00 PM -4/9/2022 at 5:00 PM Review of the resident's April 2022 MAR failed to reveal evidence that the medication was administered on the above dates and times. Record review of the facility's April 2022 schedule revealed the nurse Staff A was on for the following dates: 4/2/2022 at 11 PM to 7 AM 4/4/2022 at 3 PM to 11 PM 4/5/2022 at 3 PM to 11 PM and 11 PM to 7 AM 4/6/2022 at 3 PM to 11 PM 4/9/2022 at 3 PM to 11 PM and 11 PM to 7 AM During an interview with Staff A on 4/19/2022 at 1:50 PM, she was unable to provide evidence that the above medications were administered to the resident. Additionally, she revealed she would expect staff to document in both MAR and controlled substance record when administering controlled medications. During an interview with the Director of Nursing on 4/19/2022 at 1:00 PM, she stated she would expect the nurse signing out the medications on the controlled substance record would also document this in the MAR.

Based on record review and staff interview, it has been determined that the facility failed to ensure that 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) to the Administrator of the facility for 1 of 3 reportable allegations of abuse, Resident ID #1. Findings are as follows: Review of the facility policy titled, Abuse, states in part: Protection .Immediate suspension of suspected employee(s), pending outcome of the investigation .Reporting .Notify the Shift Supervisor/Charge Nurse/Manager immediately if suspected abuse occurs .Notify the local law enforcement and appropriate State Agency(s) immediately (no later than two hours after allegation .identification of alleged/suspected incident .Upon receiving reports of .sexual abuse the DON/designee shall immediately examine the resident. Findings of the examination must be recorded in the resident's record .(NOTE: If sexual abuse is suspected .Call police immediately) . Review of the facility reported incident of alleged abuse received by the Rhode Island Department of Health on 4/7/2021 at 10:02 AM, revealed in part: .The HR [Human Resources] director received a written statement from C.N.A. [Certified Nursing Assistant] on Monday .she did not read the letter until Tuesday afternoon .C.N.A. [name redacted] reported that on 3/31/21 resident .requested that the CNA place her fingers in his/her rectum in which she complied. She also reported that the resident requested that she place lubricant in his/her rectum. The resident then rolled over and requested that the CNA place her fingers in [his/her private area]. The initial written statement reads as if she complied. This was called in last night . Review of the 2/22/2021 care plan for this resident revealed, .exhibits behavior symptoms such as .inappropriate sexual behavior .interventions/task .document all behaviors. Attempt to identify pattern to target interventions . Review of the original written statement, dated 4/2/2021, provided by Certified Nursing Assistant, Staff A, revealed in part: .On the last day that state was in the building, i was told by the D.O.N. that [redacted] had a bad day and to give extra attention to resident in [redacted]. That no matter what [s/he] asked of me Do it. That request literally put me in a position of feeling like I had no other choice .Every time [redacted] had a request it was followed up by remarks from [redacted] saying that [s/he] had a one to one conversation with the D.O.N allegedly told [him/her] that whom ever fails to meet [his/her] demands will be terminated and license flagged. Last request made by [redacted] was to give [him/her] a sponge bath. That was the most degrading 2 hr [hour] and 15 minutes ever spent with a resident in my entire work history. Resident has me putting finger in [his/her] rectum and cleaning it and then applying lubricant jelly. [S/he] then turned on [his/her] back and said, Now do the same to my [private area]. I hesitated and [redacted] followed up with, I told D.O.N that I only wanted you and two others to care for me. So you won't be fired. I did it as requested. Extremely uncomfortAable [sic] and degrading. As i was bagging up linens, [redacted]reached over and with [his/her] fingertips, rubbed my arm .I pulled my arm a way and left the room. I reported this to Nurse and documented it. I want to make it clear that i was degraded and felt very much sexually violated . Further review of the first page of this statement revealed hand written notes on the upper right corner stating, Received 4/5/21 3P [3:00 PM] By [Director of Human Resources] .Received 4/6/21 4:45 PM by [Administrator] .received by 4/6/21 5 PM [Director of Nursing] . Review of the time card punches for Staff A revealed that she worked on the following dates: - 3/31/2021 - 4/1/2021 - 4/2/2021 - 4/3/2021 - 4/4/2021 - 4/5/2021 During an interview on 4/8/2021 at approximately 12:06 PM, after reviewing the statement provided by the HR Director, it was revealed that the statement she received from Staff A on 4/5/2021 was not sealed closed or in an envelope. It was indicated that on this date Staff A verbalized to her that the complaint was involving Resident ID #1, however she did not inquire further at that time or read the statement until an unspecified time in the afternoon on 4/6/2021. During an interview on 4/8/2021 at 1:43 PM with the Administrator, he acknowledged receiving the statement from Human Resources at 4:45 PM on 4/6/2021 and discussed the statement with the Director of Nursing (DNS), who was in the facility at that time, and with the facility's regional team via conference call. He then stated that this conference call was to discuss concerns relative to reporting this statement because he and the DNS were unsure if this was a reportable incident. After the conference call was completed at approximately 7:00 PM, a call was placed to the Department of Health hotline and a message was left on the voicemail reporting the incident. During an interview with the DNS on 4/8/2021 at 2:00 PM, she indicated that she re-interviewed Staff A via telephone on 4/6/2021 from 8:00-9:00 PM and Staff A stated that she did not enter the resident's private area, only his/her rectum using a wash cloth to ensure cleanliness at the residents request. When the resident requested additional cleaning to the private area Staff A did not comply. Additionally, when she interviewed the resident on the evening of 4/6/2021, s/he denied any inappropriate behaviors. During an interview on 4/8/2021 at approximately 4:00 PM with Staff A, she revealed that a second statement was written on 4/7/2021, after two additional interviews were conducted, on the evening of 4/6/2021 with the DNS by phone and again in person on the morning of 4/7/2021 with the Regional DNS. She indicated that she did not realize her first statement alleged that she sexually abused the resident and stated that she would not do that. During an interview with the Administrator and DNS on 4/8/2021 at approximately 3:00 PM, they acknowledged that this incident occurred on 3/31/2021 and was not reported to the Administrator until 4/6/2021, which is 7 days after the alleged event occurred. In addition, they acknowledged that this CNA did not follow facility policy regarding abuse.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the residents receive treatment relative to foot care for 3 of 8 sample residents observed, Resident ID #s 8, 25, and 35. Findings are as follows: Review of the facility's policy titled, FOOT CARE - NAIL CLIPPING, states in part, .Residents requiring toenail clipping will be referred to facility podiatrist or resident's podiatrist of choice if applicable. Residents requiring toenail clipping should not be performed by facility staff and will be referred to a podiatrist. 1. Record review for Resident ID #8 revealed they were admitted to the facility in January 2018. The record lacked evidence of podiatry services since 8/24/2020. Surveyor observation of Resident ID #8's toenails in the presence of Nursing Assistant (NA), Staff F, on 3/3/2021 at 10:19 AM, revealed thickened, breaking, yellow, discolored toenails on both feet. Additionally, both feet had dried yellow matter, some of which fell off their feet when their socks were removed by the NA. 2. Record review for Resident ID #25 revealed they were admitted to the facility in May 2020. Further review revealed a physician's orders [REDACTED]. The record lacked evidence of podiatry services since 8/24/2020. Surveyor observation of Resident ID #25's toenails, in the presence of Staff Nurse D, on 3/3/2021 at 11:47 AM, revealed long toenails, approximately ¼ inch beyond the nail bed, some of which were curling under the toes. 3. Record review for Resident ID #35 revealed they were admitted to the facility in September 2020. The record lacked evidence of podiatry services since admission. Surveyor observation of Resident ID #35's toenails, in the presence of the Assistant Director of Nursing Services on 3/3/2021 at 10:09 AM, revealed long toenails, approximately ¼ to ½ inch beyond the nail bed on all toes. During a surveyor interview with the Regional Consultant Nurse on 3/3/2021 at 10:16 AM, she was unable to provide evidence that the above-mentioned residents received routine foot care.

Based on surveyor observation and staff interview, it has been determined that the facility failed to label and store medications in accordance with the facility policy and manufacturer's instructions for 1 of 1 medication room and 1 of 2 medication carts (lower medication cart). Findings are as follows: Review of the consultant pharmacy policy titled, 3.4 Emergency Pharmacy Service and Emergency Kits (E-Kits) states in part, .8. Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy or placed within the resealed emergency kit until it is scheduled for exchange .10. The faxed log sheet will inform the pharmacy of items used from the emergency kit. This will notify the pharmacy to replace the kit or item . Review of the consultant pharmacy policy titled, 9.10 Medications with Shortened Expiration Dates states in part, .General Guidelines: The opened date should be noted on each container/vial of medication known to have a shortened beyond use date or expiration dates. 1. Surveyor observation of the medication room on 3/3/2021 at 9:58 AM in the presence of Staff Nurse D, revealed the following: A. Emergency medication kit revealed the emergency kit log documentation revealed on 1/19/2021 the [MEDICATION NAME] Pen was removed from the emergency kit for Resident ID #24. Further observation of the E-Kit revealed a [MEDICATION NAME] Insulin pen missing from the emergency kit. B. [MEDICATION NAME] oral concentrate 2 mg/1 mL, belonging to Resident ID #25 was observed opened and not dated when opened. Manufacturer's instructions for the [MEDICATION NAME] oral concentrate states, .Discard opened bottle after 90 days. 2. Surveyor observation of the lower medication cart on 3/3/2021 at 10:48 AM, in the presence of Staff Nurse O, revealed the following: A. (2) [MEDICATION NAME] inhalers belonging to Resident ID #13, opened, and not dated. Manufacturer's instructions state, .Throw away [MEDICATION NAME] when the counter reaches zero (0) or 3 months after you take [MEDICATION NAME] out of its foil pouch, whichever comes first . B. (1) Breo Ellipta belonging to Resident ID #9, opened and not dated. C. (1) Breo Ellipta belonging to Resident ID #28 opened, and not dated. Manufacturer's instructions state, .BREO ELLIPTA should be stored inside the moisture-protective foil tray and only removed from the tray immediately before initial use. Discard BREO ELLIPTA 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first . D. (1) [MEDICATION NAME]pen belonging to Resident ID #19 opened, and not dated. Manufacturer's instructions for [MEDICATION NAME] states, .In-use (opened) 28 days Room temperature only . During a surveyor interview with the Director of Nursing Services on 3/4/2021 at 9:50 AM, she revealed medications should be dated when opened. Additionally, she was unable to explain why the emergency kit was not replaced after it was opened.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to assist residents in obtaining routine dental services for 1 of 1 resident reviewed for dental services, Resident ID #4. Findings are as follows: Record review revealed that Resident ID #4 was admitted to facility in June 2017 with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident is cognitively intact. Additionally, Section L of the MDS for Oral/Dental Status did not reflect present oral or dental problems. Record review of the facility's policy for Dental Services last revised on 2/2019 states, Policy: Both routine and emergency dental services are available to meet the resident's oral health care needs based upon resident assessment and plan of care. Procedure .8. Dentures will be protected from loss or damage, to the extent practicable, while being stored .10. If dentures are damaged or lost, residents will be referred for dental services within 3 days of notification. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay . Record review revealed a care plan for Resident ID #4 for .missing teeth dated 7/31/2018 that states in part, .Monitor/document/report to MD PRN (as needed) s/sx (signs and symptoms) of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, [MEDICAL CONDITION]. Record review revealed a progress note dated 2/24/2019 at 10:22 PM that states in part, Resident states that (s/he) has miss placed (sic) (his/her) dentures in (his/her) room some where (sic). Staff .have tried to locate dentures and none were found as of this writing (sic). Further record review failed to reveal evidence that a referral was made within 3 days of the loss. Additionally, the record failed to reveal documentation to ensure that the resident was able to eat and drink adequately after losing his/her dentures. Record review failed to reveal evidence that Resident ID #4 was seen by a dentist in 2019 or in 2020. Record review revealed a physician's orders [REDACTED]. dated 2/18/2020. During a surveyor interview on 3/1/2021 at 11:17 AM with Resident ID #4, s/he was observed to have missing teeth. The resident revealed that s/he lost their dentures but could not recall the date they went missing. Resident ID #4 also stated s/he has pain when s/he eats and has to gum his/her food. During a surveyor interview on 3/3/2021 at 1:15 PM with Nursing Assistant Staff E, she revealed that she was not aware that Resident ID #4 previously wore dentures. During a surveyor interview on 3/3/2021 at 1:26 PM with the Director of Nursing Services and the Assistant Director of Nursing Services, they both revealed that they were not aware that Resident ID #4 previously wore dentures and had lost them. The DNS was unable to provide evidence that the resident was assisted in obtaining routine dental services since July of 2018 and when his/her dentures were documented as being lost on 2/24/2019.

Based on surveyor observation and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food, in accordance with professional standards for food service safety, relative to ice storage in a resident accessible area (upper level dining area). Findings are as follows: Surveyor observation of the upper level dining area on 3/1/2021 at 12:06 PM, revealed an orange 5-gallon, circular container labeled Home Depot drinking water in a resident accessible area. Resident ID #35 was observed bringing a Styrofoam cup from outside of the dining area, utilizing an ice scoop to put ice from the container into the cup, and leaving the ice scoop in the container. During a surveyor interview with Resident ID #35 immediately following the observation s/he revealed that s/he gets ice from the container when needed. During a surveyor observation and interview with the Food Service Director on 3/1/2021 at 12:50 PM, she acknowledged that residents should not be serving their own ice and she acknowledged that the scoop was left in the container with the handle resting on top of the ice.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that an alleged violation involving injuries of unknown source was reported immediately, but not later than 2 hours after the allegation was made, in accordance with State law through established procedures, for 1 of 1 sample residents reviewed for abuse, Resident ID #8. Findings are as follows: The facility policy titled, Abuse states in part, The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property .injury of unknown origin - A suspicion related to the source of injury is not observed or the extent or location is unusual or related to the number of injuries at a single point or over time .Allegations/reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management .Notify the local law enforcement and State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident . Record review revealed Resident ID #8 was admitted to the facility in January 2018 with medical [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the Brief Interview for Mental Status was scored as a 4, indicating severe cognitive impairment. Additional record review of the nursing progress notes revealed documentation by Staff Nurse A on 2/28/2021 at 3:09 AM which stated in part, CNA (nursing assistant) notified this writer of bruise she noticed on residents (sic) right wrist. Assessed residents arm observing yellow and dark colored bruising to wrist. Resident is unable to communicate where the bruise came from or recall events causing bruising. Surveyor observations made on 3/1/2021 at 11:02 AM and on 3/2/2021 at 2:10 PM revealed Resident ID #8 with purple and blue bruising on the underside of his/her right wrist with yellow and green bruising around the top. During a surveyor interview with Staff A on 3/3/2021 at 7:42 AM, she revealed that when the nursing assistant brought Resident ID #8's bruise to her attention, she assessed and attempted to interview the resident and observed purple and yellow bruising to his/her right wrist. She acknowledged that she failed to report the bruise to the Assistant Director of Nursing Services or Director of Nursing Services (DNS) within 2 hours. The facility was unable to provide evidence that the above injury of unknown origin had been reported to the State Survey Agency until 3/2/2021. During a surveyor interview with the DNS on 3/2/2021 at 2:21 PM, she revealed that Resident ID #8's bruise was identified on 2/28/2021 at 3:00 AM but was not reported to her until the morning of 3/1/2021. She acknowledged that the injury of unknown origin was not immediately reported to her or reported to the State Survey Agency within 2 hours.

Based on record review and staff interview, it has been determined that services provided by the facility failed to meet professional standard of quality, relative to physician's orders [REDACTED].#35. Findings are as follows: Mosby's 4th Edition, fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. Record review revealed Resident ID #35 was admitted to the facility in September of 2020. The resident's 12/25/2020 Minimum Data Set assessment revealed that the resident has moderate cognitive impairment. Further review revealed a 9/21/2020 care plan indicating that the resident is at risk for impaired skin integrity and/or pressure injury related to a history of pressure injury, being underweight, and occasional bladder incontinence. Additionally, the care plan revealed .Left hip wound resolved; protect skin with [MEDICATION NAME] (type of dressing) . Review of the physician's orders [REDACTED]. -11/22/2020, left hip protection: cleanse skin with normal saline, pat dry, and apply [MEDICATION NAME] for protection. This order was noted as discontinued on 2/23/2021. -2/23/2021, skin prep to left hip every shift for protection, resident tends to pick at skin, monitor every shift. Review of the Treatment Administration Record revealed the following: -[MEDICATION NAME] dressing was last signed as applied on 2/22/2021 -skin prep (wipes used to form a protective skin barrier) was signed as applied from 2/23/2021 at 3:00 PM to 3/1/2021 at 11:00 PM, every shift. During a surveyor observation on 3/1/2021 at 10:10 AM, Resident ID #35 was observed to have a dressing on his/her left hip area dated 2/21/21. An additional surveyor observation on 3/2/2021 at 10:57 AM, in the presence of Staff Nurse B, revealed that Resident ID #35 still had a dressing to his/her left hip dated 2/21/21 with Staff Nurse B's initials. The dressing was removed and found to have intact skin at the site of a scar from a previous injury. During a surveyor interview with Staff Nurse B immediately following the above observation he acknowledged the date of the dressing but was unable to explain why it was applied to the resident, as the order was discontinued. During a surveyor interview with the Director of Nursing Services (DNS) on 3/2/2021 at 11:07 AM, she was unable to explain why there was an [MEDICATION NAME] dressing on Resident ID #35's left hip as the order was discontinued on 2/23/2021. Additionally, she was unable to explain why the skin prep was signed off as completed and revealed that she would investigate, after the surveyor brought it to her attention. Review of the facility's investigation revealed that on 2/27/2021, 3:00-11:00 PM shift, Staff Nurse B, applied the [MEDICATION NAME] dressing to Resident ID #35's hip at the resident's request. The [MEDICATION NAME] was applied without a physician's orders [REDACTED]. Further review revealed the following: -Staff Nurse A signed off skin prep as administered but did not complete the treatment as ordered by the physician on 2/27/2021, 11:00 PM - 7:00 AM; 2/28/2021, 3:00 - 11:00 PM; and 2/28/2021, 11:00 PM- 7:00 AM. -Staff Nurse B signed off skin prep as administered but did not complete the treatment as ordered by the physician on 3/1/2021, 3:00 - 11:00 PM and 3/1/2021, 11:00 PM - 7:00 AM. -Staff Nurse C signed off skin prep as administered but did not complete the treatment as ordered by the physician on 2/28/2021 7:00 AM - 3:00 PM and 3/1/2021, 11:00 PM - 7:00 AM.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen therapy ,Resident ID #195. According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p.524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician. Findings are as follows: Record review for Resident ID #195 revealed they were admitted to the facility in February 2021 with [DIAGNOSES REDACTED]. Surveyor observations made on 3/1/2021 at 11:44 AM, 3/2/2021 at 12:35 PM, and 3/3/2021 at 2:00 PM revealed the resident was receiving oxygen via nasal cannula at 2 liters per minute. During a surveyor interview with the resident on 3/3/2021 at 2:00 PM, she revealed the oxygen was initially applied by the nurse on 3/1/2021. Record review failed to reveal an order for [REDACTED].>During a surveyor interview with the Director of Nursing Services on 3/4/2021 at 9:53 AM, she was unable to provide evidence that a physician's orders [REDACTED].

Based on surveyor observation, record review, and staff interview, it has been determined that the facility assessments failed to accurately reflect the resident's status for 4 of 12 sample residents, Resident ID #s 4, 9, 26, and 35. Findings are as follows: 1. Record review for Resident ID #4 revealed s/he was admitted to the facility in June of 2017. Record review of a significant change Minimum Data Set (MDS) assessment dated [DATE], section L0200 Dental, revealed that the resident was not coded as edentulous (lacking teeth). Additionally, a quarterly MDS assessment dated [DATE], section L0200 Dental, revealed that the resident was not coded as edentulous. Record review revealed a care plan for Resident ID #4 for .missing teeth dated 7/31/2018, which states in part, .Monitor/document/report to MD PRN (as needed) s/sx (signs and symptoms) of oral/dental problems needing attention . During a surveyor interview on 3/1/2021 at 11:17 AM with Resident ID #4, s/he was observed to be edentulous. S/he revealed that his/her dentures were lost but could not recall the date they went missing. 2. Record review for Resident ID #9 revealed s/he was admitted to the facility in February 2020. A. Further record review revealed a 7/8/2020 physician's orders [REDACTED]. Additionally, the record revealed that Resident ID #9 received [MEDICATION NAME] as ordered from 2/1/2021 through 2/19/2021. Review of the 2/16/2021 quarterly MDS assessment, section N0410 Medications Received, revealed that the resident was not coded as having received antipsychotic medications in the 7-day look back period. B. Further record review of the February 2021 Treatment Administration Record (TAR) revealed oxygen saturation levels taken while receiving oxygen via nasal cannula (tubing providing oxygen through the nose) on the following dates: 2/4/2021 through 2/8/2021, 2/11/2021, and 2/14/2021. Record review of the 2/16/2021 quarterly MDS assessment, section O0100 Special Treatments, Procedures, and Programs; revealed that the resident was not coded as receiving oxygen therapy while a resident in the 14-day look back period. 3. Record review for Resident ID #26 revealed s/he was admitted to the facility in July 2020. Further review revealed a 12/5/2020 physician's orders [REDACTED]. Additionally, the record revealed that Resident ID #26 is currently receiving hospice care. Review of the 2/18/2021 quarterly MDS assessment, section O0100 Special Treatments, Procedures, and Programs; revealed that the resident was not coded as receiving hospice care. 4. Record review for Resident ID #35 revealed s/he was admitted to the facility in September 2020. Further review revealed a 12/21/2020 physician's orders [REDACTED]. Additionally, review of the TAR revealed that Resident ID #35 had the Wanderguard in place starting on 12/21/2020. Review of the 12/25/2020 quarterly MDS assessment, section P0200 Alarms, revealed that the resident was not coded as using a wander/elopement alarm. Surveyor observation on 3/4/2021 at 10:09 AM, revealed Resident ID #35 wearing a Wanderguard bracelet to his/her right ankle. During a surveyor interview on 3/4/2021 at 9:30 AM with the MDS Nurse, she acknowledged that Resident ID #4, 9, and 35's MDS assessments were inaccurately coded. During surveyor interviews on 3/4/2021 at 10:33 AM and 12:00 PM with the Director of Nursing Services, she acknowledged that Resident ID #s 9 and 26's MDS assessments were inaccurately coded.

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe, clean, comfortable, homelike environment relative to flooring, door frames, closet doors, windows, furniture, outside storage and both upstairs and downstairs resident communal bathrooms. Findings are as follows: 1. Surveyor observations of the unit hallway and resident rooms on 2/18/2021 throughout the day of the survey revealed the following: Resident rooms: -room [ROOM NUMBER], 13, 15, 16, 18, 19, 21, 25, 26, 27, 28, and 30 had marred door frames. -room [ROOM NUMBER] had a piece of the slat missing from the left window vertical blind. -room [ROOM NUMBER] was observed with the left window shade torn in multiple areas. -room [ROOM NUMBER] was observed with a bureau with a missing drawer. -room [ROOM NUMBER] was observed without a closet door, in addition the wall behind the beds had a gouged area circular in dimension, approximate measurement 3x3 inches. -room [ROOM NUMBER] was observed with a piece of wood secured to the window frame, covering the lower to middle part of the window. Hallway: -The end of the unit hallway had a patch of flooring, approximate size was 5 x 5 feet, that was torn, lifted and curled upward in the front left of the floor and in the back left portion was an area that was lifting from the under flooring. The right side of the flooring had 4 areas with torn pieces in the flooring, exposing the under flooring. 2. Surveyor observations of the downstairs resident communal bathrooms, bathroom [ROOM NUMBER] and bathroom [ROOM NUMBER] revealed the following observations: Bathroom [ROOM NUMBER]: -The entrance to the bathroom revealed a marred door frame. Bathroom [ROOM NUMBER] -The entrance to the bathroom revealed a marred door frame. -Marred doors to the vanity. -Visible black matter on the lower portion of the shower curtain to the shower stall. 3. Surveyor observations of the upstairs resident communal bathrooms, bathroom [ROOM NUMBER], bathroom [ROOM NUMBER], and bathroom [ROOM NUMBER] revealed the following observations: Bathroom [ROOM NUMBER]: -The entrance to the bathroom revealed a marred door frame. Bathroom [ROOM NUMBER]: -The entrance to the bathroom revealed a marred door frame. -Marred doors to the vanity (4), and 3 of the 4 doors were missing pieces of wood molding at the bottom of the doors. -Two stalls within the bathroom were both without doors, one had a working toilet and the second toilet was observed with a large piece of black plastic between the toilet lid and bowl. -The tiled half wall separating the tub and vanity had a missing tile from each side of the wall, approximate size was 2x2 inches. Bathroom [ROOM NUMBER]: -The entrance to the bathroom revealed a marred door frame. -The tile wall to the right of the vanity had a missing tile, approximate size was 4x4 inches. -Baseboards were rusted with chipped and peeling paint 4. Surveyor observations at 1:00 PM of the facility exterior grounds revealed a blue tarp covering 2 bed frames, and another bed frame next to that, all were observed leaning outside against the front of the building, under a resident's room window. During a walkthrough with an interview on 2/18/2021 at 2:20 PM with the Administrator, the Director of Nursing, and the Regional Instructor for Development, they acknowledged that the above areas mentioned were in need of repair.

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 7 of 10 sample residents reviewed for nutrition (Resident ID #'s 18, 21, 33, 43, 44, 51, and 153). Findings are as follows: The facility's policy titled Weight Assessment and Interventions revised on 5/2020, indicates; .4. Weights will be recorded in the medical record . a. Any weight change of 5 lbs (pounds) in a month and 3 lbs in a week since their last weight assessment will be retaken within 48 hours for confirmation and verified by nursing. b. Re weigh should be reviewed by the Licensed Nurse c. Licensed nurse will notify Dietician of identified weight change once reviewed d. Dietician notification should be documented within the Resident's medical record e. Dietician or diet technician will respond within 72 hours of receipt of notification . 6. The threshold for significant unplanned and undesired weight change will be based on the following criteria: a. 1 Month - 5% weight change is significant; greater than 5% is severe 3 Months - 7.5% weight change is significant; greater than 7.5% is severe 6 Months - 10% weight change is significant; greater than 10% is severe . 1. Record review revealed Resident ID #18 has a care plan, initiated on 3/15/2020, which indicates the resident has a nutritional problem related to [MEDICAL CONDITION] obstruction (blockage in esophagus) and chronic pancreatitis. Further review revealed an intervention stating, Monitor weights as MD ordered. Further record review revealed a physician's orders [REDACTED]. Record review from 5/11/2020 through 9/17/2020 revealed the following weights: - 9/17/2020 = 75.8 pounds - 8/10/2020 = 75.6 pounds - 7/31/2020 = 77.0 pounds - 5/11/2020 = 91.4 pounds Further record review revealed the following: - There is no evidence that a monthly weight was obtained for the month of June 2020. - The resident was weighed on 7/31/2020 and lost 14.4 pounds (15.7% of body weight) in approximately 2 months. There is no evidence that the resident's weight was re-taken within 48 hours per policy or that the severe weight loss was addressed. 2. Record review revealed Resident ID #21 has a care plan, initiated on 2/9/2020, which indicates the resident has a nutritional problem related to obesity, DM (diabetes mellitus) and [MEDICAL CONDITIONS]. Further review of the care plan revealed an intervention stating, Monitor weights as ordered. Review of the physician's orders [REDACTED]. - 3/20/2020: an order for [REDACTED].>- 7/8/2020: an order for [REDACTED]. Record review from 4/17/2020 to 9/21/2020 revealed the following weights: - 4/17/2020 = 275.2 lbs. - 5/16/2020 = 284 lbs. - 5/23/2020 = 283.6 lbs. - 8/24/2020 = 276.4 lbs. - 9/04/2020 = 244.7 lbs. - 9/14/2020 = 240 lbs. Further record review revealed the following: - The resident gained 8.8 pounds in approximately 1 month from 4/17/2020 to 5/16/2020. There is no evidence that the resident's weight was re-taken within 48 hours per policy or that the weight gain was addressed. - There is no evidence that monthly weights were obtained from 5/23/2020 to 8/24/2020. - The resident was weighed on 9/4/2020 and lost 31.7 lbs (11.52% of body weight) in 10 days. There is no evidence that the resident's weight was re-taken within 48 hours per policy or that the severe weight loss was addressed. - The resident was weighed on 9/14/2020 and lost an additional 4.7 lbs. in 10 days, and had a total loss of 36.4 lbs. (13.17% of body weight) in 3 weeks. There is no evidence that the resident's weight was re-taken within 48 hours per policy or that the severe weight loss was addressed. 3. Record review revealed Resident ID #33 has a care plan, initiated on 8/12/2020, which indicates the resident has a nutritional problem related to dysphagia (difficulty swallowing). Further review of the care plan revealed an intervention stating, Monitor weights as ordered. Review of the physician's orders [REDACTED]. Record review revealed the following weights: - 7/31/2020 = 179.6 lbs. - 8/06/2020 = 163.2 lbs. - 8/26/2020 = 143.6 lbs. - 8/28/2019 = 157.2 lbs. - 9/17/2020 = 161.4 lbs. Further record review revealed the following: - The resident lost 16.4 lbs. (9.13% of body weight) in approximately 1 week after admission. There is no evidence that the resident's weight was re-taken within 48 hours per policy. - There is no evidence that a weekly weight was obtained on two occasions in between 8/6/2020 and 8/26/2020 per the physician's orders [REDACTED]. (12.01% of body weight) in three weeks and there is no evidence that any dietary interventions were put into place. - The resident's weight was re-taken on 8/28/2020 and had a total weight loss of 22.4 lbs. since admission, representing a 12.4% severe weight loss in 1 month. There is no evidence that any dietary interventions were put into place. 4. Record review revealed Resident ID #43 has a care plan initiated on 7/28/2020, which indicates the resident has a nutritional problem related to chewing problems. Further review of the care plan revealed an intervention stating, Monitor weights as ordered. Record review of the physician's orders [REDACTED]. Record review of the resident's weight obtained upon admission to the facility on [DATE] was 198.0 lbs. Review of the subsequent facility weights are as follows: - 8/22/2020 = 155.0 lbs. - 8/24/2020 = 200.0 lbs. - 8/28/2020 = 152.6 lbs. - 8/31/2020 = 152.8 lbs. - 9/17/2020 = 156.0 lbs. Further record review revealed the following: - There was no evidence that the facility obtained weekly weights during the time period from 7/28/2020 through 8/21/2020. - Review of the 8/22/2020 weight of 155 lbs. revealed a severe weight loss of 42 lbs. (21.72% of body weight) in 3.5 weeks. - The re-taken weight on 8/24/2020 of 200.0 lbs., indicated a weight gain of 45 lbs. There is no evidence that the resident's weight was re-taken within 48 hours per policy. - Review of the 8/28/2020 weight of 152.6 lbs indicated an additional weight loss of 2.4 lbs. from 8/22/2020. Review of the record lacked evidence that the resident's severe weight loss was addressed. 5. Record review revealed Resident ID #44 has a care plan, initiated on 8/18/2020 which indicates the resident has a nutritional problem related to DM, hypertension and chronic pressure ulcer on the left heel. Further review of the care plan revealed an intervention stating, Monitor weights as ordered. Review of the record revealed a physician's orders [REDACTED]. Review of Resident ID #44's record revealed the following: - There was no evidence that a weight was obtained until 8/26/2020, which is 11 days post admission. There was also no evidence that a weekly weight was done when it was due on 8/22/2020. Further record review revealed the following weights: - 9/13/2020: 230 lbs. - 9/19/2020: 235 lbs. Additional record review revealed that the resident gained 5 lbs. in approximately 6 days from 9/13/2020 to 9/19/2020. There is no evidence that the resident's weight was re-taken within 48 hours per policy. 6. Record review revealed Resident ID #51 has a care plan, initiated on 8/28/2020 which indicates the resident has a nutritional problem related to type 2 DM. Further review of the care plan revealed an intervention stating, Monitor weights as ordered. Review of the record revealed a physician's orders [REDACTED]. Further record review revealed the resident lost 9.8 lbs. in approximately 2 weeks from 9/1/2020 to 9/14/2020. There was no evidence that a weekly weight was obtained between 9/1/2020 and 9/14/2020. 7. Record review revealed Resident ID #153 has a care plan, initiated on 9/8/2020, which indicates the resident has a nutritional problem, requiring diuretic use (to treat conditions that have fluid retention). Further review of the care plan revealed an intervention stating, Monitor weights as ordered. Review of the record revealed a physician's orders [REDACTED]. Review of Resident ID #153's record revealed that there was no evidence that a weight was obtained until 9/14/2020, which is 9 days post admission. Further record review revealed Resident ID #153 has a physician's orders [REDACTED]. Additional record review revealed that the resident gained 7 lbs. in approximately 8 days from 9/14/2020 to 9/22/2020. There is no evidence that the resident's weight gain was addressed. During telephone interviews relative Resident #'s 21, 33, 43 and 44 on 9/18/2020 at approximately 1:00 PM, and 9/21/2020 at approximately 2:00 PM, the Dietitian acknowledged that the residents had significant weight loss and no dietary interventions were implemented. During a surveyor interview relative to Resident #'s 21, 33, 43 and 44 on 9/21/2020 at approximately 12:00 PM, the Interim Director of Nursing could not provide evidence that the orders and /or facility's policy were followed or that the resident's severe weight loss was addressed. During telephone interviews relative to Resident ID #'s 21, 33, 43 and 44 on 9/18/2020 at approximately 2:30 PM and 9/21/2020 at approximately 2:00 PM, the resident's primary care physician revealed that he was not aware of the resident's weight loss. He also revealed that he does not review the residents' weights and expects to be notified if a resident experiences weight loss and/or gain. During a surveyor interview with the Director of Nursing on 9/28/2020 at 2:30 PM, she could not provide evidence that the resident's weight were obtained per physician and/or policy for Resident #'s 18, 51 and 153. Additionally, she could not provide evidence that the resident's weight was re-taken after a severe weight loss and that it was addressed.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 sample residents reviewed with pressure ulcers (Resident ID #'s 44 and 156). Findings are as follows: A review of the facility policy titled,Ulcer/Skin Breakdown Clinical Protocol dated 11/2019, states in part, Assessment and Recognition: 2.) In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . 3.) The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions . Treatment/Management: 1.) The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents . Monitoring: 1.) During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. This can occur with the resident's attending physician or wound consulting practitioner. 2.) The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . 1. Record review revealed Resident ID #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital Continuity of Care (COC) form dated 8/15/2020 indicated the resident has a unstageable pressure ulcer on his/her left heel. Record review failed to reveal that a full assessment (including location, stage, length, width and depth, presence of exudates or necrotic tissue) of the left heel pressure ulcer were obtained until 8/26/2020, which was 11 days post admission. Additionally, record review revealed a physician's progress note dated 8/25/2020, indicating the provider recommended a wound consult for the left heel ulcer. Review of the nursing progress note dated 8/26/2020 indicated a Stage III left heel pressure ulcer which measures, 6.0 centimeters (cm) in Length (L) x 3.0 cm in Width (W) x 0.2 cm in Depth (D), with a moderate amount of exudate present. Exudate is serous (pus like or clear fluid). No wound odor, and surrounding tissue is normal for resident. Record review of the September 2020 Treatment Administration Record (TAR) failed to reveal a physician's order for a wound treatment between 9/10/2020 - 9/12/2020. Further review of the TAR revealed a treatment order for the left heel was obtained on 9/13/2020 to Cover left heel wound with Xeroform dressing, then cover with dry gauze or ABD pad and wrap with roll gauze. Leave Xeroform undisturbed for 3-5 days. May change outer dressing PRN (as needed) soilage. This order lacked a cleansing agent, before applying Xeroform dressing for the left heel ulcer. Review of a nursing progress note dated 9/16/2020 indicated .the left heel dressing removed. copious amount of green drainage with foul odor noted in dressing. wound bed is pink and surrounded by maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) . Review of a subsequent nursing progress note dated 9/17/2020 indicated changes noted to left heel wound, excessive drainage and change in color . During a telephone interview on 9/17/2020 at 2:05 PM with the Physician Assistant (Staff B), she revealed she has worked at the facility only a few months, and was unfamiliar with the facility system. She stated she did not write the order for the wound consult, rather she gave a verbal order to the nurse who was on duty on 8/25/2020. Further record review revealed no evidence that the resident had received a wound consult since it was ordered on [DATE]. A surveyor observation of the resident's left heel pressure ulcer on 9/18/2020 at 11:50 AM with the unit nurse (Staff C) revealed measurements of 6 cm in L x 4 cm in W x 0.3 cm in D, indicating ulcer width and depth increased from 8/26/2020. The wound bed was observed to be red; the peri-wound was red with pink drainage noted on the old dressing. The nurse further stated the pressure ulcer was a stage III. A surveyor interview subsequent to the dressing change with Staff C, revealed she had worked on 8/25/2020 and did not recall either the Physician Assistant or the resident's physician giving her an order to obtain a wound consult. She further stated the providers usually put orders into the computer or write the order and hand it to nurses to enter into the computer. During a surveyor interview on 9/18/2020 at 12:03 PM with the Interim Director of Nursing (DON), she was unable to provide evidence that the pressure ulcer measurements were obtained upon admission. She also acknowledged that the order obtained on 9/13/2020 for the left heel lacked a cleansing agent for the wound treatment, prior to applying the Xeroform dressing. Additionally, she was unable to provide evidence that the resident had a physician's order relative to wound care between the dates of 9/10/2020 through 9/12/2020 or that the resident had been seen by a wound specialist. 2. Record review revealed Resident ID #156 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the care plan for alterations in skin integrity initiated on 9/14/2020 indicates the resident has actual pressure ulcers, including stage III sacral (lower back) wound and stage II right [MEDICAL CONDITION]. The goal indicates the wound will show improvement appropriately for wound size/type through the review date. Further review of the care plan revealed interventions including, .document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue, monitor dressing daily to ensure it is clean dry and intact, monitor wound daily for signs and symptoms of infection, and monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage . Record review of the hospital documentation entitled, Nursing Progress Summary, dated 9/4/2020 revealed a stage 2 to R (right) stump, stage III to right and left buttock, stage II to ischium (lower and back part of hip), stage II to R shin, stage II to L (left) heel, stage III to R back, and DTI (deep tissue injury) to sacrum. Further record review failed to reveal a pressure ulcer assessment or measurements until 9/15/2020, which is 3 days post admission. The Wound assessment dated [DATE] revealed the following pressure ulcers: 1. Stage II, right knee, 2.5 cm in L x 2.5 cm in W. 2. Stage II, right buttock, 1 cm in L x 1 cm in W. 3. Stage II, left buttock, 1 cm in L x 1 cm in W. 4. Stage II, left lower leg, 3 cm in L x 1 cm in W. 5. Stage II, left heel, 3 cm in L, 1.5 cm in W, 0.1 cm in D. Scant amount of serous (clear or slightly yellow in color) drainage, surrounding skin is dark red/purple. 6. Stage II, vertebrae (upper-mid), 2.5 cm in L x 2.5 cm in W. 7. Stage II, sacrum, 2.5 cm in L x 2.5 cm in W. Record review of the September 2020 TAR failed to reveal any treatment orders for these pressure ulcers prior to 9/16/2020, which is 4 days post admission. During a surveyor interview on 9/18/2020 at 10:11 AM with the Interim DON, she acknowledged there were no treatment orders in place until 9/16/2020, 4 days post admission. Additionally, she could not explain why skin assessments were not completed until 9/15/2020, which was 3 days post admission.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the medical care of each resident is supervised by a physician for 3 of 5 sample residents reviewed relative to nutrition (Resident ID #'s 21, 33, and 43). Findings are as follows: 1. Record review for Resident ID #21 revealed the resident was weighed on 9/14/2020 and lost an additional 4.7 lbs. in 10 days, and a total of 36.4 lbs. (13.17% of body weight) in 3 weeks. 2. Record review for Resident ID #33 revealed the resident was weighed on 8/26/2020 and lost 19.6 lbs. (12.01% of body weight) in three weeks. Further record review revealed the resident's weight was re-taken on 8/28/2020 and lost a total of 22.4 lbs. since admission, representing a 12.4% severe weight loss in 1 month. 3. Record review for Resident ID #43 revealed the resident was weighed on 8/22/2020 and had a severe weight loss of 42 lbs. (21.72% of body weight) in 3.5 weeks. Review of the 8/28/2020 weight of 152.6 lbs indicated an additional weight loss of 2.4 lbs. from 8/22/2020. Record review lacked evidence that the above resident's severe weight loss was addressed by the resident's physician. During telephone interviews on 9/18/2020 at approximately 2:30 PM and 9/21/2020 at approximately 2:00 PM, the resident's primary care physician revealed that he was not aware of the above resident's weight loss. He also revealed that he does not review the residents' weights and expects to be notified if a resident experiences weight loss and/or gain. (Refer to F692)

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 for nutrition (Resident ID #1). Findings are as follows: The facility's policy titled Weight Assessment and Intervention indicates 3 .anyone with a 5lb weight change who is over 100lbs since their last weight assessment will be retaken within 24hrs for confirmation and verified by the nurse .6 .The threshold for significant unplanned and undesired weight change will be based on the following criteria: a. 1 month - 5% weight change is significant; greater than 5% is severe. Record review revealed Resident ID #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan, initiated on 2/11/2019, revealed that the resident has a nutritional problem or potential nutritional problem and documents a varied meal intake and history of diabetes. Review of the physician's orders [REDACTED]. Record review revealed the following weights: - 2/18/2019: 218.0 lb - 3/01/2019: 218.5 lb - 3/15/2019: 208.0 lb - 3/22/2019: 203.0 lb Closed record review revealed no evidence that a weekly weight was done in between 3/1/2019 and 3/15/2019 per the physician's orders [REDACTED]. There is no evidence that the resident was re-weighed within 24 hours per policy or that any dietary interventions were put into place to inhibit the weight loss. The resident was weighed on 3/22/2019 and lost an additional 5 lb, representing a 7% severe weight loss in 3 weeks. Review of the progress notes revealed a note by the Dietitian on 3/22/2019, indicating that the resident had significant weight loss and a decline in intake. The Dietitian recommended to increase the resident's nutrition supplement. During a surveyor phone interview with the Dietitian on 4/12/2019 at 8:40 AM, she acknowledged that a weekly weight was missed between 3/1/2019 and 3/15/2019, there was no documented reweight, per policy, of the weight obtained on 3/15/2019, and that the resident had significant weight loss. During a surveyor interview with the Administrator and Director of Nursing Services on 4/12/2018 at 10:30 AM, they could not provide evidence that a dietary intervention was put into place after the 10.5# weight loss was noted on 3/15/2019.