Every finding on record at Tockwotton on the Waterfront

Based on clinical record review and staff interview, the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 2 of 2 residents reviewed who are receiving hospice services, Resident ID #s 6 and 8.Findings are as follows:1. Record review revealed that Resident ID #6 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, dementia.Record review revealed the resident began receiving hospice services on 3/23/2026.a. Record review failed to reveal evidence that a Significant Change Minimum Data Set (MDS) Assessment was completed within 14 days from the date s/he began receiving hospice services, as per the regulation.During a surveyor interview on 4/15/2026 at 10:39 AM with the MDS Coordinator, Staff C, she revealed that Significant Change Assessments are completed when a resident begins receiving hospice services, and the assessment should be completed within 14 days. Additionally, she acknowledged that the Significant Change Assessment had not been completed for the resident.Further record review revealed the Significant Change Assessment was completed on 4/15/2026, after it was brought the facility's attention by the surveyor.b. Review of the electronic and paper medical records failed to reveal evidence of the following hospice information, per the regulation: - The most recent hospice plan of care- Physician certification and recertification of the terminal illness- Names and contact information for hospice personnel involved in hospice care- Hospice medication information- Hospice physician and attending physician orders- Delineation of the hospice's responsibilitiesDuring a surveyor interview on 4/15/2026 at 10:48 AM with the Director of Nursing Services (DNS), she revealed that the facility does not have individual hospice binders for each resident receiving hospice services. She was unable to provide evidence of the above-mentioned hospice documents for Resident ID #6 until after it was brought to the facility's attention by the surveyor.2. Record review revealed Resident ID #8 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, dementia.Record review revealed the resident began receiving hospice services in February of 2026.Review of the electronic and paper medical records on the morning of 4/15/2026, failed to reveal evidence of the following hospice information, per the regulation:- The most recent hospice plan of care- Hospice election form- Physician certification and recertification of the terminal illness- Names and contact information for hospice personnel involved in hospice care- Instructions on how to access the hospice's 24-hour on-call system- Hospice medication information- Hospice physician and attending physician orders- Delineation of the hospice's responsibilitiesDuring a surveyor interview on 4/15/2026 at 12:57 PM, with the DNS, she acknowledged the hospice documentation was obtained and placed in the resident's chart after it was brought to the facility's attention by the surveyor. Additionally, she was unable to provide evidence that the facility ensured that hospice services meet professional standards of principles for Resident ID #s 6 and 8 related to having the required hospice documentation.

Based on clinical record review and staff interview, the facility failed to provide appropriate treatment and services related to monitoring output for 2 of 4 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 9 and 10.Findings are as follows:According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 and 1284 states in part, .For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage .to reduce the risk of bacterial proliferation [rapid increase in numbers] empty the collection bag at least every 8 hours through the drainage spout - more frequently if there is a large volume of urine .Review of an undated facility policy titled, Emptying a Urinary Collection Bag states in part, .to prevent the collection bag from becoming full and allowing urine to flow back into the bladder and to measure output.empty the urinary collection bag at least every eight (8) hours or more often if needed.the following information should be recorded in the resident's medical record.the amount of urine emptied from the drainage bag.1. Record review revealed Resident ID #9 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, neuromuscular dysfunction of the bladder (a condition caused by a problem with the brain, nerves, or spinal cord which causes a loss of control of the bladder).Review of the care plan revealed the resident has an indwelling foley catheter and is at risk for developing a urinary tract infection.Record review revealed a physician's order dated 2/19/2025 to monitor foley output every shift.Record review failed to reveal evidence that urine output was documented on the following days and shifts:4/2- 3rd and 1st shift 4/3- 1st and 2nd shift4/4- 2nd shift4/7- 1st shift4/10- 3rd and 1st shift4/11- 1st shift4/13- 1st shiftDuring a surveyor interview on 4/15/2026 at 3:18 PM with Registered Nurse (RN), Staff A, he indicated that urine output should be documented in the electronic medical record.2. Record review revealed Resident ID #10 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, flaccid neuropathic bladder (a condition caused by nerve damage to the bladder leading to weak bladder muscles and the inability for the bladder to contract effectively to empty urine).Review of the care plan revealed the resident has a suprapubic tube (a flexible catheter inserted directly into the bladder through a small incision in the lower abdomen to drain urine when normal urination is not possible) and is at risk for developing a urinary tract infection with interventions including, but not limited to, monitor and record urinary output. Record review failed to reveal evidence that urine output was documented on the following days and shifts:4/1- 1st and 2nd shift4/2- 1st and 2nd shift4/3- all three shifts4/4- all three shifts4/5- 1st and 2nd shift4/6- 1st and 2nd shift4/7- all three shifts4/8- all three shifts4/9- all three shifts4/10- 1st and 2nd shift4/11- 3rd and 1st shift4/12- 2nd shift4/13- 1st and 2nd shift4/14- 1st and 2nd shiftDuring a surveyor interview on 4/14/2026 at 2:11 PM with RN, Staff B, she revealed urinary output from a urinary catheter should be documented each shift in the resident's electronic medical record. Additionally, she acknowledged that urinary output had not been documented each shift for Resident ID #10.During surveyor interviews on 4/14/2026 at 2:34 PM and on 4/15/2026 at 1:57 PM with the Director of Nursing Services, she revealed that she would expect urinary output from a urinary catheter to be documented each shift. Additionally, she acknowledged that urinary output had not been documented on each shift for Resident ID #s 9 and 10.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed, Resident ID #1 relative to Metoprolol use (a medication prescribed to treat high blood pressure and to control heart rate), resulting in hospitalization due to extremely low heart rate from an overdose of Metoprolol which caused bradycardia ((a severely low heart rate) that can deprive the brain and other organs of oxygen in the body from the reduced blood circulation). Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 2/24/2025 revealed that Resident ID #1 received an overdose of Metoprolol and was admitted to the hospital due to cardiac concerns after receiving a dose of 62.5 milligrams (mg), instead of his/her prescribed dose of 37.5 mg on 2/23/2025. Review of a facility policy titled, Administering Medications last revised in April of 2019 states in part, .Medications are administered .as prescribed .The individual administering the medication checks the label THREE (3) times to verify the .right dose .before giving the medication . Review of a facility policy titled, Adverse Consequence and Medication Errors last revised in February of 2023 states in part, .A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders .Examples of medication errors include .Wrong dose .A significant medication-related error is defined as .Requiring hospitalization . Record review revealed the resident was admitted in November of 2024 to the facility with diagnoses including, but not limited to, congestive heart failure (when the heart loses the ability to properly pump the blood), high blood pressure, and atrial fibrillation (extremely fast and irregular heart beat). Review of a hospital admission document dated 2/23/2025 revealed that Resident ID #1 was transferred to the hospital after being given 62.5 mg of Metoprolol instead of his/her prescribed dose of 37.5 mg which resulted in an abnormal heart rhythm and an abnormally low heart rate (HR; normal resting heart rate for adults is between 60 and 100 beats per minute [BPM]). The document revealed that the Poison Control Center was contacted and recommended that the resident's heart rhythm and other vital signs should continuously be monitored due to the long-acting formulation of the medication. Record review revealed the following progress notes: - 2/21/2025: a nursing note authored by Registered Nurse, Staff B, indicating that the resident had a HR of 44 and new orders were obtained to decrease his/her current dose of Metoprolol and start 37.5 mg daily. - 2/23/2025: a nursing note authored by Registered Nurse, Staff B, revealed that at approximately 11:30 AM, Certified Medication Technician (CMT), Staff C, indicated that she gave the resident 62.5 mg of Metoprolol instead of his/her prescribed dose of 37.5 mg. The provider was notified and gave new orders to discontinue Metoprolol, initiate vital signs monitoring every 2 hours, and obtain a STAT (immediate) electrocardiogram (EKG; a test that records the electrical signals of the heart). The resident was subsequently transferred to the hospital for evaluation due to his/her abnormally low HR of 37 and abnormal EKG results. During a surveyor interview on 2/25/2025 at 9:40 AM with CMT, Staff C, she revealed that she was aware that the resident's Metoprolol dose was changed and acknowledged that prior to administering the resident's Metoprolol on 2/23/2025, she did not reference the resident's orders or the medication label. During a surveyor interview with the Director of Nursing Services on 2/25/2025 at approximately 2:00 PM, she revealed that the CMT did not properly follow the facility's medication administration protocol. Additionally, the DNS acknowledged that Resident ID #1 received an incorrect dose of his/her Metoprolol that resulted in the resident being transferred to the hospital and subsequently admitted . Cross reference F 658

Based on record review and staff interview, it has been determined that the facility failed to follow a physician's order relative to a significant change in condition for 1 of 1 resident reviewed whom experienced bradycardia (a low heart rate), Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 2/24/2025 revealed that Resident ID #1 received an overdose of Metoprolol (a medication prescribed for high blood pressure and to control heart rate) and was admitted to the hospital after receiving a dose of 62.5 milligrams (mg), instead of his/her prescribed dose of 37.5 mg on 2/23/2025. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. Record review revealed the resident was admitted to the facility in November of 2024 with diagnoses including, but not limited to, congestive heart failure (when the heart loses the ability to properly pump the blood), high blood pressure, and atrial fibrillation (extremely fast and irregular heart beat). Review of a progress note dated 1/17/2025 authored by Registered Nurse (RN), Staff A, states in part, Called on call [provider] for PT [patient] low HR [heart rate] and high BP [blood pressure] new orders - Hold Metoprolol reassessment on 1/21 . Record review failed to reveal evidence that the resident was reassessed as ordered on 1/21/2025. During a surveyor interview with the Director of Nursing Services on 2/25/2025 at approximately 1:30 PM, she acknowledged that Resident ID #1 had a low HR and high BP on 1/17/2025 and was to be reassessed on 1/21/2025 per the physician's order. Additionally, she was unable to provide evidence ordered assessment occurred on 1/21/2025, as ordered. Cross reference F 760

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to the main kitchen. Findings are as follows: 1. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . During the initial tour of the main kitchen on 2/10/2025 at approximately 8:30 AM of the reach in refrigerator unit 4 was observed with the following: -one 32 ounce jar of Sysco capers with an open date of 1/4/2025 and a use by date of 2/4/2025. -one jar of pepperoncini peppers with an open date of 12/25/2025 and a use by date of 1/25/2025. -six Styrofoam containers containing a white food substance which were unlabeled, without identification of the contents, a preparation date or a use by date. During a surveyor interview at the time of the above observation with the Executive Chef, he indicated that the capers and pepperoncini peppers should have been discarded and the Styrofoam containers should have been labeled with the contents, preparation date and a use by date. Additional observations during the initial tour of the main kitchen, in the presence of the Dietary Manger, of the reach in refrigerator unit 1 was observed with the following: -one squeeze bottle of 32 ounce red wine vinaigrette with an open date of 12/29/2024 and a use by date of 1/29/2025. -one squeeze bottle of 24 ounce ranch dressing with an open date of 12/12/2024 and a use by date of 1/12/2025. During a surveyor interview with the Dietary Manager immediately following the above observations he indicated that the above-mentioned items should have been discarded. 2. 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 the initial tour of the main kitchen on 2/10/2025 at approximately 8:30 AM, in the presence of the Executive Chef, the following was observed: -The walk-in refrigerator's floor had a moderate amount of red liquid pooling below a box which contained a partially opened bag of chicken. -The ceiling of the walk-in freezer had icicles hanging down and accumulating ice on a food storage rack below. During a surveyor interview with the Executive Chef, at the time of the above observations he acknowledged the pooling of the red substance in the walk-in refrigerator and indicated it was blood from the box of chicken. Additionally, he acknowledged the accumulation of icicles in the freezer. During a subsequent observation of the main kitchen on 2/12/2025 at 11:50 AM, two days after the above mentioned observations were brought to the facility's attention, the following was observed: -the walk-in refrigerator floor was observed with a moderate of coagulated red liquid on the floor. -the ceiling of the walk-in freezer had icicles hanging down. -one box of spanakopita (Greek spinich pie) with an accumulation of ice directly under the frozen drips on the ceiling. During a subsequent surveyor interview on 2/12/2025 with the Dietary Manager at the time of the above observations, he acknowledged that walk-in refrigerator had a coagulated red liquid on the floor. He indicated the floor should have been cleaned. During a surveyor observation and simultaneous interview on 2/12/2025 at 12:36 PM, with the Administrator he acknowledged the build up of ice on the walk-in freezer ceiling and on the box of spanakopita.

39496 Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 2 residents reviewed with a sliding scale insulin (Insulin dosage based on blood glucose reading), Resident ID #6, and 1 of 4 residents observed during the medication administration task, Resident ID #13. Findings are as follows: Review of a policy titled Administering Medications states in part, .Medications are administered in accordance with prescriber orders, including any required time frame .within one (1) hour of their prescribed time, unless otherwise specified . 1. Record review revealed Resident ID #6 was admitted to the facility in August of 2017 with a diagnosis including, but not limited to, diabetes mellitus. Record review of the physician's orders revealed the following: -11/4/2024- Novolog (insulin) 100 unit/milliliter(ml) administer 6 units three times a day, hold for blood glucose reading less than 65. -11/5/2024-Novolog (insulin) 100 unit/ml to be given three times daily before eating if: -the blood glucose reading is between 0-180- give no insulin -the blood glucose reading is between 181- 250- give two units of insulin -the blood glucose reading is between 251-300- give four units of insulin -the blood glucose reading is between 301-400- give eight units of insulin -the blood glucose reading is above 400 add ten units of insulin Record review of the Medication Administration Record (MAR) for February 2025 failed to reveal evidence that the resident received his/her Novolog as ordered on the following dates and times: -2/7/2025 during the 11:00 AM-1:00 PM dose- the blood glucose reading was documented as 212, and six units of insulin was documented as administered. This is a dosage four units higher than the dosage that should have been administered based on the resident's blood glucose reading. -2/7/2025 during the 4:30 PM- 6:00 PM dose- the blood glucose reading was documented as 94, and six units were documented as administered. This is a dosage six units higher than the dosage that should have been administered based on the resident's blood glucose reading. During a surveyor interview on 2/11/2025 at 3:14 PM with Registered Nurse, Staff C, she acknowledged that she was the nurse who documented that six units were given on 2/7/2025 during the 11:00 AM to 1:00 PM dose. She was unable to provide evidence that she had given the resident the correct dosage of Novolog insulin, as ordered, per the sliding scale. During a surveyor interview on 2/12/2025 at 1:19 PM, with the Director of Nursing Services (DNS), she could not provide evidence that the appropriate dose of Novolog was given based on the resident's blood glucose reading during the above-mentioned times. 2. Record review revealed Resident ID #13 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, dementia and hypertension. Record review revealed a physician's order dated 11/26/2024 for Amlodipine (a medication prescribed to treat high blood pressure), 5 milligrams (mg), every morning. Further review revealed the medication was scheduled to be administered before breakfast. Record review of the February 2025 MAR revealed the Amlodipine was charted as Late administration: Charted late on 2/10/2025 at 1:13 PM and on 2/11/2025 at 12:22 PM. During surveyor interviews on 2/11/2025 at 12:09 PM and on 2/12/2025 at 1:58 PM with Certified Medication Technician, Staff D, she indicated that the time charted on the MAR, is the time that she administered the medication. Additionally, she acknowledged the medication was administered late and not before breakfast, as ordered. During a surveyor interview on 2/13/2025 at 11:03 AM with the DNS she indicated that she would expect a medication that is scheduled to be administered prior to breakfast, to be administered prior to eating breakfast.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide and prepare food in a form designed to meet individual needs for 1 of 2 residents reviewed with a physician's order for thickened consistency fluids, Resident ID #301. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, dysphagia (difficulty in swallowing), pneumonia (infection of the lungs), and dementia. Record review revealed the following physician's orders: - 2/4/2025: Aspiration precaution (guidelines to prevent food or liquid from entering the airway while eating or drinking) - 2/6/2025: 120 milliliters (ml) of nectar (mildly thick) house supplement (nutritional supplement) once in the morning - 2/10/2025: Diet order for honey thick (moderately thick) liquids Record review of the Medication Administration Record (MAR) for February 2025 revealed the order for the house supplement nectar thick consistency was signed off by the staff on 2/11/2025 and 2/12/2025 as being administered, which is two days after the order had been changed to honey thick consistency on 2/10/2025. Record review failed to reveal evidence that the nectar thick house supplement order was changed on 2/10/2025 to reflect that the resident was now receiving honey thick consistency liquids, instead of the nectar thick consistency liquids that was previously ordered. During a surveyor observation of Certified Medication Technician, Staff E, on 2/13/2025 at 9:48 AM, she was observed measuring the nectar thick house supplement and proceeded to the resident's room to administered it when she was stopped by the surveyor. Staff E acknowledged the resident was on a honey thick consistency liquid diet. She further acknowledged that the house supplement that she had prepared to administer to the resident was a nectar thick consistency, and not honey thick consistency, as ordered. During a surveyor interview on 2/13/2025 at 10:26 AM with the Director of Nursing Services (DNS), she acknowledged that the resident's diet order had been changed from nectar thick consistency liquids to honey thick consistency liquids. Additionally, the DNS acknowledged that the house supplement order should have been changed to honey thick consistency instead of nectar as indicated on the MAR. During a surveyor interview on 2/13/2025 at 12:07 PM with the Medical Director, he indicated that he would have expected the resident to receive honey thick consistency liquids, as ordered. 47939

Based on record review and staff interview, it has been determined that the facility failed to ensure that medical records are accurately documented for 1 of 2 residents reviewed for sliding scale insulin (Insulin dosage based on blood glucose reading), Resident ID #6, and for 1 of 4 residents observed during the medication administration task, Resident ID #13. Findings are as follows: 1. Record review revealed Resident ID #6 was admitted to the facility in August of 2017 with a diagnosis including, but not limited to, diabetes mellitus. Record review revealed the following physician's orders dated 11/5/2024: -Novolog (insulin) 100 units/milliliters (u/ml) to be given three times daily before eating if: -the blood glucose reading is between 0-180- give no insulin -the blood glucose reading is between 181- 250- give two units of insulin -the blood glucose reading is between 251-300- give four units of insulin -the blood glucose reading is between 301-400- give eight units of insulin -the blood glucose reading is above 400- add ten units of insulin Record review of the February 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received his/her Novolog as ordered on 2/7/2025 for the 11:00 AM-1:00 PM dose. The blood glucose reading was documented as 212, and six units of insulin was documented as administered. This dosage is four units higher than the dosage that should have been administered based on the sliding scale. During a surveyor interview on 2/11/2025 at 3:14 PM with Registered Nurse, Staff C, she acknowledged that she was the nurse who documented that six units were administered on 2/7/2025 for the 11:00 AM to 1:00 PM dose. During a surveyor interview on 2/12/2025 at 1:19 PM, with the Director of Nursing Services (DNS), she reviewed the MAR in the presence of the surveyor and revealed that on 2/7/2025 for the 11:00 AM to 1:00 PM dose, 2 units of Novolog were documented as being administered. This surveyor showed the MAR to the DNS that she saved on 2/11/2025, and the DNS acknowledged that six units of insulin was documented as being administered on 2/7/2025 for the 11:00 AM to 1:00 PM dose. The DNS indicated that Staff C must have gone back and edited the MAR to reflect the dosage of the two units. 2. Record review revealed Resident ID #13 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, dementia and hypertension. Review of the February 2025 MAR revealed the following physician's orders were documented as administered and charted late on 2/10/2025 at 1:16 PM, and on 2/11/2025 at 12:22 PM: -Amlodipine (a medication prescribed to treat high blood pressure) 5 milligrams (mg) once every morning, pre-breakfast -Eliquis (a blood thinner) 2.5 mg administer twice a day, post-breakfast -Labetalol (a medication prescribed to treat high blood pressure) 100 mg twice a day, post-breakfast During surveyor interviews on 2/11/2025 at 12:09 PM and on 2/12/2025 at 1:58 PM with Certified Medication Technician, Staff D, she indicated that the time charted on the MAR, is the time that she administered the medication. She further acknowledged that she documented that she charted late on the MAR for the Amlodipine, Eliquis, and Labetalol, however the medications were in fact, administered late. During a surveyor interview on 2/13/2025 at 11:03 AM with the DNS, she indicated that she would expect that a medication that is administered later than the scheduled time, would be documented as administered late, and not as charted late. 46118

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 infection, relative to droplet/contact precautions (utilized when a resident is known or expected to be infected to prevent the spread of germs that can be transmitted through respiratory droplets expelled when a person coughs, sneezes, or speaks) for 1 of 2 residents reviewed on droplet/contact precautions for influenza (a highly contagious respiratory illness caused by the influenza viruses which spreads through respiratory droplets), Resident ID #19. Findings are as follows: Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions states in part, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection .and is at risk of transmitting the infection to other residents .Contact Precautions: are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces .Staff wear gloves when entering the room .Droplet Precautions .Gloves, gown and goggles are worn if there is a risk of spraying respiratory secretions . Record review revealed the resident was admitted to the facility in February of 2024 with a diagnosis including, but not limited to, dementia. Record review of a progress note dated 2/6/2025 revealed the resident tested positive for influenza. Record review of a physician's order dated 2/11/2025 to maintain droplet/contact precautions for influenza, every shift. During a surveyor observation on 2/10/2025 at approximately 9:40 AM revealed the resident had signage posted on his/her door indicating that s/he was on droplet/contact precautions. Additionally, the signage indicated that staff should wear a gown, gloves, and eye protection prior to entering the room. During a surveyor observation on 2/10/2025 at 9:43 AM, revealed Nursing Assistant, Staff F, entering the resident's room with a tray of food and placed it on the table without wearing gloves or eye protection. Staff F exited the room, put on a pair of gloves, then reentered the resident's room and assisted him/her with his/her meal and did not wear eye protection. During a surveyor interview immediately following this observation with Staff F, she acknowledged that she did not wear eye protection and gloves prior to entering the resident's room. Staff F further indicated that she only wears eye protection when she is assisting the resident with his/her personal care. During a surveyor interview on 2/13/2025 at 11:01 AM with the Infection Preventionist, she indicated that the staff is expected to wear gloves and eye protection prior to entering the resident's room. During a surveyor interview on 2/13/2025 at 11:03 AM with the Director of Nursing Services, she indicated that she would expect the staff to wear gloves and eye protection prior to entering the resident's room. 46118

46118 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 1 resident reviewed with a pressure ulcer (skin and tissue injuries caused by constant pressure to a specific area of the body), Resident ID #250. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, dementia and abnormalities of mobility. Review of a Safe Patient Handling assessment dated [DATE] revealed the resident was dependent on staff for bed mobility. Review of a document titled Skin Integrity Events dated 2/5/2025 revealed an unstageable pressure ulcer (characterized by full-thickness tissue loss where the depth cannot be assessed due to the presence of dead tissue) was observed to the resident's right heel measuring 1.5 x [by] 2 x [depth] not measurable. Record review revealed the following physician's orders dated 2/5/2025: -No shoes until right heel blister resolved -Off load bilateral heels while in bed every shift During a surveyor observation on 2/10/2025 at 12:22 PM, the resident was in his/her wheelchair and wearing shoes on both feet. During surveyor observations on the following dates and times, the resident's heels were not offloaded and were resting directly on the mattress while lying in bed: -2/11/2025 at 9:36 AM -2/11/2025 at 3:17 PM -2/12/2025 at 11:26 AM -2/13/2025 at 8:53 AM During a surveyor interview on 2/13/2025 at 9:00 AM with Nursing Assistant, Staff A, she acknowledged that the resident's heels were not offloaded and they were resting directly on the mattress. She further acknowledged that the resident had a wound to his/her right heel. Additionally, she indicated that she was unaware if the resident's heels should be off loaded while in bed. During a surveyor interview on 2/13/2025 at 9:31 AM with Registered Nurse, Staff B, she indicated that the resident had a pressure ulcer to his/her right heel. She further indicated that the resident should not be wearing shoes until the pressure ulcer is healed and that his/her heels should be offloaded while in bed. Additionally, she acknowledged that the resident's heels were not offloaded while in bed at the time of the interview. During a surveyor interviews on 2/13/2025 at 9:55 AM and at 1:13 PM, with the Director of Nursing Services, she indicated that she would expect the resident's heels to be offloaded while in bed, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality, relative to following a physician's order for 1 of 1 resident reviewed relative to a respiratory diagnosis, Resident ID #19. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed the resident was admitted to the facility in January of 2024 with a diagnosis including, but not limited, to Respiratory Syncytial Virus (RSV, a virus that affects the respiratory tract). Record review revealed a physician's order dated 2/1/2024 for Mucinex tablet extended release, 600 milligrams, with instructions to administer 2 tablets, twice a day. Record review of the Medication Administration Record (MAR) for February 2024 revealed, the resident missed 11 out of 14 opportunities for the administration of Mucinex as the facility documented that the medication was unavailable. Record review failed to reveal evidence that the physician had been notified the Mucinex was unavailable and not administered to the resident as per the physician order. During a surveyor interview on 2/28/2024 at approximately 2:30 PM with the Physician, he revealed that he was not notified that the medication was unavailable and not being administered to the resident. During a surveyor interview on 2/28/2024 at approximately 2:40 PM with the Director of Nursing Services, she revealed that her expectation would be that the staff would notify the physician if a medication was unavailable. Additionally, she was unable to provide evidence that the resident received the Mucinex as ordered.

Based on record review and staff interview it has been determined that the facility failed to maintain medical records on each resident that are accurately documented and complete for 1 of 1 resident reviewed for falls, Resident ID #18, and 1 of 1 resident reviewed for a Foley catheter, Resident ID #18. Findings are as follows: 1a) Record review revealed the resident was admitted to the facility in September of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke) and neuromuscular dysfunction of the bladder. Record review of a progress note dated 1/4/2024 at 2:15 PM, revealed that the Nurse Practitioner (NP) entered a new order to remove the resident's Foley catheter and to proceed with a trial void (an assessment of the resident's ability to spontaneously urinate). During a surveyor interview on 2/29/2024 at 10:47 AM with the Unit Manager, Licensed Practical Nurse, Staff A, she revealed that the resident had a successful trial void on 1/4/2024 and s/he no longer has a Foley catheter. Record review revealed the following progress notes: - 1/23/2024 at 11:01 AM authored by the NP, states in part, .Voiding trial failed and patient is back on Foley. Daily Foley care . - 2/27/2024 at 11:03 AM states in part, .Foley patent and draining urine . - 2/29/2024 at 6:55 AM states in part, .Foley patent and draining urine . During a surveyor interview on 2/29/2024 at 10:47 AM with Staff A, she revealed that the progress notes on 2/27 and 2/29/2024 were documented inaccurately. During a surveyor interview on 2/29/2024 at 11:08 AM with the NP, she revealed that her progress note dated 1/23/2024 was documented inaccurately, the Foley was successfully removed on 1/4/2024. 1b) Record review of a care plan problem area dated 10/16/2023, revealed that the resident is at risk for falls. Record review of a progress note dated 2/26/2024 at 5:19 PM, revealed that the resident had slipped and fallen, and was found on the floor next to the door of his/her room. Record review of the fall event report dated 2/26/2024 initiated at 5:15 PM revealed that the fall assessment was incomplete. During a surveyor interview on 2/29/2024 at 11:59 AM with Staff A, she revealed that after a resident has a fall, a fall event report is initiated and completed. She acknowledged that the fall event report dated 2/26/2024 was incomplete. During a surveyor interview on 2/29/2024 at 1:48 PM with the Director of Nursing Services, she revealed that she would expect that staff documents accurately and that assessments are completed in full. Additionally, she was unable to provide evidence that the facility maintained complete and accurate medical records for the resident.

Based on surveyor observation 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 3 out of 3 kitchenettes. Findings are as follows: 1. During the initial tour of the main kitchen on 1/10/2023 at 8:10 AM revealed the following observations: A. Walk in freezer: - Floor: sticky and contained crumbs along the walls. - Ice crystal accumulation inside 3 freezer lock bags of meatballs: 35 meatballs labeled 11/28, 40 meatballs labeled 12/19, and 65 meatballs labeled 12/26. - Ice accumulation the size of a tennis ball on the floor as well as ice on the ceiling near the condenser fan. B. Walk in refrigerator contained crumbs and blueberries on the floor along the walls. During a follow up visit to the main kitchen on 1/11/2023 at 9:40 AM in the presence of the Assistant Food Service Director (FSD) he observed the above and could not provide evidence that the meatballs were free of freezer burn, that the freezer floor and ceiling were free of ice, and that the walk in freezer and refrigerator floor were kept clean. C. Two ready to use hotel pans had crumbs that were stuck to the pan. During a surveyor interview with the dishwasher, Staff A, on 1/10/2023 at approximately 8:20 AM following the above mentioned observation, he acknowledged the pans were not free of debris and needed to be washed. 2. During the initial tour of the [NAME] unit on 1/10/2023 at 11:35 AM revealed the following observations: A. Dried brown and red matter inside the microwave. B. Built up brown and black debris found stuck to the inside of the toaster. C. Orange juice and apple juice dispenser stained where the juice dispenses as well as dried up liquid substance at the bottom of the dispensers. During a surveyor interview with Certified Nursing Assistant/Homemaker, Staff B, on 1/10/2023 at 11:35 AM she acknowledged that the microwave, toaster, and juice dispensers were not kept clean. 3. During the initial tour of the Bold Point unit on 1/10/2023 at 11:56 AM revealed that the orange juice, apple juice, and citrus peach juice dispenser contained a thick build up inside and on the bottom of the dispensers. During a surveyor interview with the Assistant FSD on 1/10/2023 at 12:41 PM, he acknowledged that the juice dispensers were not kept clean. The State of Rhode Island Food Code 2018 edition, titled 2-301.14 When to Wash stated in part, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD .(E) After handling soiled EQUIPMENT or UTENSILS .(H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. A surveyor observation on 1/10/2023 at 12:03 PM, revealed the Assistant FSD was wearing gloves and not changing them or performing hand hygiene before beginning a new task. He was observed for approximately 15 minutes plating the meal onto clean plates, opening a drawer to pull out resident's menus, taking a clean plate and putting hot food on it, opening the refrigerator and serving more food without changing gloves or performing hand hygiene. Additionally, the Assistant FSD was not wearing a hairnet until brought to his attention by the surveyor. Immediately following the above observations the Assistant FSD acknowledged he did not perform hand hygiene between tasks from 12:03 PM-12:18 PM. Additionally, he acknowledged he was not wearing a hair net during this time. A surveyor observation on 1/11/2023 of homemaker Staff C, revealed the following observations while she wore the same gloves without performing hand hygiene: -8:06 AM, made pancakes, tore a piece of saran wrap to cover a dish, touched the food cart and then sliced fresh fruit (strawberries and bananas). -8:12 AM, tore another piece of saran wrap to cover a fruit bowl, took menus out of a drawer and then sliced a bagel. -8:15 AM took a loaf of bread out of the cupboard, took 2 slices of bread out and put the rest back in the cupboard, put the 2 slices of bread in the toaster, touched the menus, retrieved silverware out of a drawer, served eggs on a plate, sliced fresh fruit and retrieved more bread out of the cupboard. -8:28 AM opened the fridge to put the milk away, cleaned the counter with a towel and then poured coffee. During a surveyor interview with Staff C on 1/11/2023 at 8:40 AM, she acknowledged that she did not change gloves or perform hand hygiene between breakfast meal tasks on 1/11/2022 between 8:06 AM and 8:28 AM.

Based on surveyor observation, record review, and staff interview it has been determined the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 3 dryers observed on the the [NAME] unit. Findings are as follows: Review of the manufacturer guidance titled Section 1 Safety Information states in part, .Warning .Failure to install, maintain, and/or operate this machine according to the manufacturer's instructions may result in conditions which can produce serious injury, death and/or property damage . During a surveyor observation on 1/12/2023 at 8:58 AM of the [NAME] unit's laundry room revealed a set of 3 stacked washers and dryers. Additional observation revealed the dryer on the right side of the room failed to have an exhaust hose to allow for proper ventilation. Further observation revealed an accumulation of lint on the wall behind the dryers and on the floor. During a surveyor interview on 1/12/2023 at 9:11 AM with Nursing Assistant, Staff D, she revealed all the dryers on the [NAME] unit were in use. During a surveyor interview on 1/12/2023 at 9:13 AM with the Maintenance Director he revealed that he was unaware of any concerns in the laundry room on the [NAME] unit. During a surveyor observation on 1/12/2023 at 9:22 AM in the presence of the Maintenance Director he acknowledged the dryer's exhaust hose was missing. The Maintenance Director further acknowledged the accumulation of lint on the walls and floor. Additionally, he revealed the dryer should have an exhaust hose from the dryer to the vent for proper ventilation. Record review revealed the last service to the dryer ventilation system was completed in September of 2022. During a surveyor interview on 1/12/2023 at 1:53 PM with the Administrator he acknowledged the dryer should have an exhaust hose attached to the back of the dryer to allow for proper ventilation.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice relative to 1 of 3 sample residents reviewed for constipation, Resident ID #200. Findings are as follows: Review of the facility's document titled, Bowel Protocol states in part, .If no BM [bowel movement] times three days, the 7-3 shift administers 4 oz [ounces] of prune juice. If no results the 3-11p [PM] shift will administer 30 cc [cubic centimeter] of MOM [Milk of Magnesia, a medication used to treat constipation]. If no results the 11-7a [AM] shift will administer a [MEDICATION(S)] sup. [suppository, a medication used to treat constipation]. If no results the 7-3p [PM] shift will administer a Fleets Enema [a medication used to treat constipation]. If still no results NP/MD [Nurse Practitioner/Medical Doctor] will be notified. Record review revealed the resident was admitted to the facility in November of 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - 9/10/2018: [MEDICATION(S)] [[MEDICATION(S)]] suppository; 10 mg [milligram]: Amount to Administer: 10 mg; rectal PRN [as needed] daily for constipation - 4/19/2018: Fleets enema 1 PR [per rectal] daily PRN for constipation if no results from [MEDICATION(S)] suppository . Record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the bowel movement (BM) documentation for October 2021 revealed the following: - 10/1/2021 to 10/4/2021, no evidence of a BM for 4 days - 10/22/2021 to 10/25/2021, no evidence of a BM for 4 days - 10/27/2021 to 10/31/2021, no evidence of a BM for 5 days Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the BM documentation for September 2021 revealed the following: - 9/29/2021 to 10/4/2021, no evidence of a BM for 6 days - 9/12/2021 to 9/21/2021, no evidence of a BM for 10 days Record review of the MAR for September 2021 failed to reveal evidence that the above-mentioned bowel protocol was implemented, and that the bowel medications were administered from 9/1/2021 through 9/11/2021 and from 9/12/2021 through 9/21/2021. During a surveyor interview on 11/3/2021 at 11:03 AM with the Director of Nursing Services (DNS) in the presence of the Assistant Director of Nursing Services, both staff acknowledged that the bowel protocol was not implemented. Additionally, the DNS acknowledged that the bowel medications were not administered as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 of 4 residents reviewed for oxygen therapy, Resident ID #34. Findings are as follows: Review of the facility policy titled, Pulse Oximetry (Assessing Oxygen Saturation), revealed in part, .Documentation .the following information should be recorded in the resident's medical record: .Any unusual findings and action taken . Review of the record revealed the resident was admitted to the facility in November 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Review of the record revealed a 5/25/2021 physician's order, for O2 PRN [as needed oxygen] supplemental oxygen Special Instructions: To maintain O2 sat [saturation] greater than 92% Further review of this order failed to reveal evidence of a specified liter flow. 2. Review of the pulse oximetry documentation from 8/1/2021 through 11/4/2021 failed to reveal evidence of pulse oximetry monitoring for the following dates: - November 2021: 4 of 4 opportunities - October 2021: 10 of 31 opportunities - September 2021: 4 of 30 opportunities - August 2021: 6 of 31 opportunities 3. Additionally, the pulse oximetry readings for the following months failed to reveal evidence that the oxygen saturation was maintained greater than 92% per the physician's order: - October 2021: 14 of 21 opportunities - September 2021: 21 of 26 opportunities - August 2021: 18 of 25 opportunities Furthermore, review of the Treatment Administration Record (TAR) from 8/1/2021 through 10/31/2021 failed to reveal evidence that as needed oxygen was administered as ordered to maintain oxygen saturation greater than 92%. During an interview with the Director of Nursing Services on 11/4/2021 at 1:45 PM, she could not provide evidence that the physician order was followed.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for care of a resident with an indwelling catheter for 1 of 3 sample residents reviewed, Resident ID #25. Findings are as follows: The Center for Disease Control and Prevention (CDC) document titled, Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009 states in part, .lll Proper techniques for Urinary Catheter Maintenance .lll.B.2 Do not rest the bag on the floor . Review of the facility's policy titled, Catheter Care, Urinary states in part, .Infection Control 2.b. Be sure the catheter tubing and drainage bag are kept off the floor . Record review for this resident revealed s/he was admitted to the facility in May of 2021 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor observations revealed the following: - 11/1/2021 at 10:05 AM, 10:20 AM, 11:29 AM, the resident was observed sitting in a recliner, the catheter bag attached to the trash bin, and both the bag and tubing were directly on the floor. At 10:20 AM, two Nursing Assistants were observed entering and exiting the resident's room while the catheter bag and tubing remained directly on the floor. - 11/2/2021 at 8:40 AM and 2:22 PM, the resident was observed sitting in a recliner, the catheter bag attached to the trash bin, and both the bag and tubing were directly on the floor. - 11/3/2021 at 8:57 AM, 9:47 AM, 10:39 AM, 11:09 AM, and 11:19 AM, the resident was observed sitting in a recliner, the catheter bag attached to the trash bin, and both the bag and tubing were directly on the floor. At 9:47 AM, two Nursing Assistants were observed entering and exiting the resident's room while the catheter bag and tubing remained directly on the floor. During a surveyor interview on 11/3/2021 at 11:26 AM with Registered Nurse, Staff A, she acknowledged that the catheter bag was directly on the floor. During a surveyor interview on 11/3/2021 at 1:57 PM with the Director of Nursing Services, she indicated that she would expect the catheter bag to be attached to the side of the resident's recliner, should not be attached to the trash bin, and should not be resting directly on the floor. She further indicated that she would expect the staff to remove the catheter bag from the floor if it was observed there.

Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to ensure that each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for error observed during the medication administration task, there were 2 errors resulting in an error rate of 8%, involving Resident ID #'s 37 and 40. Findings are as follows: 1. Record review revealed Resident ID #37 has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Description: 1st AM Med [medication] Start Time: 05:00 AM End Time: 10:00 AM. The pharmacy label's instructions state, .Take on an empty stomach . Additionally, the manufacturer's instructions state in part, Administer once daily . one-half to one hour before breakfast. During an observation of the medication administration task on 11/3/2021 at 8:35 AM with Licensed Practical Nurse, Staff B, she administered the above medication to the resident. During an interview immediately following this observation with Staff B, she revealed that the resident received the above medication before breakfast and that s/he cannot eat until about an hour after it has been administered. During a surveyor observation on 11/3/2021 at 8:43 AM, the resident was observed eating breakfast in his/her room. 2. Record review revealed Resident ID #40 has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Description: PRE- Breakfast Start Time: 05:00 AM End Time: 11:00 AM. During an observation of the medication administration task on 11/3/2021 at 8:38 AM with Staff B, she administered the above medication to the resident. During an observation of the resident on 11/3/2021 at 9:10 AM, s/he was observed eating breakfast in the main dining room. During a surveyor interview with Staff B at 9:25 AM, she acknowledged that the resident has been eating breakfast for ten minutes. During a surveyor interview with the Director of Nursing Services on 11/3/2021 at 1:49 PM, she revealed that she would expect the medications to be administered at a set time frame of 5:00 AM through 6:00 AM to avoid interference with breakfast.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs under proper temperature controls for 1 of 3 medication carts observed and failed to label drugs in accordance with currently accepted professional practice. Findings are as follows: 1. Surveyor observation on 12/5/2019 at 08:05 AM revealed 1 vial of [MEDICATION NAME] 0.1 units/mililiter, with an open date of 11/13/2019, stored in the top drawer of the medication cart. Review of manufacturer's instructions indicates; store at 2° to 8°C (35° to 46°F). An interview was conducted with the nurse, Staff C, at the time of the observation. She acknowledged this medication should not be stored in the medication cart and should be discarded. 2. Further observation revealed a box of Humalog Insulin that was taped closed. Upon further observation it was revealed the insulin vial had not been opened. Review of the manufacturer's instructions indicated unopened Humalog should be stored in a refrigerator (36° to 46°F (2° to 8°C)), but not in the freezer. An interview was conducted at the time of the observation. Staff C revealed the unopened vial of Humalog should have been stored in the refrigerator and not in the top drawer of the medication cart and should be discarded.

Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure a sanitary environment and to help prevent the transmission of communicable diseases and infections for 1 of 1 residents on contact precautions (Resident ID#201). Findings are as follows: Facility policy titled Handwashing /Hand Hygiene 8. Hand hygiene is the final step after removing and disposing of personal protective equipment Record review for Resident ID#201 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Further record review revealed a physician's orders [REDACTED]. Surveyor observation on 01/29/19 at 10:40 AM, two male visitors arrived to visit resident ID #201and were told by the staff nurse (Staff A) that the resident is on contact precautions and they need to wear the personal protective equipment (PPE) before entering the room. The surveyor heard the male visitors state that they were in to the visit the resident on Sunday (1/27/2019) and no one told them to wear any PPE. The surveyor observed them putting on gowns and mask and entering the room without gloves. Surveyor observation on 1/29/2019 at 10:45 AM a male staff member, from the therapy department entered residents 'room without donning PPE nor washing hands upon leaving the room. The surveyor interviewed the nurse, staff A, on 1/29/2019 at 10:50 AM, who informed the surveyor that the resident is on Contact precautions and that PPE includes gowns, gloves and mask prior to entering the resident's room. On 01/29/19 at 10:59 AM the surveyor interviewed the male visitors who exited the resident 's room still wearing the gown and mask. When questioned they told the surveyor that they visited two days prior and were not told to wear any PPE. They stated that they thought that the resident's infection was resolved. When questions about wearing gloves, they said they did not use the gloves. During this interview the nurse, staff A, informed the visitors that they needed to return to the room and remove the PPE prior to leaving the room. The surveyor observed the visitors step back inside the room and remove their PPE and place it on the floor. Leaving the room without washing their hands. They returned to the nurse's area and pick up their coats and then returned to the resident's room, walked in and placed their coats in the resident's room and left the room. On 1/29/2019 @ approximately 11:05 AM, the resident came out of his/her room with a mask on and walked to the dining area with his visitor. Additional surveyor observation on 1/29/2019 at 2:10 PM, the surveyor observed two female visitors and the resident's physician entering the resident's room wearing PPE. Approximately 2 minutes later the physician opened the door and came out of the room still wearing the PPE to get supplies, and return to the room. At approximately 2:18 PM, the physician and the female visitors came out of the room, still wearing the PPE, and the nurse manager who is also the infection control nurse was in the area and told them to return to the room to remove the PPE. At that time, they removed the PPE and left the room without washing their hands. One of the female visitors left the room still wearing the mask around her neck and proceeded to leave the area. An additional surveyor observation on 01/30/19 at 10:13 AM, the transporter from the ambulance company arrived to take the resident to an appointment and entered the room without donning any PPE. On 01/31/2019 at 11:34 AM the surveyor interviewed the infection prevention nurse who stated that she was not aware that staff and visitors were not following the contract precautions and not washing their hands. During this interview with the infection control nurse, the sign stating see nurses was observed to be only approximately 2x2 on the door attached to the infection precautions equipment which is not clearly visible. The infection control nurse acknowledged that the facility failed to implement precautions to help prevent the transmission of communicable diseases and infections.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with standards of practice, to prevent pressure ulcers, does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable, and a resident with a pressure ulcer receives necessary treatment and services to promote healing and prevent infection for 3 of 5 sampled residents reviewed for pressure ulcers (ID #s 1,7, & 8). Findings are as follows: Documentation required with each dressing change as per The Federal Code of Regulations: With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI should be documented. At a minimum, documentation should include the date observed and: Location and staging; Size (perpendicular measurements of the greatest extent of length and width of the PU/PI),depth; and the presence,location and extent of any undermining or tunneling/sinus tract; Exudate, if present: type (such as purulent/serous),color,odor and approximate amount; Pain, if present: nature and frequency(e.g.,whether episodic or continuous); Wound bed : Color and type of tissue/character including evidence of healing (e.g.,granulation tissue), or necrosis (slough or eschar); and Description of wound edges and surrounding tissue (e.g., rolled edges, redness,hardness/induration, maceration) as appropriate. 1. Resident ID #1 was admitted to the facility on [DATE] from the acute care hospital, after a fall during which she sustained an injury to her left knee. Upon admission the resident had [DIAGNOSES REDACTED]. Four nurses, nurses (A, B, F & G), plus the nurse practitioner, (RNP), document the worsening of the resident's wound over a period of 24 days. Documentation was as follows: 7/17/2018 at 11:45 PM, staff nurse A: the resident has multiple bruises, and also states left knee is swollen, warm to the touch, has a 9 cm x 4 cm fluid filled blister intact, covered with ADB (abdominal) pad , f/b (followed by) ace wrap and knee immobilizer. 7/22/2018 at 10:19 PM, staff nurse A: the blisters is now broken, and a small amount bloody drainage is noted on discarded dressing. 7/23/2018 at 9:30 PM, the Nurse Practitioner: the left leg is in an immobilizer and is noted to be swollen. 7/24/2018 at 10:32 PM, staff nurse A: .area remains slightly swollen, bruised, blisters are starting to dry up, noted to have sanguineous drainage on discard dressing.' 7/27/2018 at 9:54 PM, the RNP: patient is not herself, flinches and grimaces when leg is touched. Left knee pain / avulsion (tearing) injury to PCL/ open wound to left knee increased pain and opening of blisters. Orders for repeat x ray, normal saline wash and xeroform to blisters, wrap with kling under immobilizer. 7/27/2018 at 10:34 PM, staff nurse A: area has increased [DIAGNOSES REDACTED] and swelling noted, blister areas are now open, noted to have bloody drainage on discarded dressing. 7/30/2018 at 10:44 PM ,staff nurse A: area remains with [DIAGNOSES REDACTED] and swelling noted, blistered areas have dried blood on the surface, bloody drainage on discarded dressing. 8/03/2018 at 10:37 PM ,staff nurse A: . area remains with [DIAGNOSES REDACTED] and swelling has diminished. Blistered areas have dried blood on the surface noted to have moderated amount sanguineous exudate on discard dressing. 8/4/2018 at 10:18 PM, staff nurse A: . area remains with [DIAGNOSES REDACTED], blistered areas have dried blood on the surface when xeroform dressing removed, the scabbed areas starting bleeding. Pressure applied and bleeding stopped. Noted to have moderate amount sanguineous exudate on discard dressing. 8/5/2018 at 10:33 PM, staff nurse A: resident's outer dressing and pants had dried blood noted on them after her evening meal .Removed ABD pad with blood stains and when the xeroform was removed, scabbed area stated to bleed . 8/6/2018 at 10:28 PM the RNP: RN says has copious drainage is red and swollen wound has now become deeper, with knee warm, red and swollen, serosanguinous drainage has soaked ABD pad in less than 45 minutes. Purulent drainage around edges of dry clots, patient verbalizes pain and guards when area is touched. [MEDICATION NAME] (antibiotic) 100 mg twice a day times seven days ordered by RNP. 8/6/2018 at 11:46 PM, staff nurse F: dressing was changed, moderate amount of bloody drainage on discarded dressing. 8/7/2018 at 11:35 PM,staff nurse A: wound has now become deep with left knee warm, red and swollen. Serosanguinous drainage has soaked ABD pad, purulent drainage around edges of dry clots, large amount of serosanguinous drainage on discard dressing, [DIAGNOSES REDACTED] and swelling extends to calf, area is warm to touch. 8/8/2018 at 1:02 PM,a social worker: started a course of ABX (antibiotics) for soft tissue infection of his/her left knee. S/he was noted by her visitors to be somewhat less animated today . It was also noted that resident has a follow up appointment with orthopedist on 8/10/2018. 8/8/2018 at 2:15 PM, staff nurse B: documented dressing was changed still draining copious amounts of of drainage .Leg is still warm and red around wound. 8/8/2018 at 10:03 PM, the RNP: leg wound/infection with not much improvement, resident subdued, nods when asked if leg hurts. 8/8/2018 at 10:40 PM, staff nurse A: resident's wound has tissue yellow/red in areas, congealed blood intact left knee remains, warm, red, and swollen. Serosanguinous drainage on discard dsg (dressing).Purulent drainage around edges of dry clots . large amt (amount) of serosanguinous dsg on discard dsg. [DIAGNOSES REDACTED] and swelling extends to calf. Area is warm to touch. Will continue to monitor. 8/9/2018 at 1:51 PM,staff nurse B: . top blood clot was off, tissue appears pink with some yellow/greenish drainage noted .surrounding area is still red and warm to touch. 8/9/2018, at 10:18 PM, staff nurse A: .wound with tissue yellow/red in areas, congealed blood intact left knee remains warm, red, and swollen. Moderated amount of serosanguinous exudate on discard dressing, purulent exudate dried around edges of dry blood clots. 8/10/2018 at 7:15 AM, pool nurse G: moderate amount of serosanguinous drainage on the old dressing, wound bed red, edges mildly swollen and surrounding skin reddened. The resident went to scheduled follow up appointment at the orthopedic clinic on 8/10/2018. Review of the staff nurses progress note on 08/10/2018 at 3:22 PM revealed nurse at orthopedic clinic called, resident being admitted to the hospital for infection left knee. Review of the hospital ER physician noted dated 8/10/2018, states in part, upon follow up appointment with orthopedic clinic today resident had a large necrotic wound to the anterior left knee. Arrived at ER for IV antibiotics, admission and surgery, for ulcerated necrotic wound to left anterior knee with surrounding [MEDICAL CONDITION]. She was admitted to the acute care hospital on [DATE], on 08/11/2018 the resident went to the operating room for an Incision and drainage of the left knee. The surveyor interviewed the resident's attending physician on 9/27/2018 at approximately 11:30 AM, relative to the residents care and learned from the physician that she became aware that the resident was admitted to the hospital when she pulled up her list of patients and the residents name was on it. She stated that she was not aware of the condition of the knee, until she saw the pictures in the resident's hospital record. She acknowledged that if she was aware of the condition of the knee, she would have wanted the resident sent for evaluation prior to her scheduled appointment on 8/10/2018. The surveyor interviewed the Director of Nurses on 9/26/2018 at approximately 1:45 PM, relative to the nursing staff reporting changes in condition in the wound status. The DNS stated that the nurses notify the RNP and they follow the orders. She stated that she was unaware of the deterioration and infection in the wound on resident ID # 1, until after the resident had been admitted to the hospital and the resident's doctor had come to speak with her and the administrator about the condition of the resident. The surveyor interviewed the staff nurse, (Staff A) on 9/28/2018 at approximately 3:45 PM, who stated that she had informed the RNP on various dates of the condition of the resident's knee and has asked her to see the resident. She stated that she was following the RNP's orders relative to the wound and administration of medications. When asked if she had notified her Director of Nurses or the resident's attending physician about the wound she replied she had not, that she follows the instructions of the RNP. The surveyor interviewed the staff nurse, (staff B) on 9/28/2018 at approximately 3:30 PM, relative to resident' ID # 1's, left knee, and her documentation on 8/8/2018 and 8/9/2018 where she has recorded large amounts of drainage and purulent drainage, and she stated that she was informed about the drainage from the prior nurse in report. She was not the first nurse to note the copious amounts of drainage or the swelling, so it was not up to her to notify anyone. Additional record review reveals that the weekly skin checks ordered for the resident were only conducted on 7/17/2018. During surveyor interview with the DNS, she was unable to produce evidence that the skin checks were completed as ordered. Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, under section reporting: #2. report other information in accordance with facility policy and professional standards of practice. During surveyor interview with the DNS on 09/27/2018 at approximately 11:45 AM, she acknowledged that the facility policy is to report changes in conditions. The facility failed to ensure that this resident who was admitted with a pressure sore received the appropriate treatment to prevent and promote healing and prevent infection. The wound progressed from a blister which measured 9 cm x 4 cm, to an ulcerated necrotic wound. 2. Record review for resident ID # 7, reveals that he/she was admitted to the facility on [DATE], with a primary [DIAGNOSES REDACTED]. The resident has a Foley catheter and is noted to be incontinent of bowel and wears a brief. Review of the weekly skin check on 9/14/2018 states skin normal, potential breakdown to coccyx/buttocks area. Stage I. Review of the weekly skin check on 9/20/2018 states skin normal no open or pink areas noted. Review of the resident interim care plan dated 9/13/2018, fails to identify the resident at risk for skin breakdown and fails to noted that the resident is incontinent of bowel and uses a brief. On the initial care plan under skin concerns the area is not completed and does not identify the resident to be at risk for skin breakdown, and does not reflect the stage I pressure as noted on the initial skin assessment. Review of the progress notes for 9/25/2018 reveals, .excoriated area on L buttocks 3.4 cm x 1.4 cm, cleansed with sacral Allevyn applied . Review of the physicians orders for 9/25/2018 states, cleanse open area on left buttocks with normal saline and apply sacral Allevyn every 3 days until resolved. An additional physician order on 9/25/2018 states, cleanse open area on left buttocks with normal saline and apply sacral Allevyn PRN if soiled until resolved. On 9/27/2018 at 9:40 AM, during surveyor observation with nurse staff C, when the nurse removed the Allevyn dressing, the resident was noted to have an additional pressure ulcer (stage 2) on the right buttocks which measured 1.2 cm x 1.4 cm. The nurse measured the left pressure to be 2.8 cm x 1.8 cm at this time. Review of the resident's care plan failed to reveal that any interventions were implemented to prevent additional pressure areas or promote healing of the identified pressure on 9/25/2018. The physician's order for the wound treatment is the only intervention. Review of the facilities policy titled Skin Care Policy and Protocol states in part; # 5 all residents identified as at risk for skin breakdown will have immediate plan to reduce the risk based on their individual preferences, choices, routines and condition. The plan may include; pressure relieving mattress and or cushions, keep resident clean and dry, educate resident to reposition self and redistribute weight. Residents weight should be redistributed every 15 minutes while resident is sitting in a chair. # 6. Resident's care plan will reflect resident's most recent condition and treatment interventions. During surveyor interview with the Director of Nurses on 9/27/2018 she was unaware that the resident had a pressure ulcer. Additionally she was unaware that the residents care plan skin concerns section failed to identify any issues with the residents skin or interventions relative to the newly acquired pressures, or that the staff was not following the skin care policy. 3. Record review for resident ID # 8, reveals that he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Skin Care Policy states in part; # 1. all residents will have a skin check assessment done by the household nurse upon move in. # 3. all residents will have a weekly body check Review of the resident's admission body observation dated 5/17/2018 in the section skin, pressure sore it is not completed with a yes or no to pressure sores, it only list no to rashes and identifies an abdominal mole. Review of the residents record on 09/27/2018 fails to reveal any weekly skin checks since the resident was admitted on [DATE]. During surveyor interview with the staff nurse, Staff C on 9/27/2018 at approximately 10:10 AM, she was unable to provide evidence that any of the weekly skin checks had been completed since the resident was admitted to the facility on [DATE]. As defined in Section §483.25(b)(1) Pressure ulcers staging of the Code of Federal Regulations: Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION] (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Review of the record reveals that on 6/20/2018 the resident is noted to have developed a stage 2 blister on the left heel. Treatment orders dated 06/22/2018 were obtained for blue heel protector booties on at bedtime off in the AM, and no sneakers until heel healed and black velcro boots on in AM after breakfast. On 7/1/2018 the resident is noted to have developed a stage 2 new pressure on the right heel. Review of the resident's record reveals that the left heel wound started on 06/20/2018 as a 2 x 2.5 cm stage 2 open blister, and progressed to a 1.6 x 2 cm stage 3 ulcer on 09/20/2018. There are inaccuracies noted in the staging of the wound. The wound is noted to have Necrotic slough or necrotic eschar, which would make the wound unstageable. Examples to follow: 8/3/2018 wound assessment: the left heel measures 3.5 x 3.5 cm 35% yellow slough Stage 3. Under character of wound bed both granulation and Necrotic slough are checked. 9/14/2018 a wound assessment: the left heel wound measures 1.6 cm x 1 cm with 70% slough and 30% [MEDICATION NAME] tissue. Under character of wound bed both [MEDICATION NAME] and Necrotic slough are checked. The wound is staged at a Stage 3. The right heel wound started with a 2 X 2.5 cm fluid filled blister (stage 2) on 07/01/2018 and progressed to a stage 3 wound measuring 1.1 X 0.6 cm which contains 90% yellow slough with 10% granulation tissue by 09/20/2018. There are inaccuracies noted in the staging of the wound. The wound is noted to have Necrotic slough or necrotic eschar, which would make the wound unstageable. Examples to follow: 8/3/2018 a wound assessment: the right heel measures 1.5 x 1.4 cm 100% yellow slough Stage 3. Under character of wound bed both granulation and Necrotic slough are checked. 9/20/2018 a wound assessment: the right heel measures 1.1 x 0.6 cm Stage 3 90% yellow slough with 10% granulation tissue. Under character of wound bed [MEDICATION NAME],granulation, and necrotic eschar are are checked. Under character of wound on the wound assessment dated [DATE] they have indicated that the wound has [MEDICATION NAME],granulation, and necrotic eschar. Review of the resident's physician orders dated 6/22/2018 states no sneakers until heel is healed and black Velcro boots on in the am post breakfast. Blue heel protector booties on QHS ( at hour of sleep bedtime) off in the AM post breakfast. During surveyor observation on 9/27/2018 at approximately 11:05 AM, the resident was observed sitting in the dinning area with slipper socks on without wearing the black boots. The staff nurse, staff C, acknowledged that the resident was not wearing the black boots. At this time Staff C went to the residents room to locate the boots. As she was unable to locate the black boots she asked the NA (nursing assistant) Staff D about the black boots. Staff D was able to locate the black boots but stated that the Staff nurse (staff E) told her over a week ago not to put the black boots on. Review of the residents TAR (treatment administartion record) for (MONTH) (YEAR), reveals that the nurses are signing off every day through 9/27/2018 that the resident has the black boots on after breakfast. Review of the resident's record fails to reveal any communication with the resident's physician to discontinue the use of the black boots. During surveyor interview with the DNS on 9/27/2018 at approximately 11:25 AM, she stated that the nurse, staff C signed off the TAR as she believed the NA has applied the boots as ordered.

Based on record review and staff interview it has been determined that the facility failed to employ nursing staff with the appropriate competencies and skills sets to provide nursing services to assure resident safety and attain or maintain the highest practicable physical, and mental well being for one of one sample residents, resident ID # 1. Findings are as follows: As defined in sec 483.35 Nursing Services of the Federal Code of Regulations for Long Term Care Facilities A key component of competency is a nurse's (CNA, LPN, RN) ability to identify and address a resident's change in condition. Facility staff should be aware of each resident's current health status and regular activity, and be able to promptly identify changes that may indicate a change in health status. Once identified, staff should demonstrate effective actions to address a change in condition, which may vary depending on the staff who is involved an RN who is informed of a change in condition may conduct an in-depth assessment, and then call the attending practitioner. Resident ID #1 was admitted to the facility on [DATE] from the acute care hospital, after a fall during which she sustained an injury to her left knee. Upon admission the resident had [DIAGNOSES REDACTED]. Left knee pain due to avulsion (tearing) injury to PCL (posterior crutiate ligament) and a blister on the left knee, which was in an immobilizer. During the course this resident's 24 day stay at the facility, where he/she was admitted for skilled service for therapy and nursing care, related to the condition of the residents injury to the left knee revealed the following. A review of the nursing progress notes, that were documented by a minimum of eight nurse and one Registered nurse practicitioner (RNP), revealed the resident was admitted with a blister to the knee which progressed to a large infected necrotic wound that required hospitalization and surgery. Record review of Resident ID #1 on 07/17/2018, a blister L (left) knee which measures 9 cm x 4 cm intact, multiple bruises, and that left knee is swollen, warm to the touch. The blister is intact, covered with ADB (abdominal) pad , f/b (followed by) ace wrap and knee immobilizer. During nursing observations of the residents left leg and wound status during dressing changes, it is noted that the blisters had broken, the redden area had extended, the wound developed drainage which progressed from a small amount of sanguinous to copious amounts including purulent drainage. The notes reveal that the resident complains of increase pain and tenderness when the dressing is changed and the redden area has extended to the resident's calf. On 8/6/2018 the note reveals the knee wound has copious drainage and is red and swollen. wound has now become deeper, with knee warm, red and swollen, serosanguinous drainage has soaked ABD pad in less than 45 minutes. Purulent drainage around edges of dry clots, patient verbalizes pain and guards when area is touched. Seen by the RNP and [MEDICATION NAME] (antibiotic) 100 mg twice a day times seven days was ordered. On 8/7/2018 the nurse notes the wound has now become deep with left knee warm, red and swollen. Serosanguinous drainage has soaked ABD pad, purulent drainage noted, and [DIAGNOSES REDACTED] and swelling extends to calf. On 8/8/2018 the RNP's note reveals she was asked to see resident, leg wound/infection with not much improvement. On 8/8/2018 an additional note by a different nurse, notes wound has tissue yellow/red in areas, left knee remains, warm, red, and swollen with large amount of serosanguinous and purulent drainage,with [DIAGNOSES REDACTED] and swelling extending to calf. Area is warm to touch. On 8/10/2018 a nurses note reveals, moderate amount of serosanguinous drainage on the old dressing, wound bed red, edges mildly swollen and surrounding skin reddened. The resident went to scheduled follow up appointment at the orthopedic clinic on 8/10/2018, and was sent directly to the hospital for admission, IV antibiotics and surgery for [REDACTED]. The surveyor interviewed the resident's attending physician on 9/27/2018 at approximately 11:30 AM, relative to the residents care and learned from the physician that she became aware that the resident was admitted to the hospital when she pulled up her list of patients and the residents name was on it. She stated that she was not aware of the condition of the knee, until she saw the pictures in the resident's hospital record. She acknowledged that if she was aware of the condition of the knee, she would of wanted the resident sent for evaluation prior to her scheduled appointment on 8/10/2018. The surveyor interviewed the Director of Nurses on 9/26/2018 at approximately 1:45 PM, relative to the nursing staff reporting changes in condition in the wound status and she stated that the nurses notify the RNP and they follow the orders. She stated that she was unaware of the deterioration and infection in the wound on resident ID # 1, until after the resident had been admitted to the hospital and the resident's doctor had come to speak with her and the administrator about the condition of the resident upon admission to the hospital. The surveyor interviewed the staff nurse, (Staff A) on 9/28/2018 at approximately 3:45 PM, who stated that she had informed the RNP on various dates of the condition of the resident's knee and has asked her to see the resident. She stated that she was following the RNP's orders relative the wound and administration of medications. When asked if she had notified her Director of Nurses or the resident's attending physician if she was concerned about the wound she replied she had not, that she follows the instructions of the RNP. The surveyor interviewed the staff nurse, ( staff B) on 9/28/2018 at approximately 3:30 PM, relative to resident' ID # 1's, left knee, and her documentation on 8/8/2018 and 8/9/2018 where she has recorded large amounts of drainage and purulent drainage, and she stated that she was informed about the drainage from the prior nurse in report, she was not the first nurse to note the copious amounts of drainage or the swelling, so it was not up to her to notify anyone. Although the nurses notes reveal changes in condition of the resident and the knee wound status the facility was unable to provide evidence that once the nursing staff had identified the wound deterioration/ infection they failed to demonstrate effective actions to address a change in condition were implemented by not notifying the physician and the Director of Nurses. Refer to F 686

Based on record review and staff interview it has been determined that the facility failed to immediately inform the resident; consult with the resident's physician; and notify, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 sample residents (Resident ID # 1). Findings are as follows: During a complaint investigation of allegations of poor quality of care and failure to notify the residents representative and physician of changes in condition the following were reviewed. Resident ID #1 was admitted to the facility on [DATE] from the acute care hospital, after a fall during which she sustained an injury to her left knee. Upon admission the resident had [DIAGNOSES REDACTED]. Left knee pain due to avulsion (tearing) injury to PCL (posterior crutiate ligament) and a blister on the left knee, which was in an immobilizer. During the course this resident's 24 day stay at the facility, where he/she was admitted for skilled service for therapy and nursing care, related to the condition of the residents injury to the left knee revealed the following. A review of the nursing progress notes, revealed the resident was admitted with a blister to the knee which progressed to a large infected necrotic wound that required hospitalization and surgery. The admission nursing note, dated 7/17/2018 at 11:45 PM states resident has multiple bruises, and also states left knee is swollen, warm to the touch, has a 9 cm x 4 cm fluid filled blister intact, covered with ADB (abdominal) pad , f/b (followed by) ace wrap and knee immobilizer. Social worker note from the care planning meeting on 8/8/2018 at 1:02 PM, states, started on course of antibiotics for soft tissue infection of her left knee. It was also noted at the meeting by her visitors for the resident to be somewhat less animated today. There is no documentation during the care plan meeting, which is held to review and update the patient and their representative of the residents status and condition, that the changes in the condition of the knee wound, the large amounts of drainage and the increase in the redness and swelling were communicated to the residents representative or the attending physician. Additionally during the care plan meeting, it was discussed that the resident still needs to wear the knee immobilizer, however she has a Orthopedic follow up appointment on 8/10/2018, and it is hoped that the immobilizer will be discontinued. During this meeting there lacks evidence of a discussion of sending the resident to be evaluated for the declining condition of the knee wound prior to her scheduled appointment on 8/10/2018. Although the nurses progress notes continued to reveal an increase in drainage including now purulent drainage, swelling and redness extending to the calf the record lacks evidence of any communication or notification of the condition to the residents representative or physician . After review of the residents records and interviews with the staff and the residents physician, it was revealed that the facility failed to notify the physician of the changes in the residents condition and subsequent admission to the hospital. (see interview with physician). The residents representative were not aware of the significant change in the residents condition by the facility and learned of the condition of the knee during the ortho appointment. Review of the hospital ER physician note dated 8/10/2018, states in part, upon follow up appointment with orthopedic clinic today resident had a large necrotic wound to the anterior left knee. Arrived at ER for IV antibiotics, admission and surgery, for ulcerated necrotic wound to left anterior knee with surrounding [MEDICAL CONDITION]. The surveyor interviewed the Director of Nurses on 9/26/2018 at approximately 1:45 PM, relative to the nursing staff reporting changes in condition in the resident and the wound status and she stated that the nurses notify the RNP and they follow the orders. She stated that she was unaware of the deterioration and infection in the wound until after the resident had been admitted to the hospital and the resident's doctor had come to speak with her and the administrator about the condition of the resident upon admission to the hospital. Additionally, she was unable to provide evidence that the facility had notified the attending physician or the resident's representative of the residents deteriorating condition. Refer to F 686 and F 726