Every finding on record at Village House Nursing & Rehabilitation Center

Based on surveyor observation, record review, and staff interview, the facility failed to ensure that food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the main kitchen.Findings are as follows:1. Review of the Food and Drug Administration (FDA) Food Code 2022 Edition, Section 5-202.13 states in part, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE .may not be less than 25mm [millimeter] (1 inch).During a surveyor observation on 3/9/2026 at approximately 9:30 AM, of the main kitchen during the initial walk through, in the presence of Cook, Staff H, the ice machine did not have a one-inch air gap, as required.During a surveyor interview immediately following the above observation with Staff H, he acknowledged that the ice machine did not have a one-inch air gap. 2. Review of the FDA Food Code 2022 Edition, Section 6-305.11(B) states in part, .lockers or other suitable facilities shall be provided for the orderly storage of EMPLOYEES' .possessions.During a surveyor observation on 3/9/2026 at approximately 9:30 AM, of the main kitchen during the initial walk through, in the presence of Staff H, a cell phone and portable speaker were observed lying on top of a food preparation worktable.During a surveyor interview immediately following the above observation with Staff H, he acknowledged the cell phone and portable speaker on the food preparation worktable. During a surveyor interview on 3/9/2026 at 12:48 PM with the Food Service Director, he acknowledged that the ice machine did not have an air gap, as outlined in the FDA Food Code. Additionally, he acknowledged that staff's personal possessions should not be stored on food preparation areas.

Based on clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who was treated with antibiotics for infected heel wounds, Resident ID #3.Findings are as follows:1. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.Record review revealed the resident was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, pressure ulcer of the right and left heels.a. Record review revealed the following progress notes:-2/4/2026 at 4:45 PM: The resident's bilateral heel wounds were noted to be tender, reddened, and had a foul odor. Additionally, the resident's physician ordered wound cultures to be obtained.-2/8/2026 at 3:55 PM: The resident's wound cultures were positive for an infection and the resident's provider ordered two oral antibiotics, ciprofloxacin 250 milligrams (mg) twice daily for ten days and metronidazole 250 mg three times daily for ten days.Record review revealed the physician's order for metronidazole 250 mg was incorrectly transcribed to be administered twice daily, instead of three times daily.Review of the February 2026 Medication Administration Record (MAR) revealed the resident was administered only 20 doses of the metronidazole 250 mg due to the transcription error, rather than the 30 doses as intended.During a surveyor interview on 3/12/2026 at 10:47 AM with the Unit Manager, Registered Nurse, Staff E, she acknowledged that the metronidazole 250 mg order was incorrectly transcribed to be administered twice daily, rather than the 30 doses as intended.During a surveyor interview on 3/12/2026 at 11:09 AM with the resident's Physician, he revealed that the metronidazole 250 mg order should have been transcribed to be administered three times daily, as that is the typical treatment course.b. Review of a progress note dated 2/10/2026 at 5:33 PM revealed that the resident's provider ordered an additional antibiotic, metronidazole 500 mg to be sprinkled directly onto the right and left heel wounds.Review of an undated document titled, Physician Information Sheet revealed to administer metronidazole sprinkles for 14 days.Review of a physician's order dated 2/10/2026 revealed to sprinkle metronidazole 500 mg to both heel wounds once a day. Additionally, the order was discontinued on 2/23/2026.Review of the February 2026 MAR revealed the resident was administered 13 total doses of the metronidazole 500 mg sprinkles, rather than the 14 doses as intended.During a surveyor interview on 3/12/2026 at 10:47 AM with Staff E, she revealed that the metronidazole 500 mg was ordered to be administered once daily for 14 days and acknowledged that the resident only received 13 of the 14 doses.During a surveyor interview on 3/12/2026 at 12:25 PM with the Director of Nursing Services, she was unable to provide evidence that the resident was kept free from significant medication errors.Cross reference F 842 and F 881

Based on surveyor observation, clinical record review and staff interview, the facility failed to meet professional standards of quality related to following physician's orders for 1 of 1 resident reviewed with an order for a cervical collar, Resident ID #11, for 1 of 1 resident reviewed with an order for no straws, Resident ID #70 and for 2 of 2 residents reviewed for non-pressure wounds, Resident ID #s 88 and 98.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .1. Record review revealed Resident ID #11 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, Parkinson's disease (a progressive neurological disorder that primarily affects movement), scoliosis (a condition characterized by an abnormal side to side curvature of the spine), and abnormal posture.Record review revealed a physician's order with a start date of 10/10/2025 for a cervical collar to be applied when out of bed and remove at 3:00 PM as tolerated by the resident. Further review of the order revealed the collar is to be applied daily with a start time of 7:00 AM and an end time of 3:00 PM. This order was discontinued on 3/11/2026.Further review of the physician's orders revealed the following orders dated 3/11/2026:-Apply cervical collar as tolerated between 5:00 AM to 7:00 AM-Remove cervical collar between 3:00 PM to 4:00 PMDuring surveyor observations on 3/10/2026, the resident was observed without his/her cervical collar in place at 9:11 AM, 9:31 AM, 9:44 AM and 10:35 AM.During a surveyor interview on 3/10/2026 at 10:36 AM, the resident stated that staff had not offered or applied his/her cervical collar and expressed a desire to wear it.During a surveyor interview on 3/10/2026 at 10:39 AM with Licensed Practical Nurse, Staff A, she acknowledged that the collar was not applied to the resident and when the nurse went to put the collar on, the resident stated, I'd be delighted if you put it on.During a surveyor interview on 3/10/2026 at 12:51 PM, with the Director of Nursing Services (DNS), she was unable to provide evidence that the cervical collar was applied as ordered.During an additional surveyor observation on 3/12/2026 at 8:46 AM, the resident was observed without his/her cervical collar in place. 2. Record review revealed Resident ID #70 was readmitted to the facility in February of 2026 with diagnoses including, but not limited to, cerebral infarction (stroke) and dysphagia (difficulty swallowing). Further review revealed the resident is receiving hospice services.Record review indicated that the resident was evaluated by a hospice nurse on 2/28/2026, who recommended modifying the diet to ground solids with nectar-thickened liquids, no use of straws, teaspoon-only intake, and one-to-one staff assistance.Record review revealed a physician's order dated 3/4/2026 for a house diet, ground consistency, nectar thick liquid and special instructions which include extra gravy and no straws.During a surveyor observation on 3/9/2026 at approximately 10:00 AM, Resident ID #70 was noted to have cups of thickened juice and thickened water, both with straws in them, on his/her bedside table.During a surveyor observation on 3/9/2026 at approximately 1:00 PM, Resident ID #70 was being assisted with lunch by Nursing Assistant, Staff C, and a straw was observed to be in the resident's drink.During a surveyor interview on 3/9/2026 at 1:14 PM, with Staff C, she acknowledged assisting the resident with his/her lunch meal today and the day before. She acknowledged the resident had a straw in his/her cup and when asked by the surveyor if the resident was allowed to use a straw, she responded yes and indicated the resident likes to use them.During a surveyor interview on 3/11/2026 at 12:43 PM, with the DNS, she revealed that she would expect the resident's diet order, which includes no straws, to be followed by staff.3. Record review revealed Resident ID #88 was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, mild cognitive impairment.Review of a care plan focus area initiated on 11/24/2025, revealed the resident is at risk for skin breakdown due to increased age and mild cognitive impairment.Record review revealed a progress note dated 3/6/2026 which revealed the resident sustained a 3.5-centimeter skin tear on the top of his/her right hand and a new order was obtained from the provider to cleanse skin tear with vashe (a wound cleanser) every day and cover with optifoam (a foam dressing for wound care).Record review revealed a physician's order dated 3/7/2026 to wash the skin tear on the top of the right hand with normal saline daily and apply optifoam until resolved.Review of the March 2026 Treatment Administration Record revealed the above order was documented as being completed on 3/8/2026, by RN, Staff D.During a surveyor observation on 3/9/2026 at 10:02 AM, the resident was noted to have an optifoam bandage on the top of his/her right hand, dated 3/7. The bandage appeared soiled with a dark discoloration visible through the bandage.During a surveyor interview on 3/9/2026 at 11:07 AM, with RN, Unit Manager, Staff E, she acknowledged the resident's bandage was dated 3/7. During a surveyor interview on 3/10/2026 at 12:43 PM, with the DNS, she revealed that she would expect wound treatments to be completed, as ordered.4. Record review revealed Resident ID #98 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, aftercare following joint replacement surgery.Review of an admission assessment dated [DATE] revealed the resident had a skin tear to his/her right upper arm.Review of a skin check dated 3/8/2026 revealed the resident had an abrasion to his/her right upper arm.During a surveyor observation on 3/9/2026 at 11:52 AM, Resident ID #98 was noted to have a 4 x 4 adhesive dressing to his/her upper right arm, dated 3/7.Record review failed to reveal evidence of a physician's order to change the resident's dressing to his/her upper right arm.During a surveyor observation and interview on 3/10/2026 at 9:41 AM, with RN, Staff F, she acknowledged Resident ID #98's dressing to his/her right upper arm dated 3/7 and acknowledged that there was not a physician's order in place to change the resident's dressing.During a surveyor interview on 3/10/2026 at 1:50 PM with the DNS, she was unable to provide evidence of a Physician's order for the treatment of Resident ID #98's right upper extremity skin tear.During a surveyor interview on 3/12/2026 at 12:07 PM, with RN, Staff G, she revealed that she had completed the resident's admission skin check and acknowledged the resident had the bandage on his/her right upper arm. She revealed that she had entered his/her admission orders but revealed that she did not call the provider to obtain an order to change the bandage to his/her right upper arm.Cross Reference: F 842

Based on record review, surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 resident observed with medications at the bedside, Resident ID #9 and for 1 of 2 medication rooms observed during the medication storage task.Findings are as follows:Record review of a facility policy titled, Medication Storage states in part, .It is the policy of this facility that medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations.to support safe effective drug administration.medications are stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 1. During surveyor observations of Resident ID #9, s/he was observed with one bottle of AREDS (an eye vitamin) and one 16-ounce bottle of chlorhexidine mouthwash (an antibacterial mouthrinse) on his/her bedside table on the following dates and times:3/9/2026 at approximately 1:00 PM3/9/2026 at 2:38 PM3/10/2026 at 9:27 AMDuring a surveyor interview on 3/10/2026 at 9:27 AM with Registered Nurse (RN), Staff F, she acknowledged that Resident ID #9 had the AREDS and Chlorhexidine mouthwash on his/her the bedside table and acknowledged that the medications should not have been stored at the bedside.2. During a surveyor observation on 3/10/2026 at 12:30 PM of the Specialty Care Unit medication refrigerator in the presence of RN, Staff B, revealed the following medications:one 30 milliliter (ml) bottle of Ativan Intensol concentrate (a medication prescribed to treat anxiety), opened and undated.one 30 ml bottle of Ativan Intensol concentrate, opened and undated.Record review of the manufacturer's instructions revealed that in-use (opened) Ativan should be discarded after 90 days.one bottle of tuberculin purified protein solution (a solution used as a diagnostic tool to determine if a person is infected with Tuberculosis- a lung infection) opened, undated and in use.Record review of the manufacturer's instructions revealed that in-use (opened) tuberculin solution should be discarded after 30 days.During a surveyor interview immediately following the above observation, RN, Staff B, acknowledged that the Ativan and the tuberculin purified protein solution were opened, undated and in use.During surveyor interviews on 3/10/2026 at 1:50 PM and 3/11/2026 at 12:43 PM with the Director of Nursing Services, she acknowledged that Resident ID #9 should not have medications at his/her bedside. Additionally, she was unable to provide evidence that the facility ensured storage of drugs and biologicals in accordance with currently accepted professional principles and per the facility policy.

Based on surveyor observation, clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented, for 1 of 1 resident reviewed who was treated with an antibiotic for infected heel wounds, Resident ID #3 and for 1 of 2 residents reviewed for a non-pressure wound, Resident ID #88.Findings are as follows:1. Record review revealed the resident was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, pressure ulcer of the right and left heels.Record review revealed the resident had wound cultures obtained of his/her right and left heel wounds.Review of a progress note dated 2/8/2026 at 3:55 PM revealed that the resident's wound cultures were positive for infectious organisms and the resident's provider ordered two oral antibiotics, ciprofloxacin 250 milligrams (mg) twice daily for ten days and metronidazole 250 mg three times daily for ten days.Record review revealed the physician's order for metronidazole 250 mg was incorrectly transcribed to be administered twice daily, instead of three times daily.Review of the February 2026 Medication Administration Record (MAR) revealed the resident was administered only 20 doses of the metronidazole 250 mg due to the transcription error, rather than the 30 doses as intended.During a surveyor interview on 3/12/2026 at 10:47 AM with the Unit Manager, Registered Nurse (RN), Staff E, she acknowledged that the metronidazole 250 mg order was incorrectly transcribed to be administered twice daily instead of three times daily for ten days.During a surveyor interview on 3/12/2026 at 11:09 AM with the resident's Physician, he revealed that the metronidazole 250 mg order should have been transcribed to be administered three times daily, as that is the typical treatment course.During a surveyor interview on 3/12/2026 at 12:25 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the resident's metronidazole 250 mg order was accurately transcribed. 2. Record review revealed Resident ID #88 was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, mild cognitive impairment.Record review revealed a progress note dated 3/6/2026 which revealed the resident sustained a 3.5-centimeter skin tear on the top of his/her right hand and a new order was obtained from the provider to cleanse the skin tear with vashe (a wound cleanser) every day and cover with optifoam (a foam dressing for wound care).Record review revealed a physician's order dated 3/7/2026 to wash the skin tear on the top of the right hand with normal saline daily and apply optifoam until resolved.Review of the March 2026 Treatment Administration Record revealed the above order was documented as being completed on 3/8/2026, by RN, Staff D.During a surveyor observation on 3/9/2026 at 10:02 AM, the resident was noted to have an optifoam bandage on the top of his/her right hand, dated 3/7. The bandage appeared soiled with a dark discoloration visible through the bandage.During a surveyor interview on 3/9/2026 at 11:07 AM, with RN, Unit Manager, Staff E, she acknowledged the resident's bandage was dated 3/7. Surveyor interviews were attempted with RN, Staff D on 3/10/2026 at 11:11 AM, 11:47 AM and on 3/12/2026 at 11:14 AM, but voicemails were unable to be left, and a return call was not received.During a surveyor interview on 3/10/2026 at 12:43 PM, with the DNS, she revealed that she would expect wound treatments to be completed, as ordered. Further, she revealed that she would expect the nurses to only sign off on treatments they complete themselves.Cross Reference: F 658, F 760 and F 881.

Based on clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program 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 5 residents reviewed for antibiotic use, Resident ID #s 2 and 3.Findings are as follows:Review of a facility policy titled, Antibiotic Stewardship Program, last reviewed 12/31/2024, states in part, It is the policy of this facility to recognize the need to monitor antibiotic use in order to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The antibiotic stewardship program is directed toward the correct use of an antibiotic- the five D's.the right dose, the duration.1. Record review revealed Resident ID #3 was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, pressure ulcer of the right and left heels.Record review revealed the following progress notes:2/4/2026 at 4:45 PM: The resident's bilateral heel wounds were noted to be tender, reddened, and had a foul odor. Additionally, the resident's physician ordered wound cultures to be obtained.2/8/2026 at 3:55 PM: The resident's wound cultures were positive for infection and the resident's provider ordered two oral antibiotics, ciprofloxacin 250 milligrams (mg) twice daily for ten days and metronidazole 250 mg three times daily for ten days.2/10/2026 at 5:33 PM: The resident's provider ordered an additional antibiotic, metronidazole 500 mg to be sprinkled directly onto the right and left heel wounds.1a. Additional record review revealed the physician's order for metronidazole 250 mg was incorrectly transcribed to be administered twice daily, instead of three times daily, as indicated in the progress note.Review of the February 2026 Medication Administration Record (MAR) revealed the resident was administered only 20 doses of the metronidazole 250 mg due to the transcription error, rather than receiving 30 doses as intended. 1b. Review of a physician's order dated 2/10/2026 revealed to sprinkle metronidazole 500 mg to both heel wounds once a day. Additionally, the order was discontinued on 2/23/2026.Review of the February 2026 MAR revealed the resident was administered 13 total doses of the metronidazole 500 mg sprinkles instead of receiving the ordered 14 doses.Record review failed to reveal evidence that the three above-mentioned antibiotics were monitored or re-evaluated to ensure accuracy and the appropriateness for use.2. Record review revealed Resident ID #2 was readmitted to the facility in December of 2025 with a diagnosis including, but not limited to, acute kidney failure.Review of a progress note dated 2/14/2026 at 1:02 PM revealed the provider ordered the resident to start Augmentin (an antibiotic) twice daily for seven days for a urinary tract infection.Review of the February 2026 MAR revealed the resident was administered 15 doses of the Augmentin, instead of receiving 14 doses, as ordered.Record review revealed an Appropriateness of Antibiotics Assessment was completed on 2/16/2026 for Augmentin. Additionally, the assessment failed to identify that the duration of the Augmentin was incorrect leading to the resident receiving an extra dose.During surveyor interviews on 3/12/2026 at 12:25 PM and approximately 1:45 PM with the Director of Nursing Services, she acknowledged Resident ID #3's three antibiotics were not re-evaluated and should have been. Additionally, she was unable to provide evidence that the incorrect duration of Resident ID #2's antibiotic was identified despite completing the assessment for it.Cross reference F760 and F842

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 and 1 of 2 nourishment areas observed. Findings are as follows: 1. Review of the Rhode Island Food Code, 2018 Edition, section ,d+[DATE].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 [DATE] at approximately 9:00 AM, in the presence of the Food Service Director (FSD), the dry storage area of the kitchen contained the following: -One bottle of Hershey's syrup opened and undated. Manufacturer's instructions on the bottle state to refrigerate after opening. During the initial tour of the main kitchen on [DATE] at approximately 9:00 AM, in the presence of the FSD, the walk-in freezer contained the following: -One box of fish cakes with both the box and the inside bag open and undated, exposing approximately 8 fish cakes. During a surveyor interview on [DATE] with the FSD at the time of the above observation, she acknowledged that the open bottle of Hershey's Syrup should have been stored in the refrigerator. She further revealed that the fish cakes should have been resealed and dated when opened. 2. Record review of the Rhode Island Food Code, 2018 Edition, section ,d+[DATE].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 [DATE] at approximately 9:00 AM, in the presence of the FSD, the walk-in freezer contained the following: -The fan unit inside of the freezer had frozen drips of ice hanging down. -One box of grilled chicken breast, that was positioned under the fan unit had an accumulation of ice on the top of the box. -One box of turkey breast roasts, was being stored directly on the floor of the freezer. -One box of [NAME] frozen baked golden buttermilk biscuits, was being stored directly on the floor of the freezer. During a surveyor interview on [DATE] with the FSD at the time of the above observations, she acknowledged that the fan unit and the box of grilled chicken breast had an accumulation of ice. She further acknowledged that the box of turkey breast roasts and the box of biscuits should not have been stored directly on the floor of the freezer. During a surveyor observation of the second-floor nourishment area in the presence of the FSD on [DATE] at approximately 10:45 AM, the following was observed: -The microwave was noted to have a moderate accumulation of dried orange and yellow matter on the glass turntable. During a surveyor interview with the FSD immediately following the above observation, she acknowledged that the microwave was dirty and needed to be cleaned. 3. The Rhode Island Food Code 2018 Edition ,d+[DATE].17 states in part, food shall be discarded .and may not exceed a manufacturer's use by date . During a surveyor observation of the second-floor nourishment area in the presence of the FSD on [DATE] at approximately 10:45 AM, revealed five 8-ounce bottles of Ensure high protein nutritional shakes with expiration dates of June of 2024. During a surveyor interview with the FSD, at the time of the above observation, she acknowledged that the bottles of Ensure were expired and should have been discarded.

Based on record review and staff interview, it has been determined that the facility failed to implement comprehensive person-centered care plans for each resident, for 2 of 2 residents reviewed with indwelling urinary catheters (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 33 and 38. Findings are as follows: 1. Record review revealed Resident ID #38 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, cutaneous vesicostomy (an opening is created in the belly, through which urine can continuously pass). Record review revealed the resident has a supra pubic catheter (a thin tube used to drain urine from the bladder). Review of the resident's care plan dated 11/21/2024, revealed the resident requires an indwelling urinary catheter due to obstructive uropathy and neurogenic bladder (bladder dysfunction caused by damage to the nervous system) with interventions including, but not limited to, monitor urinary output and report abnormal findings. Further record review failed to reveal evidence that the urinary output for Resident ID #38 was monitored on the following dates and times: 12/21/2024 7:00 AM to 3:00 PM 12/23/2024 11:00 PM to 7:00 AM 12/24/2024 11:00 PM to 7:00 AM 12/25/2024 3:00 PM to 11:00 PM 12/28/2024 7:00 AM to 3:00 PM 12/28/2024 3:00 PM to 11:00 PM 12/28/2024 11:00 PM to 7:00 AM 12/29/2024 7:00 AM to 3:00 PM 12/29/2024 3:00 PM to 11:00 PM 12/29/2024 11:00 PM to 7:00 AM 1/1/2025 7:00 AM to 3:00 PM 1/1/2025 11:00 PM to 7:00 AM 1/2/2025 7:00 AM to 3:00 PM 1/4/2025 7:00 AM to 3:00 PM 1/7/2025 7:00 AM to 3:00 PM During a surveyor interview on 1/8/2025 at 2:56 PM with License Practical Nurse, Staff A, she was unable to provide evidence that Residents ID #38's output was monitored on the above-mentioned dates and times. 2. Record review revealed Resident ID #33 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, urinary retention. Review of the resident's care plan dated 8/7/2024, revealed the resident requires an indwelling urinary catheter due to obstructive uropathy (a condition where a blockage hinders urine flow through the urinary system) with interventions including, but not limited to, monitor urinary output and report abnormal findings. Further record review failed to reveal evidence that the urinary output for Resident ID #33 was monitored on the following dates and times: 1/4/2025 7:00 AM to 3:00 PM 1/4/2025 3:00 PM to 11:00 PM 1/4/2025 11:00 PM to 7:00 AM 1/5/2025 11:00 PM to 7:00 AM 1/6/2025 11:00 PM to 7:00 AM 1/7/2025 7:00 AM to 3:00 PM 1/8/2025 7:00 AM to 3:00 PM During surveyor interviews on 1/8/2025 at 3:18 PM and on 1/9/2025 at 10:18 AM with the Director of Nursing Services, she was unable to provide evidence that Resident ID #s 33 and 38 care plans were implemented related to monitoring urinary output.

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 Enhanced Barrier Precautions (EBP; involves using a gown and gloves during high-contact resident care activities), for 1 of 2 wound treatments observed, involving Resident ID #38. Findings are as follows: Review of a facility policy titled, Guidelines for Management of MDROs [Multidrug Resistant Organism] states in part, .Enhanced Barrier Precautions - it has been determined by the CDC [Centers for Disease Control and Prevention] that focusing on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time (e.g., months) and result in the silent spread of MDROs. Enhanced Barrier Precautions .requires gown and gloves for certain residents (those with existing MDROs, colonization of MDROs or those residents in close physical vicinity of those residents) during specific high contact care activities that have been found to increase the risk for MDRO transmission .Caring for a Resident with a MDRO .Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] beyond situations in which exposure to blood and body fluids is anticipated and refers to gown and glove use during high contact with high risk residents for resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of resident care activities requiring gown and glove use for Enhanced Barrier Precautions include .Device care or use .Wound care: any skin opening requiring a dressing . Record review revealed the resident was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, cutaneous vesicostomy (an opening is created in the belly, through which urine can continuously pass). Record review revealed a physician order dated 10/28/2024 for EBP relative to the resident's suprapubic catheter (SPC; a flexible plastic tube inserted into the bladder via a surgical opening in the abdomen). Further record review revealed a physician order dated 12/31/2024 to apply optifoam (a foam dressing used for wound care) to the resident's buttocks, once daily, every three days, related to moisture associated skin damage. During a surveyor observation on 1/9/2025 at 9:25 AM, Registered Nurse, Staff B and Licensed Practical Nurse, Staff A, were observed providing wound care to the resident without wearing a gown. During a surveyor interview on 1/9/2025 at 9:30 AM, with Staff A and B, they acknowledged that they did not wear a gown during the resident's dressing change and indicated a gown is only necessary when touching the resident's SPC. During a surveyor interview with the Director of Nursing Services on 1/9/2025 at 9:30 AM, she revealed that she would expect staff to wear gloves and a gown when providing wound care to a resident who is on EBP.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's environment remains as free from accident hazards as possible, relative to the implementation of an intervention indicated on the Safe Resident Handling document, for 1 of 2 residents reviewed who had sustained a fracture while in the facility, Resident ID #1. Findings are as follows: According to an article published by STATPEARLS found in the National Library of Medicine National Center for Biotechnology Information titled, Avulsion Fractures, last updated on 8/7/2023, states in part, .Pathophysiology .An avulsion fracture occurs when a ligament or other soft tissue attachment to bone overcomes the stress capacity of the bony attachment and tears off a portion of the bone. This usually occurs with forces applied from trauma . Record review of a facility reported incident received by the Rhode Island Department of Health on 7/28/2024, revealed in part, .x-ray returned of left femur with positive fracture . Review of a written statement dated 7/29/2024, authored by NA, Staff B, stated after putting [the resident] to bed, I found [him/her] in the crack of the bed between the wall and the bed. I moved [him/her] to the center of the bed and left for the night. (Reported the resident was found between the wall and the bed to the nurse) Record review of a document titled Safe Resident Handling dated 6/11/2024, the safety and quality tool revealed the resident requires substantial/maximum assistance to roll left to right and right to left in bed, transition from sitting to lying in bed and from lying in bed to a sitting position on the edge of the bed, assistance needed to aid in transitions from a sitting position to standing and transfers. The document further indicated, that based on the resident's required assistance calculated using the safety and quality tool found on the Safe Resident Handling document, the amount of care giver assistance necessary to perform the above-mentioned tasks, which includes bed mobility, for this resident is the Assist of 2. Record review of a document provided to Nursing Assistants (NAs) that indicates each residents' necessary level of assistance required for care, titled 1st FLOOR/LIST 2/ CARE PLAN, dated 7/26/2024, fails to address how the residents are able to move in bed, the level of assistance needed, or the required number of staff needed for assistance with bed mobility for 14 of the 15 residents that reside on Resident ID #1's unit, including Resident ID #1. During a surveyor interview on 8/6/2024 at 12:10 PM with the Administrator, she acknowledged that Staff B was not assisted by another staff member when she had repositioned the resident after finding him/her wedged between the bed and the wall. Additionally, she was unable to provide evidence that the injury was not a result of this incident. Record review revealed Resident ID #1 was admitted to the facility in November 2021 with diagnoses including, but not limited to, Alzheimer's disease, vitamin D deficiency, and heart failure. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident requires Substantial [and/or] maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for rolling left and right in bed, sitting up from the lying position, and for sitting on the side of the bed to lying down flat on the bed. Record review of a care plan dated 9/28/2023 reveals a focused care area for activities of daily living (ADL) indicating the resident is not independent with care due to advancing Alzheimer's disease, impaired mobility, and strength, with an approach that includes s/he is to be extensively assisted with bed mobility. Record review of the progress notes revealed the following: - 7/26/2024 at 4:54 PM, the resident complained of discomfort in his/her left leg and hip, left leg was noted with internal rotation and difficulty noted with straightening leg, and pain noted with palpitations. The resident was also noted with several new bruises that were reported by a Nursing Assistant (NA), on 7/25/2024. Bruising and a skin tear were noted on his/her left hand, a bruise on his/her left forearm, a faint bruise noted on his/her left cheek and a black and blueish bruise on the back of his/her left knee and upper leg. -7/27/2024 at 11:20 AM, an x-ray was performed at the facility on 7/26/2024 and the results showed that the resident had an acute fracture of the proximal left femur with avulsion of the lesser trochanter. Additionally, the note indicates that the resident was found on evening rounds on 7/24/2024 to be positioned with the left side of his/her body wedged between the bed and the wall. The NA,Staff B, indicated that she alone repositioned the resident back to the center of the bed at that time. -7/27/2024 at 12:50 PM, the resident's son was informed of the x-ray results and indicated he did not want the resident to be sent to the hospital. He requested for Resident ID #1 to remain in the facility and receive pain management there. A new order was obtained for Roxanol (Morphine; an opioid medication used to relieve moderate to severe pain) 20 milligrams (mg) per milliLiter (mL), give 0.25 mL every four hours as needed for pain was ordered. -7/27/2024 at 6:47 PM, the first dose of morphine was obtained from the emergency kit and given to the resident for his/her comfort. -7/28/2024 at 6:09 AM, the resident did not display any non-verbal signs of pain. Morphine was administered for comfort and pain control. The resident was responsive to verbal and physical stimuli and was speaking in word salad (a jumble of extremely incoherent speech), as is his/her baseline. -7/28/2024 at 4:51 PM, the resident continues to speak in word salad, received morphine twice for non-verbal signs and symptoms of pain. S/he was moaning, grimacing and restless. Pain medication was effective. -7/28/2024 at 7:49 PM, the resident refused all food, drinks and supplements. Morphine was given with good effect. -7/29/2024- no documented progress notes found in the resident's record for this date. -7/30/2024 at 4:38 AM, the resident was in bed noted to be grimacing during the night. Morphine was administered with good effect. Resident is responsive to verbal and physical stimuli. -7/30/2024 at 10:25 AM, the resident was noted with congestion and coughing. S/he had frothy sputum on his/her chest and bedding. His/her diet order was downgraded to puree, was previously on a mechanical soft diet, for breakfast and only took two bites. Morphine was administered. -7/31/2024 at 5:54 AM, the resident was in bed and wide awake all night. When s/he was asked if s/he was in pain s/he would respond with Yup and continue speaking in word salad per his/her baseline. Morphine was administered with good effect. -8/1/2024 at 12:16 AM, the resident displayed facial grimacing and received morphine for pain management. -8/1/2024 at 4:39 AM, the resident was administered morphine for comfort as facial grimacing was observed. -8/1/2024 at 2:40 PM, the resident did not eat breakfast and had only 20 mLs of a supplement for lunch. Noted to grimace occasionally and morphine was administered. -8/2/2024 at 10:11 PM, the resident was alert and speaking in word salad most of the time, but when receiving care, s/he was in a lot of pain, grimacing and yelling out. The physician was notified and an order to increase the resident's morphine from every 4 hours to every 2 hours was obtained. -8/3/2024 6:03 AM, the resident displayed facial grimacing and groaning. Morphine was administered three times. The surveyor attempted to interview Staff B on 8/6/2024 at 10:07 AM via a telephone call, a voicemail was left, and a return phone call has not been received as of 8/16/2024.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 7/11/2024 alleges, Resident ID #1 lost 20 pounds in 5 weeks while a resident at the facility. Review of the facility's policy titled, Weight Loss/ Gain Protocol and Heights states in part, .All residents are to be weighed upon admission and at least monthly; so as to monitor for weight loss or gain, to assess for underlying causes of weight loss or gain, to intervene accordingly and timely to allow for an optimal level of well-being .For purpose of this policy, a significant weight discrepancy is defined as .A weight change of 3 pounds or more in one week (if resident on weekly weights) .A loss/gain of 5% or greater within one month .When a significant weight loss/gain is noted (as defined above), the following interventions may be considered .Reweigh all residents who are reported to have a significant weight discrepancy in order to assess the accuracy of the weight. The reweigh shall be done within 2 days of the initial weight .If the re-weigh is accurate and there has been a significant weight loss/gain, nursing must notify the: Physician .Dietician .DNS (Director of Nursing Services) . Record review revealed Resident ID #1 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, Parkinson's disease without dyskinesia (uncontrolled, involuntary movements of the face, arms, or leg), bacterial infections of unspecified site, type 2 diabetes mellitus, urinary tract infection, and acute prostatitis bacterial, and dementia with agitation. Review of the admission Minimum Data Set (MDS) Assessment, dated 7/10/2024, revealed a Brief Interview of Mental Status score of 5 out of 15, indicating the resident has severe cognitive impairment. Record review of the care plan, initiated 4/7/2024, revealed, .is at risk for Dehydration/alteration in Nutrition on therp [therapeutic] diet d/t [diabetes mellitus], Has Parkinson's and dementia with potential for decline with disease process, significant [weight] loss, increased nutrient needs for healing . Interventions include but are not limited to, .dietary consult as indicated . Record review of a document titled Vital Signs: Weight revealed the following documented weights: 4/7/2024- 282.8 pounds 4/8/2024- 282.2 pounds 4/9/2024- 282.2 pounds 4/29/2024- 285.6 pounds 5/6/2024- 285 pounds 6/3/2024- 285.5 pounds Record review of a progress note dated 6/18/2024 revealed the resident weighed 273.6 pounds via Hoyer Lift. The note further revealed that the Nursing Assistant was to re-weigh the resident the next day. This weight loss represents an 11.9 pound, or 4.17% weight loss in 15 days. Further record review failed to reveal evidence that a re-weigh was obtained or that the dietician or the provider were notified of the weight loss. Additionally, the record failed to reveal evidence that any interventions were implemented to mitigate the resident's weight loss. Additional record review of the document titled, Vital Signs: Weight revealed the next documented weights were as follows: 7/1/2024- 266.3 pounds 7/2/2024- 263.3 pounds This indicated an additional 10-pound weight loss. Weight loss from 6/3/2024 until 7/2/2024 now totaled 22.2 pounds or 7.78%. Record review of a Nutritional Evaluation assessment dated [DATE] revealed in part, .type of assessment .significant change in status .7/3/2024 at 3:52 PM .Continues on [therapeutic] diet [as ordered] which given significant [weight] loss and decline in appetite may be too restrictive at this time .Suggest add 220 mg [milligrams] Zinc Sulfate x [times] 14 days. Suggest 500 mg Vit C [Vitamin C] x 30 days. Suggest increase med pass 2.0 (a nutritional shake) to 90 ml [milliliters] BID [twice a day] Suggest add 30 ml liquid protein (protein supplement) BID until healed .Suggest change diet to: House-No Salt Packet . The assessment failed to reveal evidence that the dietician was aware of the weight of 273.6 that was obtained on 6/18/2024. Record review revealed the following orders with a start date of 7/8/2024: -30 ml Sugar free active protein twice daily -offer 90 ml of Med pass supplement twice daily -Vitamin C 500 mg once daily -Zinc Sulfate 50 mg once daily During a surveyor interview on 7/18/2024 at 9:58 AM with the resident's Primary Care Physician, he revealed that he would have expected a re-weigh to have been completed after the 6/18/2024 weight loss. He further revealed that he would have expected the dietician to have been notified. During a surveyor interview on 7/18/2024 at 10:17 AM with the Dietician, she revealed that she looks at the Vital Signs: Weight section of the electronic medical record to review weights. She revealed that she wasn't made aware of the weight obtained on 6/18/2024. She indicated that the expectation is that the resident would be re-weighed within 2 days. She acknowledged that the weight loss was notable and she would have expected it to have been reported. She further revealed that she was unaware of the 11.9 pound weight loss identified on 6/18/2024 as it was not documented in the Vital Signs: Weight section of the electronic medical record. She indicated that if she was notified of this initial weight loss, she would have implemented interventions rather than waiting for the resident to continue with weight loss. During a surveyor interview on 7/18/2024 at approximately 12:38 PM with the Director of Nursing and the Administrator, they acknowledged that Resident ID #1 experienced a weight loss of 11.9 pounds identified on 6/18/2024. Additionally, they were unable to provide evidence that a re-weigh was obtained or that the dietician was aware.

Based on record review, resident representative interview, and staff interview it has been determined that the facility failed to complete a discharge summary that includes, but is not limited to, a final summary of the resident's status at discharge and a reconciliation of the resident's medications for 1 of 2 discharged residents reviewed, Resident ID #2. Findings are as follows: Record review of a facility policy titled, Medication Reconciliation Process states in part, It is the policy of this facility to perform medication reconciliation for every resident upon admission, transfer or discharge .when a resident is discharged /transferred, a listing of all medications is to be provided as part of the discharge process utilizing the inter-agency transfer form .the nurse is to give a copy of the transfer form to the resident/resident representative for their records . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/25/2024 indicates that Resident ID #2's family is alleging that s/he was neglected during his/her respite stay at the facility in April of 2024. Record review for Resident ID #2 revealed s/he was admitted to the facility in April of 2024 with diagnoses including, but not limited to, type 2 diabetes mellitus, chronic systolic heart failure (a condition in which the left ventricle of your heart is weak and can't pump blood efficiently), and chronic kidney disease. Record record failed to reveal evidence that an inter-agency transfer form was completed by the facility when the resident was discharged . During a surveyor interview with Resident ID #2's representative on 5/15/2024 at 1:22 PM, they revealed that they were not made aware of any medication changes for the resident when s/he was discharged from the facility. The resident's representative further indicated that during the discharge process on 4/18/2024 they were handed a bag containing only medications and were told they were all set. Record review reveals that Resident ID #2 was prescribed the following medications at the time of his/her admission to the facility: - Metoprolol succinate (medication used to treat high blood pressure) Extended release 50 milligrams (MG) tablet extended release 24 hour - Morphine concentrate 20 per milliliter (ML) administer 0.5 ML by mouth every 3 hours, as needed for severe pain - Senna Plus 8.6 MG-50 MG capsule, three capsule every 12 hours, as needed Record review of the resident's progress notes revealed the following: - 4/4/2024 all medications reviewed with the doctor changes made as follows, Morphine was decreased to 0.25 ML every three hours, as needed - 4/4/2024 Senna plus was changed to two capsules twice daily, scheduled - 4/5/2024 Metoprolol was increased to 75 mg, daily During a surveyor interview with Registered Nurse, Staff A, on 5/15/2024 at approximately 2:30 PM, she acknowledged that she did not review any medications with Resident ID #2 or their representative prior to his/her discharge and that there were changes made to the resident's medication by the physcian. She further acknoledged that she failed to provide them an inter-agency transfer form, per the facility policy. During a surveyor interview with the Director of Nursing Services on 5/16/2024 at approximately 1:30 PM, she revealed that she would expect the nurse to have reviewed the resident's medications and any changes in the physician's orders with the resident and/or the resident's representative at the time of discharge. Additionally, she was unable to provide evidence that the resident or resident's representative was provided with an inter-agency transfer form, per the facility policy.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen. Findings are as follows: Review of The State of Rhode Island Food Code 2018 edition, titled 4-601.11 Equipment, Food-Contact Surfaces, Non-Food-Contact Surfaces, and Utensils states in part, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust . Review of the facility's policy titled, Food Storage states in part, .Leftover food is used within 3 days or discarded .All refrigerator units are kept clean .at all times .All foods should be .labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by date .or discarded . An initial tour of the main kitchen on 12/12/2022 at 8:45 AM in the presence of the Food Service Director (FSD), revealed the following observations: - A large plastic container of peeled and diced potatoes in water labeled with a date of 12/5. - One bag/pouch of whipped cream opened and not dated. During a surveyor interview with the FSD immediately following the above-mentioned observations he acknowledged the findings and indicated that his expectation is that the potatoes would be discarded 3-5 days after the date on the label. He further indicated that the opened whipped cream had a 2-week shelf life and acknowledged that it was not labeled with a date. Additionally, he was unable to provide evidence of a safe use by date. During a follow up surveyor observation of the main kitchen on 12/13/2022 at 8:03 AM in the presence of the FSD revealed the following observations: - One 1-gallon jar of Ken's Mayonnaise opened with a manufacturer's date of 11/18/2022 stamped on the jar but no visible expiration date. - One opened package of deli sliced bologna labeled with a date of 12/4. - One container of cooked ground sausage labeled with date a of 12/9 - The main refrigerator was observed to have two interior fans with a thick accumulation of dust. The surveyor was able to wipe some of the dust with a paper towel. Review of a facility provided document titled KEN'S revealed that the mayonnaise has a shelf life of 120 days/4 months after the manufacture date. Additionally, the document states in part, .Opened product stored under proper refrigeration and in our original container will remain good and wholesome for 14 days . During a surveyor interview with the FSD immediately following the above-mentioned observations, he acknowledged the findings and was unable to provide evidence of a date when the 1-gallon jar of mayonnaise was opened. Additionally, he indicated that he would expect that the bologna would have been discarded on 12/10/2022 and the cooked ground sausage discarded after 3 days. Additionally, the FSD acknowledged the dust accumulation on the interior refrigerator fans and indicated that the Environmental Services Director (ESD), is responsible for cleaning the fans. During a surveyor interview with the ESD on 12/13/2022 at 9:41 AM, he indicated that he is responsible for cleaning the fans and acknowledged the observation of the dust accumulation on the interior fans of the main kitchen refrigerator. During a surveyor interview with the Administrator on 12/14/2022 at 9:37 AM, she was unable to provide evidence that the facility stored, prepared, distributed, and served food in accordance with professional standards for food service.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to address the resident's needs including but not limited to, residents at risk for alteration in nutrition. The facility also failed to follow their policy related to nutritional supplements for 1 of 6 residents reviewed, Resident ID #18. Findings are as follows: The facility's policy for Nutrition/hydration intake monitoring states in part, .In order to assure that each resident is receiving his/her optimum level of nutrition/hydration it is the policy of this facility to monitor each resident's nutrition/hydration status on a daily basis in order to: assist in the ongoing process of evaluating the resident's clinical condition and nutritional risk factors; define and implement interventions that are consistent with the resident's needs, goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . The policy procedure states in part, .All residents who are capable of oral intake are to have their nutritional/fluid intake monitored on a daily basis if or when the resident eats less than 50% of a meal, a house nutritional supplement is to be offered by nursing. House supplements are to be documented in the electronic medical record . Record review revealed the resident was admitted to the facility in June 2021 with diagnoses including, but not limited to, dementia and Transient Cerebral Ischemic Attack (mini stroke). Record review revealed the resident has a care plan dated 6/23/2022 for Nutritional Status, which indicates the resident is at risk for alteration in Nutrition secondary to: Alzheimer's dementia with potential for decline with disease process. This care plan includes interventions which were started on 6/23/2022 indicating .Monitor and record meal intakes and .Provide additional foods/supplements prn [as needed] per protocol . Additionally, the resident has a care plan dated 6/9/2022 for ADL (Activities of Daily Living) functional/Rehabilitation which indicates the resident is unable to be independent with Self Care related to: Dementia with bd [behavioral disturbances]. The care plan has an intervention that specifies, .provide cueing/assist as needed. Abilities to feed self-fluctuate . Surveyor observations revealed the resident trying to drink independently with a two handled sippy cup. S/he was unable to consistently drink successfully. Staff was observed in the dining room and failed to offer or provide the resident with cueing or assistance in accordance to his/her plan of care on the following dates and times: -12/12/2022 during the lunch meal at 12:02 PM until approximately 1:00 PM -12/13/2022 during the breakfast meal from 9:04 AM until approximately 10:00 AM and during the lunch meal from 12:00 PM to approximately 1:00 PM. -12/14/2022 during the lunch meal from 12:00 PM until approximately 1:00 PM. Additionally, surveyor observations revealed that the resident did not eat the percentage of meal consumption that was documented in his/her meal consumption record on the following dates and times: -12/12/2022 lunch meal consumption documented that the resident consumed 76-100% of his/her meal. Surveyors observed the residents lunch meal and only a few bites were noted to have been consumed. -12/13/2022 breakfast meal consumption documented that the resident consumed 51-75% of his/her meal. Surveyors observed the resident eating only a few bites of bacon and a few bites of muffin for the breakfast meal. -12/13/2022 lunch meal consumption documented that the resident consumed 76-100% of his/her meal. Surveyors observed the resident eating less than a half of the meal served. -12/14/2022 revealed breakfast meal consumption was documented twice. The documentation was inconsistent as one was documented as 51-75% of his/her meal consumed and the other was documented as 76-100% of his/her meal consumed. -12/14/2022 lunch meal consumption documented that the resident consumed 1-25% of his/her meal. Surveyors observed the resident eating almost 50% of the meal served. Record review failed to reveal any evidence that a nutritional supplement was offered when s/he ate less than 50% of a meal as per the facility policy. Additionally, record review failed to reveal evidence that the resident was offered or had refused a supplement. During a surveyor interview with Registered Nurse, Staff A on 12/14/2022 at 2:59 PM, she revealed she worked during the first shifts on 12/13/2022 and 12/14/2022, and she was not informed of resident's meal consumption being less than 50%. She further acknowledged that she did not provide or offer the resident a nutritional supplement during her shifts. During a surveyor interview with the Assistant Director of Nurses on 12/14/2022 at 3:31 PM, she was unable to provide evidence that the facility policy for a nutritional supplement was followed. Additionally, she was unable to explain why the staff was documenting the resident's meal consumption inaccurately. 47808

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide special adaptive equipment for residents who require assistive devices when drinking for 1 of 1 residents reviewed, Resident ID #18. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2021 with diagnoses including, but not limited to, dementia and Transient Cerebral Ischemic Attack (mini stroke). Record review revealed a physician's order dated 9/23/2021 for .House, Thin Liquids .Special Instructions: Blue mug with lid . During surveyor observations the resident failed to have a blue mug with a lid during meals on the following dates and times: -12/12/2022 during the lunch meal at 12:02 PM until approximately 1:00 PM when the staff cleared his/her meal -12/13/2022 at the breakfast meal from 9:04 AM until approximately 10:00 AM when the staff cleared his/her meal and during the lunch meal from 12:00 PM to approximately 1:00 PM when the staff cleared his/her meal -12/14/2022 during the lunch meal from 12:00 PM until approximately 1:00 PM when the staff cleared his/her meal During a surveyor interview with Registered Nurse, Staff A on 12/14/2022 at 2:59 PM, she acknowledged the resident did not have the blue mug with a lid during the above observations. Staff A further stated, sometimes we do not have the blue mug with lid. During an interview with the Assistant Director of Nurses on 12/14/2022 at 3:31 PM, she was unable to provide evidence that the resident was provided with a blue mug with a lid as ordered by the physician.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication carts observed. Findings are as follows: Review of the facility policy titled Medication Storage states in part .POLICY: It is the policy of this facility that medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .PROCEDURE: 14. Outdated medications .are immediately removed from stock, disposed of according to procedures for medication disposal .and reordered from the pharmacy, if a current order exists. Surveyor observation on 10/14/2021 at 8:05 AM of the1st floor Specialty Care Unit medication cart, in the presence of Staff Nurse A revealed the following: -[MEDICATION(S)] inhaler (a medication used to treat asthma) opened and undated. Manufacturer's instructions state, discard 6 weeks after opening. -Active liquid protein 30 oz (ounces) bottle opened and undated. Manufacturer's instructions on the bottle state, 3 month shelf life after opening. - [MEDICATION(S)] inhaler (a medication used to prevent and treat shortness of breath) 90 mcg (microgram) with a manufacturer's expiration date of 10/11/2021. - [MEDICATION(S)] 10 mg (milligram) tablets (a medication used to treat confusion (dementia) related to Alzheimer's disease) with a manufacturer's expiration date of 9/30/2021. -[MEDICATION(S)] 50 mg tablets (a medication used to treat moderate to severe pain) with a manufacturer's expiration date of 7/24/2021. During a surveyor interview at the time of the above observations with Staff Nurse A, she acknowledged that the above medications should have been dated at the time of opening and discarded when expired. During a surveyor interview on 10/14/2021 at 2:23 PM with the Administrator, she indicated that she would expect staff to be storing and labeling drugs in accordance with manufacturer's recommendations. 1 of 2 med cart review revealed, 1 inhaler (Breo elipta) opened and not dated with instructions to discard after 6 wk. 1 [MEDICATION(S)] inhaler expired 10/11/21 [MEDICATION(S)] expired 9/30/2021 [MEDICATION(S)] with expiration date of 7/24/2021 active liquid protein opened and not dated, manuf. states discard 3 months after opening. FACILITY Medication Storage and Labeling 10/14/21 08:05 AM [NAME] RN 1st floor specialty care unit medication room and cart. [MEDICATION(S)] bottle [NAME] f [NAME] (ID 45) [MEDICATION(S)] 10 mg tablets date filled 9/30/2020 use before 9/30/2021 take one tablet (10 mg) by mouth everyday Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [NAME] RN acknowledged the above listed medication was expired. [NAME](ID 32) [MEDICATION(S)] 100/25 ([MEDICATION(S)] 100mcg and vilanterol 25 mcg inhalation power) Discard the inhaler 6 weeks after opening the moisture- protective foil tray and when the counter reads 0 (after all blisters have been used whichever comes first) 17 blisters left RN acknowledged the above listed medication was opened and not dated Norma Scaldino 10/9/2021 & [NAME] 3/4/2021 [MEDICATION(S)] inhalation aerosol [MEDICATION(S)] HFA 90 MCG inhaler expire 10/8/2022 opened and not dated. [NAME] RN acknowledged the above listed medication was opened and not dated Discard inhaler when dose indicator displays 0, or after the expiration date on the product whichever comes first [NAME] [MEDICATION(S)] inhalation aerosol 90 MCG inhaler opened and expired on 10/11/2021 2 puffs by mouth Q6h PRN wheezing *separate puffs by at least one minute ACTIVE liquid protein easy to ingest concentrated nutrition 30 FL OZ (887ml) sugar free cherry berry punch Shelf stable. 3 mouth shelf life from date opened EXP. [DATE] open and not dated. [NAME] RN acknowledged the above listed medication was open and not dated. [NAME] [MEDICATION(S)] 50 MG tablet Expired 7/24/2021 1/2 tab by mouth Q 6 hrs as needed (1/2 tab =25 mg) [NAME] RN acknowledged the above listed medication was expired. [NAME] RN and [NAME] RN then properly disposed of medication. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [NAME] RN 2nd floor medication cart 10/14/21 09:21 AM Linda Witkos LPN/med tech no issues or concerns noted. 10/14/21 2:23 PM During a surveyor interview with the Administrator she indicated she would expect staff to discarded expired medications according to facility policy . She also indicated she would expect staff to date medications after opening and follow manufactures guidelines.

Based on record review and surveyor interview, it has been determined that the facility failed to ensure each resident is free from verbal abuse for 1 of 4 sample residents reviewed, Resident ID# 1. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility in January of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident is cognitively intact. Record review revealed Resident ID #2 was admitted to the facility in December of 2019 and resided in the room with Resident ID #1 since February of 2021. Review of a quarterly MDS assessment dated [DATE] revealed the resident's cognition was moderately impaired and had verbal behavioral symptoms directed toward others. Review of a quarterly MDS assessment dated [DATE], revealed the resident's cognition was severely impaired and displayed verbal behavioral symptoms directed toward others. Record review of nursing progress notes for Resident ID #2 revealed the following: Progress note dated 4/19/2021 written by the social worker states, [Resident ID# 2] has a history of being unkind to roommates, [s/he] has had multiple room changes in the past . Progress note dated 4/25/2021 written by nurse Staff A stated, Resident behavioral and rude to staff all night .continues to make nasty comments to and about [his/her] roommate . Progress note dated 5/4/2021 written by the Administrator stated .continues to speak negatively towards [his/her] roommate, other residents and staff on a daily basis . Progress note dated 5/6/2021 written by Staff A stated, Resident continues to be inappropriate and mean to roommate. Roommate was on the phone with family and laughing and resident in question [Resident ID #2] called [him/her] 'an annoying pig' Resident .continues to make it an uncomfortable and hostile living situation for [his/her] roommate, who is appropriate and non-provoking. Progress note dated 5/7/2021 written by the social worker stated, .spoke with [Resident ID# 2] regarding [his/her] comments to [his/her] roommate, [Resident ID #2] does not show any remorse for making statements .completed BIMs [brief interview for mental status] .score went from moderately impaired to severely impaired cognition. Review of a quarterly social services review dated 5/10/2021 revealed, has been rude and verbally inappropriate with [his/her] roommate .was offered a room change .and declined .has a history of having 6 moves, and overall being unkind to [his/her] roommate .A behavior contract will be put into place . Review of a quarterly care conference review dated 5/18/2021 revealed, [Resident ID #2] does exhibit verbal aggressiveness with numerous aspects of the facility, every roommate [s/he] has ever had, and overall irritability and general intolerance .all parties agreed to behavior contract . Review of a facility incident report dated 5/26/2021 states, . [Resident ID #1] reported to RN [registered nurse] that [Resident ID #2] stated 'I wish you would just die already' . Review of a progress note dated 5/26/2021 written by the social worker states, [s/he] violated [his/her] behavior contract .verbal aggressiveness towards [his/her] roommate will not be tolerated. Roommate commented [s/he] was afraid of [Resident ID #2]. Review of progress notes for Resident ID #1 revealed the following: Progress note dated 5/11/2021 written by the social worker states, met with [Resident ID #1] on this date we reviewed current happenings with roommate. Roommate has been known to be randomly verbally inappropriate to prior roommates .verbalizes [s/he] 'is just fine' and declined to explore other options for a room. Progress note dated 5/25/2021 written by social worker states, stated [s/he] pays roommate no mind, and does not respond if [his/her] roommate is verbally inappropriate .[Resident ID #1] stated that [his/her] roommate is verbally aggressive with staff .stating 'I know [s/he] is not right in the head and there is something wrong with [him/her]. During an interview with Resident ID #1 on 5/28/2021 at 10:30 AM, s/he revealed, when asked about Resident ID #2 his/her former roommate, [s/he] hated everyone, I was afraid. S/he went on to say I did not want to say anything, I let it go. A couple of nights [Resident ID #2] slammed [his/her] walker up against mine, which was next to the head of my bed, one night my walker fell over. I didn't say anything, I was afraid. I feel sorry for [him/her]. I didn't know if [s/he] was going to hurt me. [S/he] blocked the door with [his/her] walker and if I moved it [s/he] would call me names. [S/he] would turn the heat up to 85, I could never adjust it, I was roasting. There was nothing [s/he] wouldn't do. I hope [s/he] doesn't come back in the middle of the night, I'm a dead duck. What did I do to get punished? Record review of a psychiatric visit note for Resident ID #2 dated 6/20/2020 revealed the resident was being seen for major depressive disorder, anxiety, and alcohol abuse. The assessment revealed the resident's mood was subdued, irritable and negativistic with no overt [CONDITION(S)]. Recommendations were to closely assess and document mood, behavior, utilize a calm supportive approach and provide active listening. Further record review of a care plan for Resident ID #2 dated 11/11/2020, revealed a category of behavioral symptoms including a history of disliking roommates with a revision date of 5/7/2021 stating continues with inappropriate behavior; the team will develop a behavior contract to assist with resident's actions. Interventions were not revised to reflect the resident's inappropriate verbal behaviors, the behavior contract, or the psychiatric consult (refer to F656). During an interview with nursing assistant (NA), Staff B, on 5/28/2021 at 12:15 PM, she revealed Resident ID #2 can be very mean and used to make nasty comments about Resident ID #1 about how s/he doesn't talk and keeps his/her television too loud. Staff B stated she would tell Resident ID #2 s/he was being rude and try to redirect the resident, but it did not always work, and Resident ID #2 continued to be rude. Staff B, revealed that both residents are much happier now that they are separated. During an interview with NA, Staff C, on 5/28/2021 at 12:30 PM, she revealed Resident ID #2 puts his/her walker in the way of the sink and the doorway so Resident ID #1 cannot get by. She stated Resident ID #2 would comment about Resident ID # 1 and say I don't care [s/he] needs to be gone. She went on to say every time Resident ID #1 walks to the sink, passing by Resident ID #2, she makes a negative comment. She stated she attempts to redirect but s/he goes right back to making negative comments. She stated she reports this to the nurse when observed. During an interview with Nurse, Staff D, on 5/28/2021 at 1:00 PM, he revealed Resident ID #2 is mean and abusive to staff and any roommate s/he has had. He recalled an incident when Resident ID #1 returned from quarantine and Resident ID #2 stated [s/he] is not dead yet? Staff D stated the behavior has escalated and attempts to redirect but s/he does not seem to comprehend. During an interview with the Administrator on 5/28/2021 at 2:00 PM, she revealed the facility is aware of the behaviors of Resident ID #2 and has drawn up a behavior contract and that Resident ID #2 was moved to a private room on 5/26/2021. She was unaware of behaviors such as blocking the sink and door and banging the walker in the middle of the night.

Based on record review and interview, it has been determined that the facility failed to develop and implement a person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's mental and psychosocial needs for 2 of 4 sample residents reviewed, ID #'s 1 and 2. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility in January of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident is cognitively intact. Record review for Resident ID #2 revealed s/he was admitted to the facility in December of 2019 and resided in the room with Resident ID #1 since February of 2021. Review of a quarterly MDS assessment dated [DATE] revealed the resident's cognition was moderately impaired and had verbal behavioral symptoms directed toward other. Review of a quarterly MDS assessment dated [DATE], revealed the resident's cognition was severely impaired and displayed verbal behavioral symptoms directed toward others. Further record review revealed Resident ID #2 had been verbally abusive to Resident ID #1 (refer to F600). 1. Review of a care plan for Resident ID #2 dated 11/11/2020 and revised 5/10/2021 revealed no evidence of a person centered care plan with specific interventions for managing Resident ID # 2's verbally inappropriate behaviors towards his/her roommate. 2. Review of a current care plan for Resident ID #1 revealed no evidence of a care plan addressing the mental and psychosocial needs of the resident relative to negative and aggressive comments directed towards him/her made by his/her roommate. During an interview with the social worker on 6/1/2021 at 11:30 AM she acknowledged that Resident ID #2 has made verbally inappropriate comments towards his/her roommate and could not provide evidence of a plan of care for staff to address the specific interactions between them.

Based on record review and staff interview, it has been determined that the facility failed to ensure that during required visits, the physician document a review of the resident's total program of care, including the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being for 2 of 4 sample resident's reviewed, Resident ID #'s 1 and 2. Record review revealed Resident ID #2 had been verbally abusive to Resident ID #1 (refer to F600). Further record review of physician's progress notes for Resident ID #'s 1 and 2 failed to reveal documentation of a review of the resident's total program of care at the time of the required visits. During an interview with the physician for both residents, on 5/28/2021 at 12:45 PM, he revealed he was unaware of the negative interaction between the two residents and acknowledged he did not document a review of the resident's total program of care at the required visits.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the medical care of each resident is supervised by the physician for 1 of 6 sampled residents relative to anticoagulant therapy (Resident ID #1). Findings are as follows: Record review for Resident ID #1 revealed that s/he was admitted to the facility in (MONTH) of 2019, with [DIAGNOSES REDACTED]. Record review revealed a 12/18/2019 verbal order that indicated to start folic acid 1mg (milligram) by mouth daily. Review of the progress note written by Staff Nurse A dated 12/18/2019 at 4:28 PM reads Labs reviewed by Dr . Folate level low at 3.7. New order for folic acid 1 mg daily. Review of the clinical record revealed a physician's telephone order dated 12/18/2019 at 4:28 PM for [MEDICATION NAME] (a medication used as a blood thinner to treat and help prevent blood clots) 1 milligram (mg) tablet to be given orally once a day, instead of the intended folic acid order. Further review revealed that the physician signed the [MEDICATION NAME] order on 1/10/2020. Review of the Medication Administration Record [REDACTED]. In a progress noted dated 1/2/2020 the physician wrote significant weight loss and now vomiting after meals . Review of the progress note dated 1/12/2020, the physician stated in part folate low and B 12w normal. will add folate to meds. The record lacked evidence that on 1/2/2020 and 1/12/2020 when the physician wrote his progress notes regarding the resident's current medical issues that he reviewed the clinical record to discover the medication error. Record review revealed progress notes on 1/13/2020 from 10:26 AM - 12:45 PM, Resident ID #1 began bleeding from his/her private area. The physician was notified and gave new orders that included discontinuation of the [MEDICATION NAME]. During that time, the resident had an episode of black tarry diarrhea and bruising was noted to bilateral legs. The vital signs were documented as: heart rate 44, oxygen saturation level 67%, respiration rate 28, temperature 97.1, and a blood pressure was unable to be obtained (normal vital signs; heart rate 60-100, oxygen saturation greater than 95%, respiration rate 12 -20, and blood pressure 120/80). The resident continued to decline and was admitted to the hospital with [REDACTED]. Review of the hospital laboratory report dated 1/13/2020 revealed that the residents INR (International Normalized Ratio: a test to monitor the effectiveness of [MEDICATION NAME] therapy) was 10.8 (therapeutic range for those receiving [MEDICATION NAME] is an INR of 2.0 - 3.0). Further review of the records revealed that while at the hospital, the resident underwent [REDACTED]. A central line was placed, s/he was resuscitated with intravenous crystalloids (used for hypovolemia, a decreased volume of blood in the body and hemorrhage ), given Kcentra (used for urgent [MEDICATION NAME] reversal), Vitamin K (used for [MEDICATION NAME] reversal), fresh frozen plasma, and packed red blood cells (used in blood [MEDICAL CONDITION] to replace blood loss). Review of the hospital [MEDICATION NAME] consult from 1/13/2020 revealed that Resident ID #1 suffered a [MEDICAL CONDITION], was hemodynamically unstable (blood flow and blood pressure in the body is unstable), and had a supratherapeutic (excessively high, out of range for therapeutic treatment) INR. During a telephone interview with the physician on 1/15/2020 at approximately 1:45 PM, he stated that he gave the nurse a telephone order on 12/18/2019 for the resident to receive folic acid not [MEDICATION NAME]. He acknowledged that he failed to identify the [MEDICATION NAME] error when signing his orders on 1/10/2020.

Based on record review and staff interview it has been determined that the consultant pharmacist failed to identify medication irregularities related to orders for anticoagulation therapy for 1 of 6 sampled residents reviewed (Resident ID# 1). Findings are as follows: The Nursing Care Center Pharmacy Policy and Procedure Manual Section 6.2 Medication Error Reporting and Adverse Drug Reaction Prevention and Detection states, in part: .Procedures: 2. When a resident receives a new medication, the medication order is evaluated for the following: a. The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. b. an active diagnosis/indication (and documented objective findings, if necessary) support the use of the medication . Findings are as follows: Record review for Resident ID #1 revealed that s/he was admitted to the facility in (MONTH) of 2019, with [DIAGNOSES REDACTED]. Record review revealed a 12/18/2019 verbal order that indicated to start folic acid 1mg (milligram) by mouth daily. Review of the progress note written by Staff Nurse A dated 12/18/2019 at 4:28 PM reads Labs reviewed by Dr . Folate level low at 3.7. New order for folic acid 1 mg daily. Review of the clinical record revealed a physician's telephone order dated 12/18/2019 at 4:28 PM for [MEDICATION NAME] (a medication used as a blood thinner to treat and help prevent blood clots) 1 milligram (mg) tablet to be given orally once a day, instead of the intended folic acid order. Record review revealed progress notes on 1/13/2020 from 10:26 AM - 12:45 PM, Resident ID #1 began bleeding from his/her private area. The physician was notified and gave new orders that included discontinuation of the [MEDICATION NAME]. During that time, the resident had an episode of black tarry diarrhea and bruising was noted to bilateral legs. The vital signs were documented as: heart rate 44, oxygen saturation level 67%, respiration rate 28, temperature 97.1, and a blood pressure was unable to be obtained (normal vital signs; heart rate 60-100, oxygen saturation greater than 95%, respiration rate 12 - 20, and blood pressure 120/80). The resident continued to decline and was admitted to the hospital with [REDACTED]. Review of the hospital laboratory report dated 1/13/2020 revealed that Resident ID #1's INR (International Normalized Ratio: a test to monitor the effectiveness of [MEDICATION NAME] therapy) was 10.8 (therapeutic range for those receiving [MEDICATION NAME] is an INR of 2.0 - 3.0). Further review of the records revealed that while at the hospital, the resident underwent [REDACTED]. A central line was placed, s/he was resuscitated with intravenous crystalloids (used for hypovolemia, a decreased volume of blood in the body and hemorrhage ), given Kcentra (used for urgent [MEDICATION NAME] reversal), Vitamin K (used for [MEDICATION NAME] reversal), fresh frozen plasma, and packed red blood cells (used in blood [MEDICAL CONDITION] to replace blood loss). Review of the hospital [MEDICATION NAME] consult from 1/13/2020 revealed that Resident ID #1 suffered a [MEDICAL CONDITION], was hemodynamically unstable (blood flow and blood pressure in the body is unstable), and had a supratherapeutic (excessively high, out of range for therapeutic treatment) INR. Review of the monthly pharmacy medication regimen review dated 12/30/2019 revealed that the pharmacist failed to identify that Resident ID #1 was administered [MEDICATION NAME] in error since 12/19/2019, without any lab order to adequately monitor it, and without an active diagnosis/indication to support the use of an anticoagulant medication. During a telephone interview with the consultant pharmacist on 1/15/2020 at approximately 2:12 PM, he acknowledged that he failed to identify the [MEDICATION NAME] order or any related irregularities during his monthly drug regimen review.

Based on record review and staff interviews, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 6 sample 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 (MONTH) of 2019, with [DIAGNOSES REDACTED]. Record review revealed a 12/18/2019 verbal order that indicated to start folic acid 1mg (milligram) by mouth daily. Review of the progress note written by Staff Nurse A dated 12/18/2019 at 4:28 PM reads Labs reviewed by Dr . Folate level low at 3.7. New order for folic acid 1 mg daily. Review of the clinical record revealed a physician's telephone order dated 12/18/2019 at 4:28 PM for [MEDICATION NAME] (a medication used as a blood thinner to treat and help prevent blood clots) 1 milligram (mg) tablet to be given orally once a day, instead of the intended folic acid order. Further review revealed that the physician signed the [MEDICATION NAME] order on 1/10/2020. Review of the Medication Administration Record [REDACTED]. Record review revealed progress notes on 1/13/2020 from 10:26 AM - 12:45 PM, Resident ID #1 began bleeding from his/her private area. The physician was notified and gave new orders that included discontinuation of the [MEDICATION NAME]. During that time, the resident had an episode of black tarry diarrhea and bruising was noted to bilateral legs. The vital signs were documented as: heart rate 44, oxygen saturation level 67%, respiration rate 28, temperature 97.1, and a blood pressure was unable to be obtained (normal vital signs; heart rate 60-100, oxygen saturation greater than 95%, respiration rate 12-20, and blood pressure 120/80). The resident continued to decline and was admitted to the hospital with [REDACTED]. Review of the hospital laboratory report dated 1/13/2020 revealed that the residents INR (International Normalized Ratio: a test to monitor the effectiveness of [MEDICATION NAME] therapy) was 10.8 (therapeutic range for those receiving [MEDICATION NAME] is an INR of 2.0 - 3.0). Further review of the records revealed that while at the hospital, the resident underwent [REDACTED]. A central line was placed, s/he was resuscitated with intravenous crystalloids (used for hypovolemia, a decreased volume of blood in the body and hemorrhage ), given Kcentra (used for urgent [MEDICATION NAME] reversal), Vitamin K (used for [MEDICATION NAME] reversal), fresh frozen plasma, and packed red blood cells (used in blood [MEDICAL CONDITION] to replace blood loss). Review of the hospital [MEDICATION NAME] consult from 1/13/2020 revealed that Resident ID #1 suffered a [MEDICAL CONDITION], was hemodynamically unstable (blood flow and blood pressure in the body is unstable), and had a supratherapeutic (excessively high, out of range for therapeutic treatment) INR. During a telephone interview with Staff Nurse A on 1/15/2020 at approximately 9:30 AM, she reported that on 12/18/2019 she received a physician's telephone order for folic acid. She stated that she incorrectly transcribed the order as [MEDICATION NAME] in error. Review of Staff Nurse B's written statement dated 1/13/2020, revealed that she received a call from the hospital requesting information regarding why the resident was receiving [MEDICATION NAME]. During a telephone interview with the physician on 1/15/2020 at approximately 1:45 PM, he stated that he gave the nurse a telephone order on 12/18/2019 for the resident to receive folic acid not [MEDICATION NAME]. He acknowledged that he failed to identify the [MEDICATION NAME] error when signing his orders on 1/10/2020.