Every finding on record at Stillwater Assisted Living and Skilled Nursing Com

Based on record review and staff interview, the facility failed to provide mandatory in-service training relative to the Quality Assurance and Performance Improvement (QAPI) program that outlines and informs staff of the elements and goals of the program for 3 of 10 staff reviewed; Staff C, D, and E. Additionally the facility failed to provide required in-service training for nurse aides, to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year, including dementia management training and resident abuse prevention for 1 of 5 nurse aides reviewed, Staff F. Findings are as follows:1. Record review failed to reveal evidence mandatory training for QAPI was completed for the following staff within the last year:-Cook, Staff C-Cook, Staff D-Nursing Assistant, Staff EDuring a surveyor interview on 7/3/2026 at approximately 11:00 AM with the Administrator, he was unable to provide evidence that Staff C, D, and E received training for QAPI, as required.2. Record review failed to reveal evidence that any mandatory in-service training was completed by Staff F within the last year. During a surveyor interview on 7/3/2026 at approximately 11:00 AM with the Administrator, he was unable to provide evidence that Staff F completed mandatory in-service training, as required.

Based on clinical record review and staff interview, the facility failed to ensure that medical records for each resident are complete and accurately documented for 2 of 2 resident reviewed who experienced significant medication errors, Resident ID #s 82 and 61.Findings are as follows:1. Record review revealed Resident ID #82 was readmitted to the facility in June of 2026 with a diagnosis of a urinary tract infection with ESBL (extended beta lactamase infection; a multidrug resistant organism that produces enzymes capable of destroying many common antibiotics). Review of a hospital Continuity of Care document dated 6/26/2026 revealed an order for Ertapenem (an antibiotic prescribed to treat serious bacterial infections) intravenously (IV) 500 milligrams (mg) once daily for 8 days for ESBL.Record review of the June 2026 Medication Administration Record (MAR) revealed that the order was transcribed inaccurately for Ertapenem as 1 gram IV daily instead of the intended 500 mg daily, which resulted in the resident receiving double the intended dose, for three days. During a surveyor interview on 7/3/2026 at 1:56 PM, with Registered Nurse, Staff A, she acknowledged that she inaccurately transcribed the order for Ertapenem as 1 gram daily instead of 500 mg daily, as ordered. During a surveyor interview on 7/1/2026 at 3:00 PM, with the Director of Nursing Services (DNS), she acknowledged that the Ertapenem IV order was inaccurately transcribed. 2. Record review revealed Resident ID #61 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, heart failure (a condition when the heart muscle does not pump blood as effectively as it should) and chronic kidney disease.Record review of the physician's orders revealed an order dated 6/22/2026 for Bumetanide 2 mg twice daily every Monday, Wednesday, and Friday for edema (swelling that is caused by excess fluid trapped in the body's tissues), with a stop date of 6/26/2026.Record review of a provider progress note dated 6/26/2026 revealed Resident ID #61 was assessed by his/her physician for fluid volume overload and heart failure symptoms. As a result, the physician ordered an increase to the resident's Bumetanide to 2 mg twice daily and to repeat a basic metabolic panel (a blood test) in one week. Further record review of the June and July 2026 MARs revealed evidence that the order for Bumetanide was transcribed with an inaccurate start date of 7/3/2026, resulting in the resident not receiving Bumetanide on 6/27, 6/28, 6/29, 6/30, 7/1, and 7/2, a total of 12 missed doses.During a surveyor interview on 7/3/2026 at 1:02 PM, with the resident's physician, he indicated that he ordered to increase the Bumetanide to 2 mg twice daily on 6/26/2026 and that he would have expected the new order to start on 6/27/2026. During a surveyor interview on 7/3/2026 at 2:25 PM, with the DNS, she acknowledged that the order for Bumetanide was transcribed inaccurately to start on 7/3/2026 instead of 6/27/2026, as ordered. Cross reference F760

Based on clinical record review and staff interview, the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed receiving the medication Ertapenem (an antibiotic prescribed to treat serious bacterial infections) intravenously (IV), Resident ID #82; and for 1 of 1 resident reviewed receiving the medication Bumetanide (a diuretic prescribed to increase the excretion of urine to help relieve fluid retention), Resident ID #61.Findings are as follows:1. Record review revealed Resident ID #82 was readmitted to the facility in June of 2026 with a diagnosis of a urinary tract infection with ESBL (extended beta lactamase infection; a multidrug resistant organism that produces enzymes capable of destroying many common antibiotics). Review of a hospital Continuity of Care document dated 6/26/2026, revealed an order for Ertapenem 500 milligrams (mg) IV once daily for 8 days for ESBL.Record review of the physician's orders revealed the Ertapenem order was transcribed incorrectly as, Ertapenem 1 gram (which is equal to1000 mg) IV one time a day x 8 days.Record review of the June 2026 Medication Administration Record (MAR) indicated that the Ertapenem 1 gram IV was signed off as administered on 6/27, 6/28 and 6/29/2026, indicating the resident received double the amount of the antibiotic that was ordered.During a surveyor interview on 7/3/2026 at 1:56 PM, with Registered Nurse, Staff A, she acknowledged that she transcribed the order for Ertapenem incorrectly as 1 gram daily instead of 500 mg daily. During a surveyor interview on 7/1/2026 at 3:00 PM, with the Director of Nursing Services (DNS), she revealed that a review of the admission orders should have been completed by the nurse that was working with Staff A to ensure the accuracy of the orders that were transcribed. The DNS further acknowledged that the Ertapenem IV order was transcribed incorrectly, which resulted in the resident receiving the incorrect dose of the antibiotic.2. Record review revealed Resident ID #61 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, heart failure (a condition when the heart muscle does not pump blood as effectively as it should) and chronic kidney disease.Record review of the physician's orders revealed an order dated 6/22/2026, for Bumetanide 2 mg twice daily; every Monday, Wednesday, and Friday for edema (swelling that is caused by excess fluid trapped in the body's tissues), with a stop date of 6/26/2026. Record review of a provider progress note dated 6/26/2026, revealed Resident ID #61 was assessed by his/her physician for fluid volume overload and heart failure symptoms. Further review of the progress note revealed the resident experienced an increase in weight and bilateral (affecting both sides) lower extremity edema. As a result, the physician ordered an increase to the resident's Bumetanide to 2 mg twice daily and to repeat a basic metabolic panel (a blood test) in one week.Record review of a physician's order dated 6/26/2026 for Bumetanide 2 mg twice daily revealed it was incorrectly transcribed with a start date of 7/3/2026. Further record review of the June and July 2026 MARs failed to reveal evidence the order for Bumetanide was initiated on 6/26/2026, indicating that the resident did not receive Bumetanide on 6/27, 6/28, 6/29, 6/30, 7/1, and 7/2, a total of 12 doses.During a surveyor interview on 7/3/2026 at 1:02 PM, with the resident's physician, he revealed that he was unaware that Resident ID #61 had not received his/her Bumetanide since 6/26/2026. Additionally, he indicated that he ordered to increase the Bumetanide to 2 mg twice daily on 6/26/2026 and he would have expected the new order to start on 6/27/2026. During a surveyor interview on 7/3/2026 at 2:25 PM, with the DNS, she acknowledged that the resident was not administered his/her Bumetanide since 6/26/2026, as ordered, and missed a total of 12 doses. Cross reference F842

Based on surveyor observation, clinical record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections related to contact precautions (an infection control intervention designed to reduce the transmission of diseases and infections spread by direct and indirect physical contact, requiring staff to wear a gown and gloves before entering a resident's room) for 2 of 3 residents observed on contact precautions, Resident ID #s 87 and 91.Findings are as follows:Review of an undated facility policy titled, Guidelines for Management of MDROs, states, in part: .MDROs (multi-drug resistant organisms) are increasingly important causes of infection and colonization in long-term care facilities .Placement of the resident: Ideally, a resident on Contact Precautions should be placed in a private room. If a private room is unavailable, the resident may be placed in a room with another resident who has the same microorganism and no other known infection or colonization with a different MDRO .1. Record review revealed Resident ID #87 was admitted to the facility in June of 2026 with diagnoses including, but not limited to, vascular dementia and acute respiratory failure.Record review revealed Resident ID #87 was diagnosed with MRSA (an MDRO strain of bacteria that has developed a resistance to many common antibiotics) in the nares and was placed on contact precautions. Record review revealed the following physician's orders:-6/28/2026 for Contact Precautions requiring staff to wear gowns and gloves upon entering the room and to wear a face mask and eye protection if splashes or sprays were anticipated.-6/28/2026 for Mupirocin 2% external ointment (a medication prescribed to treat bacterial skin infections), to be applied to the nares three times daily for five days for MRSA.2. Record review revealed Resident ID #91 was readmitted to the facility in June of 2026 with diagnoses including, but not limited to, vascular dementia and urinary tract infection.Record review of the census report revealed Resident ID #91 was placed in a room with Resident ID #87 upon his/her readmission to the facility.During surveyor observation on 7/1/2026 at approximately 10:00 AM, Resident ID #91 was observed residing in the same room with Resident ID #87. Additional observation revealed signage posted at the doorway indicating the room was under Contact Precautions.Immediately following the above observation, during an interview with Registered Nurse, Staff B, she stated that she was unsure if Resident ID #91 had MRSA upon readmission, but revealed Resident ID #87 had an established MRSA diagnosis. Clinical record review failed to reveal evidence that Resident ID #91 had a diagnosis of MRSA.Record review of a progress note dated 7/1/2026 at 1:42 PM revealed, education was provided to Resident ID #91's spouse regarding the resident's exposure to his/her roommate who had MRSA. A room change was initiated; Resident ID #91 was being moved to another room and was placed on Contact Precautions due to being exposed to his/her roommate with MRSA.During a surveyor interview on 7/1/2026 at 2:46 PM with the Director of Nursing Services, she revealed that she was informed by the admission Coordinator that the hospital paperwork indicated that Resident ID #91 was positive for MRSA and upon returning to the facility from the hospital on 6/30/2026, s/he was placed in a room with Resident ID #87, who was already on Contact Precautions for MRSA. The DNS further revealed that on 7/1/2026, after the surveyor brought this concern to the facility's attention, the hospital records were reviewed, and the documentation failed to reveal that Resident ID #91 was positive for MRSA upon readmission. The DNS acknowledged that Resident ID #91 should not have been placed in a room with Resident ID #87 who was positive for MRSA.

Based on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 3 residents reviewed relative to physician's orders for laboratory testing, Resident ID #s 1 and 2.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which 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. 1. Record review revealed Resident ID #1 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, a history of acute pulmonary edema (the buildup of fluid in the lungs).Record review of the Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident has intact cognition.During a surveyor interview on 3/2/2026 at approximately 1:30 PM with Resident ID #1 s/he indicated that the facility was giving him/her a fluid pill for swelling in his/her legs, but it has not helped.Record review revealed a physician's order dated 8/10/2025 to obtain a Brain Natriuretic Peptide (BNP- a blood value used to monitor and diagnose heart failure) every second Monday in February and August.Record review of the February of 2026 Medication Administration Record (MAR) revealed the BNP was scheduled to be completed as ordered on 2/9/2026. The order was not signed off as completed in the MAR.Further record review failed to reveal evidence that the BNP was completed as ordered on 2/9/2026.During a surveyor interview on 3/2/2026 at 3:04 PM with the Assistant Director of Nursing Services (ADNS), she acknowledged that the BNP that was ordered to be obtained on 2/9/2026 was not completed. Additionally, she indicated that a physician's order was received to obtain a pro BNP (a blood test that measures a protein released by the heart when it is under stress, that is obtained to diagnose and monitor heart failure) on 3/3/2026, after it was brought to the facility's attention by the surveyor.Record review of a laboratory test provided to the surveyor on 3/3/2026 after exiting the facility revealed a pro BNP level was obtained for resident on 3/3/2025 with a value of 945 picograms per milliliter (pg/ml), a normal range is less than 300 pg/ml.Record review of a progress note dated 3/3/2026 at 2:58 PM authored by Registered Nurse, Staff A, revealed the pro BNP was reviewed with the provider and a new order was obtained for Lasix (a medication prescribed to treat excess fluid), once daily for three days. 2. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 1/26/2026, alleges that Resident ID #2 was hospitalized due to a lack of timely medical intervention by the facility.Record review revealed Resident ID #2 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, hypertension (high blood pressure).Record review of a progress note dated 12/19/2025 at 4:53 PM, authored by the Physician revealed, a new order to obtain a repeat Basic Metabolic Panel (BMP-a blood test used to monitor the body's fluid balance and electrolyte levels) in one week.Record review failed to reveal evidence that the BMP was repeated for Resident ID #2 in one week, as ordered.During a surveyor interview on 3/2/2026 at approximately 3:30 PM with the ADNS, she was unable to provide evidence that the repeat BMP was obtained in one week, as ordered, for Resident ID #2.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare, serve and distribute food in accordance with professional standards for food service safety relative to the main kitchen. Additionally, the facility failed to ensure a certified food protection manager was available during the preparation of all meals. Findings are as follows: 1. Review of the Rhode Island Food Code, 2018 Edition, section 3.501.16 states in part, .Time/Temperature Control for Safety Food, Hot and Cold Holding .shall be maintained at .5 degrees ( ) C [Celsius] (41 Fahrenheit [F]) or less . During surveyor observations of the lunch meal tray service on 3/17/2025 at 11:49 AM in the presence of the Food Service Director (FSD) the following was revealed: - [NAME] bean salad on a tray set in ice, with a cold holding temperature of 53 F. - Turkey salad sandwiches on a tray set in ice, with a cold holding temperature of 49.3 F. Following the above observation, the surveyor asked the FSD if there were any other sandwiches. The following food items and temperatures were then observed in the walk-in refrigerator: - 24 prepared turkey salad sandwiches, with a temperature of 48.9 F. - A four quart container, approximately half filled with turkey salad dated 3/13, with a temperature of 43 F. - A four quart container with egg salad, dated 3/13, with a temperature of 44.2 F. During a surveyor interview on 3/17/2025 at 12:05 PM with the FSD and Cook, Staff F, who had prepared the lunch meal, they acknowledged the above mentioned items were not at the appropriate cold holding temperatures and immediately discarded. During a follow-up visit to the main kitchen on 3/18/2025 at 11:40 AM, the following was observed in the walk-in refrigerator in the presence of the FSD: - A four quart container, approximately 3/4 filled with chicken salad, dated 3/17, with a cold holding temperature of 59.4 F. An additional temperature was obtained using the surveyor's thermometer which indicated the chicken salad was 58.8 F. During a surveyor interview immediately following the observation with the FSD, he was unsure why the prepared chicken salad was not at a cold holding temperature of 41 F or below. 2. Review of the Rhode Island Food Code, 2018 Edition, section 2-102.12, Certified Food Protection Manager states in part, (A) At least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program . During a subsequent tour of the main kitchen on 3/18/2025 at 11:28 AM, surveyor observation failed to reveal evidence of a Food Safety Manager certification for Cook, Staff G. During a surveyor interview with the FSD at the time of the above observation, he indicated that when he reports to work he arrives in the kitchen at 6:00 AM and leaves at approximately 3:30 PM. During a surveyor interview with Staff G, in the presence of the FSD on 3/18/2025 at 1:35 PM, he revealed that his responsibilities as a cook include preparing, cooking, and serving the evening meal. Additionally, he was unable to provide evidence that he has a Food Safety Manager certification, as required. Record review of the kitchen staff schedule from 3/2/2025 through 3/18/2025 revealed that Staff G was the only cook working during the evening meal service on the following dates and times: - Sunday, 3/2/2025, 2:00 PM - 7:30 PM - Tuesday, 3/4/2025, 3:30 PM - 7:30 PM - Wednesday, 3/5/2025, 3:30 PM - 7:30 PM - Thursday, 3/6/2025, 3:30 PM - 7:30 PM - Friday, 3/7/2025, 3:30 PM - 7:30 PM - Monday, 3/10/2025, 4:00 PM - 7:30 PM - Tuesday, 3/11/2025, 4:00 PM - 7:30 PM - Wednesday, 3/12/2025, 3:30 PM - 7:30 PM - Thursday, 3/13/2025, 3:30 PM - 7:30 PM - Saturday, 3/15/2025, 1:45 PM - 7:30 PM - Sunday, 3/16/2025, 2:00 PM - 7:30 PM During a surveyor interview with the FSD on 3/18/2025 at 1:45 PM, he was unable to provide evidence that a certified Food Safety Manager was on the premises during all meal service and preperation on the above-mentioned dates and times. 41729

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, relative to following physician's orders relative obtaining laboratory test panels for 1 of 3 residents receiving Atorvastatin (a medication prescribed to treat high cholesterol, without proper monitoring Atorvastatin can lead to liver and kidney damage), Resident ID #52. Findings are as follows: Record review revealed the MRR dated 12/18/2024 had recommendations made by the pharmacist to consider an annual lipid panel (a blood test that measures the levels of various fats in the bloodstream) and a hepatic function panel (a blood test that assess liver health and function) to monitor for therapeutic effects and side effects of Atorvastatin. Additional review of the report indicated the provider signed in agreement on 1/3/2025. Record review revealed a physician's order dated 1/13/2025, to obtain a laboratory test for the lipid panel and hepatic function panel. Record review failed to reveal evidence that the above-mentioned laboratory tests were obtained. During a surveyor interview on 3/19/2025 at 10:58 AM with the Director of Nursing Services, she was unable to provide evidence that a lipid panel and a hepatic function panel were obtained, as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to respect the residents' right to personal privacy for 1 of 1 resident observed relative to his/her weight, Resident ID #10, and for 1 of 1 resident observed during a wound dressing change, Resident ID #52. Findings are as follows: 1. Record review of a policy titled POLICY/PROCEDURE PRIVACY states in part, .The resident has a right to secure and confidential personal and medical records . Surveyor observations of Resident ID #10 revealed his/her name and weight was posted at the entrance of his/her room, which was visible from the hallway on the following dates and times: - 3/17/2025 at approximately 9:30 AM and 2:00 PM - 3/18/2025 at 9:15 AM During a surveyor interview on 3/18/2025 at 10:11 AM with the Assistant Director of Nursing Services, she acknowledged that Resident ID #10's weight was posted at his/her doorway and visible to anyone who walked by. 2. Additional record review of the policy titled POLICY/PROCEDURE PRIVACY states in part, .Personal privacy includes accommodations, medical treatment . Record review revealed Resident ID #52 was admitted to the facility in October of 2023 with a diagnosis including, but not limited to, pressure ulcer of the left heel, stage 3 (a wound caused by pressure with full-thickness skin loss with damage to subcutaneous tissue without visible bone, tendon, or muscle). During a surveyor observation on 3/18/2025 at 2:37 PM of a wound dressing change to the resident's left heel pressure ulcer, Registered Nurse, Staff A, failed to close the privacy curtain between Resident ID #52 and his/her roommate, prior to starting the wound treatment. During a surveyor interview with Staff A following the above observation, she was unable to provide evidence that the resident's privacy was protected, as the privacy curtain remained open during the wound dressing change. During a surveyor interview on 3/18/2025 at 4:17 PM with the Director of Nursing Services, she revealed that she would expect staff to provide privacy for the residents.

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 relative to 1 of 3 residents reviewed with a wound, Resident ID #66. Findings are as follows: Record review revealed the resident was readmitted to the facility on [DATE] with diagnoses including, but not limited to, a history of a right ankle fracture involving both the middle and the outer ankle bones, which required a surgical procedure involving the removal of the right ankle hardware (surgical screws, plates or rods that hold bones together) and debridement (the process of removing dead, damaged or infected tissue) of wounds. Review of the hospital Continuity of Care document dated 3/5/2025 indicates the resident was readmitted to the facility with right lower extremity wounds. Record review of the facility's Admission Skin assessment dated [DATE], which was completed by Registered Nurse, Staff B, identified that the resident had surgical wounds and that the wound was to be described in detail on the assessment. Additional review of the skin assessment failed to reveal evidence that the resident's surgical wounds were assessed or that a description of the wounds were provided on the assessment. Review of the admission nursing progress note dated 3/5/2025, authored by Staff B, indicated that the resident was readmitted with a dressing to his/her right lower extremity, which was noted to be clean, dry and intact. Further review of the progress note failed to reveal evidence that the right lower extremity wounds were assessed or that a wound treatment was implemented. Record review of the physician's orders failed to reveal evidence of a treatment order for the resident's right lower extremity wounds from his/her admission until 3/7/2025. Further review of the progress notes revealed a note dated 3/7/2025, authored by the Director of Nursing Services (DNS), indicating the resident had multiple wounds to his/her right lateral (outer) ankle, right top of foot, right medial (inner) ankle and a pressure wound (a wound caused by prolonged pressure to an area on the body, usually over a bony prominence) to his/her right heel. Further review of the physician's orders revealed a treatment order dated 3/7/2025 to cleanse the wound daily with wound cleanser and apply Medi-Honey (a wound treatment with antibacterial properties) to the right lateral ankle, right top of foot, right medial ankle, and the right heel pressure wounds, followed by a border gauze dressing. During a surveyor interview on 3/19/2025 at 12:05 PM with Staff B, she revealed that she received in report that the resident had wounds, but was not made aware of any treatments for the wounds. Additionally she acknowledged that the resident had a dressing to his/her right foot which was dated 3/5 and that she did not remove the dressing to assess it, or inquire about any treatment orders. During a surveyor interview on 3/19/2025 at 8:57 AM and 11:44 AM with the DNS, she acknowledged that Staff B failed to assess the resident's right lower extremity wounds upon re-admission to the facility. Additionally, she indicated she would have expected the nurse to have assessed the wounds upon re-admission and obtain treatment orders.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of practice in accordance with physician orders and the comprehensive person-centered care plan, for 1 of 1 resident reviewed receiving antibiotics via a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications), Resident ID #125. Findings are as follows: Review of a facility pharmacy policy titled, IV Site Care and Maintenance Flush Chart, indicates that a 10 milliliter (ml) IV flush with a normal saline solution (a sterile fluid containing salt and water) is required before and after using the PICC line. Additionally, the policy indicates minimum intervals for flushing each lumen (an internal tube within the catheter that allows for the administration of fluids and medications) with 10 ml of saline, every 8 hours and as needed. Record review revealed the resident was admitted to the facility in March of 2025 with a diagnosis including, but not limited to, sepsis due to methicillin resistant staphylococcus aureus (MRSA, a bacterial infection caused by a type of staph bacteria that has become resistant to commonly prescribed antibiotics). Record review revealed the resident had a PICC line placed on 3/6/2025. Record review revealed the resident was receiving Vancomycin (an antibiotic prescribed to treat various infections) solution 1.5 grams intravenously, every 12 hours. Further record review failed to reveal evidence of a physician's order for a 10 ml saline flush, before and after administering the Vancomycin. During a surveyor interview on 3/19/2025 at 1:45 PM with Registered Nurse, Staff C, she acknowledged that the resident did not have an order for a 10 ml saline flush for his/her PICC line before and after administering the Vancomycin antibiotic. During a surveyor interview on 3/19/2025 at 1:36 PM with the pharmacist, from the facility's contracted pharmacy, he revealed that a 10 ml saline flush is indicated before and after administering a medication via the PICC line. Additionally, he indicated that an additional 10 ml saline flush should be administered on the shift that the resident is not receiving the antibiotic.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, relative to a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications) for 1 of 1 resident reviewed with a PICC, Resident ID #125. Findings are as follows: According to the Lippincott Nursing Procedures Ninth Edition (2023), states in part, .Peripherally Inserted Central Catheter Use .Use a sterile measuring tape or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated .Troubleshooting a PICC .if external PICC migration [unintended movement from it's intended position] is greater than 3/4 inches (2 [centimeter] cm), notify the practitioner. Obtain an order for an X-ray or other diagnostic test to confirm tip placement [ensuring that the catheter's tip internally is still located in the optimal place for PICC line use] . Record review revealed the resident was admitted to the facility in March of 2025 with a diagnosis including, but not limited to, sepsis due to methicillin resistant staphylococcus aureus (MRSA, a bacterial infection caused by a type of staph bacteria that has become resistant to commonly prescribed antibiotics). Record review of a document titled, PICC Insertion Record indicated that the resident's PICC line was placed on 3/6/2025 at 4:45 PM. Additionally, the external catheter length measurement (the length of the visible portion of the PICC line outside the body) had a measurement of 0 cm. Record review of a progress note dated 3/13/2025, authored by Registered Nurse (RN), Staff D, revealed that during the dressing change, he obtained an external catheter measurement of 8 cm. During a surveyor interview on 3/19/2025 at 1:25 PM with Staff D, he revealed by demonstration, that he measured the external catheter length from the insertion site on the resident's arm to the beginning of the hub located at the end of the PICC lumen (the internal opening or channel within the catheter tubing that allows for fluids or medications to flow). When asked further about the difference in the external catheter length measurement documented from the day the PICC line was placed, and his documented external catheter measurement obtained on 3/6/2025, he could not explain why the measurement had a difference of 8 cm in length. During a subsequent interview with Staff D, approximately 15 minutes later, he revealed that he had just obtained an additional measurement of the external catheter length and indicated that the measurement is less than 0.5 cm. Staff D acknowledged that he initially measured the external catheter length incorrectly on 3/13/2025 and that he did not review the previous external catheter length measurement prior to obtaining the 3/13/2025 measurement. During a surveyor interview on 3/19/2025 at 1:45 PM with RN, Staff C, when asked how she measures the external catheter length of a PICC line, she was unable to accurately explain how to obtain the measurement of the external catheter length. During a surveyor interview on 3/19/2025 at 2:11 PM with RN, Staff A, when asked how she measures the external catheter length of a PICC line, she was unable to accurately explain how to measure the external catheter length. During a surveyor interview on 3/19/2025 at approximately 3:00 PM with the Nursing Staff Educator, Staff E, she revealed that the external portion of a PICC line has small lines indicating a measurement and that she would expect staff to utilize those lines to measure the external catheter length. 37158

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 2 of 2 kitchenettes observed. Findings are as follows: 1. Record review of Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . During the initial tour of the kitchen in the presence of the Food Service Director (FSD), on 4/8/2024 at 8:15 AM, the following was observed in the main kitchen: - A 1.5-quart pan containing approximately 12 muffins, individually wrapped in plastic wrap, unlabeled and undated in the walk-in freezer - A box with a manufacturer's label of Shells with a use by label of 4/1/2024 in the walk-in freezer - A white pitcher labeled ice coffee with a use by date of 4/7/2024 in the reach in refrigerator During a surveyor interview, immediately following the above observations, the FSD acknowledged the above-mentioned items and indicated they should be discarded. 2. Record review of facility policy titled Food & Nutrition Services revealed in part .Food brought from other sources, such as restaurant leftovers or family home cooking, must be labeled with the residents name, date and will be destroyed upon reaching the 72-hour mark . During a surveyor observation of the 2nd floor kitchenette on 4/8/2024 in the presence of the FSD at approximately 9:07 AM, the following was observed: - A white pitcher labeled juice with use by date of 4/7/2024 - An undated loaf of bread - A container of yogurt with a manufacturer use by date of 3/31/2024 - A large paper plate containing food wrapped in aluminum foil dated 4/1/2024 - A 1.5-quart container of food with a red lid dated 4/3/2024 - A black to-go style container of food undated - A plastic container of food with a purple lid dated 4/4/2024 During a surveyor observation of the 3rd floor kitchenette on 4/8/2024 in the presence of the FSD at approximately 9:25 AM, the following was observed: - 3 undated and unlabeled blue bowls with lids containing dry cereal During a surveyor interview, immediately following the above observations, the FSD acknowledged the above-mentioned items and indicated they should be discarded. 3. Record review of the Rhode Island Food Code, 2018 Edition, section 4-601.11 states in part, .(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT .shall be kept free of encrusted grease deposits and other soil accumulations. (C) NON-FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . During a surveyor observation of the 2nd floor kitchenette on 4/8/2024 in the presence of the FSD at approximately 9:20 AM, the following was observed: - A microwave that was noted to have splattered dried food particles, black and red in color on the inside of the door window along with spots of dried food debris on the glass rotating dish and walls. During a surveyor interview, immediately following the above observations, the FSD acknowledged the above-mentioned microwave needed to be cleaned. 4. The Rhode Island Food Code 2018 Edition 5-202.13 reads in part, .an airgap between the water supply inlet and the flood level rim of the plumbing fixture equipment .shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) . During the initial tour of the main kitchen in the presence of the FSD, on 4/8/2024 at 8:30 AM, revealed the ice machine did not have an air gap twice the diameter of the water supply inlet and 1 inch. Additionally, the drain below the pipe was noted to be overflowing and spilling onto the floor. During a surveyor interview with the FSD on 4/8/2024 immediately following the observation of the ice machine, he acknowledged the ice machine did not have an air gap of at least twice the diameter of the water supply inlet and 1 inch.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a suprapubic catheter (a flexible rubber or plastic tube inserted into your bladder via a surgical opening in the abdomen), Resident ID #1. Findings are as follows: Review of a facility policy titled, Foley Catheters dated 1/16/2024 states in part, .Keep the bag below the resident's waist/bladder . Record review revealed that Resident ID #1 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, obstructive and reflux uropathy (a blockage of urinary flow), and chronic kidney disease stage 3 (mild to moderate damage to the kidneys which may lead to fluid build up). Further record review revealed that the resident has a suprapubic catheter (SP) tube in place. During multiple surveyor observations on 4/10/2024 the resident was observed with his/her drainage bag hung on the back of his/her wheelchair near his/her shoulders above the level of his/her bladder in the common area: - 9:03 AM - 9:25 AM - 9:41 AM - 10:04 AM - 12:16 PM During a surveyor interview on 4/10/2024 at 12:18 PM, with Registered Nurse Staff B, she acknowledged that the resident's drainage bag was hung on the back of his/her wheelchair near his/her shoulders above the level of his/her bladder and that it should be moved below the resident's waist/bladder. During a surveyor interview on 4/10/2024 at 1:39 PM with the Infection Preventionist and Regional Infection Preventionist, they revealed that they would expect the resident's drainage bag to be below the resident's waist/bladder.

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 1 of 3 residents reviewed for the use of insulin, Resident ID #65. Findings are as follows: Record review revealed that Resident ID #65 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, type 2 diabetes mellitus and urinary tract infection. Review of the care plan dated 2/5/2024 revealed that s/he is at increased risk for hypo/hyperglycemia (low or high blood sugar) with an intervention which includes, but is not limited to, administer medication as ordered. Record review revealed a physician's order dated 2/3/2024 for insulin glargine-yfgn (a long-acting type of insulin that works slowly), insulin pen to administer 5 units subcutaneously daily. Review of the Medication Administration Report from 3/20/2024 through 4/10/2024 revealed the follow days the insulin was not administered and was held: - 3/21/2024 - 4/6/2024 - 4/7/2024 - 4/8/2024 Record review failed to reveal evidence of an order to hold the resident's insulin. Record review failed to reveal evidence that the provider was notified that the resident's insulin was held. During a surveyor interview on 4/11/2024 at 8:45 AM with the Nurse Practitioner, he revealed that he would expect the facility to notify him when a resident's insulin is not administered. During a surveyor interview on 4/11/2024 at 9:57 AM with the Assistant Director of Nursing Services, she was unable to provide evidence that the resident's insulin was administered per the physician's order or that the provider was notified that the insulin was held on the above dates.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents observed for wound care, Resident ID #32. Findings are as follows: Record review revealed that the resident was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, pressure-induced deep tissue damage (pressure ulcer) and Methicillin Resistant Staphylococcus Aureus infection (multidrug resistant organism). Record review revealed a physician's order dated 3/26/2024 to cleanse the resident's left posterior calf unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by yellow, tan, gray, green, brown, or black tissue in the wound bed) pressure ulcer with Dakin's (wound cleanser) solution apply skin prep to the area surrounding the wound followed by medi-honey (wound treatment) and alginate (wound treatment) and wrap with kerlix (gauze wrap). The order further revealed to change the dressing every day and as needed. Review of the March and April 2024 Medication Administration Records revealed that the order was to be completed on Monday, Wednesday and Friday, and not daily which resulted in 9 missed dressing changes. During a surveyor interview on 4/10/2024 at 11:27 AM with the Infection Preventionist and the Regional Infection Preventionist, they acknowledged the wound order was transcribed incorrectly for the unstageable wound to the resident's left calf and that it should have been transcribed to be changed daily.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure a resident receives appropriate assistive devices to prevent accidents for 1 of 5 residents reviewed for falls, Resident ID #44. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2024 with diagnoses including, but not limited to, traumatic subdural hemorrhage (a type of bleeding near your brain that can happen after a head injury) with loss of consciousness and down syndrome. Record review of the progress notes revealed the following: - 2/4/2024: The resident was ambulating without assistance in hall outside of day room. S/he leaned over to give a staff member a hug, sustained a loss of balance, resulting in a fall. - 2/24/2024: While in the bathroom with a staff member the resident sustained a fall with a head strike and was sent to the emergency room for evaluation resulting in the resident being readmitted to the hospital. S/he returned to the facility on [DATE]. - 3/17/2024: The resident ambulated with supervision, from unit dining room to bathroom in shower room, the resident washed his/her hands and started walking out of bathroom, s/he leaned backwards and fell on to his/her buttocks, the staff member witnessed fall. - 3/23/2024: S/he sustained a witnessed fall in his/her room. Record review of a document titled, Discharge Summary dated 2/26/2024, revealed the resident had an acute subdural hematoma that had increased in size since his/her prior subdural hematoma diagnosis. Review of an order for safe patient handling dated 2/2/2024, revealed the resident requires one assist for transfers and ambulation with the use of a gait belt. Surveyor observations on the following dates and times failed to reveal evidence that a gait belt was being used during ambulation and transfers with staff to aid in fall prevention: - 4/9/2024 at 1:44 PM - 4/9/2024 at 3:11 PM - 4/9/2024 at 3:38 PM During a surveyor interview with the Director of Rehabilitation on 4/9/2024 at 3:40 PM, she revealed that the resident's safe patient handling is determined by the Rehabilitation Department and communicated with the staff in writing in the following three areas: The facility electronic medical records in Matrix, in a 3-ring binder at the nurses' stations, and on a form that is filled out and hung inside the resident's closet doors. During a surveyor interview on 4/9/2024 at 3:50 PM with Physical Therapist, Staff A, she revealed it is her expectation that the staff would use a gait belt for all transfer and ambulation when assisting the resident. Additionally, she was unable to explain why the staff was not utilizing a gait belt on the above observations with Resident ID #44.

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 3 residents reviewed for antibiotic use, Resident ID #s 124 and 129. Findings are as follows: Review of a facility provided policy titled Antibiotic Stewardship Program states in part, .The antibiotic stewardship program is directed toward the correct use of antibiotic- the five D's -right diagnosis, the right medication, the right dose, the right duration, and the right deceleration . 1. Record review revealed that Resident ID #124 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, urinary tract infection and vascular dementia. Record review revealed a physician's order for Macrobid (an antibiotic) 100 milligram (mg) capsule every 12 hours from 4/2/2024 through 4/10/2024. Record review failed to reveal evidence of a urine culture and sensitivity from the hospital or facility to determine if the antibiotic is still indicated, adjustments should be made, or if the resident was on the correct antibiotic related to the infectious organism. 2. Record review revealed that Resident ID #129 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, urinary tract infection and cough. Record review revealed a physician's order for cefuroxime axetil (an antibiotic) 500 mg tablet every 8 hours from 4/9/2024 through 4/15/2024. Review of the hospital discharge summary dated 4/9/2024, revealed that Resident ID #129 was discharged from the hospital to the facility on cefuroxime axetil for the treatment of a urinary tract infection and pneumonia. Additional review of the hospital documents failed to reveal evidence of a urine culture and sensitivity result. Record review failed to reveal evidence of a urine culture and sensitivity to determine if the antibiotic is still indicated, adjustments should be made, or if the resident was on the correct antibiotic related to the infectious organism. During a surveyor interview on 4/11/2024 at 8:51 AM with the Nurse Practitioner, he revealed that if the resident is on an antibiotic and there are no sensitivities, the staff should either call the hospital to obtain the results or repeat the cultures in house to determine if the resident is on the correct antibiotic or if the antibiotic should be adjusted. During a surveyor interview on 4/11/2024 at 9:28 AM with the Infection Preventionist, she was unable to provide evidence that the facility had a process related to the review of, or obtaining of laboratory or diagnostic testing to determine if the antibiotic is still indicated or adjustments should be made when the resident is new to the facility or when the resident returns or is admitted from the hospital.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent an incident from occurring, for 2 of 5 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: Record review of a facility reported incident submitted to The Rhode Island Department of Health on 12/27/2023, indicated that Resident ID #1 and 2 were roommates and were found touching each other's genitals by a staff member. Record review of Resident ID #1 revealed s/he was admitted to the facility in November of 2023 and was diagnosed with, but not limited to, vascular dementia, unspecified severity, with other behavioral disturbance and mood disorder due to known physiological condition with major depressive-like episode. Additionally, record review revealed a Minimum Data Set (MDS) Assessment that revealed a Brief Interview for Mental Status Score (BIMS) of 99, indicating that the resident was unable to complete the test due to his/her severely impaired cognition. Record review of Resident ID #2 revealed s/he was admitted to the facility in November of 2023 and was diagnosed with, but not limited to, vascular dementia and Alzheimer's disease. Additionally, record review revealed a MDS Assessment that revealed a BIMS score of 00 out of 15 indicating s/he has severe impaired cognition. Record review of a police report revealed that Resident ID #s 1 and 2 were found engaged in sexual behaviors with one another. Additionally, the police report indicated that Resident ID #1 was observed laying in bed and that Resident ID #2 was standing next to the bed with his/her pants down and that both residents were observed touching each other's genitals. Record review of a statement authored by Nursing Assistant, Staff A, dated 12/27/2023, revealed in part, .Both of them was playing with each other private part and they was trying to kiss. During a surveyor interview with the Assistant Director of Nursing on 12/28/2023 at 1:24 PM she was unable to provide evidence that the facility provided Resident ID#s 1 and 2 with adequate supervision to prevent an incident from occurring.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident was free from significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review for Resident ID #1 revealed that s/he was admitted to the facility in August of 2023 with diagnoses including, but not limited to, pain disorder with related psychological factors, vascular dementia with agitation, [NAME] lymphoma (cancer of the immune system involving the lymphatic system), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Record review of the physician's orders revealed the following: -Vimpat (a medication prescribed to treat seizures) 50 milligram (mg) twice per day daily (7:00 AM- 11:00 PM and from 7:00 PM- 11:00 PM) with a start date of 8/25/2023 and an end date of 8/31/2023. -Lasix (a medication prescribed to treat fluid retention and congestive heart failure) 40 mg daily (7:00 AM- 11:00 AM) with a start date of 8/25/2023 and an end date of 8/28/2023. -Tramadol (a medication prescribed to treat moderate to severe pain) 50 mg twice per day with a start date of 8/25/2023 and an end date of 8/28/2023. Record review of the August 2023 Medication Administration Record (MAR) revealed the following: -Vimpat was not administered from 8/25/2023 through 8/28/2023. This resulted in 7 missed opportunities for this drug to be given. -Lasix was not administered on 8/26/2023. This resulted in 1 missed opportunity for this drug to be given. -Tramadol was not administered from 8/25/2023 through 8/27/2023. This resulted in 5 missed opportunities for this drug to be given. During a surveyor interview with the Assistant Director of Nursing on 9/1/2023 at 3:15 PM, she was unable to provide evidence that the resident was given the above medications as ordered by the physician.

Based on record review and staff interview it has been determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice relative to observation and assessment of an access site and comprehensive care plan for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, Nursing facilities .must develop dialysis specific policies/procedures, based upon current standards of practice. This includes the care of a resident receiving dialysis services whether in the facility or at an offsite location .The development and implementation of a coordinated comprehensive care plan(s) that identifies nursing home and dialysis responsibilities and provides direction for nursing home staff; and .The development and implementation of interventions, based upon current standards of practice including, but not limited to documentation and monitoring of complications, pre-and post-dialysis weights, access sites, nutrition and hydration, lab tests, vital signs including blood pressure and medications .Assessing, observing and documenting care of access sites, as applicable, such as: - Auscultation/palpation of the AV fistula (pulse, bruit, and thrill) to assure adequate blood flow - Significant changes in the extremity when compared to the opposite extremity (edema, pain, redness) - Steal Syndrome (pain, numbness, discoloration, or cold to touch in the fingers or hand indicating inadequate arterial flow) - Skin integrity (waxy skin, ulcerations, drainage from incisions - Bruising/hematoma - Collateral vein distension (veins in access arm close to AV fistula becoming larger) - Complaints of pain or numbness - Evidence of infection at the surgical site, such as drainage, redness, tenderness at incision site, fever . Review of the facility provided policy titled Dialysis Patients; Care of states in part, .The thrill and bruit, when applicable, will be checked routinely per MD [Medical Doctor] order .The care plan will reflect the resident's dialysis status and any preferences and choices the resident verbalizes related to dialysis care and treatment. 1a. Record review revealed the resident was admitted to the facility in June of 2023 with a diagnosis of, but is not limited to, chronic kidney disease. Additional record review revealed the resident attends dialysis on Monday, Wednesday, and Fridays and receives the dialysis via an AV fistula (connection of a vein and an artery, usually in the forearm, to allow access to the vascular system for hemodialysis). Record review failed to reveal evidence that the facility was assessing, observing, and documenting the care of his/her access site, such as auscultation/palpation of the AV fistula to assure adequate blood flow since 7/28/2023. During a surveyor interview on 8/30/2023 at 11:58 AM, with Registered Nurse, Staff A, she revealed that the only care she provides to the AV fistula is to check the dressing upon return from dialysis. During a surveyor interview on 8/30/2023 at 1:26 PM with the Director of Nursing Service (DNS) and the Administrator, they were unable to provide evidence that the facility was assessing, observing, and documenting the care of the access site per the regulation since 7/28/2023. 1b. Record review of the resident failed to reveal evidence of the development and implementation of a coordinated comprehensive care plan(s) that identifies nursing home and dialysis responsibilities and provides direction for nursing home staff, the development of interventions, based upon current standards of practice including, but not limited to documentation and monitoring of complications, pre-and post-dialysis weights, access sites, lab tests, vital signs including blood pressure and medications, and assessing, observing and documenting care of access sites. During a surveyor interview on 8/30/2023 at 1:26 PM, with the DNS she was unable to provide evidence that a care plan was initiated per the regulation.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to a norovirus outbreak and COVID-19, Resident ID #'s 2, 4, 6, 11, 16, 21, 29, 33, 37, 43, 47, 51, 60, 65, 70, 132, 135, 136, 137,138, and 238. Findings are as follows: 1. Record review of a facility provided policy titled Isolation states in part, if equipment must be shared remove from the room it must be adequately disinfected before another use . According to the CDC document provided by the facility titled Key Infection Control Recommendations for the control of Norovirus Outbreak [Norovirus is a very contagious virus that causes vomiting and diarrhea] in Healthcare Settings states in part, .disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis .disinfected .using EPA [Environmental Protection Agency]-approved products [products that are approved to kill specific bacteria, viruses, or fungi] . Record review revealed that Resident ID #2 tested positive for Norovirus on 2/15/2023. During surveyor observation from 2/13/2023 through 2/15/2023 of Resident ID #'s 2, 4, 6, 11, 16, 21, 29, 33, 37, 43, 47, 51, 60, 65, 70, 132, 135, 136, 137,138, and 238 rooms revealed isolation carts outside of each room with Micro Kill + wipes and were on precautions related to Norovirus symptoms. During a surveyor observation on 2/15/2023 at 9:04 AM revealed RN, Staff O in Resident ID #132's room with a vital sign machine taking the resident blood pressure and oxygen level. At 9:06 AM Staff O wiped the multiuse equipment with Micro Kill + and then went to the resident roommate and obtained his/her blood pressure with the same machine. Staff, O then obtained an additional multiuse blood pressure cuff and obtained Resident ID #132's blood pressure and stated to the surveyor, the resident's blood pressure was low and was vomiting the prior day. Staff O then exited the room and wiped down the multiuse equipment with Micro Kill + wipes and then gave it back to the other RN Staff, B who placed it on his nurse medication cart. Record review of a cleaner called Micro-Kill + revealed the cleaner kills 13 infectious microorganisms listed in the table in up to 5 minutes. Further review of the Micro Kill + table failed to reveal Norovirus as one the microorganisms listed that the product kills. During a surveyor interview on 2/15/2023 at 9:18 AM with RN, Staff B and RN Staff, O, they acknowledged that the facility uses multiuse equipment and Resident ID #132 was on precautions for norovirus. Additionally, they acknowledge the multiuse equipment is cleaned with the Micro Kill + and all the isolation carts had Micro Kill + on them. Furthermore, they acknowledged Micro Kill + did not list Norovirus as a microorganism killed by the product. During a surveyor interview on 2/15/2023 at 9:26 AM with the Director of Nursing Services and IP they acknowledged the Micro Kill + wipes that were on all the isolation carts and nurses cart failed to kill the norovirus microorganism. During a surveyor observation on 2/16/2023 at 12:02 PM revealed Micro Kill + wipes on the isolation cart outside of Resident ID #132's room. During a surveyor interview on 2/16/2023 with Staff O, she was unsure as to why the Micro Kill + wipes were on the resident isolation cart and removed them from the area. 2. Record review of a facility provided policy titled Isolation states in part, Policy: It is the policy of this facility to prevent the spread of infection within the facility through the use of isolation precautions .Transmission Based precautions- use the CDC [Center for Disease Control and Prevention] guidelines for Isolation Precautions to determine the infective materials, precautions needed, duration of precautions . According to the CDC document provided by the facility titled Key Infection Control Recommendations for the control of Norovirus Outbreak [Norovirus is a very contagious virus that causes vomiting and diarrhea] in Healthcare Settings states in part, .Personal Protective Equipment (PPE) if norovirus infection is suspected, adherence to PPE use according to Contact .Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) . Surveyor observation upon entering the building on 2/13/2023 at approximately 7:50 AM revealed signage on the main door stating the facility was experiencing a gastrointestinal illness. Record review revealed a facility provided document titled, Gastrointestinal Illness Outbreak: Cumulative* Line List for RESIDENTS with a start date of the initial outbreak of 2/6/2023. Record review of contact precaution signs posted on rooms through the facility state in part, Stop .CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown .Clean and disinfect reusable equipment before use on another person. During a surveyor observation on 2/13/2023 at 8:58 AM of Resident ID #70's room revealed signage which states, PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown . Further observation revealed Nursing Assistant (NA), Staff H entering Resident ID #70's room without a gown or gloves on. During surveyor observation on 2/13/2023 at 9:40 AM revealed Resident ID #60's room had an isolation cart outside of the room with Micro Kill + wipes and contact precaution signage. Additionally, the resident was sitting out in common area of unit and was not redirected to return to his/her room. During a surveyor interview immediately following the above mentioned observation with Registered Nurse (RN) Staff D, she revealed that the resident is independent and noncompliant with care. Additionally, she revealed she received report the resident vomited overnight. During a surveyor observation on 2/13/2023 at 9:59 AM of Resident ID #238's room had an isolation cart outside of the room with Micro Kill + wipes and contact precaution signage. Additional observation revealed Nursing Assistant (NA), Staff I in Resident ID #238's room without a gown or gloves on. During a surveyor observation on 2/13/2023 at 10:36 AM of Resident ID #16's room that revealed signage which states, PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown .Two housekeepers Staff J and Staff K were observed taking down the privacy curtain and replacing it with a new one without a gown or gloves on. Further observation revealed Staff J dragging the soiled curtain on the floor down the hallway. During a surveyor interview on 2/13/2023 immediately following the above mentioned observation with Staff K, he acknowledged they did not wear the appropriate PPE in the resident's room. During an additional surveyor observation on 2/13/2023 at 12:16 PM revealed NA, Staff I entering Resident ID #238's room without a gown and gloves. Additionally, during this observation the facility Social Worker entered the room without wearing a gown and gloves. During a surveyor interview immediately following the above mentioned observation with NA, Staff I, she acknowledged the signage outside of the resident's room stated to wear a gown and gloves when entering. Additionally, she revealed she forgot to put on the proper PPE. During a surveyor observation on 2/13/2023 at 12:42 PM revealed NA, Staff L in Resident ID #60's room without gloves or gown on per the signage at the door. During a surveyor interview immediately following the above mentioned observation Staff L acknowledged that the signage on the door indicated the use of gloves and gowns when entering the room and that she did not wear the proper PPE. During a surveyor interview on 2/13/2023 at 2:13 PM with the Infection Preventionist (IP), she revealed her expectation is the staff to wear gloves gown and goggle for resident on precautions. During a surveyor observation on 2/14/2023 at 8:46 AM of Resident ID #16's room revealed signage which states, Stop .CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown . Staff H entered Resident ID #16's room without a gown or gloves on and failed to wash her hands prior to entering or exiting the room. During a surveyor observation on 2/14/2023 at 8:58 AM of Resident ID #6's room revealed signage which states in part, .PROVIDERS AND STAFF MUST ALSO: .Put on gloves .put on gown . Further surveyor observation revealed NA, Staff M entering Resident ID #6's room without a gown or gloves on. During a surveyor observation on 2/14/2023 at 8:50 AM of Resident ID #70's room revealed signage which states, Stop .CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown . NA, Staff H entering Resident ID #70's room without a gown or gloves on and failed to wash her hands prior to entering or exiting the room. During a surveyor interview on 2/14/2023 at 8:53 AM with Registered Nurse (RN) Staff N, she revealed the staff should wear a gown and gloves into each room on contact precautions. During a surveyor observation on 2/14/2023 at 11:25 AM of Resident ID #60, revealed the resident out in the common dining area. Additionally, the contact precaution signage was posted on the resident's door with an isolation cart. During a surveyor observation on 2/16/2023 at 8:08 AM of Resident ID #21's room revealed signage which states in part, Contact Precautions . During a surveyor observation on 2/16/2023 at 8:08 AM revealed Resident ID #21 was sitting in the common area next to another resident. During a surveyor interview on 2/16/2023 at 8:12 AM with RN, Staff D, she acknowledged Resident ID #21 was on precautions related to having loose stool. During a surveyor interview on 2/16/2023 at approximately 1:00 PM with the DNS, she was unable to provide evidence that the staff wore the appropriate PPE and performed hand hygiene per the facility policy and signage. 3. Review of a facility policy titled Testing (and Refusal) of Facility Staff and Residents and a facility provide document titled COVID-19 information for Nursing Homes dated 10/12/2022 revealed in part, Nursing home use empiric transmission based precautions (use of N95, goggles, gown and gloves) to mitigate COVID-19 transmission in order to rule out COVID-19 infection for symptomatic residents (symptoms include fever, diarrhea body aches, cough, head ache). Empiric transmission-based precautions and source control may be discontinued when residents test negative for COVID-19. During the facility entrance conference on 2/13/2023 at 8:12 AM with the Director of Nursing Services, she revealed that there was on positive case of COVID-19 in the facility. Record review revealed that on 2/10/2023: -Resident ID #70 had one episode of vomiting and diarrhea and was on contact precautions. -Resident ID #29 had two episodes of vomiting and was placed on the Norovirus Protocol [orders for labs and medication provided by the medical director]. -Resident ID #238 had four episodes of large loose stools between 7AM-10 AM and has been symptomatic since 2/8/2023. Additional record review failed to reveal evidence that the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/11/2023: -Resident ID #43 had two episodes of diarrhea and was on contact precautions. Additional record review failed to reveal evidence that the above mentioned resident was tested to rule out COVID-19 per the policy. Record review revealed that on 2/12/2023: -Resident ID #16 had one episode of vomiting and was placed on contact precautions. -Resident ID #138 had two loose stools and was started on the Norovirus Protocol. -Resident ID #4 had two episodes of loose stool. -Resident ID #47 had loose stools and vomiting. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/13/2023: -Resident ID #60 had vomited twice and was on precautions. -Resident ID #33 had two episodes of vomiting, who is also the roommate to Resident ID #43, who was initially symptomatic on 2/11/2023. -Resident ID #65 was on contact precautions related to episodes of diarrhea. -Resident ID #136 had complaints of nausea and vomited small amounts of thick vomitus. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/14/2023: -Resident ID #6 had two episodes of diarrhea, who is also the roommate to Resident ID #29, who was initially symptomatic on 2/10/2023. -Resident ID #132 had initial episode of vomiting, who is also the roommate to Resident ID #47, who was initially symptomatic on 2/12/2023. -Resident ID #2 reported nausea and vomiting. -Resident ID #37 had nausea and diarrhea with his/her hospice nurse. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/15/2023: -Resident ID #2 stool sample had resulted positive for Norovirus. -Resident ID #137 progress note revealed s/he has the norovirus, who is also the roommate to Resident ID #138, who was initially symptomatic on 2/13/2023. -Resident ID #11 had one episode of vomiting. -Resident ID #2 roommate Resident ID #51 had episode of vomiting and was placed on precautions. -Resident ID #135 received Ondansetron (a medication used for nausea and vomiting) 4 milligrams on 2/15/2023 at 1:39 AM related to upset stomach. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. Record review revealed that on 2/16/2023: -Resident ID #21 had one large diarrhea. -Resident ID #39 had two episodes of diarrhea. Additional record review failed to reveal evidence the above mentioned residents were tested to rule out COVID-19 per the policy. During a surveyor interview on 2/16/2023 at approximately 1:00 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that residents with symptoms of COVID-19 were tested to rule out infection per their policy. Record review and surveyor observations on 2/16/2023 at approximately 12:00 PM revealed Resident ID #s 132 and 137 were receiving intravenous hydration following signs and symptoms of the norovirus. During a surveyor interview on 2/16/2023 at approximately 1:00 PM with the Director of Nursing Services, she acknowledged the outbreak initially started on 2/6/2023 and was still ongoing on 2/16/2023. Additionally, she was unable to provide evidence the facility provided effective infection control practices to prevent the spread of Norovirus.

Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents relative to transfers for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/2/2022 alleges that on Wednesday 11/23/2022 the family called the resident at 8 AM. The resident revealed something occurred the night prior while in the restroom and his/her right arm hurt. On 11/23/2022, the resident's right arm .lied like a dead fish on that bed all day . The resident was unable to lift it or move it that day. An X-ray was obtained at 7:30 PM and resulted on 11/24/2022, the residents .right arm was broken . Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, unspecified fracture of unspecified lumbar vertebra subsequent encounter for fracture with routine healing (spinal fracture), rheumatoid arthritis, and cognitive communication deficit. Record review revealed a Physical Therapy Treatment Encounter Note(s) dated 11/22/2022 which states in part, .patient will need to be hoyer lift until able to participate safely with functional transfers . Record review revealed a document titled Safe Patient Handling (SPH) Recommendations dated 11/22/2022 which states in part, .Patent requires hoyer lift to ensure safety with functional transfers . Record review of the residents ADL [Activities of Daily Living]: Transfer revealed on 11/22/2022 at 9:34 PM the resident was lifted manually with a 2-person physical assist, documented by Nursing Assistant (NA), Staff B. Record review of the progress notes revealed the following entries: -11/23/2022 at 9:31 AM .complained of pain 9/10 to right upper arm, [s/he] requested and received 5 mg of oxycodone [pain medication] PO [by mouth] prn [as needed] x [times] 1 at this now. -11/23/2022 at 2:57 PM Written order from .RNP [Registered Nurse Practitioner] .X-rays of right upper arm, r/o [rule out] fracture. -11/23/2022 10:50 PM Patient is alert and anxious. Complained of pain with administration of vital signs .X-ray of arm pending . -11/24/2022 7:30 AM Resident is alert and oriented. c/o [complaint of] right arm pain. -11/24/2022 8:53 AM X-ray results of right upper arm .Acute humeral neck fracture and greater tuberosity fractures with moderate displacement . During a surveyor interview on 12/2/2022 at 10:40 AM with Registered Nurse (RN), Staff A, revealed the resident had a history of pain in his/her left arm. Additionally, he revealed the resident was able to move his/her right arm prior to 11/23/2022 and that the right arm was his/her good arm. Furthermore, he revealed the resident was a 2 person assist to transfer with the use of a gait belt prior to 11/22/2022. On 11/22/2022 the resident was changed to a hoyer lift for all transfers. During a surveyor interview on 12/2/2022 at 1:36 PM with Staff B, she revealed that she documented the was resident lifted manually with a 2-person physical assist. She further explained that one NA would hooked the resident under one arm and the other NA would hooked the resident under the other arm and lifted the resident up to transfer. She acknowledged that she did not use a hoyer lift to transfer the resident. During surveyor interviews on 12/2/2022 at 11:24 AM and 1:57 PM with the Director of Nursing Services (DNS), she revealed she would expect staff to follow SPH recommendations for residents' transfers. She acknowledged that the resident's SPH recommendations to be transferred via hoyer lift were not followed on 11/22/2022. Additionally, she acknowledged the resident's x-ray revealed a a right acute humeral neck and greater tuberosity fracture following the transfer on 11/22/2022.

Based on surveyor observation, record review and staff interview, it has been determined that the facility has failed to provide treatment and services consistent with the facility's skin protocol and resident's care plans to promote healing, prevent infection and prevent new ulcers from developing for 1 sample resident (ID # 48). Findings are as follows; The facility's Skin Care Protocol states in part; . For those residents identified as at risk interventions must be carried out in a timely manner. Interventions to consider include, but not limited to the following: Repositioning, . Minimized exposure to moisture; keep resident dry and clean . Record review for resident ID #48 revealed the resident has a [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) dated 7/28/2017 indicates the resident is at risk for skin breakdown due to incontinence, decreased mobility, and wrist splint increased risk of skin breakdown. The resident's current care plan edited on 12/3/2017 indicates s/he is at risk for skin alteration/pressure areas as evidence by limited mobility, incontinence and activity tolerance. The resident has a history of left heel pressure ulcer which also increases the risk at this time. The care plan states; avoid friction and shearing resident's skin during positioning, transferring and turning. The Clinical Documentation-Weekly Skin Integrity Review dated 1/2/2018 indicates the resident's skin condition is intact. Surveyor observation on 1/3/2018 from 8:56 AM to 1:15 PM revealed the resident was sitting in his/her wheelchair. There was no evidence that the resident was assisted with incontinence care or staff assisted with repositioning during this time. During surveyor observation with the unit manager (staff B) on 01/03/2018 at approximately 1:30 PM revealed an open area on the resident's coccyx with slough (dead tissue) on the wound bed. The unit manager stated she was not aware that the resident had developed this pressure ulcer. During subsequent observation on 01/03/2018 at approximately 2:00 PM with the wound nurse (staff A). Wound nurse measured the wound and it was approximately 0.4 x 0.3 x depth not measurable in centimeters. The wound nurse confirmed there is slough on the wound bed and that she was unable to measure the depth of the wound. The wound nurse stated this is an unstageable pressure ulcer and that she was unaware that the resident had developed a pressure ulcer.

Based on surveyor observation, record review, staff and resident interviews, it has been determined that the facility has failed to ensure resident care plans are implemented for 5 of 16 residents relative to weight loss,ID#'s 2,3,4,5,6, 1 of 1 residents relative to strengthening exercises ID#7. Findings are as follows: 1. Resident ID# 2 's care plan dated 6/28/12 to the present specifies the resident is to be weighed per physician orders. Review of the resident's record revealed no orders for weekly weights. However, during an interview with the DNS, he stated the resident should have been weighed weekly. The care plan also specifies staff are to report to the MD and dietician weight changes of 3 plus pounds. Additionally, the resident was to receive a dietary supplement for a dietary intake less than 75 %. Record review revealed the resident was admitted to the facility on [DATE] and weighed 131 pounds. The resident's weight in October of 2012 was noted as 91.5 pounds. Record and interviews with staff revealed no evidence of the above care plan measures being implemented as per the plan of care. 2. Resident ID#3 has a current care plan dated 09/07/2012 to the present time with a stated problem, "at risk for weight loss due to intake less than 25% or less". Approaches to the problem include: monitor and record weight every week and notify physician; Report to charge nurse if resident consumes less than 75 % of her meal; dietary consult and follow up as needed. Record review revealed the resident weighed 100 pounds on 7/20/2012. The resident's weight in August 2012 was recorded as 92.4 pounds for a 9.5% weight loss. Further record review and staff interviews revealed none of the above interventions were implemented. 3. Resident ID# 4 has a current care plan dated 7/27/2012 which specifies the "resident is at high nutritional risk" and "at risk for choking and aspiration due to dysphasia and unintended weight loss due to dementia". The care plan approaches for intervention are as follows: (a) Keep in seated upright with head erect (for swallowing) (b) Offer small bites and wait for swallow. Remind to swallow if needed (c) Assist with all meals (d) Weigh as ordered. Report changes to MD and Dietician (e) Dietician's recommendations of Ensure Plus 10 AM, 2 PM and 8 PM and add Ensure Plus at meal times. Surveyor observations at the noon meal on 10/31/2012 and 11/1/2012 revealed ID# 4 sitting in her wheelchair with her head slouched forward, not eating and with no evidence of staff assistance or encouragement for the resident to eat or drink. The tray of food remained untouched and with no supplement on the meal tray. The facility was unable to provide evidence the resident's care plan was followed. Additionally, record review failed to reveal notification of the dietitian and physician. During surveyor interview on 11/1/2012 at approximately 12:20 PM with the facility's dietitian, she indicated she was unaware that the interventions she and the facility had care planned were not implemented, monitored, evaluated or reported to the dietitian or physician as expected to prevent avoidable weight loss. 4. Resident ID# 5's care plan dated 09/11/2012 to the present time has a stated problem, "shows elevated blood glucose, at risk for worsening and unintended weight loss. As an approach to the problem the plan indicates weight changes of 3 pounds are to be reported to the MD and dietician. On 8/24/2012 the resident weighed 201.4 pounds. Record review revealed the last visit by the dietician was on 09/03/12. On 10/22/2012 the resident weighed 181.2 pounds, a 10% weight loss in three months. There is no evidence of the physician or the dietician being contacted as per the plan of care. 5. Review of resident ID # 6's clinical record revealed a documented weight for 10/2012 of 124.2 pounds, and a documented November weight of 112.5 pounds for a significant weight loss of 9% in one month. The July 2012 dietary plan of care for this resident indicates the resident 's weight is to be monitored. The resident's 04/24/2012 care plan to the present time specifies to continue to monitor the resident's nutritional status. During surveyor interview with the staff nurse and the (DON) Director of Nurses on 11/2/2012 at approximately 2:00 PM, they stated they were unaware of the weight loss for resident ID #' 6. Refer to F157 and F325 which are at a K level. 6. Resident ID#7's care plan dated 5/10/2012 to the present time specifies the resident is to receive strengthening exercises to the resident' right lower extremity. Record review revealed no evidence of strengthening exercised to the resident's right lower extremity. During surveyor interview with the nursing assistant caring for this resident, she stated that she was unaware of any exercises regimen for this resident.

Based on review of the Quality Assurance Program, it has been determined the facility failed to identify issues related to quality assessment activities and failed to develop and implement appropriate plans of action to correct deficiencies. Findings are as follow: Although the facility's Quality Assurance committee meets monthly, there is no evidence that the current deficiencies had been identified and appropriate plans of action had been implemented. REFER TO THE FOLLOWING LEVEL TAGS: F 317, F 325. "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions."

Based on surveyor observation, record review, staff and resident interviews, it has been determined that the facility has failed to ensure resident care plans are implemented for 5 of 16 residents relative to weight loss,ID#'s 2,3,4,5,6, 1 of 1 residents relative to strengthening exercises ID#7. Findings are as follows: 1. Resident ID# 2 's care plan dated 6/28/12 to the present specifies the resident is to be weighed per physician orders. Review of the resident's record revealed no orders for weekly weights. However, during an interview with the DNS, he stated the resident should have been weighed weekly. The care plan also specifies staff are to report to the MD and dietician weight changes of 3 plus pounds. Additionally, the resident was to receive a dietary supplement for a dietary intake less than 75 %. Record review revealed the resident was admitted to the facility on [DATE] and weighed 131 pounds. The resident's weight in October of 2012 was noted as 91.5 pounds. Record and interviews with staff revealed no evidence of the above care plan measures being implemented as per the plan of care. 2. Resident ID#3 has a current care plan dated 09/07/2012 to the present time with a stated problem, "at risk for weight loss due to intake less than 25% or less". Approaches to the problem include: monitor and record weight every week and notify physician; Report to charge nurse if resident consumes less than 75 % of her meal; dietary consult and follow up as needed. Record review revealed the resident weighed 100 pounds on 7/20/2012. The resident's weight in August 2012 was recorded as 92.4 pounds for a 9.5% weight loss. Further record review and staff interviews revealed none of the above interventions were implemented. 3. Resident ID# 4 has a current care plan dated 7/27/2012 which specifies the "resident is at high nutritional risk" and "at risk for choking and aspiration due to dysphasia and unintended weight loss due to dementia". The care plan approaches for intervention are as follows: (a) Keep in seated upright with head erect (for swallowing) (b) Offer small bites and wait for swallow. Remind to swallow if needed (c) Assist with all meals (d) Weigh as ordered. Report changes to MD and Dietician (e) Dietician's recommendations of Ensure Plus 10 AM, 2 PM and 8 PM and add Ensure Plus at meal times. Surveyor observations at the noon meal on 10/31/2012 and 11/1/2012 revealed ID# 4 sitting in her wheelchair with her head slouched forward, not eating and with no evidence of staff assistance or encouragement for the resident to eat or drink. The tray of food remained untouched and with no supplement on the meal tray. The facility was unable to provide evidence the resident's care plan was followed. Additionally, record review failed to reveal notification of the dietitian and physician. During surveyor interview on 11/1/2012 at approximately 12:20 PM with the facility's dietitian, she indicated she was unaware that the interventions she and the facility had care planned were not implemented, monitored, evaluated or reported to the dietitian or physician as expected to prevent avoidable weight loss. 4. Resident ID# 5's care plan dated 09/11/2012 to the present time has a stated problem, "shows elevated blood glucose, at risk for worsening and unintended weight loss. As an approach to the problem the plan indicates weight changes of 3 pounds are to be reported to the MD and dietician. On 8/24/2012 the resident weighed 201.4 pounds. Record review revealed the last visit by the dietician was on 09/03/12. On 10/22/2012 the resident weighed 181.2 pounds, a 10% weight loss in three months. There is no evidence of the physician or the dietician being contacted as per the plan of care. 5. Review of resident ID # 6's clinical record revealed a documented weight for 10/2012 of 124.2 pounds, and a documented November weight of 112.5 pounds for a significant weight loss of 9% in one month. The July 2012 dietary plan of care for this resident indicates the resident 's weight is to be monitored. The resident's 04/24/2012 care plan to the present time specifies to continue to monitor the resident's nutritional status. During surveyor interview with the staff nurse and the (DON) Director of Nurses on 11/2/2012 at approximately 2:00 PM, they stated they were unaware of the weight loss for resident ID #' 6. 6. Resident ID#7's care plan dated 5/10/2012 to the present time specifies the resident is to receive strengthening exercises to the resident' right lower extremity. Record review revealed no evidence of strengthening exercised to the resident's right lower extremity. During surveyor interview with the nursing assistant caring for this resident, she stated that she was unaware of any exercises regimen for this resident.

Based upon record review and staff interview it was determined that the facility failed to ensure that a resident maintain acceptable parameters of nutritional status, such as body weight, for 5 of 16 sample residents (ID's # 2, 3, 4, 5,and 6). Findings are as follows: 1. Review of resident ID # 2's clinical record, who was admitted to facility on 6/15/2012, with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS) on 6/22/2012, show the resident's admission weight of 131 lbs, that the resident needs full staff performance for eating, and has poor appetite. The Care Area Assessment (CAA) Summary reveals the "resident suffers from dysphasia for which she receives a ground diet, and is usually fed by staff due to cognitive impairment." Per dietician current wt 135 lbs and generally eats 75% or more of meals. Additionally the CAA states that she is "at risk for unintentional weight loss" and the facility will care plan to assist maintain her current weight. A 8/18/2012 physician's telephone order specified "Add Ensure Plus 120 cc at 10 AM- 2PM and 8PM." Review of the resident's record reveals the following weights: Admission weight on 6/15/2012 was 131 lbs. Resident's weight on 10/29/2012 was 91.5 lbs, for a significant weight loss of 39.5 lbs (30%) in 4 months. The facility failed to provide interventions for this resident, although she continued to lose weight, the resident was not receiving the ensure plus supplement as ordered, nor was she being assisted with her meal when observed by surveyor. 2. Review of resident ID # 3's clinical record, who was originally admitted to the facility on [DATE], with a re- admission date of [DATE], with [DIAGNOSES REDACTED]. A current care plan dated 9/07/2012 states "at risk for weight loss"; interventions include provide finger foods. Review of the resident's annual MDS on 5/25/2012, reveals a weight of 115 lbs The resident's weight on the July 2012 weight sheet is documented as 100 lbs, on 8/6/2012 the resident's weight is 92.4 lbs, with a re-weight of 90.5 lbs, for a significant weight loss of 9.5 lbs (9.5%) in one month. The facility failed to provide interventions for this resident, the resident was not provided with finger foods as ordered, nor was she followed by the dietitian until brought to the dietitians attention by the survey team. 3. Review of resident ID # 4's clinical record, who was admitted to the facility on [DATE], had a documented admission weight of 110.8 lbs. The resident's weight on 10/8/2012 is documented as 85.8 lbs, for a significant weight loss of 25 lbs (22.5%) in 3 months Review of the dietitian note of 8/3/2012, reveals a weight loss of 17.1 lbs (16%) in 30 days. She recommended to add ensure plus 120 cc three times a day at 10 AM 2 PM 8 PM. On 8/23/2012 a dietitian note reveals the addition of Ensure Plus 120 cc at meals and add fortified foods. Although the resident's record reveal a nurses note dated 8/22/2012 indicated the resident had been receiving 120 cc Ensure Plus three times a day, the resident's (MAR) Medication Administration Record, [REDACTED]. Additionally there was no evidence in the clinical record that the Ensure Plus was administer at meals. Review of the current list of resident' diets provided by the food service director, revealed no evidence that the resident had received the Ensure Plus at meals or the fortified foods. During surveyor observation of the resident on 10/31/2012 and 11/1/2012 the resident was observed with her lunch tray in front of her, not eating, without the supplement on her tray. During interview with the Dietitian on 11/1/2012, at 12:20 PM, the dietitian was unable to provide evidence that the resident had received Ensure Plus with her meal,or the fortified foods. The facility failed to provide interventions to prevent weight loss for resident ID #4, as evidence by the continued weight loss, no re- weights, and failure to implement the recommendations for supplements or fortified foods by the dietitian, nor was the resident assisted with meals per her plan of care. 4. Review of resident ID # 5's clinical record, who was admitted to the facility on [DATE], has diagnosis that include Senile Dementia, Anxiety, Depression and [MEDICAL CONDITION]. He has a documented weight of 201.4 lbs on the September weight record. Further record review revealed a 8/27/2012 physicians order for Ensure Plus 120 cc three times per day. The record lacks evidence it was implemented. The resident's weight on 10/22/2012 is documented as 181.2 lbs, for a 19 lb weight loss, a significant weight loss of 10 % in three months. The facility failed to provide intervention to prevent this residents continued weight loss, as evidenced by the lack of implementation of recommended changes made by the dietitian, and their failure to be aware of the resident's continued weight loss. 5. Review of resident ID # 6's clinical record reveals that the resident has dementia with severe cognitive impairment and dysphasia (difficulty swallowing). During an interview on 11/2/2012, the dieitian stated her weight on 10/1/2012 was 124.2 lbs. A quarterly dietitian evaluation on 7/8/2012 notes the resident generally eats 50-75% of her meals and that her decreased [MEDICATION NAME] level (3.1 on 6/18/2012) suggests mild protein [MEDICAL CONDITION]. Her plan included rechecking the [MEDICATION NAME] and [MEDICATION NAME]. There is no evidence that a quarterly nutritional evaluation was completed in October, nor is there evidence that the lab recommendations were communicated to the physician. On 11/2/2012 at approximately 12:00 PM, the surveyor asked the dietitian to obtain a weight on the resident. She reported her weight to be 112.5 lbs on 11/2/2012, down 11.7 lbs in one month. The dietitian was unable to provide evidence that her recommendation for the labs had been followed up on. She also stated she should have completed a quarterly nutrition evaluation in October 2012. Additionally, after questioning by the surveyor, an [MEDICATION NAME] level was drawn on 11/6/2012, which resulted at a "critically low" level of 2.5. During surveyor interview with the staff nurse on 11/1/2012, when questioned regarding the weight records, and significant weight loss for the above resident's, he was unaware of the significant weight loss as he had not been informed by the staff. He stated that the staff had not informed him when weights are taken and there is a 3 lb gain or loss. Surveyor interviewed the DNS on 11/1/2012 regarding the weights for the above resident's, he informed the surveyor that he was not aware and had not been informed by the staff nurse of the weight loss on these resident's. Additionally he was unable to explain why the staff was not obtaining a re-weight when there was a loss of 3 or more pounds, as per facility policy. He was also unable to explain why the weight loss policy was not being followed regarding the notification of the physician, dietitian and family regarding weight loss. During interview with the dietitian on 11/2/2012 she was unable to explain why she did not follow up on the above resident's with known weight loss, or on her recommendations for supplements, fortified foods, and labs that she had made for these residents. The facility has a dietitian communication book on the nursing units. Review of the communication book failed to reveal any communication to the dietitian for any of the above resident's. During surveyor interview with the DNS on 11/2/2012 he was unaware that the staff was not using the Dietitian Communication book to notify her of changes regarding the resident's weight loss. Surveyor interview with the Administrator on 11/1/2012, at approximately 2:30 PM, revealed he was unaware of the significant weight loss for these resident. He was unable to explain why the recommendations by the dietitian had not been implemented. Additionally when questioned he was unaware that the dietitian had not followed up on these resident's weight loss. The Administrator was also unaware that resident's requiring assistance with meals, and resident's with orders for finger foods, fortified foods and supplements such as ensure were not receiving them. Additionally, when questioned by the surveyor, he was unable to provide evidence that the Quality Improvement Program had identified or was tracking theses issues regarding significant weight loss. Refer to F 224, F 282, F 365, F 514 and F 520.

Based on surveyor observation, record review, and resident and staff interview, it was determined that the facility failed to effectively manage pain for 2 of 10 residents who experience pain, (ID #'s 11 & 7). Findings are as follows: 1. A review of resident ID #11's clinical record reveals the resident has [DIAGNOSES REDACTED]. The annual Minimum Data set, ((MDS) dated [DATE] indicates she has pain frequently. The Care Area Assessment (CAA) Summary dated 9/29/2012 notes, "It is at night that she is in pain...She is at risk for further exacerbation of her pain..." As part of the plan to eliminate this pain, the resident has a physician's orders [REDACTED].) 1 tablet by mouth at bedtime, and [MEDICATION NAME] 5 mg. 1/2 tab (2.5 mg.) every 6 hours, PRN (as needed) for pain. Additionally, she has a physician's orders [REDACTED]. 1 tablet by mouth daily in the morning and 600 mg 1 tablet by mouth at bedtime. Surveyor observation on 11/1/2012 at 10:10 AM at the 2nd floor nurses' station revealed the unit charge nurse on the phone with two different pharmacies inquiring about the delivery of the resident's [MEDICATION NAME]. She was overheard stating, "She's been waiting over a week." In a subsequent interview with the nurse at 11:10 AM, she indicated that she had learned of the delay in obtaining the [MEDICATION NAME] earlier that morning in report. She was attempting to "find out why we don't have it." The nurse further stated that the resident "needs this medication. It's not right." Review of the resident's October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated awaiting pharmacy delivery" on the back of the MAR. Further review of the October MAR indicated [REDACTED]. on 10/2; 10/3; 10/4/2012 and circled initials of [MEDICATION NAME] 600 mg on 10/1; 10/2; 10/3; 10/4; and 10/5/2012. Two different nurses and one medication technician noted on the back of the MAR indicated and "waiting for delivery." When brought to the attention of the Director of Nurses (DNS) by the surveyor on 11/1/2012 at 1:40 PM, he stated that he was unaware of the delivery delay and the resultant missed doses of [MEDICATION NAME]. He stated that it is the responsibility of the nurses administering the medication to facilitate the refill and delivery from the pharmacy and that it is his expectation that the nurses would notify him in the event of any problems or delays in the process. Further review of the resident's MARs for the past six months to present revealed the following omissions in addition to the missed doses in October 2012: July 2012 MAR [MEDICATION NAME] 5 mg bedtime dose not administered on 07/15/2012 through 07/22/2012 (8 missed doses) [MEDICATION NAME] 300 mg morning dose not administered on 7/17/2012 ;07/18/2012 and 07/23/2012,(3 doses) Oxcarbazeoine 600 mg bedtime dose not administered on 07/15/2012 though 07/18/2012 (4 doses) A 07/18/2012 entry on the back of of the MAR indicated . August 2012 MAR [MEDICATION NAME] 5 mg. bedtime dose not administered on 08/5/2012, with no documentation as to why is was not given. Oxcodone 5 mg. bedtime dose not administered on 08/22; 8/23; through 8/28/2012 (7 doses) due to "not available." Surveyor interview with the resident on 11/5/2012 at 9:00 AM revealed that she did not receive her bedtime dose of [MEDICATION NAME] on the previous night, as the nurse told her that it had not been delivered from the pharmacy. She further indicated that she had lower back pain throughout the night, preventing her from sleeping. She stated that she had to get up into her wheelchair during the night in an attempt to alleviate the pain. She stated that her pain is "always there" and that the [MEDICATION NAME] helps reduce the pain significantly, "...especially at night." When questioning the DNS on 11/5/2012 at 10:07 AM about the missed dose of [MEDICATION NAME], he indicated that he had personally driven to the pharmacy on 11/1/2012 to obtain a three day emergency supply (3 pills) of the [MEDICATION NAME] to carry over until the 30 day supply was delivered to the facility. The DNS had no explanation as to why the 30 day supply of the narcotic was not delivered to the facility over the weekend, resulting in another missed bedtime dose on 11/4/2012. The resident's physician was interviewed at 12:50 PM on 11/8/2012. He stated that he was unaware of any missed doses of [MEDICATION NAME] or [MEDICATION NAME]. He further indicated that both medications continue to be necessary for management of this resident's chronic pain. Interview with the Nursing Home Administrator (NHA) and the DNS on 11/8/2012 reveals that they were unaware of the repeated pattern of unavailability of this resident's medications. When brought to the attention of the DNS on 11/1/2012, the facility continued to fail to implement a system to ensure the availability of the resident's pain medications. 2. Review of resident ID # 7's clinical record reveals she has [DIAGNOSES REDACTED]." According to the evaluation, the pain is noted to be 7 out of 10 with movement, and the resident states, "It hurts a lot...The resident's right lower extremity is noted to have impaired range of motion (- 35 degrees extension with painful and tight end feel, arthritic changes noted in joint, hamstrings)." Interview with the resident's nursing assistant (NA) on 11/7/2012 revealed that the resident has right knee pain with transfers. The NA indicated that the nurse was made aware of the resident's pain. Review of the resident's care plan and Medication Administration Records (MARs) for the months of October 2012 and November 2012 failed to accurately identify and address the resident's pain. There is no evidence that this resident was medicated for pain.

Based on record review and staff interview, it was determined that the facility failed to ensure that a resident is free of significant medication errors for 3 of 16 sample residents (ID #s 11, 14 & 15). Findings are as follows: 1. Clinical record review for resident ID # 11 revealed physician's orders [REDACTED].) 1 tablet by mouth at bedtime, and a physician's orders [REDACTED]. 1 tablet by mouth daily in the morning and 600 mg 1 tablet by mouth at bedtime. Review of the July 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. at bedtime on 7/15; 7/16; 7/17; 7/18; 7/19; 7/20; 7/21; 7/22/2012, and 3 missed doses of the [MEDICATION NAME] 300 mg. in the morning on 7/17; 7/18; 7/23/2012; and 4 missed doses of the [MEDICATION NAME] 600 mg at bedtime on 7/15; 7/16; 7/17; and 7/18/2012. Review of the August 2012 MAR indicated [REDACTED]. at bedtime on 8/5; 8/22; 8/23; 8/24; 8/25; 8/26; 8/27; 8/28/2012. Review of the October 2012 MAR indicated [REDACTED]. at bedtime on 10/24; 10/25; 10/26; 10/27; 10/28; 10/29; 10/30; 10/31/2012, and 3 missed doses of the [MEDICATION NAME] 300 mg. in the morning on 10/2; 10/3; and 10/4/2012, and 5 missed doses of the [MEDICATION NAME] 600 mg. at bedtime on 10/1; 10/2; 10/3; 10/4; and 10/5/2012. Review of the November 2012 MAR indicated [REDACTED]. (Refer to F309) 2. Review of the closed clinical record for resident ID # 14 revealed a physician's orders [REDACTED]. Review of the August 2012 MAR indicated [REDACTED]. Review of the September 2012 MAR indicated [REDACTED]. 2. Clinical record review for resident ID # 15 revealed a physician's orders [REDACTED]. by mouth three times per day times 7 days for right arm [MEDICAL CONDITION]. Review of the July 2012 MAR indicated [REDACTED]. When interviewed on 11/5/2012, the Director of Nurses (DNS) was unable to produce evidence that the antibiotics was administered in accordance with the physician's orders [REDACTED].

Based on record review and interviews with staff and family, it was determined the facility failed to immediately inform, the physician, the resident and or the resident's legal representative of a significant change in the resident's physical conditions regarding weight, bruises of unknown origin and medications. The facility failed to notify the physician and the residents legal representative or interested family member for 5 of 16 residents relative to weight loss (ID #'s 2, 3, 4, 5 & 6) , failed to notify for 1 of 15 sample residents relative to bruises of unknown origin (ID # 1), and failed to notify for 1 of 2 sample residents relative to medications (ID # 11). Findings are as follows: 1. Review of resident ID # 2's clinical record, who was admitted to facility on 6/15/2012, had an admission weight of 131 lbs. On 10/29/2012, the residents weight was recorded on the weight sheet as 91.5 lbs, a significant weight loss of 39.5 lbs (30% ) in 4 months. 2. Review of resident ID # 3's clinical record revealed the resident's weight on the July 2012 weight sheet was documented as 100 lbs, on 8/6/2012 the resident's weight is 92.4 lbs, with a re-weight of 90.5 lbs, for a significant weight loss of 9.5 lbs (9.5%) in one month. 3. Review of resident ID # 4's clinical record, who was admitted to the facility on [DATE], had a documented admission weight of 110.8 lbs. The resident's weight on 10/8/2012 is documented as 85.8 lbs, for a significant weight loss of 25 lbs (22.5%) in 3 months. 4. Review of resident ID # 5's clinical record, who was admitted to the facility on [DATE], had a documented weight of 201.4 lbs on the September weight record. The resident's weight on 10/22/2012 is documented as 181.2 lbs, for a 19 lb weight loss, a significant weight loss of 10 % in three months. 5. Review of resident ID # 6's clinical record, had a documented weight for October 2012 of 124.2 lbs, and a documented November weight of 112.5 lbs, a weight loss of 11.7 lbs for a significant weight loss of 9% in one month. During surveyor interview with the staff nurse and the Director of Nursing Services (DNS) on 11/2/2012 at approximately 2:00 PM, they stated they were unaware of the weight losses for resident's ID #'s 2, 3, 4, 5, and 6,who reside on the Dementia unit, and were unable to produce evidence that they had notified the resident's physician's or legal representative of interested family member of the significant weight losses or altered the resident's plan of care. 6. Review of resident ID # 1's clinical record, revealed the resident was admitted on [DATE] and that her initial skin assessment indicated her skin was intact and with no open areas or bruising. Further review of her skin assessments and nurse's notes revealed the following: ? On 8/26/2012 a nurses note documents one bruise "10 centimeters (1/2 inch) in diameter on her right upper thigh". ? On 9/3/2012 the skin assessment noted " bruises on the left and right upper arm, bruise on bridge of nose, bruise on left side of back". ? On 9/21/2012 the skin assessment states "bruise noted to right upper arm, right upper thigh, left upper eye, left temple area, left knee". ? On 10/11/2012 nurses note at 8:55 AM notes " slight bruising to left buttocks yellow- brown in color 2-21/2 inches in diameter. "The resident did not know how it happened". ? On 10/12/2012 the skin assessment states " old bruise on buttock,... slight red mark across lower back". ? On 10/17/2012 at 1:35 PM nurses note " bruise on left upper thigh and three bruises on right outer thigh ... did not look like new bruises. The nursing assistant said they were not there on Monday 10/15/2012". ? On 10/19/2012 the skin assessment states " small old faded bruise on anterior and posterior thigh (upper) on right and left posterior hip area". . The surveyor conducted a telephone interview with ID# 1's family member on 10/23/2012 at 11:45 AM. She informed the surveyor, that she had questioned the nursing staff as to how ID# 1 received the bruises. She further stated the staff could not give her answers, and sometimes they were unaware of her bruises. On 10/23/2012 at 1:45 PM the surveyor reviewed the the facility's incident reports from 8/22/2012 through 10/23/2012. There were no incident reports for ID # 1 for the multiple bruises. On 10/23/2012 at 12:45 PM the surveyor reviewed the facilities abuse policy with the DNS, he acknowledged that the staff failed to follow their procedure of informing and reporting injuries of unknown origin to the Charge nurse, Administrator and DNS and therefore they were unaware and failed to contact the physician and interested family members.. 7. A review of resident ID #11's clinical record reveals on the annual Minimum Data set, ((MDS) dated [DATE] indicates she has pain frequently. The Care Area Assessment (CAA) Summary dated 9/29/2012 notes, "It is at night that she is in pain...She is at risk for further exacerbation of her pain..." As part of the plan to eliminate this pain, the resident has a physician's orders [REDACTED].) 1 tablet by mouth at bedtime, and [MEDICATION NAME] 5 mg. 1/2 tab (2.5 mg.) every 6 hours, PRN (as needed) for pain. Additionally, she has a physician's orders [REDACTED]. 1 tablet by mouth daily in the morning and 600 mg 1 tablet by mouth at bedtime. Surveyor observation on 11/1/2012 at 10:10 AM at the 2nd floor nurses' station revealed the unit charge nurse on the phone with two different pharmacies inquiring about the delivery of the resident's [MEDICATION NAME]. She was overheard stating, "She's been waiting over a week." In a subsequent interview with the nurse at 11:10 AM, she indicated that she had learned of the delay in obtaining the [MEDICATION NAME] earlier that morning in report. She was attempting to "find out why we don't have it." The nurse further stated that the resident "needs this medication. It's not right." a) Review of the resident's October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"awaiting pharmacy delivery" on the back of the MAR. b) Further review of the October MAR indicated [REDACTED]. on 10/2; 10/3; 10/4/2012 and circled initials of [MEDICATION NAME] 600 mg on 10/1; 10/2; 10/3; 10/4; and 10/5/2012. Two different nurses and one medication technician noted on the back of the MAR indicated and "waiting for delivery." c) Further review of the resident's MARs for the past six months to present revealed the following omissions, * July 2012 MAR indicated [REDACTED] * [MEDICATION NAME] 300 mg morning dose not administered on 7/17/2012 ;07/18/2012 and 07/23/2012,(3 doses) * Oxcarbazeoine 600 mg bedtime dose not administered on 07/15/2012 though 07/18/2012 (4 doses) * A 07/18/2012 entry on the back of of the MAR indicated . d) Review of the August 2012 MAR indicated [REDACTED] * [MEDICATION NAME] 5 mg. bedtime dose not administered on 08/5/2012, with no documentation as to why is was not given * [MEDICATION NAME] 5 mg. bedtime dose not administered on 08/22; 8/23; through 8/28/2012 (7 doses) due to "not available." Surveyor interview with the resident on 11/5/2012 at 9:00 AM revealed that she did not receive her bedtime dose of [MEDICATION NAME] on the previous night, as the nurse told her that it had not been delivered from the pharmacy. She further indicated that she had lower back pain throughout the night, preventing her from sleeping. She stated that she had to get up into her wheelchair during the night in an attempt to alleviate the pain. She stated that her pain is "always there" and that the [MEDICATION NAME] helps reduce the pain significantly, "...especially at night." The resident's physician was interviewed at 12:50 PM on 11/8/2012. He stated that he was unaware of any missed doses of [MEDICATION NAME] or [MEDICATION NAME]. He further indicated that both medications continue to be necessary for management of this resident's chronic pain. Interview with the Nursing Home Administrator (NHA) and the DNS on 11/8/2012 reveals that they were unaware of the repeated pattern of unavailability of this resident's medications. When brought to the attention of the DNS on 11/1/2012, the facility continued to fail to implement a system to ensure the availability of the resident's pain medications.

Based on surveyor observation and staff interviews it was determined that although the facility has employed a qualified consulting dietitian, the facility failed to ensure that she and the director of food services function collaboratively in planning, managing and implementing effective dietary programs in meeting the nutritional needs of the residents. This is evidenced by unintended and avoidable weight loss of five residents (ID#s 2, 3, 4, 5 and 6). Findings are as follows: During an interview on 11/1/2012 with the consultant dietitian approximately 11:30 AM in the presence of all the surveyors, she indicated she could not provide answers for nutritional interventions that had not been implemented, monitored, evaluated, and reported as necessary. Additionally, an interview with the director of food services on 11/1/2012 at 1:30 PM and 11/2/2012 at approximately 10:00 AM he indicated that the program relative to " fortified foods " had not been implemented. Refer to 224K, K225, 282K, 325K, 353K, 490K, 501K and 520K.

Based upon record review and staff interview it was determined that the facility failed to ensure that a resident maintain acceptable parameters of nutritional status, such as body weight, for 5 of 16 sample residents (ID's # 2, 3, 4, 5,and 6). Findings are as follows: 1. Review of resident ID # 2's clinical record, who was admitted to facility on 6/15/2012, with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS) on 6/22/2012, show the resident's admission weight of 131 lbs, that the resident needs full staff performance for eating, and has poor appetite. The Care Area Assessment (CAA) Summary reveals the "resident suffers from dysphasia for which she receives a ground diet, and is usually fed by staff due to cognitive impairment." Per dietician current wt 135 lbs and generally eats 75% or more of meals. Additionally the CAA states that she is "at risk for unintentional weight loss" and the facility will care plan to assist maintain her current weight. A 8/18/2012 physician's telephone order specified "Add Ensure Plus 120 cc at 10 AM- 2PM and 8PM." Review of the resident's record reveals the following weights: Admission weight on 6/15/2012 was 131 lbs. Resident's weight on 10/29/2012 was 91.5 lbs, for a significant weight loss of 39.5 lbs (30%) in 4 months. The facility failed to provide interventions for this resident, although she continued to lose weight, the resident was not receiving the ensure plus supplement as ordered, nor was she being assisted with her meal when observed by surveyor. 2. Review of resident ID # 3's clinical record, who was originally admitted to the facility on [DATE], with a re- admission date of [DATE], with [DIAGNOSES REDACTED]. A current care plan dated 9/07/2012 states "at risk for weight loss"; interventions include provide finger foods. Review of the resident's annual MDS on 5/25/2012, reveals a weight of 115 lbs The resident's weight on the July 2012 weight sheet is documented as 100 lbs, on 8/6/2012 the resident's weight is 92.4 lbs, with a re-weight of 90.5 lbs, for a significant weight loss of 9.5 lbs (9.5%) in one month. The facility failed to provide interventions for this resident, the resident was not provided with finger foods as ordered, nor was she followed by the dietitian until brought to the dietitians attention by the survey team. 3. Review of resident ID # 4's clinical record, who was admitted to the facility on [DATE], had a documented admission weight of 110.8 lbs. The resident's weight on 10/8/2012 is documented as 85.8 lbs, for a significant weight loss of 25 lbs (22.5%) in 3 months Review of the dietitian note of 8/3/2012, reveals a weight loss of 17.1 lbs (16%) in 30 days. She recommended to add ensure plus 120 cc three times a day at 10 AM 2 PM 8 PM. On 8/23/2012 a dietitian note reveals the addition of Ensure Plus 120 cc at meals and add fortified foods. Although the resident's record reveal a nurses note dated 8/22/2012 indicated the resident had been receiving 120 cc Ensure Plus three times a day, the resident's (MAR) Medication Administration Record, [REDACTED]. Additionally there was no evidence in the clinical record that the Ensure Plus was administer at meals. Review of the current list of resident' diets provided by the food service director, revealed no evidence that the resident had received the Ensure Plus at meals or the fortified foods. During surveyor observation of the resident on 10/31/2012 and 11/1/2012 the resident was observed with her lunch tray in front of her, not eating, without the supplement on her tray. During interview with the Dietitian on 11/1/2012, at 12:20 PM, the dietitian was unable to provide evidence that the resident had received Ensure Plus with her meal,or the fortified foods. The facility failed to provide interventions to prevent weight loss for resident ID #4, as evidence by the continued weight loss, no re- weights, and failure to implement the recommendations for supplements or fortified foods by the dietitian, nor was the resident assisted with meals per her plan of care. 4. Review of resident ID # 5's clinical record, who was admitted to the facility on [DATE], has diagnosis that include Senile Dementia, Anxiety, Depression and [MEDICAL CONDITION]. He has a documented weight of 201.4 lbs on the September weight record. Further record review revealed a 8/27/2012 physicians order for Ensure Plus 120 cc three times per day. The record lacks evidence it was implemented. The resident's weight on 10/22/2012 is documented as 181.2 lbs, for a 19 lb weight loss, a significant weight loss of 10 % in three months. The facility failed to provide intervention to prevent this residents continued weight loss, as evidenced by the lack of implementation of recommended changes made by the dietitian, and their failure to be aware of the resident's continued weight loss. 5. Review of resident ID # 6's clinical record reveals that the resident has dementia with severe cognitive impairment and dysphasia (difficulty swallowing). During an interview on 11/2/2012, the dieitian stated her weight on 10/1/2012 was 124.2 lbs. A quarterly dietitian evaluation on 7/8/2012 notes the resident generally eats 50-75% of her meals and that her decreased [MEDICATION NAME] level (3.1 on 6/18/2012) suggests mild protein [MEDICAL CONDITION]. Her plan included rechecking the [MEDICATION NAME] and [MEDICATION NAME]. There is no evidence that a quarterly nutritional evaluation was completed in October, nor is there evidence that the lab recommendations were communicated to the physician. On 11/2/2012 at approximately 12:00 PM, the surveyor asked the dietitian to obtain a weight on the resident. She reported her weight to be 112.5 lbs on 11/2/2012, down 11.7 lbs in one month. The dietitian was unable to provide evidence that her recommendation for the labs had been followed up on. She also stated she should have completed a quarterly nutrition evaluation in October 2012. Additionally, after questioning by the surveyor, an [MEDICATION NAME] level was drawn on 11/6/2012, which resulted at a "critically low" level of 2.5. During surveyor interview with the staff nurse on 11/1/2012, when questioned regarding the weight records, and significant weight loss for the above resident's, he was unaware of the significant weight loss as he had not been informed by the staff. He stated that the staff had not informed him when weights are taken and there is a 3 lb gain or loss. Surveyor interviewed the DNS on 11/1/2012 regarding the weights for the above resident's, he informed the surveyor that he was not aware and had not been informed by the staff nurse of the weight loss on these resident's. Additionally he was unable to explain why the staff was not obtaining a re-weight when there was a loss of 3 or more pounds, as per facility policy. He was also unable to explain why the weight loss policy was not being followed regarding the notification of the physician, dietitian and family regarding weight loss. During interview with the dietitian on 11/2/2012 she was unable to explain why she did not follow up on the above resident's with known weight loss, or on her recommendations for supplements, fortified foods, and labs that she had made for these residents. The facility has a dietitian communication book on the nursing units. Review of the communication book failed to reveal any communication to the dietitian for any of the above resident's. During surveyor interview with the DNS on 11/2/2012 he was unaware that the staff was not using the Dietitian Communication book to notify her of changes regarding the resident's weight loss. Surveyor interview with the Administrator on 11/1/2012, at approximately 2:30 PM, revealed he was unaware of the significant weight loss for these resident. He was unable to explain why the recommendations by the dietitian had not been implemented. Additionally when questioned he was unaware that the dietitian had not followed up on these resident's weight loss. The Administrator was also unaware that resident's requiring assistance with meals, and resident's with orders for finger foods, fortified foods and supplements such as ensure were not receiving them. Additionally, when questioned by the surveyor, he was unable to provide evidence that the Quality Improvement Program had identified or was tracking theses issues regarding significant weight loss. Refer to F 282, F 365, F 514 and F 520.

Based on record review and interviews with staff, it has been determined the facility failed to acquire medication to meet the residents needs for 1 of 2 sample residents, ID# 11. Findings are as follows: Record review of the October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated awaiting pharmacy delivery" on the back of the MAR. Further review of the October MAR indicated [REDACTED]. on 10/2; 10/3; 10/4/2012 and circled initials of Oxcarbazepine 600 mg on 10/1; 10/2; 10/3; 10/4; and 10/5/2012. Two different nurses and one medication technician noted on the back of the MAR indicated and "waiting for delivery." When brought to the attention of the Director of Nurses (DNS) by the surveyor on 11/1/2012 at 1:40 PM, he stated that he was unaware of the missed doses of Oxycodone. During a subsequent interview with the DNS on 11/02/2012 he stated that staff should re-order resident's medication 5 days prior to the medication running out.

Based on record review and staff interviews, it was determined the facility failed to timely act upon the recommendations of the consulting pharmacist for 1 of 16 sample residents, (ID #11). Findings are as follows: Review of the clinical record for resident ID#11 revealed a Consultant Pharmacist Medication Regimen Review form dated 09/04/2012 noting the following omissions: Oxcarbazepine 300 mg morning dose not administered on 7/17/2012 ;07/18/2012 and 07/23/2012,(3 doses) Oxcarbazepine 600 mg bedtime dose not administered on 07/15/2012 through 07/18/2012 (4 doses) A 07/18/2012 entry on the back of of the MAR indicated . Oxycodone 5 mg. bedtime dose not administered on 8/5/2012, with no documentation as to why is it was not given. Oxycodone 5 mg. bedtime dose not administered on 8/22; 8/23; 8/24; 8/25; 8/26; 8/27; 8/28/2012 due to "not available." Interview on 11/08/2012 with the consulting pharmacist revealed she has had multiple training's with staff regarding the timely ordering of medications. Additionally, she added that most of the staff that had attended the inservices are no longer employed at the facility. During an interview on 11/08/2012 at 12:00 PM with the DNS, he stated that both he and the administrator receive the pharmacy recommendations each month. After receiving the recommendations, they are passed along to the nurses on each unit for them to act upon. He further stated he was unaware of the pharmacy recommendations for this resident. During a subsequent interview on 11/08/2012 with the Administrator, he stated that he too was unaware of the pharmacy recommendations. He added, "It's clinical, so the DNS handles them".

Based on record review, and staff interviews, it has been determined the facility failed to involve the medical director in identifying, evaluating and addressing medical and clinical concerns and issues that affect resident care, quality care and coordination of medical care in the facility. Findings are as follow: 1. As evidenced by the facility's failure to inform residents' physicians of weight loss as evidenced in F 157 at level K. 2. As evidenced by the facility's failure to prevent neglect as referenced in F 224, with S/S at level K. 3. As evidenced by the facility's failure to report and investigate bruises of unknown origin as referenced in F 225 S/S at level K. 4. As evidenced by the facility's failure to implement policies and procedures relative to reporting and investigating alleged abuse as referenced in F 226 with S/S at level K. 5. As evidenced by the facility's failure to accurately assess a resident relative to pain as referenced in F 278 with S/S at level K. 6 As evidenced by the facility's failure to ensure services by qualified persons in accordance with plans of care as referenced in F 282 with S/S at level K. 7. As evidenced by the facility's failure to provide care/services for residents to achieve or maintain their highest well-being as referenced in F 309 with S/S at level K. 8. As evidenced by the facility's failure to prevent decrease in range of motion as referenced in F 317 with S/S at level G. 9. As evidenced by the facility's failure to maintain residents highest physical well being as referenced in F309 with S/S at level K. 10. As evidenced by the facility's failure to prevent avoidable weight loss as referenced in F325 with S/S at level K. 11. As evidenced by the facility's failure to provide sufficient 24-hr nursing staff as referenced in F 353 with S/S at level K. 12. As evidenced by the facility's failure to provide education and follow up relative to weight loss as referenced in F 361 at level K. 13. As evidenced by the facility's failure to assure medications are acquired in a timely manner for residents as referenced in F425 at level K. 14. As evidenced by the facility's failure to act upon pharmacy recommendations as referenced in F428 at level K. 15. As evidenced by the facility's failure to provide an effective Administration as referenced in F 490 with S/S at level K. 16. As evidenced by the facility's failure to provide an effective Quality Assurance program as referenced in F 520 with S/S at level K.

Based on record review and interview, it was determined that the facility failed to develop and operationalize policies and procedures relative to neglect. The facility failed to keep all residents free from neglect , as evidenced by a pattern of not reporting and investigating bruises of unknown origin for 1 of 15 resident ID # 1, and for 5 of 16 sample residents relative to weight loss for resident's ID #'s 2,3,4,5, and 6. Findings are as follows: 1. Review of the clinical record for ID # 1 revealed the resident was admitted on [DATE] and that her initial skin assessment indicated her skin was intact and with no open areas or bruising. Further review of her skin assessments and nurse's notes revealed the following: On 8/26/2012 a nurses note documents one bruise "10 centimeters (1/2 inch) in diameter on her right upper thigh". On 9/3/2012 the skin assessment noted " bruises on the left and right upper arm, bruise on bridge of nose, bruise on left side of back". On 9/6/2012 nurses note "all bruises are resolving". On 9/7/2012 the skin assessment notes "previous bruise remains". On 9/14/2012 the skin assessment notes "previously noted bruise slightly remains". On 9/21/2012 the skin assessment states "bruise noted to right upper arm, right upper thigh, left upper eye, left temple area, left knee". On 10/7/2012 the skin assessment indicates "resolving bruise on left buttocks, skin very itchy". On 10/11/2012 nurses note at 8:55 AM notes " slight bruising to left buttocks yellow- brown in color 2-21/2 inches in diameter. "The resident did not know how it happened". On 10/12/2012 the skin assessment states " old bruise on buttock,... slight red mark across lower back". On 10/17/2012 at 1:35 PM nurses note " bruise on left upper thigh and three bruises on right outer thigh ... did not look like new bruises. The nursing assistant said they were not there on Monday 10/15/2012". On 10/19/2012 the skin assessment states " small old faded bruise on anterior and posterior thigh (upper) on right and left posterior hip area". During an interview on 10/23/2012 at 10:45 AM, the unit nurse was questioned regarding the facility's policy relative to bruises of unknown origin. She stated that bruises of unknown origin are to be investigated and documented on an incident report, which is given to the Director of Nurses (DNS). The nurse then stated she was unaware of the origin of ID# 1's bruises, nor could she provide evidence that they were investigated. Furthermore, she stated she was unaware of the bruises until brought to her attention by the family. The surveyor conducted a telephone interview with ID# 1's family member on 10/23/2012 at 11:45 AM. She informed the surveyor, that she would question the nursing staff as to how her mother received the bruises and the staff could not give her answers, and sometimes they were unaware of the bruises. On 10/23/2012 at 1:45 PM the surveyor reviewed the facility's incident reports from 8/22/2012 to present. There were no incident reports for ID # 1's multiple bruises. On 10/23/2012 at 12:45 PM the surveyor reviewed the facility's abuse policy with the DNS. He acknowledged that the staff failed to follow their procedure of reporting injuries of unknown origin to the Charge nurse, Administrator and (DNS) Director of Nurses Services. 2. Review of resident ID # 2's clinical record, who was admitted to facility on 6/15/2012, had an admission weight of 131 lbs. On 10/29/2012, the resident's weight was recorded on the weight sheet as 91.5 lbs, a significant weight loss of 30% in 4 months. Further review reveals a dietitian note dated 8/18/2012, which states "recent weight loss of 9%, 10.9 lbs over 90 days, puts resident at increase nutritional risk, goal weight 120 with a plus or minus 5 lbs. Add nutritional supplement to boost calorie/protein/fluid intake." The resident's record contains a physician's telephone order on 8/18/2012 , "Add Ensure Plus 120 cc at 10 AM-2 PM and 8 PM." The order for the Ensure Plus was never instituted and the resident did not receive the supplement as recommended by the dietitian. During surveyor interview with the dietitian on 11/2/2012 at approximately 10 AM, she acknowledged that she did not follow up with her recommendation for the Ensure Plus and was unaware that the resident had not received the supplement and had continued to lose weight. Review of the resident's admission Minimum Data Set (MDS) on 6/22/2012, functional status for eating, states "4 Total dependence, full staff performance. " During surveyor observation on 11/2/2012 at 8:20 AM, resident ID # 2 was observed sitting in her wheelchair in the dining room, and her breakfast tray was set in front of her. The resident continued to sit in her wheelchair with her head down not touching her food. At 9:20 AM the surveyor, requested that another member of the survey team observe resident ID # 2 and her untouched tray of food. At this time the nursing assistant (NA) who was assigned to resident ID # 2, attempted to give her a bite of her oatmeal. The surveyor interviewed the NA who was now attempting to feed the resident, one hour after the breakfast was served. When questioned by the surveyor as to whether he would eat hot cereal one hour after being served, the NA stated he would not. Additional surveyor interview with the NA on 11/2/2012 at approximately 2:30 PM, when questioned as to why he did not assist the resident with her meal, the NA stated that he had other residents to feed and was helping them in the dining room. 3. Review of resident ID # 3's clinical record, who was admitted to the facility on [DATE], had a documented admission weight of 111 lbs. The resident's weight on the July 2012 weight sheet is documented as 100 lbs, on 8/6/2012 the resident's weight is 92.4 lbs, with a re-weight of 90.5 lbs, for a significant weight loss of 9.5 lbs in one month. Review of the dietitian's note dated 8/18/2012, indicates "PO (by mouth) intake poor...weight loss significant decrease 9.5 lbs in 30 days and 24.1 lbs since 5/7/2012." During surveyor interview with the dietitian on 11/2/2012 at approximately 10:30 AM, when questioned regarding the resident's weight loss, she acknowledged that she was unaware of the resident's further weight loss and had not followed up on the resident's weight or nutritional status since 8/18/2012. During surveyor observation of resident ID # 3, on 11/1/2012 at 12:30 PM, the resident was sitting in the dining room, her diet and meal card state finger foods, ground lowfat NAS (no added salt). The resident's lunch was served and contained a ground meatball sandwich, vegetables (carrots, broccoli, and beans) and apple crisp. The resident's sandwich was not cut into pieces, and she was observed by the surveyor trying to break a piece of the sandwich off. On 11/1/2012 at approximately 12:45 PM, the surveyor interviewed the NA in the dining room regarding resident ID # 3's meal, she stated she was unsure of what finger foods were and that the resident does not eat the bread many days. During surveyor interview with the staff nurse on 11/1/2012 at approximately 12:55 PM, when questioned regarding finger foods, he stated that he was "unaware of what finger foods were" and he "thought they were snacks." During surveyor interview with the food service manager on 11/1/2012 at approximately 1:30 PM, when questioned regarding the diet of finger foods that was sent to the unit for resident ID # 3, he stated that his staff should have cut up the resident's sandwich. 4. Review of resident ID # 4's clinical record, who was admitted to the facility on [DATE], had a documented admission weight of 110.8 lbs. The resident's weight on 10/8/2012 is documented as 85.8 lbs, for a significant weight loss of 25 lbs, a 22.5% weight loss in 3 months. Review of the resident's record reveals a dietician note on 8/3/2012 which states, " weight decrease reflects a 16% decrease 17.1 lbs in 30 days, PO intakes reported 25-50% usual, not meeting goal, continues at nutritional risk." The recommendation for Ensure Plus 120 cc at 10 AM, 2 PM, and 8 PM on 8/3/2012, was not implemented until 10/1/2012. A dietitian note on 8/23/2012 shows a further decline in the resident's weight of "4.7 lbs in 30 days". The dietitian's plan was to add additional Ensure Plus 120 cc to breakfast, lunch and dinner, and to try fortified foods for increased calories and protein. When interviewed on 11/1/2012 at approximately 12:20 PM, the dietitian acknowledged that she was unaware that the resident had not been getting the Ensure Plus that she had recommended on 8/3/2012 when she made the additional recommendation for the Ensure Plus at meals, nor was she aware that the resident had not been given fortified foods. Surveyor observation of the resident on 10/31/2012 and 11/1/2012 during the noon meal, revealed the resident sitting in her wheelchair with her head slouched forward not eating with no evidence of staff assistance or encouragement to eat or drink. 5. Review of resident ID # 5's clinical record, who was admitted to the facility on [DATE], had a documented weight of 201.4 lbs on the September weight record. The resident's weight on 10/22/2012 is documented as 181.2 lbs, for a 19 lb weight loss, a significant weight loss of 10 % in three months. Review of the resident's record reveals an order on 8/27/2012 for Ensure Plus 120 cc three times a day, that was never implemented. Further review shows a dietitian note dated 9/3/2012, that stated the resident eats 75% of her meals, and there lacks any further documentation from the dietitian. When questioned regarding the resident's weight loss during surveyor interview with the dietitian on 11/2/2012, the dietician stated she was unaware of the weight loss and that she should have checked. She further stated that she would have changed the plan of care if she was aware of the resident's weight loss. 6. Review of resident ID # 6's clinical record reveals a documented weight on 10/1/2012 of 124.2 lbs, and a documented weight of 112.5 lbs on 11/2/2012, a weight loss of 11.7 lbs for a significant weight loss of 9% in one month. Review of the resident's record reveals a dietitian note on 7/8/2012 which states, "taking Ensure 120 cc at 2:00 PM and 8:00 PM...decreased [MEDICATION NAME] suggests mild protein [MEDICAL CONDITION] rechecking [MEDICATION NAME] and [MEDICATION NAME] and monitor." Further review of the clinical record fails to reveal evidence that the labs were repeated and there is no evidence of a quarterly evaluation, by the dietician, due to be done in October. When interviewed on 11/2/2012 at approximately 1:00 PM, the dietitian stated that she was unaware that the resident had lost weight, and she acknowledged that she failed to assess the resident in October. She was unable to provide evidence that the recommended lab tests were completed. During surveyor interview with the nurse on the 3rd floor and the DNS on 11/2/2012 at approximately 2:00 PM, they stated they were unaware of the weight losses for residents ID #'s 2, 3, 4, 5, and 6 and were unable to produce evidence that they had notified the residents' physicians or legal representative or interested family member of the significant weight losses or altered the residents' plan of care. The facility failed to prohibit mistreatment, neglect and abuse of the residents as evidenced by the above systems failures. These failures resulted in Immediate Jeopardy.

Based on record review and staff interview, it was determined that the facility failed to report injuries (bruises) of unknown origin for 3 of 10 sample residents (ID #1, ID# 10, and ID# 16). Findings are as follows: Review of a Complaint submitted to the Department of Health (DOH) dated 10/10/2012 indicated that sample resident ID# 1 had bruises of unknown origin on multiple occasions and the staff were unaware of how the resident received them. 1). Review of the ID# 1's clinical record revealed the resident was admitted on [DATE] and that her initial skin assessment indicated her skin was intact and with no open areas or bruising. Further review of her skin assessments and nurse's notes revealed the following: a). On 8/24/2012 and 8/31/2012 skin assessments reveal " no skin issues". b). On 8/26/2012 a nurses note documents one bruise "10 centimeters (1/2 inch) in diameter on her right upper thigh". c). On 9/3/2012 the skin assessment noted " bruises on the left and right upper arm, bruise on bridge of nose, bruise on left side of back". d). On 9/6/2012 nurses note "all bruises are resolving". e). On 9/7/2012 the skin assessment notes "previous bruise remains". f). On 9/14/2012 the skin assessment notes "previously noted bruise slightly remains". g). On 9/21/2012 the skin assessment states "bruise noted to right upper arm, right upper thigh, left upper eye, left temple area, left knee". h). On 10/7/2012 the skin assessment indicates "resolving bruise on left buttocks, skin very itchy". i). A 10/11/2012 nurses note at 8:55 AM notes " slight bruising to left buttocks yellow- brown in color 2-21/2 inches in diameter. "The resident did not know how it happened". j). On 10/12/2012 the skin assessment states "old bruise on buttock,... slight red mark across lower back" k). On 10/17/2012 at 1:35 PM nurses note " Husband asked me to look at bruises on wife. Bruise on left upper thigh and three bruises on right outer thigh ... did not look like new bruises. The nursing assistant said they were not there on Monday 10/15/2012". l). On 10/19/2012 the skin assessment states " small old faded bruise on anterior and posterior thigh (upper) on right and left posterior hip area". During an interview on 10/23/2012 at 10:45 AM, the unit charge nurse was questioned as to what the facility's policy and procedure was relative to bruises of unknown origin . The nurse stated that when bruises of unknown origin are discovered, the facility's policy is to fill out an " Incident Report " and forward it to the Director of Nursing Services (DNS). The nurse indicated that the DNS keeps these reports in his office. Additionally, other staff nurses indicated that they did not know the origin of ID# 1's bruises, nor could they produce any evidence that they investigated the origin of the bruises. There is no evidence that the staff followed the above process. The surveyor conducted a telephone interview with ID# 1's family member on 10/23/2012 at 11:45 AM. She informed the surveyor , that she would question the nursing staff as to how ID# 1 received the bruises and the staff could not give her answers, and sometimes they were unaware of her bruises. On 10/23/2012 at 1:45 PM the surveyor reviewed the the facility's incident reports from 8/22/2012. There were no incident reports for ID # 1 for the multiple bruises. During surveyor review of the facilities abuse policy with the DNS, he acknowledged that the staff failed to adhere to the facilities policies relative to investigation and reporting injuries of unknown origin. During an additional interview with the DNS at 3:45 PM , he acknowledged that he did not investigate or report any of these bruises of unknown origin for ID# 1 as he was unaware of them. 2). Review of ID #10's clinical record including weekly skin assessments and nurse's notes from 9/3/2012 through 10/25/2012 revealed the following: a). On 9/3/2012 the skin assessment states "skin tear on right elbow - therapy in place" b). On 9/6/2012 the skin assessment states "skin tear on right elbow -band-aid in place" c). On 9/13/2012 the skin assessment states "...skin tear to right forearm, multiple old bruises to bilateral forearms..." d). On 10/4/2012 the skin assessment states " both arms has old yellow looking bruises" e). 10/11/2012 the assessment notes "multiple old bruise to bilateral arm..." f). On 10/16/2012 a nurses note indicates " at 6:30 PM during care, the nursing assistant noticed a skin tear on the resident's left upper arm." g). On 10/18/2012 the skin assessment states "some old bruise to both arms" h). On 10/25/2012 the skin assessment states " left and right extremities have old bruises" During an interview on 11/2/2012 at 8:20 AM with the DNS, he was unable to provide evidence that the facility had investigated and reported bruises / injuries of unknown origin for ID# 10. 3). Review of ID #16's clinical record including telephone orders from 9/3/2012 through 10/25/2012 revealed the following: a). On 7/27/2012 a telephone order states " cleanse skin tear on right elbow with normal saline. Apply [MEDICATION NAME] and bandage daily and as needed (prn) until resolved." b). On 8/8/2012 a telephone order states "Skin tear (2), to right elbow with normal saline, apply Dermoned discontinued, change daily(qd) until resolved c). On 8/16/ 2012 a telephone order states "normal saline left elbow skin tear f/b medi honey, dry dressing, change daily and as needed(PRN till resolved" These injuries and bruises of unknown origin for ID# 16 have no evidence of being investigated or being reported as required by State law.

Based on record review and staff interview it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for 3 residents ID#'s 1,6 & 10. The facility also failed to provide in service education relative to training and prevention. Findings are as follows: The facility's policy entitled : Resident Rights/Abuse and/or Resident Neglect indicates: Definitions as follows: Abuse indicates , but is not limited to......unexplained bruises. Procedure: Anyone who witnesses and or suspects an incident of resident abuse is to report to the Charge Nurse, DNS or the Administrator immediately Charge Nurse to document on incident and report form in nurses' notes. A review of the records for ID#'s 1, 6 & 10 reveal on several occasions the residents sustained injuries/bruises of unknown etiology. Further review of these records and interviews with staff revealed no evidence of these injuries/bruises being reported to the Charge Nurse, DNS or Administrator. Additionally, there is no evidence of any incident report in the residents' records and no evidence of any investigation of these injuries/bruises or report to the State Agency. Training and Prevention: A review of the facility's training for employees relative to Abuse/neglect/mistreatment revealed no evidence of in-service training for newly hired employees. During surveyor interview on 10/31/2012 at approximately 10:30 AM, with the charge nurse on the third floor, who was hired in September 2012, he informed the surveyor that he had not received any in-service training on abuse and neglect upon hire. Refer to F 225 K

Based on record review and staff interview it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for 3 residents ID#'s 1,6 & 10. The facility also failed to provide in service education relative to training and prevention. Findings are as follows: The facility's policy entitled : Resident Rights/Abuse and/or Resident Neglect indicates: Definitions as follows: Abuse indicates , but is not limited to......unexplained bruises. Procedure: Anyone who witnesses and or suspects an incident of resident abuse is to report to the Charge Nurse, DNS or the Administrator immediately Charge Nurse to document on incident and report form in nurses' notes. A review of the records for ID#'s 1, 6 & 10 reveal on several occasions the residents sustained injuries/bruises of unknown etiology. Further review of these records and interviews with staff revealed no evidence of these injuries/bruises being reported to the Charge Nurse, DNS or Administrator. Additionally, there is no evidence of any incident report in the residents' records and no evidence of any investigation of these injuries/bruises or report to the State Agency. Training and Prevention: A review of the facility's training for employees relative to Abuse/neglect/mistreatment revealed no evidence of in-service training for newly hired employees. During surveyor interview on 10/31/2012 at approximately 10:30 AM, with the charge nurse on the third floor, who was hired in September 2012, he informed the surveyor that he had not received any in-service training on abuse and neglect upon hire.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that the resident's assessment accurately reflects the resident's status for 2 of 16 residents, (ID#s 11 & 7) regarding pain. Findings are as follows: 1. Review of resident ID # 11's clinical record reveals the resident's [DIAGNOSES REDACTED]. The annual Minimum Data set, ((MDS) dated [DATE] indicates she has pain frequently. The Care Area Assessment (CAA) Summary dated 9/29/2012 notes, "It is at night that she is in pain...She is at risk for further exacerbation of her pain..." The patient's pain regimen includes standing and PRN (as needed) orders for [MEDICATION NAME] (a narcotic), Tylenol and [MEDICATION NAME]. In separate interviews on 11/7/2012 with the resident's attending physician, the Director of Nurses (DNS), and two nurses who care for the resident, all indicate that the resident has frequent pain and that it "peaks" at various times, especially at night. Review of the resident's daily pain assessments on the October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"0" (no pain). Upon questioning the DNS on 11/7/2012 at 9:00 AM about the use of pain medication and the frequent assessments of "0" on the MARs, he acknowledged that the assessments are not accurate and do not reflect the resident's pain. 2. Review of resident ID#7's clinical record reveals the resident has a [DIAGNOSES REDACTED]. also reveals that the resident describes the intensity of her right knee pain as a 7 out of 10 and that "it hurts a lot" when she stands. When interviewed on 11/7/2012 at 8:20 AM, the resident's nursing assistant stated that the resident has pain with transfers and that nursing had been informed. Interview with the physical therapist on 11/7/2012 at 8:25 AM reveals that the resident has pain with transfers and extension of her right leg and that she has been receiving therapy since 10/15/2012 secondary to pain and decreased range of motion of her right lower extremity. Although the physical therapist and the nursing assistant were aware of this resident's pain, the nurses' pain assessments are consistently noted to be "0" for the resident's pain. Refer to F309

Based on staff interviews and surveyor observations, it has been determined the facility failed to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans for care for residents on 2 of 2 units. Findings are as follows: A review of the list relative to most recent hires in the facility revealed that since March of 2012 to the present time there have been 34 new employees (nurses and nursing assistants) hired for this facility. Additionally from 1/2012 to the present time, there have been 55 terminations (nursing & nursing assistants). A review of the training relative to the special care unit (dementia unit), revealed that newly hired staff have not received the necessary training relative to residents with dementia care. Refer to tags F157 K, F 224 K, F225 K , F226 K, F309 K, F333 K, F425, F428

Based on review of the Quality Assurance Program, it has been determined the facility failed to identify issues related to quality assessment activities and failed to develop and implement appropriate plans of action to correct deficiencies. Findings are as follow: Although the facility's Quality Assurance committee meets monthly, there is no evidence that the current deficiencies had been identified and appropriate plans of action had been implemented. REFER TO THE FOLLOWING K LEVEL TAGS: F 157, F 224, F 225 , F 226, F 278, F 282, F 309, F 317, F 325, F 333, F 353, F 361, F 425, F 428, F 490, and F 501. "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions."

Based on record review and staff interview, it has been determined the facility is not administered in a manner that enables it to use its resources effectively and maintain the highest practicable physical and mental well-being of each resident. The failure of the facility resulted in immediate jeopardy. Findings are as follow: 1. As evidenced by the facility's failure to inform residents' physicians of weight loss as evidenced in F 157 at level K. 2. As evidenced by the facility's failure to prevent neglect as referenced in F 224, with S/S at level K. 3. As evidenced by the facility's failure to report and investigate bruises of unknown origin as referenced in F 225 S/S at level K. 4. As evidenced by the facility's failure to implement policies and procedures relative to reporting and investigating alleged abuse as referenced in F 226 with S/S at level K. 5. As evidenced by the facility's failure to accurately assess a resident relative to pain as referenced in F 278 with S/S at level K. 6 As evidenced by the facility's failure to ensure services by qualified persons in accordance with plans of care as referenced in F 282 with S/S at level K. 7. As evidenced by the facility's failure to provide care/services for residents to achieve or maintain their highest well-being as referenced in F 309 with S/S at level K. 8. As evidenced by the facility's failure to prevent decrease in range of motion as referenced in F 317 with S/S at level G. 9. As evidenced by the facility's failure to maintain residents highest physical well being as referenced in F309 with S/S at level K. 10. As evidenced by the facility's failure to prevent avoidable weight loss as referenced in F325 with S/S at level K. 11. As evidenced by the facility's failure to provide sufficient 24-hr nursing staff as referenced in F 353 with S/S at level K. 12. As evidenced by the facility's failure to provide education and follow up relative to weight loss as referenced in F 361 at level K. 13. As evidenced by the facility's failure to assure medications are acquired in a timely manner for residents as referenced in F425 at level K. 14. As evidenced by the facility's failure to act upon pharmacy recommendations as referenced in F428 at level K. 15. As evidenced by the facility's failure to provide an effective Medical Director as referenced in F 501 with S/S at level K. 16. As evidenced by the facility's failure to provide an effective Quality Assurance program as referenced in F 520 with S/S at level K.

Based on surveyor observation, record review and interview with staff , it has been determined that the facility failed to ensure that residents entering the facility without a limited range of motion, do not experience reduction in range of motion unless the resident's clinical condition demonstrates that this was unavoidable for 1 of 1 pertinent residents, ID #7. Findings are as follows: A review of the 1/31/20/12, Admission Assessment for Resident ID # 7 indicates the resident has no loss in range of motion for upper and lower extremities. A review of the 07/26/2012 quarterly assessment indicates no loss of range of motion of both upper and lower extremities. A review of the resident's 05/10/12 current care plan to the present time has a stated problem, need to improve ambulation ability. As an approach to the problem the care plan specifies that the resident is to receive strengthening exercises to the resident's right lower extremity. A review of a 10/15/2012 Physical Therapy Evaluation and Plan of Treatment indicates the resident was referred to physical therapy due to an exacerbation of arthritis of the right knee with increased pain and decreased range of motion which is affecting functional transfers and wheelchair mobility. The assessment further indicates "Patient was performing transfers and bed mobility with minimal assistance; and able to self propel wheelchair with support on unit prior to recent onset of pain right knee,and decline in function. Further review of the physical therapy assessment indicates the resident now with a minus 35 degree loss in range of motion to the right lower extremity. Review of the resident's record reveals no evidence of the resident receiving strengthening exercises. Review of the Nursing Assistant's Information Sheet, list no information regarding exercises for this resident. During an interview on 11/07/2012 with the nursing assistant caring for the resident, she informed the surveyor that she does not perform exercises with the resident as she was unaware the resident was to receive exercises. During a subsequent interview with the DNS on the same date, he stated that the resident should have been receiving range of motion exercises daily by staff as per the plan of care. The facility was unable to provide evidence of any strengthening exercises for this resident.

Based on surveyor observation, record review and interview with staff , it has been determined that the facility failed to ensure that residents entering the facility without a limited range of motion, do not experience reduction in range of motion unless the resident's clinical condition demonstrates that this was unavoidable for 1 of 1 pertinent residents, ID #7. Findings are as follows: A review of the 1/31/20/12, Admission Assessment for Resident ID # 7 indicates the resident has no loss in range of motion for upper and lower extremities. A review of the 07/26/2012 quarterly assessment indicates no loss of range of motion of both upper and lower extremities. A review of the resident's 05/10/12 current care plan to the present time has a stated problem, need to improve ambulation ability. As an approach to the problem the care plan specifies that the resident is to receive strengthening exercises to the resident's right lower extremity. A review of a 10/15/2012 Physical Therapy Evaluation and Plan of Treatment indicates the resident was referred to physical therapy due to an exacerbation of arthritis of the right knee with increased pain and decreased range of motion which is affecting functional transfers and wheelchair mobility. The assessment further indicates "Patient was performing transfers and bed mobility with minimal assistance; and able to self propel wheelchair with support on unit prior to recent onset of pain right knee,and decline in function. Further review of the physical therapy assessment indicates the resident now with a minus 35 degree loss in range of motion to the right lower extremity. Review of the resident's record reveals no evidence of the resident receiving strengthening exercises. Review of the Nursing Assistant's Information Sheet, list no information regarding exercises for this resident. During an interview on 11/07/2012 with the nursing assistant caring for the resident, she informed the surveyor that she does not perform exercises with the resident as she was unaware the resident was to receive exercises. During a subsequent interview with the DNS on the same date, he stated that the resident should have been receiving range of motion exercises daily by staff as per the plan of care. The facility was unable to provide evidence of any strengthening exercises for this resident.