Every finding on record at St Clare Home

Based on clinical record review and staff interview, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 3 residents reviewed related to nutrition, Resident ID #32.Findings are as follows:Record review revealed the resident was admitted to the facility in June of 2022 with diagnoses including, but not limited to, bilateral knee osteoarthritis and type 2 diabetes mellitus.Record review of the resident's documented weights revealed s/he had a weight loss of 24.4 pounds (lbs.) (12.5%) within a month; from 195 lbs. on 12/11/2025 to 170.6 lbs. on 1/10/2026.Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section K, titled Swallowing/Nutritional Status, indicated the resident was not coded as experiencing a weight loss of 5% or more within the last month.Further record review revealed the resident had a weight loss of 40.6 pounds (20.5%) within the last 6 months; from 197.6 lbs. on 10/2/2025 to 157 lbs. on 4/1/2026.Record review of the Comprehensive MDS assessment dated [DATE], Section K, titled Swallowing/Nutritional Status, indicated that the resident was not coded as experiencing a weight loss of 10% or more in the last 6 months.During a surveyor interview on 5/13/2026 at 3:05 PM with the MDS Coordinator, she acknowledged that the MDS assessments mentioned above were inaccurate and did not reflect the resident's weight loss. During a surveyor interview on 5/14/2026 at 3:25 PM with the Director of Nursing Services, she indicated that she would expect the MDS assessments to accurately reflect the resident's weight loss, as required.

Based on clinical record review and staff interview, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented for 2 of 4 residents reviewed who utilize psychotropic medications, Resident ID #s 4 and 7, for 1 of 2 residents reviewed for pain management and for 1 of 1 resident reviewed related to bladder continence, Resident ID #9.Findings are as follows:1a. Record review revealed Resident ID #4 was admitted to the facility in December of 2025 with diagnoses including, but not limited to, major depressive disorder and generalized anxiety disorder.Record review revealed physician's orders for Sertraline (a medication prescribed to treat depression) 100 milligrams (mg) in the evening and Buspirone (a medication prescribed to treat anxiety) 10 mg daily. Record review of the care plan for depression and anxiety revealed interventions including, but not limited to, monitor and document for effectiveness and possible side effects of the above-mentioned medications every shift, and to monitor, document, and report changes in behavior, mood, and/or cognition.Record review failed to reveal evidence that the resident was being monitored every shift for effectiveness and possible side effects of the above-mentioned medications. Additionally, the record failed to reveal evidence that nurses are monitoring and documenting changes in the resident's mood, behavior, and/or cognition.1b. Record review revealed Resident ID #7 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, major depressive disorder and post-traumatic stress disorder.Record review revealed a physician's order dated 9/4/2024 for Sertraline 75 mg in the morning for depression.Record review of the care plan dated 8/2/2024 for anti-depressant medication use revealed interventions including, but not limited to, monitor and document for the effectiveness and possible side effects of Sertraline every shift and to monitor, document, and report changes in behavior, mood, and/or cognition.Record review failed to reveal evidence that the resident was being monitored every shift for effectiveness and possible side effects of the sertraline. Additionally, the record failed to reveal evidence that nurses are monitoring and documenting changes in the resident's mood, behavior, and/or cognition.During a surveyor interview on 5/14/2026 at 12:09 PM with the Director of Nursing Services (DNS), she revealed that there should be specific orders for monitoring for the effectiveness and possible side effects of the above-mentioned medications, as well as specific orders to monitor for the resident's mood and behavior.2a. Record review revealed Resident ID #9 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, chronic pain.Record review of the physician's orders revealed the following medication orders for pain:-3/14/2026 Gabapentin 600 mg two times a day-3/13/2026 Acetaminophen 325 MG, give 2 tablets by mouth every 6 hours as needed, not to exceed 3 grams in 24 hours-3/17/2026 Oxycodone/Acetaminophen 10-325 MG, give 1 tablet by mouth three times a dayRecord review of the care plan dated 3/20/2026 revealed the resident has chronic pain and receives pain medication therapy. Interventions include, but are not limited to, administering analgesic medications as ordered and to monitor and document the effectiveness and side effects of the medication every shift.Record review failed to reveal evidence that the effectiveness and possible side effects of the pain medications were being monitored and documented every shift.During a surveyor interview on 5/14/2026 at 12:09 PM with the DNS, she was unable to provide evidence that the medication effectiveness and possible side effects of the medications were being monitored every shift.2b. Record review of Resident ID #9's Bowel and Bladder Program Screener, completed upon his/her admission, revealed s/he always voids appropriately without incontinence.Record review of Resident ID #9's point of care documentation revealed s/he was documented as continent of urine for 24 of 25 opportunities from 3/14/2026 through 3/24/2026. Further review revealed that from 3/25/2026 through 5/14/2026, s/he was documented to be incontinent of urine for 38 of 111 opportunities.Record review of the admission Minimum Data Set assessment dated [DATE] revealed s/he was occasionally incontinent of urine and failed to have documentation that a trial toileting program had been attempted to improve or restore his/her continence.During a surveyor interview on 5/14/2026 at 11:55 AM with Nursing Assistant, Staff D, she revealed that Resident ID #9 is usually continent of urine but had an incontinent episode today.During a surveyor interview on 5/14/2026 at 11:56 AM with Resident ID #9 revealed that s/he can walk to the bathroom, but needs assistance with putting his/her brief up and down, and to wipe him/herself after toileting.During a surveyor interview on 5/14/2026 at approximately 12:00 PM with the DNS, she revealed that Resident ID #9 is not on a toileting program. She acknowledged that the the care plan failed to be developed and implemented to address the resident's bladder status.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 1 of 1 resident observed with a with a wound dressing applied without a physician's order, and for 1 of 4 residents reviewed with a physician's order for weekly weights that were not obtained, Resident ID #32.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.Record review for Resident ID #32 revealed s/he was admitted to the facility in June of 2022 with diagnoses including, but not limited to, type 2 diabetes mellitus (DM) with hyperglycemia (inadequate insulin production resulting in elevated blood glucose levels), and a skin picking disorder. 1a. During a surveyor observation of the resident on 5/14/2026 at 11:30 AM in the presence of Registered Nurse, Staff A, revealed a bordered gauze dressing (a type of wound dressing with a central absorbent pad and an adhesive border) dated 5/13, to the resident's right lower extremity. When Staff A removed the bordered gauze, a xeroform (a non-adherent gauze impregnated with petroleum and a bacterial protectant) dressing was observed covering a skin tear. Staff A acknowledged that the resident did not have a treatment order in place for the observed wound.During a surveyor interview on 5/14/2026 at 12:09 PM with the Director of Nursing Services, she was unable to provide evidence of a treatment order for the above-mentioned wound and would expect staff to obtain a physician's order for a wound treatment.1b. Further record review for Resident ID #32 revealed a physician's order dated 2/15/2026 to obtain weekly weights to start on 2/22/2026. Record review of a care plan dated 5/22/2024 identified nutrition as a focus area, with interventions including, but not limited to obtaining and monitoring weights as ordered. Review of the documented weights revealed the following:172.8 lbs. on 1/19/2026169.2 lbs. on 1/27/2026166.4 lbs. on 2/2/2026157.8 lbs. on 2/28/2026160.2 lbs. on 3/1/2026155.2 lbs. on 3/12/2026154.2 lbs. on 3/19/2026156.0 lbs. on 3/26/2026157.0 lbs. on 4/1/2026155.8 lbs. on 4/16/2026157.2 lbs. on 5/1/2026Record review failed to reveal evidence that weekly weights were obtained on 2/22/2026, 4/9/2026, 4/23/2026, and 5/7/2026, as ordered. During a surveyor interview on 5/13/2026 at 12:46 PM with Registered Dietitian, Staff C, she acknowledged that weekly weights were not obtained as ordered and that she does not verify whether ordered weights are obtained.During a surveyor interview on 5/13/2026 at 1:07 PM with Registered Nurse, Staff B, she acknowledged that the resident's weekly weights were not obtained as ordered and should have been.During a surveyor interview on 5/13/2026 at 3:42 PM with the Director of Nursing Services, she was unable to provide evidence that the resident's weekly weights were obtained as ordered.

Based on clinical record review and staff interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 1 resident reviewed with pressure ulcers (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #32. Specifically, the facility failed to obtain and implement timely treatment orders, failed to complete comprehensive weekly wound assessments, failed to ensure accurate documentation, and failed to ensure pressure-relieving equipment was properly set and monitored for Resident ID #32. These failures resulted in the worsening of the resident's skin condition, including the development of additional pressure injuries, deep tissue injuries, and progression of a sacral wound to an unstageable necrotic ulcer. Findings are as follows: According to the facility's undated policy titled, Wound Care states the following, The purpose of this procedure is to provide guidelines for the care of wounds, to promote healing .Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident .Documentation The following information should be recorded in the resident's medical record .All assessment data (ie., wound bed color, size, drainage, etc.) obtained when inspecting the wound . Record review revealed the resident was admitted to the facility in June of 2022 with diagnoses including, but not limited to, type 2 diabetes mellitus (DM) with hyperglycemia (inadequate insulin production resulting in elevated blood glucose levels), excoriation (skin-picking) disorder. Record review of an Annual Minimum Data Set Assessment, dated 4/18/2026 revealed the resident has three unhealed Stage 2 pressure ulcers (partial loss of skin thickness presenting as a shallow open ulcer with a red-pink wound bed). Further record review revealed s/he has a Brief Interview for Mental Status score of 14 out of 15, indicating s/he is cognitively intact.Record review revealed a care plan revised in August of 2025 addressing the impaired skin integrity due to impaired mobility, incontinence, DM, peripheral vascular disease, chronic kidney disease, and pruritus (irritated skin sensation causing you to scratch) with a history of self-inflicted scratches. Interventions include, but are not limited to, an air mattress to the bed as ordered, apply lotions and medications as ordered, and a full skin inspection will be completed weekly by the nurse and as needed. Additionally, the record failed to reveal evidence that a care plan was developed and implemented for the resident's actual pressure ulcers. 1. Review of the Weekly Skin and Wound Assessment dated 4/7/2026, indicated the resident developed the following Stage 2 Pressure Ulcers:Right hip, 3 x 1.4 x 0 centimeters (cm)Right buttock, 0.8 x 1.4 x 0Right buttock, 0.6 x 0.8 x 0An additional sacral wound measuring 1.8 x 4.6 x 0 cm was also identified; however, the wound stage (refers to the classification of the extent and severity of a pressure ulcer) was not documented.The assessment failed to include required wound descriptions, including wound bed characteristics, wound edges, surrounding tissue, the presence and type of exudate (drainage), odor, undermining or tunneling (wound complications where tissue damage extends beyond the visible surface opening), and pain. Record review revealed the following physician's orders implemented for wound treatments:4/2/2026, wash buttocks (bilateral) using normal saline (a salt/water solution used in wound care), pat dry and apply Triad cream (a topical wound treatment prescribed to treat various wounds) to the excoriated areas (the order was discontinued on 5/12/2026). 4/7/2026, cleanse the right upper buttock, right lower buttock, right hip, and sacrum wounds with normal saline, pat dry, apply Triad cream to the wound bed, skin prep the periwound (skin surrounding a wound) and cover each wound with a bordered foam dressing every day and prn (as needed). Review of the Weekly Skin and Wound Assessment dated 5/4/2026 revealed the resident developed an additional Stage 2 pressure ulcer to the left inner thigh measuring 1 x 2.2 x 0.1 cm. Record review failed to reveal evidence that treatment orders were initiated for this wound after its identification.Record review failed to reveal evidence that a wound treatment was initiated after the wound was identified on 5/4/2026, to prevent the resident's left inner thigh pressure ulcer from worsening.Further record review revealed an additional Weekly Skin and Wound Assessment dated 5/11/2026 that identified two right inner thigh Stage 2 pressure ulcers with measurements of 2 x 1 cm (missing depth) and 1.5 x 1 x 0.1 cm.Record review failed to reveal evidence that any wound treatments were implemented after the wounds were identified on 5/11/2026, to prevent the resident's left inner thigh pressure ulcer from worsening.During a surveyor interview on 5/14/2026 at 12:53 PM with the Director of Nursing Services (DNS) she acknowledged that treatment orders had not been implemented for the resident's right and left inner thigh pressure ulcers. 2. Record review of the following documents titled Weekly Skin and Wound Assessment revealed a consistent failure to provide evidence that the required descriptions for the resident's pressure ulcers were documented including; the wound stage, complete measurements, type of exudate, wound bed characteristics, wound edges, surrounding skin tissue, the presence of odor, the presence and extent of undermining or tunneling, and the presence of pain:- Review of the weekly wound assessment, dated 4/20/2026 revealed that a Stage 2 pressure ulcer was identified on the resident's left buttock with documentation of only a wound measurement, 1.8 x 1.8 x 0.1 cm. The assessment failed to provide evidence of the required descriptions for the Stage 2 pressure ulcer as stated above. - Review of the weekly wound assessment, dated 4/27/2026 continued to document the left buttock Stage 2 pressure ulcer with only a wound measurement, 1.7 x 1.7 x 0.2 cm. The assessment failed to provide evidence of the required descriptions for the Stage 2 pressure ulcers as stated above.- Review of the weekly wound assessment, dated 5/4/2026 revealed the resident's skin worsened as s/he had the following Stage 2 pressure ulcers: Left buttocks ulcers measuring 4 x 1.5 x 0.1 cm and 0.6 x 1 x 0.1 cmRight outer thigh ulcer measuring 1 x1 x 0.1 cmLeft inner thigh measuring 1 x 2.2 x 0.1 cmAdditionally, the 5/4/2026 assessment failed to provide evidence of the required descriptions for each Stage 2 pressure ulcer, including the presence of exudate, wound bed characteristics, wound edges, surrounding tissue description, the presence of odor, the presence and extent of undermining or tunneling, and the presence of pain.- Review of the weekly skin and wound assessment dated [DATE], revealed that the resident had the following pressure ulcers:Right outer hip measuring 1 x 1 cm (missing depth)Right inner thigh wounds measuring 3.5 x 1 cm and 2 x 1 cm (both missing depth)Sacral wounds measuring 1.5 x 1 x 0.1 cm. and 4 x 4 x 0.3 cmAdditionally, the 5/11/2026 assessment failed to include the required descriptions for each pressure ulcer. Further review of the assessment revealed no evidence that the resident's Stage 2 pressure ulcers on the left buttock and left inner thigh were assessed. In addition, there was no documentation that either pressure ulcers had healed. During a surveyor interview on 5/14/2026 at 12:53 PM with the DNS she was unable to provide evidence that the weekly wound assessments were completed with the required descriptions for each of the resident's pressure ulcers as mentioned above.Additional record review revealed a Wound Consult was ordered to have the contracted Wound Physician complete an evaluation of the resident's wounds on 5/18/2026. Record review of the Wound Physician's report dated 5/18/2026 revealed the following pressure ulcers that were identified:A new deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) to his/her left 5th toe measuring, 1.5 x 1.2 x 0.0 cm, without odor or exudate, and the periwound noted as unhealthy and unstable. A new deep tissue injury to his/her left outer foot, measuring 4.0 x 2.5 x 0.0 cm, without odor or exudate and the periwound noted as unhealthy and unstable. Sacral wound, an unstageable ulcer (full thickness tissue damage where the base of the wound is completely obscured by dead tissue (necrosis, eschar or slough) and the depth or severity of the wound is unable to be determined), measuring 4.0 x 3.5 cm (unable to determine depth), with a mild odor, unhealthy periwound, necrotic edges, moderate serosanguineous (thin watery pale pink or light red fluid) exudate, with 100 % necrotic tissue.Further review of the Wound Physician's report failed to include the previously identified pressure injuries to the resident's right and left buttocks, right hip, or left and right inner thighs. Additionally, the sacral wound is now an unstageable pressure ulcer with 100% necrotic tissue. During a surveyor interview on 5/21/2026 at 11:07AM with the DNS, she revealed that the resident no longer has the previously identified Stage 2 pressure ulcers to his/her right and left buttocks, right and left inner thighs and the right hip. Additionally, she acknowledged that during the Wound Physician's evaluation, the resident was identified with 2 deep tissue ulcers and that his/her sacral pressure ulcer is now an unstageable pressure ulcer. 3. Record review revealed a physician's order dated 10/2/2025 for an air mattress to be applied to the bed and to check the pressure every shift for skin integrity.Record review revealed the resident's weight on 5/1/2026 was 157.2 pounds (lbs.).During a surveyor observation and interview on 5/11/2026 at 11:56 AM, revealed the resident's air mattress with the setting of 180. The resident was observed sitting in his/her recliner, and when asked about the comfort of his/her bed, s/he replied that the bed was really not that comfortable, indicating the air mattress setting may not have been adjusted to meet his/her individual comfort needs.Record review on 5/14/2026 at approximately 11:15 AM of the May 2026 Treatment Administration Record (TAR), revealed a physician's order to check the pressure setting of the air mattress every shift. Further review revealed that nursing staff documented the air mattress setting at 190, for 40 of 40 opportunities.During a surveyor observation on 5/14/2026 at 11:20 AM revealed the resident was sleeping on his/her air mattress with the setting on 180. Further observation failed to reveal evidence of 190 as a setting.During a surveyor observation and interview conducted on 5/14/2026 at 11:30 AM with Registered Nurse, Staff A, she stated that the air mattress setting should be adjusted according to the resident's weight. During the observation of the mattress settings, Staff A acknowledged that there was not a setting for 190 lbs., and that the mattress was currently set at 180, and that the appropriate setting should have been 150. Additionally, Staff A acknowledged that she documented the air mattress setting at 190 this morning on the TAR.During a surveyor interview on 5/14/2026 at 12:53 PM and 5/21/2026 at 11:07 AM with the DNS, she revealed that air mattress settings should be set according to the resident's weight, which would be at 150. She was unable to provide evidence that staff ensured the correct setting for the resident's air mattress. Additionally, the DNS acknowledged that the resident now has 2 deep tissue injuries and that his/her sacral pressure ulcer is now necrotic. During a surveyor interview on 5/21/2026 at 1:12 PM with the resident's provider, Registered Nurse Practitioner, Staff E, she revealed that she would expect the correct setting to be implemented and documented for the resident's air mattress. Additionally, she would expect that weekly skin assessments are consistently documented and that the Wound Physician is consulted for all pressure ulcers and treatment orders are obtained and implemented upon identifying any wounds. The facility failed to ensure the resident received appropriate assessment, monitoring, treatment, and prevention of pressure ulcers in accordance with facility policy and accepted standards of practice. Specifically, the facility failed to obtain and implement timely treatment orders, failed to complete comprehensive weekly wound assessments, failed to ensure accurate documentation, and failed to ensure pressure-relieving equipment was properly set and monitored. These failures resulted in the worsening of the resident's skin condition, including the development of additional pressure injuries, deep tissue injuries, and progression of a sacral wound to an unstageable necrotic ulcer.

Based on clinical record review and staff interview, the facility failed to maintain nutritional status, such as usual body weight, for 1 of 3 residents reviewed who experienced actual weight loss, Resident ID # 4. Findings are as follows:Record review of the facility's undated policy titled, Weight Assessment and Intervention, states in part, .Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation.nursing will immediately notify the dietitian.5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria.a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 7.5% is severe. Record review revealed Resident ID #4 was re-admitted to the facility in December of 2025 with diagnoses including, but not limited to, right hip fracture, hypothyroidism (abnormally low function of the thyroid), dysphagia (difficulty swallowing) and Parkinson's Disease (a progressive brain disorder that occurs when nerve cells of the brain die or become impaired).Record review revealed the following physician's orders:1/7/2026, Remeron (a medication prescribed to stimulate appetite) 15 milligrams (mg) daily4/21/2026, Prostat (a liquid protein supplement prescribed to provide additional protein) 30 milliliters (ml) daily4/21/2026, obtain weekly weights Record review of a care plan dated 12/23/2025 revealed the resident has a nutritional problem related to weight loss with a goal that s/he will maintain adequate nutritional status as evidenced by maintaining his/her weight.Record review revealed the following documented weights:112.5 pounds (lbs.) on 12/18/202599.0 lbs. on 4/3/2026 93.6 lbs. on 4/23/2026 88.4 lbs. on 5/4/2026Record review revealed the resident experienced the following weight loss:A severe weight loss of 12% (13.5 lbs.) from 12/18/2025 to 4/3/2026.A significant weight loss of 5.45% (5.4 lbs.) in less than 3 weeks from 4/3/2026 to 4/23/2026.A significant weight loss of 5.56% (5.2 lbs.) in less than 2 weeks from 4/23/2026 to 5/4/2026.Further record review failed to reveal evidence that weekly weights were obtained on 4/30 and 5/11/2026, as ordered. Additionally, the record failed to reveal evidence that a reweight was obtained within one day of the 4/3/2026, 4/23/2026 and 5/4/2026 weights, after the resident's weight revealed a 5% or more weight loss, per the facility policy. During a surveyor interview on 5/13/2026 at 12:32 PM with Registered Dietitian, Staff C, she acknowledged the resident experienced a significant weight loss and that the resident was not weighed weekly on 4/30 and 5/11/2026 after orders were implemented for weekly weights. She indicated that she does not verify if staff obtains weights as ordered, even for the residents who are being monitored for weight loss.During a surveyor interview on 5/13/2026 at 1:07 PM with the Registered Nurse, Staff B, she acknowledged that the resident had a significant weight loss and that s/he had not been weighed weekly on 4/30 and 5/11/2026 and should have been. Additionally, she revealed that she would obtain the resident's weight today. During a surveyor interview on 5/21/2026 at 1:58 PM with the resident's provider, she confirmed that she was aware of the resident's weight loss since January and had ordered for weekly weights to be obtained. She further revealed that she was unaware that staff failed to obtain the resident's weights weekly and that she would expect orders to be followed.During a surveyor interview on 5/13/2026 at 3:42 PM with the Director of Nursing Services, she acknowledged that the resident's weights were not obtained weekly as ordered and indicated that the expectation is that orders are followed.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to post cautionary and safety signs related to oxygen use for 2 of 3 residents reviewed receiving oxygen therapy, Resident ID #s 33 and 47.Findings are as follows:Record review of a policy titled Oxygen Administration states in part, .Steps in the procedure .Place an 'Oxygen in Use' sign on the outside of the room entrance door .1. Record review revealed Resident ID #33 was admitted to the facility in April of 2026 with a diagnosis including, but not limited to, acute respiratory failure with hypoxia (low levels of oxygen in the blood).Record review revealed a physician's order dated 4/20/2026 to titrate oxygen to maintain an oxygen saturation level (a measure of oxygen-carrying hemoglobin in the blood) greater than 92%.Surveyor observation of the resident's room failed to reveal evidence that a cautionary and safety sign was posted indicating oxygen was in use on the following dates and times:- 5/13/2026 at 9:00 AM- 5/14/2024 at 11:11 AM2. Record review revealed Resident ID #47 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD - a progress, irreversible lung disease that blocks airflow, making it difficult to breathe).Record review revealed a physician's order dated 12/20/2025 to administer oxygen continuously via nasal cannula (a flexible tube used to deliver supplemental oxygen directly into your nose) continuously to maintain oxygen saturation greater than 90%.Surveyor observations of the resident's room failed to reveal evidence that a cautionary and safety sign was posted indicating oxygen was in use on the following dates and times:- 5/13/2026 at approximately 9:00 AM- 5/14/2026 at 11:11 AMDuring a surveyor interview on 5/14/2026 at 11:15 AM with the Registered Nurse, Staff A, she acknowledged that both resident rooms failed to have a cautionary safety sign posted indicating oxygen was in use.During a surveyor interview on 5/14/2026 at approximately 11:30 AM with the Director of Nursing Services, she acknowledged that the facility failed to post cautionary safety signs indicating oxygen was in use for both residents.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to have sufficient nursing staff to assure resident safety and attain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care relative to insufficient staffing for 2 of 3 residents reviewed, Resident ID #s 2 and 3. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/30/2025 alleged that on 6/27 - 6/28/2025 during the 10:30 PM to 6:30 AM shift, the facility had a significant staffing issue. The complaint alleged that the nurse was left to provide nursing care for residents on two units, which were on two different floors. The complaint further alleged that during that shift, there were only two Nursing Assistants (NA) assigned to three units. Additionally, the complaint alleged that the facility was understaffed and unsafe. Review of a policy titled, Staffing Nursing states in part, .The facility provide sufficient numbers of nursing staff .to provide nursing and related care and services for all residents .Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including .assuring resident safety .attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident .assessing, evaluating, planning, and implementing resident care plans .[and] responding to resident needs . 1. During a surveyor interview with Licensed Practical Nurse (LPN), Staff A, she indicated that on 6/27 - 6/28/2025 during the 10:30 PM to 6:30 AM shift, the facility did not have sufficient staff, there were only two NAs and two nurses responsible for the three units in the facility. She indicated that a resident fell at approximately 5:20 AM, Resident ID #2. Additionally, she revealed that she did not have time to complete all of the residents' morning medications due to the short staffing, in particular, Resident ID #3's medications that were due at 6:00 AM. Furthermore, Staff A indicated that the [NAME] Unit was left without any staff just after the fall, because the NA assigned to that unit had to go to the downstairs unit to relieve her, before she could go up to the [NAME] Unit to assess and assist Resident ID #2 off of the floor. During a surveyor interview on 7/2/2025 at approximately 9:30 AM with an Ombudsman, she indicated that four families of residents residing at the facility contacted the Ombudsman's office following the weekend of 6/27/2025 with complaints of insufficient staffing. She further indicated that one of the anonymous complainants alleged that the residents were left alone, without any staff for an unknown period of time, which caused the resident to be fearful. Review of the facility's actual working schedule for the 10:30 PM - 6:30 AM shift on 6/27 - 6/28/2025 revealed only two nurses and two NAs worked in the facility during that night shift. Record review revealed the facility has 3 units and approximately 50 residents. The Gooseberry Unit is the short-term unit with approximately 22 residents, the [NAME] Unit has approximately 15 residents, and the [NAME] Point Unit, which is on a lower level of the facility, has approximately 12 residents. 2a. Record review revealed Resident ID #2 was admitted to the facility in October of 2024 with diagnoses including, but not limited to, Parkinson's disease and a history of falling. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. Record review revealed the resident required the assistance of one staff member for transfers. Record review revealed the following progress notes: -6/28/2025 at 6:14 AM- Resident had an unwitnessed fall approx .0525 [5:25 AM] in [his/her] room. [Resident ID #2] stated [s/he] was getting out of the bathroom and [his/her] leg buckled and [s/he] fell .denied any pain while on the floor but while getting [him/her] off the floor and putting [his/her] legs into [his/her] bed [his/her] pain became a 4/10 . -6/28/2025 at 7:48 AM- .reached out to [Director of Nursing Services (DNS)- Name redacted] regarding the resident fall .I also did make [DNS] aware of these unsafe staffing ratios which has played a big part in patient safety. -7/1/2025 at 6:34 AM- .resident did not sleep well but quiet. [Complained of] pain to right leg and medicated with scheduled Tylenol . During a surveyor interview on 7/2/2025 at approximately 10:40 AM with Resident ID #2, s/he indicated that s/he had fallen over the weekend and that .it wasn't fun, and it hurt . The resident further indicated that s/he was lying on the floor of his/her room for approximately an hour until staff found him/her. During a surveyor interview on 7/2/2025 at 11:45 AM with NA, Staff B, she indicated that she worked on the 6/27 - 6/28/2025 10:30 PM - 6:30 AM shift and was told that she had to switch from the [NAME] Unit to the downstairs [NAME] Point Unit because the facility was short staffed. She indicated that she was the only staff member on the [NAME] Unit for most of the shift and that many of the residents require two staff members for care, bed mobility, and transfers. She further indicated that she had to leave the unit unstaffed to go downstairs so the nurse could come upstairs to administer the residents medications. Additionally, she indicated that she asked an Assisted Living staff member to come to the unit to assist with turning one of the residents, and when she exited that resident's room to obtain more hygiene supplies, she noticed Resident ID #2 lying on the floor of his/her room. Furthermore, she indicated that she feels the facility's staffing is inadequate to properly care for the acuity of the residents. During a surveyor interview on 7/3/2025 at approximately 10:30 AM with NA, Staff C, she indicated that she was originally scheduled to work on the downstairs [NAME] Point Unit for the 10:30 PM - 6:30 AM shift on 6/27 - 6/28/2025, however, when she realized the facility was short an NA, she had to complete patient care on all of the residents residing on the [NAME] Point Unit and on the Gooseberry Unit, a total of approximately 37 residents. She indicated that being short staffed has happened in the past and it is difficult to do, however, she was able to complete two rounds of care on both units during that shift. Additionally, she revealed when the facility is short staffed, staff members from the Assisted Living Residence will come to help the units when needed. 2b. Record review revealed Resident ID #3 was readmitted to the facility in October of 2024 with diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebral infarction (weakness and loss of function on one side of the body following a stroke), repeated falls, and hypertension (high blood pressure). Review of an MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, indicating intact cognition. Further review revealed the resident was dependent on the assistance of staff for activities of daily living and the assistance of two staff members for transfers. Record review revealed a care plan with a focus of hypertension and a goal for the resident's blood pressure to be within normal limits. Further review revealed an intervention to administer cardiac medications as ordered. Record review revealed the following orders: - Acetaminophen 1000 milligrams (mg) every 8 hours - Hydralazine (a cardiac medication) 50 mg every 8 hours Record review of the June 2025 Medication Administration Record revealed the 6:00 AM scheduled dose of the Acetaminophen and the Hydralazine was not administered on 6/28/2025. During a surveyor interview on 7/2/2025 at approximately 10:55 AM with Resident ID #3, s/he indicated that s/he feels that the facility does not have enough staff. The resident further indicated that s/he waits 30 minutes for staff to answer his/her call bell at times. During a surveyor interview on 7/2/2025 at approximately 11:00 AM with Certified Medication Technician, Staff D, she indicated that she sometimes feels like the facility could use more staff but the staff members work well as a team. She further acknowledged that Resident ID #3's Acetaminophen and Hydralazine were not documented as administered for the 6:00 AM dose on 6/28/2025. During a surveyor interview on 7/2/2025 at 2:25 PM with the Administrator, she indicated that she was aware that Resident ID #2 had an unwitnessed fall on 6/28/2025. She further indicated that she was unaware that Resident ID #3 had not received his/her 6:00 AM scheduled Acetaminophen and Hydralazine on 6/28/2025.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 3 of 5 residents reviewed with constipation, Resident ID #s 2, 3 and 4. Findings are as follows: Review of a facility policy titled Bowel Protocol states in part, .maintain a healthy bowel regime for each resident .After 48 hours with no [Bowel Movement] BM the resident will be placed on the laxative list by the evening [3:00 PM to 11:00 PM] shift Licensed nurse to document GI [Gastrointestinal] assessment .[For example] (BS [bowel sounds], N/V [Nausea and vomiting], abdominal pain/distention) .The resident will be given MOM [Milk of Magnesia; a laxative] on the next evening shift .If no BM by the following morning, a suppository will be given upon waking .If no BM following the suppository, a fleet [enema] is to be given .If still no BM a complete assessment is done by the nurse and MD [medical doctor] to be called if indicated . 1. Record review revealed Resident ID #2 was admitted to the facility in February of 2025 with a diagnosis including, but not limited to, right side hemiplegia (paralysis) and hemiparesis (weakness) following a stroke. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is incontinent of bowels and is dependent on staff for toileting. Record review of the bowel records revealed the following: - last documented BM was on 5/3/2025, indicating that s/he did not have a BM for 4 days. - last documented BM was on 5/10/2025, indicating that s/he did not have a BM for 4 days. Record review of the Laxative list dated 5/4/2025 indicates the resident refused MOM on two occasions despite not needing the MOM on 5/4/2025 as s/he had a documented BM on 5/3/2025. Record review failed to reveal evidence that the resident received bowel interventions on 5/6 and 5/7/2025, that a GI assessment was completed or that the MD was notified that the resident had not had a bowel movement for 4 days, per the bowel protocol. 2. Record review revealed Resident ID #3 was admitted to the facility in April 2025 with diagnoses including, but not limited to, Alzheimer's disease and urinary incontinence. Review of an Admission MDS assessment dated [DATE] revealed the resident is incontinent of bowels and requires assistance from staff for toileting. Review of the bowel records revealed that the resident had no BM documented from 4/30/2025 until 5/5/2025, indicating that s/he did not have an BM for 5 days. Record review failed to reveal evidence that the resident received bowel interventions per the facility's bowel protocol on 5/2/2025. On 5/2/2025 the resident should have received MOM. Additional review revealed the was offered MOM on 5/3/2025 but refused it. Further the resident received MOM and a suppository on 5/4/2025 with no result and no further interventions were completed by the facility. Record review failed to reveal evidence of a completed GI assessment or that the MD was notified that the resident had refused MOM on 5/3/2025 and had no results from the MOM and suppository administered on 5/4/2025. Further the record failed to reveal evidence that the provider was notified that the resident had not had a bowel movement for 5 days. 3. Record review revealed Resident ID #4 was admitted to the facility in April 2025 with diagnoses including, but not limited to, mild cognitive impairment and malignant neoplasm of the urinary organ (a cancer of the urinary system). Review of an Admission MDS assessment dated [DATE] revealed that the resident is continent of bowels and requires supervision or touching assistance from staff for toileting. Review of the bowel records revealed the resident had one small BM documented from 5/1/2025 until 5/5/2025, indicating that s/he did not have an adequate BM for 4 days. Record review revealed a physician's order dated 4/29/2025 for Polyethylene Glycol powder (a medication used for constipation), give 17 grams by mouth every 24 hours as needed for constipation. Record review of the May 2025 Medication Administration Record failed to reveal evidence that the Polyethylene Glycol was administered to the resident as ordered. Record review failed to reveal evidence that the resident received bowel interventions per the facility's bowel protocol on 5/3 and 5/4/2025. The resident should have received MOM on 5/3 and a suppository on 5/4/2025. Record review failed to reveal evidence of a completed GI assessment or that the MD was notified that the resident had not had a BM for 4 days. During a surveyor interview on 5/16/2025 at approximately 10:10 AM with Registered Nurse, Staff A, she indicated that a small bowel movement is not adequate, and that the bowel protocol should be implemented following three days without an adequate bowel movement. During a surveyor interview on 5/16/2025 at 2:50 PM with the Director of Nursing Services, she acknowledged that an adequate bowel movement had not been documented for Resident ID #'s 2, 3 and 4 on the above-mentioned dates. Additionally, it would be her expectation to notify the provider if there is a refusal or no result from interventions. Further, she could not provide evidence that the facility completed a GI assessment per the facility protocol for Resident ID #'s 2, 3, and 4.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents are treated with respect and dignity for 1 of 1 resident observed who was not being assisted with eating, Resident ID #39. Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and anxiety. Review of the Minimum Data Set assessment dated [DATE] revealed the resident required physical assistance with eating. During a surveyor observation in the unit's common dining area on 4/8/2025 at 12:04 PM, Resident ID #39 was served his/her lunch tray along with other resident's in the common area. The resident sat at the table with the food in front of him/her while two other residents were being fed. At 12:34 PM, 30 minutes after his/her meal was placed at the table, staff began to assist the resident. During a surveyor interview on 4/8/2024 at 12:34 PM with Certified Medication Technician, Staff A, she acknowledged that there are a lot of residents who require assistance with eating and that Resident ID #39 had to wait to eat while other residents were eating at the table. During a surveyor interview on 4/9/2024 at 1:07 PM with the Director of Nursing Services, she indicated that six residents on the unit require staff to assist them with eating and it's difficult for them to all be assisted at the same time. She further indicated that a transport aide typically assists with feeding the residents however she was on vacation. She further indicated that she would expect that the resident would not sit for 30 minutes unassisted, while other residents were having their meals.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident reviewed receiving hospice services, Resident ID #21. Findings are as follows: Record review revealed the resident was readmitted to the facility in December of 2024 with diagnosis including, but not limited to, adult failure to thrive. Review of a hospice admission service agreement dated 1/27/2025 revealed the resident had signed a consent to receive hospice services, as of this date. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], Section O, titled Special Treatments, Procedures, and Programs revealed the resident was coded as not receiving hospice services. During a surveyor interview on 4/8/2025 at 12:49 PM with the MDS Coordinator, she acknowledged that the resident's MDS assessment was inaccurate and did not reflect that the resident is receiving hospice services. During a surveyor interview on 4/9/2025 at 10:08 AM with the Director of Nursing Services, she indicated that she would expect the resident's MDS to accurately reflect the resident's hospice status. 47939

Based on record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care for 1 of 1 resident reviewed for Post Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or a terrifying event), Resident ID #41. Findings are as follows: Record review revealed the resident was admitted to the facility with a diagnosis including, but not limited to, PTSD. Record review of a Social Service Trauma-Informed Care Screening Tool dated 11/27/2024 states in part, .Have you ever had an experience that was so upsetting to you that it changed you, emotionally, spiritually, physically, or behaviorally ., revealed the resident indicated yes. Record review of the resident's comprehensive care plan failed to reveal evidence that any care plan or interventions were implemented for the resident's history of trauma until it was brought to the facility's attention by the surveyor. During a surveyor interview on 4/9/2025 at 1:00 PM with the Director of Operations, she indicated she would have expected that a care plan would be implemented for the resident related to his/her diagnosis of PTSD.

Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's comprehensive care plan for 1 of 2 residents reviewed with a deep tissue injury (DTI; a type of pressure injury where damage occurs to the underlying soft tissue) and a Foley catheter (a device that drains urine from the bladder into a collection bag), Resident ID #35. Findings are as follows: Record review revealed the resident was readmitted to the facility in March of 2025 with diagnoses including, but not limited to, urinary retention and diabetes. Review of a progress note dated 3/21/2025 revealed the resident returned to the facility from the hospital with a DTI to his/her left heel and had a Foley catheter in place. Record review revealed the resident's comprehensive care plan was last revised on 3/8/2025, indicating it had not been updated to include that the resident now had a DTI to his/her left heel or had a Foley catheter in place. During a surveyor interview on 4/10/2025 at 10:57 AM with the Minimum Data Set (MDS) Assessment Coordinator, she was unable to provide evidence that the resident's comprehensive care plan had been reviewed and revised to reflect that the resident has a DTI to his/her left heel and has a Foley catheter in place. Additionally she indicated that the care plan should have been updated to reflect the current status. During a surveyor interview on 4/10/2025 at 11:30 AM with the Director of Nursing Services, she indicated that she would expect the resident's comprehensive care plan to have been reviewed and revised to reflect that the resident has a Foley catheter and a DTI to the left heel.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for 1 of 1 resident reviewed, with an order for a nutritional consult, Resident ID #41. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #41 was admitted to the facility with diagnoses including, but not limited to, high blood pressure and high cholesterol. Record review revealed a physician's order dated 3/17/2025 for a nutritional consult related to weight gain. Record review failed to reveal evidence that the nutritional consult was completed per the above physician's order. During a surveyor interview on 4/9/2025 at 8:57 AM with Registered Nurse, Staff B, she acknowledged that the nutritional consult was not completed. During a surveyor interview on 4/9/2025 at 11:44 AM with the Director of Nursing Services, she revealed that she would have expected the physician's order to have been completed.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 2 residents reviewed with constipation, Resident ID #s 29 and 148. Findings are as follows: Review of a facility policy titled Bowel Protocol states in part, .maintain a healthy bowel regime for each resident .After 48 hours with no [Bowel Movement] BM the resident will be placed on the laxative list by the evening [3:00 PM to 11:00 PM] shift .The resident will be given MOM [Milk of Magnesia; a laxative] on the next evening shift .If no BM by the following morning, a suppository will be given upon waking .If no BM following the suppository, a fleet [enema] is to be given .If still no BM a complete assessment is done by the nurse and MD [medical doctor] to be called if indicated . 1. Record review revealed Resident ID #29 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, dementia and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is incontinent of bowels and is dependent on staff for toileting. Review of the bowel records revealed the resident had only one small BM documented from 3/30/2025 until 4/8/2025, indicating that s/he did not have an adequate BM for 8 days. Record review of the April 2025 Medication Administration Record (MAR) revealed the resident was not administered any of the medications outlined in the Bowel Protocol until 4/8/2025. Record review failed to reveal evidence of a completed assessment or that the MD was notified that the resident had not had a bowel movement for 8 days. During a surveyor interview on 4/9/2025 at approximately 9:45 AM with Registered Nurse, Staff C, she acknowledged that an adequate bowel movement had not been documented for the resident from 3/30/2025 until 4/8/2025. She further indicated that a small bowel movement is not an adequate bowel movement, and that the bowel protocol should have been implemented following three days without an adequate bowel movement. During a surveyor interview on 4/9/2025 at 9:59 AM with the Director of Nursing Services (DNS), she acknowledged that an adequate bowel movement had not been documented for the resident from 3/30/2025 until 4/8/2025 and that the bowel protocol should have been implemented. 2. Record review revealed Resident ID #148 was admitted to the facility in February 2025 with diagnoses including, but not limited to, Alzheimer disease and gastro-esophageal reflux disease with esophagitis and bleeding (inflammation of the esophagus [the tube connecting the mouth to the stomach] due to frequent severe stomach acid backflow). Review of an Admission MDS assessment dated [DATE] revealed the resident is occasionally incontinent of bowels and requires moderate assistance from staff for toileting. Record review of a document titled Task revealed Resident ID #148 had no bowel movements on the following dates: - 3/1, 3/2, 3/3, 3/4 and 3/5/2025, for 5 consecutive days - 3/13, 3/14, 3/15, 3/16, and 3/17/2025, for 5 consecutive days - 3/21, 3/22, and 3/23/2025, for 3 consecutive days - 3/25, 3/26, 3/27, and 3/28/2025, for 3 consecutive days -4/6, 4/7, and 4/8/2025, for 3 consecutive days Record review failed to reveal evidence that the resident received bowel interventions per the facility's bowel protocol on the above-mentioned dates. During a surveyor interview on 4/9/2025 at 12:53 PM with the DNS, she indicated that the resident should have had orders for bowel medication as indicated in the facility's bowel protocol. 41729

Based on surveyor observation and staff interview, it has been determined that the facility failed to store food in accordance with professional standards of food service safety, relative to the main kitchen. Findings are as follows: During the initial tour of the main kitchen on [DATE] at approximately 8:50 AM, in the presence of the Food Service Director (FSD), the following observations were made: - Seven -24-ounce (oz) containers of grits with a Best by date of [DATE]. - Two -1-gallon containers of relish with a Best by date of [DATE]. - Six -20 oz French's mustard with a Best by date of [DATE]. - Four - 97 oz cans of evaporated milk with a Best by date of [DATE]. During a surveyor interview immediately following the above observations with the FSD, he acknowledged that the items were expired and should have been discarded.

1. Record review revealed Resident ID #2 was transferred to the hospital on 2/6/2025, 2/14/2025 and 2/17/2025. Record review failed to reveal evidence that the Office of the State Long-Term Care Ombudsman was notified of the hospital transfers for Resident ID #2. 2. Record review revealed Resident ID #20 was transferred to the hospital on 3/5/2025. Record review failed to reveal evidence that the Office of the State Long-Term Care Ombudsman was notified of the hospital transfer for Resident ID #20. During a surveyor interview with the Director of Operations on 4/9/2025 at 9:33 AM, she acknowledged that the Ombudsman was not notified of the transfers for Resident ID #s 2 and 20.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles, for 2 of 3 residents reviewed for medication storage, Resident ID #s 4 and 5. Findings are as follows: Record review revealed the facility policy titled, Medication Labeling and Storage, states in part, .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . 1. Resident ID #4 was admitted to the facility in September of 2024 with a diagnosis that includes, but is not limited to, pneumonia. Record review of a progress note dated revealed that the resident had expired on [DATE]. During a surveyor observation of the nursing medication cart on [DATE] at approximately 2:15 PM with Registered Nurse, Staff A, and in the presence of the Director of Nursing Services (DNS), revealed a blister medication card with 10 tablets of Methylphenidate HCL (Ritalin, a medication that is a stimulant that improves focus and impulsive behaviors) 5 mg (milligrams) with Resident ID #4's name on it. 2. Resident ID #5 was admitted to the facility in November of 2024 with a diagnosis that includes, but is not limited to, Alzheimer's disease. Record review of a document titled, 'Medication Error, reads in part, Resident ID #5 was administered 1 tab of Alprazolam (Xanax, an anxiety medication) instead of 1 tab of Lorazepam (also an anxiety medication) on [DATE]. Record review revealed there was not a physichian's order for Alprazolam for Resident ID #5 at any time during the resident's admission to the facility. During a surveyor observation on [DATE] at approximately 2:00 PM of the nursing medication cart on the [NAME] nursing unit, with Registered Nurse, Staff A, in the presence of the Director of Nursing Services (DNS), a blister medication card with 26 tablets of 0.25mg. Alprazolam with Resident #5 name on it was identified. Surveyor observations revealed medications were not removed from the medication carts per the facility policy. During a surveyor interview on [DATE] at approximately 2:30 PM with the DNS, she acknowledged that the medications for Resident ID #s 4 and 5 should have been destroyed, per facility policy.

Based on record review and staff interview it has been determined that the facility failed to ensure that residents are free of any significant medication error for 1 of 3 residents reviewed, Resident ID #6. Findings are as follows: 1. Resident ID #6 was admitted to the facility in April of 2022 with a diagnosis including, but is not limited to, multiple sclerosis (a disease in which the immune system eats away the protective covering of the nerves). Record review of the November Medication Administration Record (MAR) revealed s/he is to receive Methylphenidate HCL (Ritalin, type of medication that is a stimulant that improves focus and impulsive behaviors) oral tablet 30 Milligrams(mg) three times daily. Record review of the MAR revealed a missed dose of Ritalin on 11/7/2024, 11/8/2024, and 11/9/2024. During a surveyor interview on 11/13/2024 at approximately 2:00 PM with a Registered Nurse, Staff A, she revealed the resident did receive a 10:00 AM dose of the medication at approximately 12:00 PM and the 2:00 PM dose at approximately 2:20 PM. Additionally, she revealed the medication was not available for a period of time, as the keys to the medication cart were locked in the cart. Record review of progress notes failed to reveal evidence that the medical provider was notified that the prescribed medication was not administered as ordered on 11/7/2024, 11/8/2024, and 11/9/2024. During a surveyor interview on 11/13/2024 at approximately 2:00 PM with Staff A, she was unable to provide evidence that the medical provider was contacted. During a surveyor interview with the Director of Nursing Services on 11/13/2024 at approximately 3:00 PM, she was unable to provide evidence that the resident did receive the medication at the scheduled times. Additionally, she could not provide evidence the medical provider was made aware of the missed doses of medication.

Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan relative to 2 of 3 residents reviewed for falls, Resident ID #s 1 and 2. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility in June of 2018 and re admitted in August of 2024 with a diagnosis that includes, but is not limited to, a displaced fracture of the base of neck of left femur (thighbone). Record review of a document titled Monthly Falls Tracking revealed s/he had sustained falls on 9/27/2024 and on 10/16/2024. Record review of a care plan that was initiated on 6/10/2024 and revised on 11/13/2024, after it was brought to the Director of Nursing Sevices attention had a focus of the resident having falls on 6/9/2024, 9/27/2024, and 10/16/2024. The care plan interventions failed to be reviewed and revised for the falls that occurred on 6/9/2024 and 9/27/2024. 2. Record review revealed Resident ID #2 was admitted to the facility in April of 2024 with a diagnosis that includes, but is not limited to, orthopedic aftercare following a surgical amputation. Record review of a care plan dated 5/20/2024 had a focus of the resident being at risk for falls and sustaining falls on 5/23/2024, 7/27/2024, 9/29/2024, 10/22/2024, and 10/25/2024. Further record review of the care plan failed to reveal evidence that the care plan interventions were reviewed and revised for the above-mentioned falls. During a surveyor interview on 11/13/2024 at approximately 3:00 PM with the Director of Nursing Services, she was unable to provide evidence that the care plans were reviewed and revised for Resident ID #s 1 and 2.

Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the influenza or pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 4 of 6 residents reviewed for pneumococcal vaccination, Residents ID #s 1, 6, 23, and 26 and for 3 of 6 residents reviewed for the influenza vaccination, Resident ID #s 23, 26, and 29. Findings are follows: 1a. Record review for Resident ID #1 revealed the resident was admitted to the facility in May of 2019. Record review of the resident's immunization record failed to reveal evidence that the PPSV23 or PCV20 was offered, received, or declined. 1b. Record review for Resident ID #6 revealed the resident was admitted to the facility in July of 2023. Record review of the resident's immunization record failed to reveal evidence that the PPSV23 or PCV20 was offered, received, or declined. 1c. Record review for Resident ID #23 revealed the resident was admitted to the facility in January of 2024. Record review of the resident's immunization record failed to reveal evidence that the PVC13, PCV15, or PCV20 was offered, received, or declined. 1d. Record review for Resident ID #26 revealed the resident was admitted to the facility in October of 2022. Record review of the resident's immunization record failed to reveal evidence that the PVC13, PCV15, PPSV23 or PCV20 was offered, received, or declined. 2a. Record review for Resident ID #23 revealed the resident was admitted to the facility in January of 2024. Record review of the resident's immunization record failed to reveal evidence that the influenza vaccine was offered, received, or declined. 2b. Record review for Resident ID #26 revealed the resident was admitted to the facility in October of 2022. Record review of the resident's immunization record failed to reveal evidence that the influenza vaccine was offered, received, or declined. 2c. Record review for Resident ID #29 revealed the resident was admitted to the facility in May of 2022. Record review of the resident's immunization record failed to reveal evidence that the influenza vaccine was offered, received, or declined. During an interview on 4/17/2024 at 10:57 AM , with the Infection Preventionist, she acknowledged there there were no consent or declination forms for the above-mentioned residents, relative to the pneumococcal vaccine or influenza vaccine. Additionally, she was unable to provide evidence that the above-mentioned resident's medical records included documentation that indicates, at a minimum, if the residents either received the pneumococcal immunization or influenza vaccine or did not receive the pneumococcal immunization or influenza vaccine due to medical contraindication or refusal, until brought to the attention of the facility by the surveyor. 46539

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new pressure ulcers from developing for 3 of 6 residents reviewed, Resident ID #'s 20, 31 and 38. Findings are as follows: Review of the facility policy titled, Skin and Wound Management, dated February 2022, states in part, .The facility will ensure that .A resident .does not develop pressure ulcers .Interventions will be implemented in the resident's care plan to prevent pressure ulcer development .prevent deterioration and promote healing of the pressure ulcer .The facility may utilize an outside wound care specialist, to assist with wound management and treatment, if deemed necessary . 1. Review of the record for Resident ID #38 revealed that s/he was admitted to the facility in August of 2020 with diagnoses including, but not limited to, Alzheimer's disease and dementia. Review of the order summary report, revealed the following physician's orders: - 12/15/2021, to .off load bilateral heels while bed resting/heel boots .for protection . -9/1/2021, for .skin prep [forms a protective film or barrier] bilateral heels 2 [times] day . Review of his/her care plan, revised on 9/1/2022, revealed that s/he has the potential of impairment to skin integrity related to fragile skin and a deep tissue injury [a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure] to the right heel. Further review of the care plan revealed interventions including, but not limited to, offloading his/her heels when in bed. Record review of a skin and wound assessment dated [DATE] revealed that there were no new skin areas identified. Surveyor observations of the resident in bed on 2/13/2023, failed to reveal evidence that the heel protector boots were worn or that his/her heels were off loaded as ordered at the following times: - 9:45 AM - 9:54 AM - 10:05 AM - 10:32 AM - 10:57 AM During an additional surveyor observation of this resident in bed on 2/13/2023 at 11:16 AM in the presence Nursing Assistant (NA), Staff D, she acknowledged that the resident's heels were not offloaded, and that his/her boots were not applied. During a surveyor observation of the resident in the presence of Registered Nurse (RN), Staff C, on 2/14/2023 at 8:16 AM, she acknowledged the resident's heels were not offloaded, resting directly on the mattress. At this time a new dark, discolored, non blanchable area was found on the left heel. During a surveyor interview at the time of the above observation Staff C indicated that the wound on the left heel was previously unidentified and described it as a stage 2 or 3 (Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis. Stage 3 pressure ulcers affect the top two layers of skin, as well as fatty tissue.). Review of the resident's record on 2/15/2023 at approximately 8:30 AM failed to reveal evidence of measurements or a description of the non-blanchable area to the resident's left heel. During a surveyor observation of the resident, in the presence of RN, Staff B, on 2/15/2023 at 8:40 AM, a non-blanchable (discoloration of the skin that does not turn white when pressed) area was noted to his/her left heel. This skin abnormality had been brought to the attention of Staff C by the surveyor on 2/14/2023. During a surveyor interview with the Director of Nursing Services on 2/15/2023 at 9:00 AM, she revealed that her expectation would be that the measurements and description of the non-blanchable area, would have been documented on 2/14/2023, when it was brought to the nurse's attention by the surveyor. Furthermore, the facility procedure is to request a wound consult with the provider when a skin irregularity is identified. Record review revealed a progress note dated 2/15/2023 at 11:21 AM, written by Staff B which states in part, .resident has an area of discoloration and callousing on bottom of L[left] heel [length] 1.5 x 0.2 cm [centimeters][width] Applied skin prep to bilateral heels. Will request orders for a wound consult . Further record review revealed that on 2/20/2023, 5 days after the wound was identified the wound was assessed and measured by the wound physician. Review of a document titled Surgical Note indicates that the physician was asked to see the resident for a new DTI on his/her left heel. The wound measured 3.0 centimeters (cm) in length, by 1.3 cm in width and the depth is undetermined and had 50% eschar (dead tissue) and 50% epithelial tissue (signifies a healing wound). 2. Record review for Resident ID #20 revealed that s/he was admitted to the facility in December of 2017 with diagnoses including, but not limited to, Alzheimer's disease and type 2 diabetes mellitus. Review of his/her current orders revealed the following physician's orders: - 7/30/2021: .Off load heels every shift .for Boggy [abnormal texture of tissues characterized by sponginess, usually because of high fluid content] Heels . - 2/7/2023: .Right heel: Apply skin prep and offload every shift for skin integrity . Review of his/her care plan, revised on 2/11/2022, revealed that s/he has potential for pressure ulcer development related to immobility with interventions, including but not limited to, following the facility policies and protocols for prevention and treatment of skin breakdown. Surveyor observations of the resident in bed on 2/13/2023, failed to reveal evidence that his/her heels were offloaded as ordered at the following times: - 9:47 AM - 10:20 AM - 10:32 AM During an additional surveyor observation of this resident in bed on 2/13/2023 at 10:53 AM in the presence of NA, Staff D, she acknowledged that the resident's heels were not offloaded and were resting on the bed. During a surveyor interview on 2/15/2023 at 3:41 PM with the Director of Nursing Services, she revealed that her expectation would be that the resident's heels would be offloaded as ordered. 3. Record review for Resident ID #31, revealed that s/he was admitted to the facility in August of 2022 with diagnoses including, but not limited to, open wound to left foot and pressure ulcer of sacral [tailbone] region. Review of the wound continuity of care documentation, dated 1/23/2023, revealed in part, .WOUND LOCATION: Left Lateral Foot .ETIOLOGY: Pressure injury/ulcer . Review of a 12/2/2022 document titled, Braden Scale-For Predicting Pressure Sore Risk, revealed that s/he is at moderate risk for pressure sores. Review of the order summary report, revealed in part, the following physician's orders: - 1/23/2023: .Left lateral upper foot .apply skin prep and leave open to air every day and evening shift for skin integrity . - 2/7/2023: .Wound care to sacrum-clean and dry with NS [normal saline], apply skin prep around wound bed, apply Santyl [prescription medicine that removes dead tissue from wounds], cover with sacrum allevyn [dressing] two times a day . Surveyor observations on 2/15/2023 at 9:13 AM of RN, Staff C, performing dressing changes for this resident, revealed that she failed to apply skin prep to his/her left lateral upper foot wound and leave it open to air. Further observations of the sacrum wound dressing revealed that she failed to apply skin prep around the wound bed. During an interview with Staff C following these observations on 2/15/2023 at 9:36 AM, she acknowledged that she did not apply skin prep to the resident's left lateral upper foot wound and did not leave it open to air as stated in the physician's treatment order. She further acknowledged that she failed to apply skin prep to the skin around the sacrum wound bed, per the physician's treatment order. During a surveyor interview on 2/15/2023 at 3:46 PM, with the Director of Nursing Services she stated her expectation would be that the nurse would follow the physician's treatment order.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free of any significant medication error for 1 out of 5 residents reviewed for insulin, Resident ID #1. Findings are as follows: Record review of a facility policy titled Diabetes-Clinical Protocol, states in part, .Steps in the Procedure (insulin injections via Syringe) .Check the order for the amount of insulin .Double check the order for the amount of insulin .Re-check that the amount of Insulin drawn into the syringe matches the amount of insulin ordered . Review of a 7/14/2022 document titled, Department of Health, Center for Health Facilities Regulations Nursing Facility Required Reporting, states in part, .Date of Alleged Event: 07/10/2022 .My [parent] was given 10 times the amount of insulin that [s/he] was supposed to receive around dinner time. (80 units vs 8) . Record review revealed the resident was admitted to the facility in April of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan revised 6/22/2022, states in part, .at risk for complications related to diabetes mellitus .Interventions .Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness . Additional record review of a document titled, Order Summary Report, dated July 2022 revealed in part, the following 11/27/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Inject as per sliding scale: if 0 - 180 = 0; 181 - 250 = 4 .251 - 350 = 6; 351 - 450 = 8 .in the evening for diabetes . Record review of July 2022 progress notes, revealed the following note: - 7/10/2022 at 5:00 PM, .911 EMS [Emergency Medical Services] called for suspected insulin overdose .MD [medical doctor] and resident family notified. During a surveyor interview on 7/15/2022 at 11:13 AM, with the Acting Director of Nursing Services (DNS), she indicated Nurse Staff A was a new hire, which required her to be supervised while administering medications. At the time of the incident, she revealed she was in Resident ID #1's room with Staff A obtaining a blood glucose level to administer the correct amount of insulin, and further revealed that the resident's blood glucose level was measured at 400, which required 8 units of insulin to be administered, per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During the same interview, the DNS indicated that after leaving Resident ID #1's room, they went into Resident ID #3's room, where Staff A began drawing up 40 units of insulin, instead of the ordered 4, causing her to question the amount of insulin Staff A previously administered to Resident ID # 1. When questioned, the DNS revealed Staff A responded by stating, Call 911. At that time, 911 was called and the resident was sent to the hospital. During an interview on 7/15/2022 at 12:26 PM, with Staff A, she acknowledged administering the 80 units of insulin to the resident in error. Review of the 7/10/2022 Continuity of Care (COC) form revealed in part, .resident rec'd [received] wrong dose of [MEDICATION(S)] BS [blood sugar] was 400 rec'd 80 units instead of 8 @ [at] 1630 .Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of hospital documentation revealed his/her glucose levels on the following dates and times: 7/10/2022: - 109 at 8:11 PM - 83 at 8:48 PM 7/11/2022: - 90 at 12:28 AM - 81 at 12:59 AM - 86 at 1:42 AM - 109 at 2:13 AM During a surveyor interview on 7/15/2022 at approximately 9:00 AM with the Administrator and DNS, they were unable to provide evidence that the appropriate steps were taken before administering insulin to Resident ID #1, per the facility policy. Additionally, they would have expected the resident to receive the correct dose of insulin, per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents relative to transfers requiring two staff assistance and the use of an E-Z stand lift device for 2 of 2 residents reviewed, Resident ID#s 1 and 2. Findings are as follows: Review of the facility policy titled, St Clare Home Operational Policy and Procedure Manual .Safety Precautions-Lifting/Handling Heavy Objects, states in part: .As St. Clare is a no lift facility, there are mechanical devices available to assist you in moving residents more safely. All mechanical lifts require 2 staff . 1) Record review of the plan of care, revised on 7/16/2020, for Resident ID #1 revealed that s/he requires extensive to total assistance to complete his/her ADL's (Activities of Daily Living) related to decreased independent mobility .with use of EZ stand (a device used to transfer resident/patients) and 2 person assist . Review of the 7/16/2020 Minimum Data Set (MDS) for this resident revealed in part, .Transfers 2+ person extensive manual EZ stand x 2 . Review of a 1/7/2019 document titled, Safe Resident Handing and Movement Assessment and Care Plan, revealed that this resident has a history of falls and is care planned for an electric sit to stand equipment/assuasive device with 2 staff assistance relative to tasks requiring transfers to and from the bed to chair. Review of a 1/22/2021 nursing progress note, written by the Charge Nurse, Staff B, revealed in part: At approx. 11:30 this writer was paged to resident's room STST (term used as a directive to medical personnel during an emergency situation meaning immediately). Resident was sitting on the floor parallel to the bed. The wheel chair was directly behind (him/her). CNA (Certified Nursing Assistant) (Staff A) stated she was attempting to transfer resident, no sit to stand device was in the room. CNA stated she was sliding (him/her) from bed to chair and resident could not support (his/her) weight, thus fell on the floor. Resident's left leg and foot appeared abnormally twisted outward and resident did state that (s/he) was having pain in both knees and upper back. The decision was made at that time that resident required ER services to r/o (rule out) fracture . During an interview with Staff B on 1/27/2021 at 10:51 AM, she indicated that she reviewed the staff schedule at the beginning of the shift on 1/22/2021 and was aware that the CNA scheduled to orient with Staff A had called out and that she did not coordinate a replacement CNA for the assignment, stating .call outs are a problem . and that she needed someone to work. Furthermore, Staff B acknowledged that she was aware that Staff A was working on the wing as an orient without proper supervision, assumed that Staff A was shadowing with Staff D and failed to adequately monitor the staff on the floor to ensure the resident's safety. Review of a statement provided by Registered Nurse, Staff C, dated 1/22/2021, revealed that she observed Resident ID# 1 sitting on the floor of his/her room. Staff C asked him/her what happened, and s/he stated, .I told her this wasn't going to work. (Staff C) did notice that Staff A did not have a gate belt on nor any transfer equipment in the room . Review of the 1/27/2021 written statement provided by CNA, Staff D revealed that he worked with Staff A on 1/22/2021. Prior to leaving the unit he stated to her that he was taking a break and to not touch anyone while he was gone. During an interview with, CNA/Scheduler, Staff E on 1/26/2021 at 10:04 AM, she stated that multiple staff reported safety concerns to her regarding Staff A, stating that she .does not listen . Staff E stated that she encouraged the staff to report these concerns to the Director of Nursing Services (DON). Review of a 1/27/2021 written statement provided by CNA/Medication Technician, Staff F and subsequent interview on 1/27/2021 at 11:05 AM revealed that Staff A was shadowing her during re-orientation on 1/20/2021. She further stated, . her training consisted of constant reminders to ensure that call bells were in reach . and ensuring that Staff A followed the facility policy regarding 2-staff assistance when using a mechanical lift for transfers. Staff F also stated that Staff E instructed her to go over the orientation checklist with Staff A and that she was .not comfortable signing off her checklist . due to a lack of confidence in Staff A's competency with the tasks on the checklist. In addition, Staff F indicated that while passing medications on Easton's wing in December of 2020 she observed Staff A retrieving the EZ stand lift then entering the room of a resident. She verbally redirected Staff A regarding transferring without another staff then followed her into the room, but Staff A continued with the transfer and replied, .I know what I'm doing .people do it all the time . During an interview with Therapy Leader, Staff G, on 1/27/2021 at 9:30 AM, it was revealed both she and her staff had safety concerns regarding Staff A's transfer techniques. She attempted to reach out to Staff A after the general orientation training on 1/20/2021 for further discussion but was unable to do so. Staff G further stated these concerns were also discussed during therapy staff meetings and weekly risk meetings with nursing management. During a telephone interview with Staff A on 1/27/2021 at approximately 2:00 PM, she stated that she was scheduled to orient with another CNA on 1/22/2021 but instead worked alone with Staff D. She further stated that she did not follow the facility policy, resident care plans and the safe patient handling assessments. She acknowledged that she transferred Resident ID #1 independently without the assistance of a second staff member and without the use of an EZ stand resulting in the resident's fall. Review of the 1/25/2021 hospital Continuity of Care (C.O.C.) Emergency Department documentation revealed, in part: .presents to the ED as a transfer from (hospital name redacted) activated as a level A for [MEDICAL CONDITION] .Left Extremity impression: Displaced fracture distal femoral shaft .R Extremity impression: Comminuted displaced intra-articular fracture distal femur. Comminuted displaced fractures proximal tibia and proximal fibula . Further review of the C.O.C. Discharge Summary documentation revealed, in part: .Discharge Diagnoses: [REDACTED]. and the following [DIAGNOSES REDACTED].acute blood loss [MEDICAL CONDITION], lactic acidosis .patient is not a surgical candidate .this is likely a terminal event .CMO (comfort measures only) status. Hospice referral made . Review of a 1/27/2021 document titled, Nursing Facility 5-Day Investigation Report revealed, in part, After speaking with several staff members it was determined that said CNA attempted to transfer the resident without having a second staff member to assist .on re-orientation due to other infractions . During an interview with DON and the Administrator on 1/27/2021 at approximately 4:00 PM, the DON stated that after the two incidents of unsatisfactory care on the morning of 1/13/2021, Staff A was placed back on orientation for re-training. Furthermore, the DON acknowledged having a discussion with Staff F regarding her concerns while rounding on the floors on the morning of 1/20/2021 but acknowledged that she failed to continue to monitor Staff A's progression during the on-the-job training after this date. Review of the 2/2/2021 Rhode Island Department of Health Office of State Medical Examiners Report revealed the cause of death for this resident was multiple injuries due to a fall. 2) Record review for Resident ID # 2 revealed a Plan of Care, revised on 1/19/2021, revealing the resident is at risk for falls and requires a 2 person manual EZ stand extensive assist to complete his/her ADL's (Activities of Daily Living) . Review of the 11/11/2020 Minimum Data Set (MDS) for this resident revealed in part, .Transfers 2+ person manual EZ stand x 2 with gait belt . Review of a 7/1/2020 document titled, Safe Resident Handing and Movement Assessment and Care Plan, revealed that Resident ID #2 is care planned for a manual stand assuasive device with 2 staff assistance relative to tasks requiring transfers to and from the bed to chair. Review of a 1/13/2021 nursing progress note, written by Charge Nurse Staff B, revealed in part: At 7:15 this morning this writer notified that resident was on the floor. Entered the room to see resident laying parallel to (his/her) bed. Asked what happened and was told by both resident and CNA that (s/he) had slipped and was lowered to the floor. One CNA in the room at the time, resident requires mechanical assistance for transfers, CNAs are aware of this . On 1/27/2021 at 10:51 AM during an interview with Staff B, she stated that on 1/13/2021 she gave a verbal warning to Staff A regarding a fall incident relative to transferring Resident ID #2 alone and not utilizing an assuasive device per the care plan. Review of a 1/13/2021 document titled, Fall Scene Investigation Report, revealed in part, .Root Cause/Post Huddle Review of Contributing Factors/risk . with the following answer selected, .amount of assistance in effect . Further review of this document revealed, .In retrospect, what could have been done differently? 2 person to position + transfer resident . During a telephone interview with Staff A on 1/27/2021 at approximately 2:00 PM, she acknowledged that she failed to follow the care plan for Resident ID #2 and the facility policy regarding transferring a resident with a mechanical lift and utilizing a second staff member for assistance. She acknowledged that this resident fell . During an interview with the DON and the Administrator on 1/27/2021 at approximately 3:00 PM, they acknowledged that Staff A failed to follow the care plan, safe patient handling procedures and the facility's No lift policy for Resident's ID#'s 1 and 2.

Based on record review and staff interview it has been determined that the facility has failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 3 of 3 new hires reviewed related to orientation competency evaluations, Staff A, H and I. Review of the facility policy titled, Facility Operational Manual Orientation On-the Job Training , states in part: .2. Department Supervisors will be responsible for on-the-job training to assure that our established training schedules are followed .3. On-the Job Training begins on the first day of employment and is completed when the Department Supervisor is satisfied that the employee can perform his/her assigned duties .without any further supervision . Review of the employee file for Staff A revealed that she was hired on 11/23/2020. Review of the facility document titled, St.(NAME)Home Job Description/Orientation/Performance Evaluation Certified Nursing Assistant, revealed in part: .Equipment and Supply Functions .Operate all lifts safely and with minimum of two staff .Care Plan and Assessment Functions .follow the individualized care plan for each resident on their assignment and uses the appropriate equipment .uses lift sheets, gait belt, mechanical lifts as necessary and per policy . Further review of this document revealed a section where the employee attests to understanding the functions of the job position and accepts the duties. Both the employee and the Department Director are required to sign this document. Further review of this file revealed a document titled, Checklist of Employee Paperwork, that both the Job description and Orientation sections were not checked off as received. Review of a 1/27/2021 written statement provided by Certified Nursing Assistant/ Certified Medication Technician Staff F, and subsequent interview on 1/27/2021 at 11:05 AM revealed that Staff A was shadowing her during re-orientation on 1/20/2021. She further stated, .her training consisted of constant reminders to ensure that call bells were in reach . and ensuring that Staff A followed the facility policy regarding 2-staff assistance when using a mechanical lift for transfers. In addition, Staff F indicated that while passing medications on Easton's wing in December of 2020 she observed Staff A retrieving the EZ stand lift then entering the room of a resident. She verbally redirected Staff A regarding transferring without another staff then followed her into the room, but Staff A continued with the transfer and replied, .I know what I'm doing .people do it all the time . During an interview with the Director of Nursing (DON) on 1/27/2021 at approximately 3:00 PM, she could not provide evidence of any competency evaluations for Staff A. During a follow-up interview with the Administrator on 1/28/2021 at approximately 4:00 PM, she also could not provide evidence of any competency evaluations for Staff A. Review of the employee file for Staff H revealed that she was hired on 12/14/2020. Review of the employee file for Staff I revealed that she was hired on 12/3/2020. Further review of the employee files for both Staff H and I failed to reveal evidence of any completed competency evaluations. During an interview with the DON on 1/28/2021 at 3:30 PM, she acknowledged that the competency evaluations for Staff H and I were completed on 1/28/2021, after it was brought to her attention by the surveyor.

Based on record review and staff interview, it has been determined that the facility failed to protect the resident's right to be free from abuse and neglect for 2 of 3 residents reviewed, Resident ID#s 3 and 5. Findings are as follows: Review of the facility policy, titled, Abuse Reporting, states in part, .4a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical mental and psychosocial well-being . 1. Record review for Resident ID #3 revealed a revised care plan dated 1//26/2021 indicating that the resident requires a 2 person assist with transfers via his/her personal manual EZ stand (a device used for resident/patient transfers) including from his/her bed or chair to a commode. Further review of this plan of care revealed in part, .Keep call light within reach when in room . Review of a document titled, Employee Disciplinary Report, dated 1/15/2021 for Staff A revealed that on 1/13/2021 at 10:30 AM, a Certified Nursing Assistant (CNA), Staff A, brought Resident ID #3 to the bathroom and left her/him on the toilet in the room for approximately 3.5 hours. Review of the Quarterly and Comprehensive Minimum Data Set Resident Assessment and Care Screenings, dated 12/7/2020 and 9/14/2020 respectively, revealed that this resident scored a 15/15 on a Brief Interview for Mental Assessment, indicating intact cognition. During an interview with Resident ID #3 on 1/27/2021 at approximately 11:00 AM, it was revealed that s/he was sitting on the shower chair waiting for Staff A to return to assist him/her with transferring, yelling out repeatedly for assistance because s/he could not reach the call light. Additionally, observations made during this interview of the call light in the bathroom revealed modifications were made to this call light. Resident ID #3 stated that s/he added an extension making the call light longer as to ensure that this incident does not happen again. During a telephone interview with Staff A on 1/27/2021 at approximately 2:00 PM, she stated that she brought the resident to the bathroom and left him/her on the shower chair on 1/13/2021 from 10:15 AM and did not return to assist with transferring until another CNA assisted her with the transfer in the afternoon. During an interview with Director Of Nursing (DON) on 1/27/2021 at approximately 4:00 PM, she indicated that based on her investigation Resident ID #3 was left on the shower chair in the bathroom for approximately 3.5 hours. The DON stated that her expectation is that staff would not leave a resident on the shower chair for an extended period of time and without access to the call light. 2. Record review revealed on 1/27/2021 at 5:20 AM, a nursing assistant, Staff J, found Resident ID #4 in bed with Resident ID #5 with his/her (ID #5) pants down, fondling him/her private. Review of a 1/27/2021 written statement provided by Staff J indicates that she found Resident ID #4 in Resident ID #5's room with his/her pants down playing with his/her private. Further record review of the nursing progress note dated 1/27/2021 revealed that Resident ID #5 was shook up, crying ., stating, Believe me I did not do anything. I have to make confession now ., while crying and making sign of the cross.Please take (Resident ID #4) from this unit. I am scared . During the interview with the Director of Nursing Services (DON) and the Administrator on 1/28/2021 at approximately 4:00 PM, they acknowledged Resident ID #5 was abused by Resident ID #4.

Based on surveyor observation, record review, and staff interview, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible. This is related to the facility failing to maintain safe water temperatures on 2 of 2 residential floors (1st and 2nd floor) and securing chemicals on 1 of 2 secure dementia units (Bailey's Unit). Findings are as follows: Per the State Operations Manual, for Long Term Care Facilities, (rev. 11-22-17), .Some States have regulations regarding allowable maximum water temperature . According to TITLE 216 - DEPARTMENT OF HEALTH, CHAPTER 40 - PROFESSIONAL LICENSING AND FACILITY REGULATION, SUBCHAPTER 10 - FACILITIES REGULATION, PART 1 - Licensing of Nursing Facilities, .In resident areas, hot water temperatures shall not be less than one-hundred degrees Fahrenheit (100 ºF) nor exceed one-hundred and eighteen degrees Fahrenheit (118 ºF). Thermometers (accuracy of which can be plus or minus two degrees Fahrenheit (±2 ºF)) shall be provided in each residential area to check water temperature periodically on that unit and at each site where residents are immersed or showered . Review of the facility's policy titled, Safe Water Temperature, states in part, .In resident areas, hot water temperatures shall not be less than one-hundred degrees Fahrenheit (100°F) nor exceed one-hundred and ten degrees Fahrenheit (118°F) (sic) (plus or minus two degrees Fahrenheit (±2 °F)) .A log of water temperatures shall be maintained for Quality Assurance purposes. This is kept by the Maintenance Department. 1. The surveyors observed and measured water temperatures on all units on 9/8/2020. The following water temperatures exceeding 120 degrees F were obtained on 9/8/2020 using digital thermometers: Bailey's Unit, 1st floor: -1:13 PM, room [ROOM NUMBER], sink 123.4 °F -1:16 PM, room [ROOM NUMBER], sink 123.3 °F -1:21 PM, room [ROOM NUMBER], sink 124.0 °F -1:24 PM, shared bathroom between rooms 131/130, sink 136.6 °F -1:28 PM, bathroom across from the piano on Sandy Point Unit, sink 133.3 °F -1:32 PM, shared bathroom between rooms 123/122, sink 136.9 °F -2:00 PM, room [ROOM NUMBER], sink 125 °F -2:04 PM, room [ROOM NUMBER], sink 125.2 °F -2:06 PM, room [ROOM NUMBER], sink 123.6 °F -2:08 PM, room [ROOM NUMBER], sink 124.9 °F -2:10 PM, room [ROOM NUMBER], sink 124.3 °F -2:13 PM, room [ROOM NUMBER], sink 124.3 °F -3:31 PM, room [ROOM NUMBER], sink 122.8 °F -3:35 PM, room [ROOM NUMBER], sink 122.5 °F -3:40 PM, room [ROOM NUMBER], sink 122.2 °F -3:40 PM, room [ROOM NUMBER], sink 122.5 °F -3:43 PM, room [ROOM NUMBER], sink 122.0 °F F -3:45 PM, room [ROOM NUMBER], sink 124.2 °F Sandy Point Unit, 1st floor: -1:24 PM, shared bathroom between rooms 131/130, sink 136.6 °F -1:28 PM, bathroom across from the piano on Sandy Point Unit, sink 133.3 °F -1:32 PM, shared bathroom between rooms 123/122, sink 136.9 °F -2:18 PM, room [ROOM NUMBER], sink 124.2 °F -4:05 PM, room [ROOM NUMBER], shower 129.0 °F -4:05 PM, room [ROOM NUMBER], shower 126.0 °F -4:05 PM, room [ROOM NUMBER], shower 127.0 °F Gooseberry Unit, 2nd floor: -1:25 PM, shared bathroom between rooms 238/240, sink 126.2 °F Easton's Unit, 2nd floor: -1:49 PM, room [ROOM NUMBER], sink 123.6 °F -1:53 PM, room [ROOM NUMBER], sink 124.2 °F -1:57 PM, room [ROOM NUMBER], sink 123.8 °F -3:34 PM, room [ROOM NUMBER], sink 122.5 °F -3:36 PM, room [ROOM NUMBER], sink 122.4 °F -3:50 PM, room [ROOM NUMBER], sink 122.5 °F -3:54 PM, room [ROOM NUMBER], sink 122.8 °F -3:56 PM, room [ROOM NUMBER], sink 122.9 °F -4:02 PM, room [ROOM NUMBER], sink 122.0 °F Surveyor observations with the Housekeeping and Maintenance Director on 9/8/2020, revealed that different temperatures were obtained using separate thermometers. At 2:18 PM, the water temperature was measured in the sink of room [ROOM NUMBER]. The surveyor's digital thermometer measured the water at 124.2 °F and the facility's thermometer, General 8:1 infrared thermometer, measured 115 °F. Review of a 9/9/2020, 11:47 AM, email communication from General Tools (manufacturer of the facility's General 8:1 infrared thermometer), in reference to surveyor question if the thermometer can accurately test the temperature of running water, states, This device will not be able to read temperature on running water. It cannot read temperature on transparent or reflective surfaces, and running water has both of those qualities. During a surveyor interview with an alert and oriented, Resident ID #19, on 9/8/2020 at 2:05 PM, s/he revealed that the water has been too hot for months but has not told anyone. During a surveyor interview on 9/8/2020 at 1:54 PM with Staff Nurse B, she revealed that there are residents on the two secure dementia units who utilize the sinks independently. During surveyor interviews on 9/8/2020 at 1:38 PM and 2:16 PM with the Housekeeping and Maintenance Director, she revealed that water temperatures should be no higher than 120°F. Further, she acknowledged that the last time that water temperatures were measured and logged within the facility was on 4/17/2020. During surveyor interviews with the Administrator on 9/8/2020 at 1:47 PM and 3:09 PM, she revealed that water temperatures should not exceed 120 °F and daily water temperatures should be measured at random locations throughout the facility and logged daily by the maintenance department. Additionally, she acknowledged that the water temperatures were last documented by the Maintenance Department on 4/17/2020. 2. Surveyor observations on 9/8/2020 on the Bailey's secure dementia unit revealed the following: -10:39 AM, 11:09 AM, 1:09 PM, and 3:48 PM, room A144, custodian closet, unlocked without staff in sight, containing: a. Ecolab, Oasis 146 Multi-Quat Liquid Sanitizer b. Ecolab, Peroxide Multi Surface Cleaner and Disinfectant c. Ecolab, Oasis 115 XP (floor cleaner) d. 3M Glass Cleaner Concentrate e. 3M Quat Disinfectant Cleaner Concentrate -10:43 AM, 1:10 PM, and 4:20 PM, room A148, laundry room, unlocked without staff in sight, containing: a. Greenex laundry detergent b. (2) Clorox disinfecting Bio Stain and Odor Remover c. Clorox Healthcare Bleach Germicidal wipes During a surveyor interview with Staff Nurse C on 9/8/2020 at 4:20 PM, she revealed that all chemicals should be in a locked area and acknowledged that these two rooms were unlocked. During a surveyor with the Administrator on 9/9/2020 at 8:31 AM, she acknowledged that cleaning products should be secured on the Bailey's Unit when staff not present.