Every finding on record at AdviniaCare Oakland Grove LLC

Based on clinical record review and staff interview, the facility failed to ensure that an accident resulting in hospital admission was reported to the appropriate authorities, including the State Survey Agency, as required by state law, for 1 of 1 resident reviewed who sustained a fall and was admitted to the hospital as a result, Resident ID #2.Findings are as follows:Record review of a facility-reported incident submitted to the Rhode Island Department of Health on 6/26/2026 revealed Resident ID #2 underwent a chest x-ray on 6/26/2026 that identified a left rib fracture, which the facility reported as an injury of unknown source. The report further documented that the resident had experienced recent falls and previously underwent radiological evaluation while hospitalized . Record review revealed that Resident ID #2 was readmitted to the facility in June of 2026 with diagnoses including, but not limited to, type 3 heart block (a communication failure in the heart between the atria (the upper chamber) and ventricles (the lower chamber) and hypertension.Record review of a progress note dated 6/5/2026 at 1:53 PM revealed, the resident fell and hit his/her head then began vomiting. The in-house Nurse Practitioner was informed and gave a new order to send out to the hospital for evaluation.Further record review of a progress note dated 6/5/2026 at 11:24 PM revealed, the resident was admitted to the hospital with a diagnosis of a complete heart block.Record review failed to reveal evidence that the facility reported the accident resulting in hospital admission to the appropriate authorities, including the State Survey Agency, in accordance with state law through established procedures.During a surveyor interview on 7/8/2026 at 1:03 PM with the Administrator, she acknowledged that the resident was sent to the hospital as a result of the fall on 6/5/2026 and was admitted . Additionally, she was unable to provide evidence that the facility reported the incident to the appropriate authorities, including the State Survey Agency, in accordance with state law through established procedures, as required.

Based on record review, surveyor observations, staff and resident interviews, the facility failed to provide an environment that remained as free of accident hazards as possible and failed to implement adequate supervision and interventions to prevent avoidable harm. Specifically, the facility failed to ensure safe water temperatures in resident-accessible hand sinks throughout all four resident care floors, exposing residents to the potential for serious burn injuries. In addition, the facility failed to ensure that Resident ID #2 received timely and appropriate post-fall assessment, monitoring, and interventions in accordance with facility policy following a fall, placing the resident at risk for undetected injury and potential worsening of condition. Findings are as follows:1. According to TITLE 216 - DEPARTMENT OF HEALTH, CHAPTER 40 - PROFESSIONAL LICENSING AND FACILITY REGULATION, SUBCHAPTER 10 - FACILITIES REGULATION, PART 1 - Licensing of Nursing Facilities, .In resident areas, hot water temperatures shall not be less than one-hundred degrees Fahrenheit (100 F) nor exceed one-hundred- and eighteen-degrees Fahrenheit (118 F). Thermometers [accuracy of which can be plus or minus two degrees Fahrenheit (+/-2 F)] shall be provided in each residential area to check water temperature periodically on that unit and at each site where residents are immersed or showered .Review of an undated facility procedure titled, F-689-Water Temperatures states in part, .Each state will have its own regulation on maximum water temperature allowed, but typically will fall between 105 to 115 degrees Fahrenheit( F ).for burn prevention, federal guidelines advise that you keep domestic water temperature below 120 degrees Fahrenheit, although this temp can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set the maximum temperatures less than 120 degrees Fahrenheit. Although 100 degrees Fahrenheit is considered a safe water temperature for bathing.Test temperature in shower areas.Check resident rooms at the end of each wing on a rotating basis or per facility policy.common area bathrooms, public bathrooms and any other areas having sinks should be checked and recorded.During a surveyor observation on 6/17/2026 at approximately 7:42 AM, the surveyor attempted to wash their hands in the first-floor public bathroom. The water temperature was too hot for the surveyor to maintain hand contact under the running stream. A digital thermometer reading at that time registered 122.1 F.Subsequent surveyor observations on 6/17/2026 revealed a systemic, facility-wide failure to regulate water temperatures within the safe, regulatory range (100 F to 120 F). The following elevated water temperatures were obtained and documented by the surveyors at the following locations:- 7:42 AM 1st floor public bathroom [ROOM NUMBER].2 F.- 8:09 AM 4th floor Resident room [ROOM NUMBER] 121.1 F.- 8:11 AM 4th floor main bathroom sink 122.4 F.- 8:20 AM 3rd floor Resident room [ROOM NUMBER] 122.9 F.- 8:23 AM 3rd floor main bathroom sink 123.7 F.- 8:38 AM 3rd floor Resident room [ROOM NUMBER] 124 F.- 8:47 AM 2nd floor Resident room [ROOM NUMBER] 121.8 F.During a surveyor interview on 6/17/2026 at 8:09 AM with Resident ID #3 s/he revealed that the water feels boiling hot and feels like it could burn his/her hands.During a surveyor interview on 6/17/2026 at 8:12 AM with Nursing Assistant (NA), Staff A, she revealed that the water sometimes feels too hot. Additionally, she further reported that she was unsure of the maximum safe water temperature for resident bathing. During a surveyor interview on 6/17/2026 at 8:33 AM with NA, Staff B she revealed that she was unsure what temperature is safe for a resident to bathe in.During a surveyor interview on 6/17/2026 at 8:35 AM with Resident ID #4, s/he revealed the water is too hot and that s/he has to let the water cool down once it is put into a basin to wash with.During a surveyor observation on 6/17/2026 at 8:52 AM in the presence of the Maintenance Staff, Staff C, the mixing valve temperature was set to 125-126 F.Record review of the facility's water temperature logs on 6/17/2026 revealed that the last recorded date for facility water temperature monitoring was completed on 1/16/2026. The facility failed to monitor, log, or track water delivery temperatures for exactly five months prior to this survey, demonstrating a breakdown in preventative maintenance.During a surveyor interview directly following the above observation of the mixing valve temperature setting and of the water temperature logs with Staff C, he acknowledged that water temperatures have not been completed since January and that the water temperature at the mixing valve was set above 120 F.During a surveyor interview on 6/17/2026 at 8:55 AM with the Administrator, she acknowledged that water temperatures should not exceed 120 F. Additionally, she was unable to provide evidence that the facility ensured a safe environment was maintained, relative to water temperatures.The facility's failure to maintain water temperatures accessible to residents exceeded both state regulatory requirements and facility policy on all four resident care floors, with temperatures ranging from 121.1 F to 124 F in resident rooms and common-use areas. Resident interviews confirmed that the water was perceived as hot and capable of causing burns. Staff interviews revealed a lack of knowledge regarding safe bathing water temperatures, and facility records demonstrated that required water temperature monitoring had not been completed for approximately five months. Further observation identified the facility's mixing valve set above the maximum safe temperature range. This exposed all residents, including those with cognitive impairment, sensory deficits, impaired mobility, and decreased ability to recognize or react to hazards, to the likelihood of serious injury. The deficient practice was facility-wide, ongoing, and had the potential to affect all residents with access to resident room and common area sinks and bathing areas. The Administrator and Maintenance Staff acknowledged the excessive temperatures and the failure to conduct required monitoring. Therefore, the facility's noncompliance placed residents at risk for serious injury, serious harm, impairment, or death and constituted Immediate Jeopardy. 2. Review of a facility policy titled, Fall Prevention and Management dated 1/2023 states in part, .In the event that a resident has fallen and/or is found on the ground, a complete head to toe assessment must be performed. Only move the resident if there is a life-threatening safety concern present.Upon arrival of the nurse, a quick head to toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings.If no obvious injury move the resident to a comfortable position. If injury, severe pain or abnormal assessment observed, call 911 for transfer.Review of a facility reported incident received by the Rhode Island Department of Health on 5/18/2026 revealed Resident ID #2 was found on the floor in his/her room in the prone position and was bleeding from his/her face. Additionally, the report revealed that the resident was admitted to the hospital following a fall and the facility was unsure if there was a new or old subdural hematoma (bleeding between the brain and skull, often due to head trauma).Record review revealed that Resident ID #2 was readmitted to the facility in May of 2026 with diagnoses including, but not limited to, dementia and a traumatic subdural hemorrhage.Review of a facility provided statement dated 5/16/2026 authored by Licensed Practical Nurse, Staff D states in part, .I observed the resident laying in the prone position between [his/her] bed and the roommates bed.I immediately alerted the second shift nurse [Staff E], and the 2nd shift supervisor, [Staff F] that the resident was on the floor face down. Myself, [Staff F], [Staff E], [Staff G], and one other male aide, who I did not get the name of, entered the room and got the patient back in bed.I noted resident's right side of face was discolored, with bruising to the cheek and forehead. Dried blood noted to right side of face and mouth and noted on floor where resident was found.Review of a facility provided statement dated 5/16/2026 authored by NA, Staff H states in part, .When I came back she told me that some one fall on the floor. So I and [Staff G ] pick [him/her] from the floor with blood or fluid coming out of [his/her] nose and mouth. We put [him/her] back to bed with the two nurses present and the supervisor present.Review of an Rhode Island Emergency Medical Services Report dated 5/16/2026 states in part, .unwitness fall at a skilled nursing facility. On arrival patient was found laying in bed.Review of the hospital documentation revealed that the resident presented to the hospital after an unwitnessed fall at his/her facility with a subdural hematoma found on a CT scan (a medical imaging test that uses a series of X-ray images taken from different angles around the body and computer processing to create detailed cross-sectional images (slices) of bones, organs, blood vessels, and soft tissues). During a surveyor interview with Staff F on 6/17/2026 at approximately 2:40 PM she revealed that she did not recall the fall or the situation surrounding it.During a surveyor interview with the Director of Nursing Services on 6/17/2026 at approximately 2:25 PM, she acknowledged staff lifted Resident ID #2 from the floor into the bed despite finding the resident prone and bleeding from the face. The DNS revealed that the facility attempts to make the residents comfortable following a fall. She was unable to provide evidence that a life-threatening environment justified the immediate move or that the staff followed the facility policy related to falls when an abnormal assessment was observed for Resident ID #2.

Based on clinical record review, surveyor observation, and resident and staff interviews, the facility failed to immediately consult with the physician when a resident's condition significantly changed or when treatment required alteration for 2 of 2 residents reviewed, Resident ID #1 and #5. The facility failed to notify the practitioner of Resident ID #1's worsening respiratory status, fever, lethargy, and labored breathing while receiving hospice services, and failed to obtain a physician order or notify the practitioner regarding Resident ID #5's urinary retention requiring catheterization. These failures had the potential to delay medical evaluation and treatment and resulted in actual harm for Resident ID #5, who required hospitalization for urinary retention. Findings are as follows: Review of a facility policy titled, Physician Services dated 10/2022 states in part, It is the policy of the facility to ensure the medical supervision of a resident's care during their stay, orders for immediate care and needs are met by a physician. 1. Review of a facility policy titled, Hospice Services states in part, .When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and the resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. Record review revealed that Resident ID #1 was admitted to the facility in June of 2026 with diagnoses including, but not limited to, pneumonia and respiratory failure. Record review revealed that Resident ID #1 was admitted to Hospice Services on 6/10/2026 with a diagnosis of protein calorie malnutrition. Review of a Visit Notes-Hospice dated 6/10/2026 authored by Hospice Registered Nurse (RN), Staff I, revealed the resident was admitted to hospice services and that s/he is alert and oriented to person, place, and time. Additionally, Staff I, revealed that the resident is going outside to smoke 8-10 cigarettes a day. Further review revealed vital signs including, but not limited to, temperature of 98.8 degrees Fahrenheit (normal is 97-99 degrees Fahrenheit), respirations of 28 breaths per minute (normal 16-20 breaths per minute), and a heart rate of 105 beats per minute (normal 60-100 beats per minute). Review of a Visit Notes- Hospice dated 6/12/2026 authored by Hospice RN, Staff J, revealed the resident has an elevated temperature of 101.1 degrees Fahrenheit, a heart rate 114-122 beats per minute and respirations of 38-42 breaths per minute. Additionally, the note revealed the resident is minimally responsive with increased lethargy and labored breathing. Review of a Visit Notes- Hospice dated 6/13/2026 authored by Hospice RN, Staff K, revealed the resident had an elevated temperature of 102.1 degrees Fahrenheit, a heart rate of 116 beats per minute and respirations of 32 breaths per minute. Additionally, the resident was noted to be lethargic, pale and lying in a fetal position in the bed. Record review failed to reveal evidence that the resident's change in condition including worsening vital signs, increased lethargy, and labored breathing was reported to a provider on 6/12/2026 or 6/13/2026. During a surveyor interview on 6/16/2026 at 10:32 AM with Nurse Practitioner (NP), Staff L, she revealed that she spoke to the staff on 6/12/2026 regarding not having Morphine (a narcotic medication) to administer to the resident. Additionally, she revealed that the facility staff did not communicate to her the resident's change in condition including that s/he had a fever and other worsening symptoms. 2. Record review revealed that Resident ID #5 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, dementia and anxiety. Review of a progress note dated 6/12/2026 revealed that Resident ID #5 was complaining of abdominal pain and a previously obtained urine specimen was sent to the laboratory for urinalysis and new orders were obtained for blood work to be completed on 6/13/2026. Review of a progress note dated 6/13/2026 authored by RN, Staff M states in part, C/o [complained of] lower abdominal cramp/discomfort. Upon assessment and palpation supra-pubic distention noted. Writer emptied 800cc [cubic centimeter. 1cc is equal to 1 milliliter of fluid] of amber colored Urine from the bladder, Resident verbalized relief. Record review failed to reveal evidence of a physician's order for Resident ID #5 to be catheterized for urinary retention. Further review failed to reveal evidence that a provider was made aware of the catheterization or that the resident retained 800 cc of urine on 6/13/2026. During a surveyor observation and interview on 6/16/2026 at 12:41 PM, Resident ID #5 was lying in bed with only a shirt and brief on with his/her abdomen exposed. The resident's abdomen appeared distended. Resident ID #5 revealed that s/he was not feeling well and that his/her stomach was upset. During a surveyor interview on 6/16/2026 at 1:06 PM via telephone with NP, Staff N, he revealed that he did not give an order to catheterize Resident ID #5 for urinary retention and that he had not been notified that the resident retained 800 cc of urine on 6/13/2026. Per Staff N, he was working up Resident ID #5 for constipation. Review of a progress note dated 6/16/2026 revealed Resident ID #5 was yelling out in pain, and his/her abdomen was noted to be distended and firm. Additionally, Resident ID #5 was transferred to the hospital for further treatment. Review of the emergency room documentation revealed that the resident had been complaining of abdominal pain for 4 days and has abdominal distention. Additionally, the staff report s/he was screaming in pain. Review of the Hospital admission Documentation revealed the resident was admitted to the hospital with a primary diagnosis of urinary retention. During an interview on 6/17/2026 at 7:31 AM, RN Staff M acknowledged that there was no physician order to catheterize Resident ID #5 on 6/13/2026. She further stated that she did not notify the provider that 800 cc of urine was obtained during the catheterization and was unable to provide evidence that the resident's change in condition had been reported to the provider. During a surveyor interview on 6/17/2026 at 8:05 AM with the Director of Nursing Services (DNS) she revealed that she would have expected staff to obtain an order for catheterization and to report urinary retention to the provider. Additionally, the DNS was unable to provide evidence that the facility immediately consulted with the resident's physician when there was a need to commence a alter treatment significantly for Resident ID #s 1 and 5. The facility's failure to immediately consult with the physician regarding significant changes in condition and the need to alter treatment prevented timely practitioner assessment and intervention. As a result, Resident ID #5 experienced ongoing abdominal pain, urinary retention, and deterioration in condition requiring hospitalization. Additionally, Resident ID #1 experienced worsening respiratory distress, fever, and lethargy without evidence of physician notification or evaluation. These failures placed residents at risk for adverse outcomes and demonstrate the facility's failure to ensure appropriate physician involvement in resident care. Cross Reference F 684 and F 755

Based on clinical record review and staff interview, the facility failed to provide care and services in accordance with the resident's physician-approved hospice plan of care for 1 of 1 resident reviewed receiving hospice services, Resident ID #1. Specifically, the facility failed to ensure timely administration of physician-ordered Morphine Sulfate for the management of pain and shortness of breath despite repeated hospice recommendations, worsening clinical symptoms, and the medication being available within the facility. As a result, Resident ID #1 experienced prolonged unmanaged pain and respiratory distress, including worsening lethargy, labored breathing, tachypnea (rapid shallow breathing), tachycardia (rapid heart rate), and fever. Findings are as follows:Review of a facility policy titled, Hospice Services states in part, .When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and the resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms.Record review revealed that Resident ID #1 was admitted to the facility in June of 2026 with diagnoses including, but not limited to, pneumonia and respiratory failure.Record review revealed that Resident ID #1 was admitted to Hospice Services on 6/10/2026 with a diagnosis of protein calorie malnutrition.Review of a Visit Notes-Hospice dated 6/10/2026 authored by Hospice Registered Nurse (RN), Staff I revealed the resident was admitted to hospice services and that s/he is alert and oriented to person, place, and time. Additionally, Staff I revealed that the resident is going outside to smoke 8-10 cigarettes a day. Further review revealed vital signs including, but not limited to, temperature of 98.8 degrees Fahrenheit (normal is 97-99 degrees Fahrenheit), respirations of 28 breaths per minute (normal are 16-20 breaths per minute), and heart rate of 105 beats per minute (normal is 60-100 beats per minute). Staff I made recommendations for care including, but not limited to, Morphine Sulfate (a narcotic) Concentrate 20 milligrams per milliliter (mg/ml), give 5 mg (0.25ml) by mouth every 8 hours scheduled for pain/shortness of breath and give 5 mg by mouth every two hours as needed for breakthrough pain or shortness of breath.Review of a progress note dated 6/10/2026 revealed the resident's physician approved all hospice recommendations including, but not limited to, Morphine Sulfate Concentrate 20 mg/ml, give 5 mg (0.25ml) by mouth every 8 hours scheduled for pain/shortness of breath and give 5 mg by mouth every two hours as needed for breakthrough pain or shortness of breath.Record review failed to reveal evidence of an active physician's order for Morphine Sulfate until 6/11/2026, although the order was received on 6/10/2026.Review of a Visit Notes-Hospice dated 6/11/2026 revealed Resident ID #1 had increased shortness of breath and had visible signs of respiratory distress. Additionally, the note revealed new hospice recommendations to increase the Morphine Sulfate Concentration 20 mg/ml to give 5 mg every 6 hours scheduled.Review of a progress note dated 6/11/2026 states in part, .Resident was visited by Hospice care team, all recommendations was approved by the provider.Review of the June 2026 Medication Administration Record (MAR) failed to reveal evidence that the scheduled or as needed Morphine Concentrate was administered on 6/11/2026.Review of a Visit Notes- Hospice dated 6/12/2026 authored by Hospice RN, Staff J revealed the resident has an elevated temperature of 101.1 degrees Fahrenheit, a heart rate of 114-122 beats per minute, and respirations of 38-42 breaths per minute. Additionally, the note revealed the resident is minimally responsive with increased lethargy and labored breathing. Further review revealed Hospice was requesting for the Morphine be administered as soon as it arrives.Review of the June 2026 MAR failed to reveal evidence that the scheduled or as needed Morphine Concentrate was administered on 6/12/2026.Review of a Visit Notes- Hospice dated 6/13/2026 authored by Hospice RN, Staff K revealed the resident had an elevated temperature of 102.1 degrees Fahrenheit, a heart rate of 116 beats per minute and respirations of 32 breaths per minute. Additionally, the resident was noted to be lethargic, pale and lying in a fetal position in the bed. Per Staff K the facility staff report that the resident does not have any Morphine Concentrate and that no pain medication had been administered since it was ordered. Staff K revealed she spoke with the facility nurse, Staff O who then was able to get the medication from the facility's emergency supply and administer the Morphine at 2:15 PM.Review of the Electronic Medication Dispenser (EMD, a machine that is an automated medication dispensing system used in healthcare facilities to securely store, track, and manage medications) supply log identified Morphine Sulfate Concentrate as an available medication.Review of the EMD morphine inventory revealed the Morphine Sulfate Concentrate was not restocked in the inventory for use until 6/12/2026 at 2:31 PM.Record review revealed that although the medication was restocked in the EMD on 6/12/2026 at 2:31 PM, it was not administered to Resident ID #1 until 1:58 PM on 6/13/2026, as documented in the facility's Narcotic Log Book. This resulted in an additional delay of 23 hours and 27 minutes after the medication became available within the facility. During this period, the resident exhibited worsening clinical symptoms, including an elevated temperature of 101.1 degrees Fahrenheit, a heart rate ranging from 114 to 122 beats per minute, and respirations of 38 to 42 breaths per minute. Furthermore, the resident missed two scheduled doses that were due at 12:00 AM and 6:00 AM on 6/13/2026.During a surveyor interview on 6/17/2026 at 7:36 AM, Registered Nurse Staff M acknowledged working the overnight shift from 11:00 PM on 6/12/2026 to 7:00 AM on 6/13/2026. Staff M revealed that during the shift-to-shift report, she was informed by the outgoing nurse that the Morphine Sulfate Concentrate was unavailable in the EMD system. She stated that she did not check to see if the morphine sulfate concentrate was available in the EMD inventory prior to the scheduled 12:00 AM and 6:00 AM doses on 6/13/2026. Furthermore, Staff M revealed that she did not notify the attending provider regarding the unavailability of the medication to allow for any adjustments to the resident's plan of care required to manage pain and uncomfortable symptoms that were documented by the hospice provider.During a surveyor interview on 6/17/2026 at approximately 2:25 PM, the Director of Nursing Services (DNS) acknowledged that a review of the EMD automated medication dispensing supply logs identified Morphine Sulfate Concentrate as an available medication within the facility's inventory system but that the medication was initially unavailable. The DNS acknowledged that the EMD inventory records show the Morphine Sulfate Concentrate was restocked and physically available for nurse retrieval on 6/12/2026 at 2:31 PM. The DNS acknowledged that despite being restocked, the medication was not administered to the resident until 6/13/2026 at 1:58 PM. She was unable to provide evidence that the resident's plan of care between the facility, hospice agency and the resident/family were followed for managing pain and other uncomfortable symptoms.The facility failed to ensure the implementation of a physician-approved hospice plan of care intended to manage Resident ID #1's pain and respiratory distress. Despite hospice identifying worsening symptoms and requesting prompt administration of Morphine Sulfate, the resident did not receive the medication for approximately three days after it was ordered and for more than 23 hours after it became available within the facility. Staff failed to verify medication availability, administer the ordered medication, or notify the provider regarding missed doses and unmanaged symptoms. Consequently, Resident ID #1 experienced prolonged pain and respiratory distress, including worsening lethargy, labored breathing, tachypnea, tachycardia, and fever. These failures resulted in actual harm and were inconsistent with the resident's hospice plan of care and the facility's responsibility to provide necessary care and services to attain or maintain the resident's highest practicable well-being. Cross reference F 580 and F 755

Based on surveyor observation, staff interview, and clinical record review, the facility failed to ensure appropriate foot care was provided and arranged for 1 of 1 resident observed with overgrown toenails, Resident ID #2.Findings are as follows:Review of a facility policy titled Foot Care-Nail Clipping last revised 10/2022, states in part, Residents will be provided with foot care and treatment in accordance with professional standards of practice.Residents requiring toenail clipping will be referred to facility podiatrist or resident's podiatrist of choice.Record review revealed that Resident ID #2 was admitted to the facility in May of 2018 with diagnoses including, but not limited to, hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following a cerebrovascular disease (stroke) affecting the left non-dominant side and peripheral vascular disease.During a surveyor observation in the presence of Licensed Practical Nurse, Staff P, on 6/16/2026 at 12:45 PM, Resident ID #2 was observed lying in bed in their room barefoot. The toenails on both his/her feet were observed to be extremely long, thickened, and curved downward toward the nail beds.During a surveyor interview immediately following the observation, Staff P acknowledged that Resident ID #2's toenails were long, thick and curving downwards. She was unaware of the last time the resident was seen by a podiatrist but revealed that a podiatrist was in the building recently. Record review revealed that the resident's last podiatry visit was on 12/10/2025. Review of the podiatry visit revealed the resident will be seen in 10 weeks, indicating the patient was due for a visit around 2/18/2026.Record review failed to reveal evidence that the resident was evaluated after 10 weeks as indicated in the podiatry visit note. Further review revealed the resident's last podiatry visit was 26 weeks prior to the observations on 6/16/2026.During a surveyor interview on 6/17/2026 at 10:07 AM with the Director of Nursing, she was unable to provide evidence of timely, required podiatry services, resulting in the resident exhibiting long, overgrown toenails.

Based on clinical record review and staff interview, the facility failed to provide specialized dialysis care in accordance with professional standards of practice and the facility's policy by failing to monitor and document the patency of a newly placed Arteriovenous (AV) fistula (a surgically created connection between an artery and a vein that allows blood to flow directly from the artery into the vein, bypassing capillaries) for 1 of 1 resident reviewed, Resident ID #6. Findings are as follows:Review of the facility's policy titled Dialysis Management, revised 10/2022, revealed: .The nurse will obtain orders for monitoring of site and interventions as appropriate. Orders to include. Access site/type.Observe shunt for thrills [vibrating or buzzing sensation felt over an AV fistula, often caused by turbulent blood flow] and bruits [sound heard over an AV fistula, typically due to turbulent blood flow] .every shift.Record review revealed that Resident ID #6 was admitted to the facility in February of 2026 with diagnoses including, but not limited to, chronic kidney disease and dependence on renal dialysis (a treatment to remove extra fluid and waste from the body when the kidneys can no longer due so).Record review revealed on 5/4/2026, Resident ID #6 underwent surgical placement of a new right-arm AV fistula intended for future dialysis access.Record review failed to reveal evidence that the facility checked and documented the patency of the AV fistula every shift. Record review of Resident ID #6's clinical record from 5/4/2026 through 6/16/2026, a period of 44 days, failed to reveal evidence of documented monitoring of the newly created right AV fistula access site. Based on the facility's requirement to assess the fistula for the presence of a bruit and thrill once per shift, there were 132 monitoring opportunities during this review period. Of those 132 opportunities, documentation was absent for 124 assessments, indicating that the required monitoring was either not performed or not documented. During a surveyor interview with the Director of Nursing Services on 6/17/2026 at 1:53 PM, she revealed that she would expect the nurses to monitor the Resident's AV fistula site every shift in accordance with the facility's policy.

Based on surveyor observation and staff interview, the facility failed to provide and maintain a sanitary, safe, and comfortable environment by allowing the accumulation of extensive black and brown buildup throughout 3 of 3 communal shower rooms observed. Findings are as follows:A surveyor tour of the second, third, and fourth floor communal shower rooms revealed unsanitary conditions in all shower rooms observed.During a surveyor observation on 6/17/2026 at 8:11 AM, with Nursing Assistant, Staff A, the fourth-floor communal shower stall was observed to have a substantial accumulation of black and brown buildup along the lower one-fourth of the shower stall wall. Staff A acknowledged the presence of the buildup.During a surveyor observation conducted on 6/17/2026 at 8:25 AM, the third-floor communal shower stall was observed to have a similar accumulation of black and brown irregular buildup extending along the lower one-fourth of the shower stall wall.During a surveyor observation conducted on 6/17/2026 at 8:45 AM, with the Maintenance Staff, Staff C, the second-floor communal shower stall was observed to have extensive black and brown buildup covering the lower one-fourth of the shower stall wall.During a surveyor interview conducted on 6/17/2026 at 8:45 AM, Staff C acknowledged the accumulation of black and brown matter present in the shower stalls and stated that the shower stalls required cleaning.During a surveyor interview conducted on 6/17/2026 at 2:22 PM, the Director of Nursing Services stated she would expect resident shower stalls to be maintained in a clean and sanitary condition and free from accumulations of black and brown buildup. The presence of visible accumulations of black and brown buildup in 3 of 3 communal shower rooms observed demonstrates the facility's failure to maintain resident bathing areas in a clean and sanitary condition, resulting in residents being exposed to unsanitary environmental conditions.

Based on surveyor observation, clinical record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for 1 of 1 resident observed for enteral nutrition tube feeding, (a delivery of nutrition into the stomach or small intestine via an enteral access device), Resident ID #2.Findings are as follows:Review of a facility policy titled Enteral Feedings last revised on 10/2022, states in part, .Position resident in semi-Fowler's position or according to plan of care.Record review revealed that Resident ID#2 was admitted to the facility in May of 2018 with diagnoses including, but not limited to, hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) due to cerebrovascular disease (a stroke) affecting the left non-dominant side and gastrostomy status (the medical state of a resident who has had a surgically created opening through the abdominal wall directly into the stomach to deliver nutrition or medications).Review of a physician's order dated 5/19/2026 revealed in part to elevate resident 30 -45 at all times during feeding and for one hour after gravity feeds .During a surveyor observation in the presence of Licensed Practical Nurse, Staff P, on 6/16/2026 at 12:45 PM, Resident ID #2 was observed lying in bed with the head of bed less than 30 elevated while receiving his/her enteral feed. The resident was in a fetal position. Staff P attempted to raise the head of the bed but was initially unsuccessful. Staff P then plugged the bed into the wall and was able to control the head of the bed height.During a surveyor interview immediately following the above-mentioned observation, Staff P acknowledged that the resident's head of the bed was not at the ordered height and should have been.During a surveyor interview conducted on 6/17/2026 at 10:27 AM, the Director of Nursing Services acknowledged that the resident's physician order required the head of the bed to be elevated and stated that staff were expected to ensure the order was consistently implemented.

Based on clinical record review and staff interview, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to urinary catheter (a flexible tube inserted into the bladder to empty urine) use, gastrostomy (g tube; a surgically created opening through the abdominal wall into the stomach to allow for nutrition or medications) tube care, thickened liquids, and dialysis (a treatment to remove extra fluid and waste when kidneys can no longer do so adequately) for 5 of 5 licensed staff reviewed, Staff E, M, P, Q, and R.Findings are as follows:Review of the Facility Assessment dated 6/9/2026 states in part, A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment.Services Provided Based on Resident Need.The intent is to identify and reflect on resources needed to provide these types of care.list the types of care that your resident population requires and that you provide for your resident population.intermittent or indwelling or other catheter.dialysis.end of life care.tube feeding.dietary requirements.specialized diets.1. Record review revealed that Resident ID #5 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, dementia and anxiety.Review of a progress note dated 6/13/2026 authored by Registered Nurse (RN), Staff M states in part, C/o [complained of] lower abdominal cramp/discomfort. Upon assessment and palpation supra-pubic distention noted. Writer emptied 800cc [cubic centimeters. 1 cc is equal to 1 milliliter of fluid] of amber colored Urine from the bladder, Resident verbalized relief.Record review failed to reveal evidence of a physician's order for Resident ID #5 to be catheterized for urinary retention.During a surveyor interview on 6/17/2026 at 7:31 AM with RN, Staff M she acknowledged that she utilized a foley catheter to catheterize Resident ID #5 on 6/13/2026 although there was not an order to do so.Record review failed to reveal competency-based training for catheterization for Staff E, M, P, Q, and R. 2. Record review revealed that Resident ID #6 was admitted to the facility in February of 2026 with diagnoses including, but not limited to, chronic kidney disease and dependence on renal dialysis (a treatment to remove extra fluid and waste when kidneys can no longer adequately do so).Record review revealed on 5/4/2026, Resident ID #6 underwent surgical placement of a new right-arm AV fistula (a surgically created connection between an artery and a vein that allows blood to flow directly from the artery into the vein, bypassing capillaries) intended for future dialysis access.Record review failed to reveal evidence of a physician's order to assess and document the patency of the AV fistula every shift.Record review of Resident ID #6's clinical record from 5/4/2026 through 6/16/2026, a period of 44 days, failed to reveal evidence of documented monitoring of the newly created right AV fistula access site. Based on the facility's requirement to assess the fistula for the presence of a bruit and thrill once per shift, there were 132 monitoring opportunities during this review period. Of those 132 opportunities, documentation was absent for 124 assessments, indicating that the required monitoring was either not performed or not documented. Record review failed to reveal competency-based training for dialysis including, but not limited to, care of an AV fistula for Staff E, M, P, Q, and R.3. Record review revealed that Resident ID #7 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing).Record review revealed a physician's order dated 3/10/2026 specifying a therapeutic diet consisting of Nectar Thick Liquids (mildly thickened beverages designed to help individuals with swallowing difficulties).During a surveyor observation on 6/16/2026 at approximately 12:31 PM, Resident ID #7's meal tray was on the table in front of the resident. The meal tray contained a 4-ounce pre-packaged container of raspberry sherbet. Additionally, the sherbet was melted inside its container on the tray.During a surveyor observation on 6/16/2026 at 12:34 PM in the presence of Licensed Practical Nurse, Staff S, she utilized a spoon to test the consistency of the melted sherbet, observing it to have a fluid, free-flowing consistency identical to water (a thin liquid), failing to meet the required nectar consistency.Record review failed to reveal competency-based training for nectar thick liquids for Staff E, M, P, Q, and R.4. Record review revealed that Resident ID #2 was admitted to the facility in May of 2018 with diagnoses including, but not limited to, hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) due to cerebrovascular Disease (a stroke) affecting the left non-dominant side and gastrostomy status. Review of a physician's order dated 5/19/2026 revealed in part to elevate resident 30 -45 at all times during feeding and for one hour after gravity feeds .During a surveyor observation in the presence of Licensed Practical Nurse, Staff P, on 6/16/2026 at 12:45 PM, Resident ID #2 was observed lying in bed with the head of the bed less than 30 degrees elevated. The resident was in a fetal position. Staff P attempted to raise the head of the bed but was initially unsuccessful. Staff P then plugged the bed into the wall and was able to control the head of the bed height.During a surveyor interview immediately following the above-mentioned observation, Staff P acknowledged that the resident's head of the bed was not at the ordered height and should have been.Record review failed to reveal competency-based training for G-tubes for Staff E, M, P, Q, and R.During a surveyor interview on 6/17/2026 at 2:22 PM with the Director of Nursing Services she was unable to provide evidence that 5 licensed nurses received competency-based training on catheterization, dialysis, G-tubes, and thickened liquids although the facility assessment indicates all services are provided.

Based on clinical record review and staff interview, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents reviewed relative to end of life care, Resident ID #1. Findings are as follows:Review of a facility policy titled, Electronic Medication Dispenser (EMD) dated 1/2023 states in part, Policy: To have a selection of oral medications available in the facility for immediate use.The pharmacy should deliver replacement medication used for the nurse to return to the EMD.Review of a community reported complaint received by the Rhode Island Department of Health on 6/15/2026 revealed that Resident ID #1 was on hospice services and has not received his/her scheduled Morphine for more than 18 hours due to it not being available.Record review revealed that Resident ID #1 was admitted to the facility in June of 2026 with diagnoses including, but not limited to, pneumonia and respiratory failure.Record review revealed that Resident ID #1 was admitted to Hospice Services on 6/10/2026 with a diagnosis of protein calorie malnutrition.Record review revealed a physician's order for Morphine Sulfate (a narcotic) Concentrate 20 milligrams per milliliter (mg/ml), give 5 mg (0.25ml) by mouth every 6 hours scheduled for pain/shortness of breath and give 5 mg by mouth every two hours as needed for breakthrough pain or shortness of breath.Review of the June 2026 Medication Administration Record (MAR) revealed that the scheduled or as needed Morphine Sulfate was not administered on 6/11/2026.Review of a progress note dated 6/11/2026 states in part, .medication not available at this time, ordered, pharmacy called, awaiting delivery from the pharmacy.Review of the EMD supply log identified Morphine Sulfate Concentrate as an available medication.Review of the EMD Morphine Sulfate Concentrate inventory revealed it was out of stock on 6/11/2026.Review of the June 2026 MAR revealed that the scheduled or as needed Morphine Sulfate was not administered on 6/12/2026.Review of the EMD inventory revealed the Morphine Sulfate Concentrate was restocked in the inventory for use on 6/12/2026 at 2:31 PM. The Morphine Sulfate Concentrate was not available in the facility for administration on 6/11 or 6/12/2026 causing the resident to miss 7 consecutive doses.During a surveyor interview on 6/17/2026 at approximately 2:25 PM, the Director of Nursing Services (DNS) acknowledged that a review of the EMD supply logs identified Morphine Sulfate Concentrate as an available medication within the facility's inventory system but that the medication was unavailable on 6/11 and 6/12/2026. Additionally, she was unavailable to provide evidence that the facility provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of Resident ID #1.

Based on surveyor observation, staff interview, and clinical record review, the facility failed to ensure food and fluids were provided in a modified form designed to meet the individual clinical needs for 1 of 1 resident reviewed for therapeutic diets, Resident #7. Findings are as follows:According to the OnTray, LLC. Long Term Care Diet Manual, 2025 Edition, provided by the facility, .Popsicles, Ice Cream, Sherbert, Freeze Pops, Frozen Lemonade, slushies, milk shakes, or any product that melts at body temperature .cannot be thickened.Record review revealed that Resident ID #7 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing).Record review revealed a physician's order dated 3/10/2026 specifying a therapeutic diet consisting of Nectar Thick Liquids (Liquids that are thicker than water, fall slowly from a spoon).During a surveyor observation on 6/16/2026 at approximately 12:31 PM, Resident ID #7's meal tray was on the table in front of the resident. The meal tray contained a 4-ounce pre-packaged container of raspberry sherbet. Additionally, the sherbet was melted inside its container on the tray.During a surveyor observation on 6/16/2026 at 12:34 PM in the presence of Licensed Practical Nurse, Staff S, she utilized a spoon to test the consistency of the melted sherbet, observing it to have a fluid, free-flowing consistency identical to water (a thin liquid), failing to meet the required nectar consistency.During a surveyor interview immediately following the observation with Staff S, she acknowledged that the sherbert was not at nectar thickened consistency and was too thin for the resident.During surveyor interviews on 6/16/2026 at 12:59 PM and 1:02 PM with the Food Service Director (FSD), he acknowledged that any food item that becomes liquid at room or body temperature such as sherbet is classified as a thin liquid and must not be served to residents on a nectar-thickened diet. The FSD acknowledged that the kitchen staff should not have provided Resident ID #7 with a sherbert on his/her lunch tray.

Based on clinical record review, staff interviews, and policy review, the facility failed to adhere to its established bowel management protocol by not initiating timely interventions after 9 consecutive shifts without a bowel movement, failing to notify the provider of medication refusal and a new diagnosis of constipation, and neglecting to reassess and update the care plan. These failures resulted in prolonged fecal impaction, hospitalization, and contributed to the Resident's clinical deterioration and death. This deficient practice was identified in 1 of 3 residents reviewed for bowel management, Resident ID #1. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/8/2025, alleged that while Resident ID #1 was at the facility, the facility failed to address the resident's constipation. It further alleged that the resident was hospitalized related to this failure.Review of a facility policy titled, BOWEL EVACUATION PROTOCOL, dated March 2016, revealed, The facility has the responsibility to ensure that each resident develops regular bowel habits with or without cathartic [laxative] assistance. The purpose is to prevent impaction and incontinence promote psychological and social well-being. Procedure.if the resident has had no bowel movement for 9 consecutive shifts, begin the bowel protocol on the 3:00 p.m. - 11:00 p.m shift.The bowel protocol is to give Milk of Magnesia (MOM) on the 3:00 p.m. - 11:00 p.m. shift. If the MOM is ineffective, then the resident is to receive a Bisacodyl [laxative] suppository on the 11:00 p.m. to 7:00 a.m. shift. If the Bisacodyl suppository is ineffective, then the resident is to receive a Fleet enema on the 7:00 a.m. to 3:00 p.m. shift. Record the results of the Bowel Protocol on the reverse side of the M.A.R [Medication Administration Record] and/or in the Nurses Notes. Notify the physician if the Bowel Protocol is ineffective.Record review revealed Resident ID #1 was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, acute kidney failure. Additionally, the resident was discharged from the facility on 10/22/2025, to an acute care hospital.Review of the resident's bowel movement report revealed that s/he went 15 consecutive shifts from 10/15/2025, through the end of day on 10/19/2025, without a bowel movement. The resident went 6 additional shifts after the bowel protocol should have been initiated without intervention. Record review failed to reveal evidence that the bowel protocol was initiated or followed on the 9th consecutive shift, per the facility policy. The facility failed to begin the bowel protocol on the 3:00 p.m. - 11:00 p.m shift, beginning with the initiation of Milk of Magnesia (MOM) on the 3:00 p.m. - 11:00 p.m. shift. Followed by administering the Bisacodyl suppository, followed by a fleet if needed. Record review revealed on 10/19/2025, the 14th shift without a bowel movement, Certified Medication Technician (CMT), Staff A, attempted to administer the resident MOM, which the resident refused. Further review failed to reveal evidence that the refusal of the MOM was reported to the provider for further instruction or a change in the bowel management protocol. The facility failed to notify the physician that the bowel protocol was unable to be followed or was ineffective as stated in the facility policy. Record review revealed on 10/20/2025, the resident was then sent to an acute care hospital for stroke-like symptoms. Further review revealed the resident returned the same day from the hospital with a new diagnosis of constipation.Record review of the acute care hospital summary dated 10/20/2025 revealed, the resident was found to have abdominal distention and constipation but no abdominal pain.Record review failed to reveal evidence that the provider was notified that the resident returned on 10/20/2025 with a new diagnosis of constipation to allow for an adjustment to the resident plan of care to manage his/her constipation, although the provider was contacted on 10/21/2025 by Registered Nurse, Staff B.Record review of the progress notes for 10/22/2025 revealed, at 12:19 PM, the resident presented with a distended abdomen that was tender to the touch and MOM was administered at this time and a message was left with the provider. Additionally, at 4:56 PM, an order was provided by the provider to obtain a STAT (immediate) kidney, ureter, and bladder (KUB- an abdominal x ray). Further review of the progress notes revealed, documented at 6:44 PM that the resident had increased pain upon palpation (touching) of the abdomen, which at this time is extremely distended with bowel sounds only in the left upper quadrant of the abdomen (bowel sounds should be heard in all four quadrants of the abdomen). The resident was then sent to the hospital via emergency medical services.Further record review of a progress note dated 10/23/2025 revealed that the resident was admitted to the acute care hospital at 1:37 AM with a diagnosis of constipation.Review of the acute care hospital summary from 10/22/2025 through 10/23/2025 revealed, the resident came to the emergency department with complaints of constipation. A CT scan was completed with finding suggestive of stercoral colitis (a condition characterized by inflammation of the colon due to fecal impaction) and last stool burden (an accumulation of fecal matter in the large intestine, also known as the colon) along with diffused hepatic metastatic disease (liver metastases are cancerous tumors that spread to the liver from another part of the body, such as the stomach, esophagitis, colon, rectal, kidney, etc.). The resident was admitted for management and evaluation of constipation. Additionally, the resident was evaluated by gastroenterology for the constipation, and a decision was made regarding a possible colonoscopy due to the constipation. The acute care hospital decided to avoid any invasive procedure in view of the residents age and frailty. During the inpatient stay the resident had a small bowel movement but remained constipated. On 10/23/2025 the resident became hypotensive (low blood pressure), hypoxic (low oxygen), and was started on intravenous fluids and oxygen. The resident was examined at bedside and found to be unresponsive with agonal (abnormal) breathing. The resident passed away at 10:00 PM. During a surveyor interview on 12/10/2025 at 10:58 AM, with Registered Nurse, Staff B, he was unable to recall reporting to the provider on 10/21/2025 that the resident returned to the facility with a diagnosis of constipation. Additionally, he revealed the process for monitoring the resident bowels is as followed; the 7:00 a.m. to 3:00 p.m. shift generates a list of residents who have been identified as meeting the requirements for bowel management. That list is then passed from shift to shift and ends back on the 7:00 a.m. to 3:00 p.m. shift the next day. When asked for yesterday's bowel list that was generated and passed from shift to shift, he revealed that he worked yesterday and did not generate a list and indicated one was not received back to him at the beginning of his shift from the prior shift.During a surveyor interview on 12/10/2025 at 11:02 AM, with Licensed Practical Nurse (LPN), Staff C, she acknowledged that the resident went 15 shifts without a documented bowel movement or intervention.During a surveyor interview with LPN, Staff D, on 12/10/2025 at 12:10 PM, she revealed that on 10/22/2025 the resident presented with increased abdominal distention, indicating it was worse than the last time she saw the resident. She revealed that during the conversation with the provider, a decision was made to send the resident to the hospital, as she was unsure if it was constipation or some other issue occurring in the resident's abdomen.During a surveyor interview on 12/10/2025 at 1:24 PM, with CMT, Staff A, he revealed that he was unable to recall the day the resident refused his/her MOM, but indicated that he writes all refusal of medications, including as needed medications, on a list to communicate to the nurses, for the nurses to follow up on.Record review failed to reveal evidence that the Nurse working on 10/19/2025 notified the provider that Resident ID #1 refused the MOM. During surveyor interviews on 12/10/2025 at 12:49 PM and 1:00 PM, with the resident's Nurse Practitioner, she revealed that she was not notified that the resident went 15 consecutive shifts without having a bowel movement. Additionally, she revealed had she been notified that the resident refused the MOM on the 14th shift of no bowel movement, she would have changed the medication and offered the resident a different type of laxative. Furthermore, she revealed that she was unaware that the resident returned from the hospital on [DATE] with a new diagnosis of constipation. She revealed that had she been notified she would have ordered new interventions added into the resident plan of care to address the constipation.During a surveyor interview on 12/10/2025 at 2:32 PM, with the Director of Nursing Services, she acknowledged that the resident was document as going 15 consecutive shifts without a bowel movement. Additionally, she was unable to provide evidence that the facility followed their bowel protocol for Resident ID #1. Furthermore, she was unable to provide evidence that the provider was notified related to the refusal of the MOM and the new diagnosis of constipation.The facility's failure to monitor and manage Resident ID #1's bowel status in accordance with the facility's bowel protocol, failure to notify the provider of significant changes and treatment refusals, and failure to implement timely interventions, resulted in the resident experiencing prolonged constipation, hospitalization, and subsequent decline.

Based on surveyor observation and staff interview, the facility failed to maintain all mechanical, electrical, and patient care equipment, in a safe operating condition for the walk-in freezer unit in the main kitchen.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 10/15/2025 alleged in part, a concern related to residents experiencing foodborne illness while at the facility. Record review of Rhode Island Food Code, 2022 Edition, Section 4-501.11 states in part, .EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2 . During the initial tour of the kitchen on 12/1/2025 at approximately 11:00 AM, the walk-in freezer was holding at an ambient temperature of 28 degrees Fahrenheit. Additionally, the following items were observed in a partially thawed condition:- one bag containing approximately 5 pounds (lbs.) of chicken wings- one bag containing approximately 5 lbs. of chicken tenders- four bags containing 2 lbs. of lobster- one box containing 10 lbs. of [NAME] dean mild pork sausage pattiesDuring a surveyor interview with the Food Service Director following the above observation, he acknowledged the walk-in freezer temperature, and the above-mentioned items were not frozen solid. Additionally, he indicated the freezer temperatures taken recently had been erratic. He further indicated that the freezer is in need of replacement.

Based on record review and staff interview, the facility failed to meet professional standards of quality for 1 of 1 resident reviewed with a physician's order for a neck brace, Resident ID #1.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 of a facility reported incident submitted to the Rhode Island Department of Health on 10/27/2025 states in part, the resident has a neck fracture requiring a neck brace and was neglected.Record review revealed Resident ID #1 was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, type 2 odontoid fracture (a fracture at the base of the second cervical vertebra).Record review revealed a physician's order dated 10/24/2025 for a neck brace to be applied at all times.Record review of the October 2025 Treatment Administration Record revealed that s/he had not received his/her neck brace, as ordered, by the physician, as it was not available on the following dates and times:- 10/25/2025, 7:00 AM to 3:00 PM- 10/25/2025, 3:00 PM to 11:00 PM- 10/26/2025, 7:00 AM to 3:00 PM- 10/26/2025, 11:00 PM to 7:00 PMRecord review of a Physical Therapy progress note dated 10/27/2025, revealed that the residents neck brace was not on and the nurse was unable to locate it.During a surveyor interview on 12/2/2025 at approximately 3:30 PM with the Director of Nursing Services, she indicated it would be her expectation for the neck brace to be applied, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that all residents receive treatment and care in accordance with professional standards, relative to follow up physician appointments for 2 of 2 residents reviewed, Resident ID #s 11 and 85. Findings are as follows:1. Record review revealed that Resident ID #11 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, type II diabetes and hypertension (high blood pressure).Record review revealed Resident ID #11 was transferred to the hospital on 5/4/2025 due to abdominal pain and vomiting.Review of a Discharge Summary dated 5/7/2025, revealed a referral to outpatient cardiology for chest pain.Review of a progress note dated 5/8/2025, authored by Nurse Practitioner, Staff F, revealed, the resident was seen in the hospital for chest pain and shortness of breath and is to follow up outpatient cardiology.Record review failed to reveal evidence that Resident ID #11 had a follow up appointment with outpatient cardiology.During a surveyor interview on 10/1/2025 at 10:37 AM, with Licensed Practical Nurse (LPN), Staff E, he was unaware that Resident ID #11 was supposed to follow up with outpatient cardiology following his/her hospitalization in May.During a surveyor interview with Unit Secretary, Staff G, she revealed that she schedules appointments for the unit that Resident ID #11 is on. Additionally, she revealed that she was unaware that Resident ID #11 was supposed to have a follow up appointment with cardiology. Further, Staff G looked through the appointment calendar and was unable to find an appointment for Resident ID #11 for cardiology and revealed that she will make an appointment.During a surveyor interview on 10/1/2025 at 1:41 PM, with the Director of Nursing Services (DNS), she was unable to provide evidence that Resident ID #11 followed up with outpatient cardiology, as ordered.2. Record review revealed that Resident ID #85 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, necrotizing fasciitis (a bacterial infection that affects the tissue under your skin called fascia) and a right foot wound.Record review revealed Resident ID #85 had a follow up appointment with infectious disease scheduled for 9/29/2025.Record review failed to reveal evidence that Resident ID #85 went to the infectious disease appointment on 9/29/2025.During a surveyor interview on 10/1/2025 at 10:32 AM with LPN, Staff H, she acknowledged that Resident ID #85 did not go to the follow up appointment with infectious disease.During a surveyor interview on 10/1/2025 at 11:07 AM with Unit Secretary, Staff I, she revealed that she is responsible for scheduling appointments on the unit that Resident ID #85 resides on. Additionally, Staff I revealed she was unaware that Resident ID #85 had a follow up appointment with infectious disease on 9/29/2025 and that s/he did not go.During a surveyor interview via telephone on 10/1/2025 at 11:24 AM with the Unit Secretary of the Infectious Disease Provider revealed, the resident did not show up to his/her appointment on 9/29/2025. Additionally, she revealed that the facility called to make an appointment for Resident ID #85 after the missed appointment was brought to their attention by the surveyor.During a surveyor interview on 10/1/2025 at 12:53 PM with the DNS, she was unable to provide evidence that Resident ID #85 followed up with infectious disease as ordered.

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 2 residents reviewed for antibiotics, Resident ID #85, 1 of 2 residents reviewed for pain management, Resident ID #82, and 1 of 1 resident reviewed for divalproex sodium (Depakote, a medication prescribed for off-label use to manage agitation and other challenging behaviors in dementia patients), Resident ID #30.Findings are as follows:A. Record review revealed Resident ID #82 was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, low back pain and polyneuropathy (a disorder that affects nerves throughout the body potentially causing pain).Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status Score (BIMS) of 12 out of 15, indicating moderately impaired cognition. Additionally, it revealed that s/he has pain almost constantly.Review of a care plan focus area dated 4/21/2025, revealed that Resident ID #82 has pain and/or the potential for pain related to chronic left hip and back pain, and polyneuropathy. Additionally, interventions include to administer pain medications, as ordered. During a surveyor interview on 9/29/2025 at 10:32 AM with Resident ID #82, s/he expressed concerns regarding his/her pain management regarding the chronic pain.Record review revealed a physician's order for a buprenorphine patch 10 microgram/hour, and to apply one patch to the skin once daily every seven days for pain (indicating that after seven days, a new patch is applied, and the pre-existing patch is removed and discarded). Review of the September 2025 Medication Administration Record (MAR) revealed that Resident ID #82 was not administered his/her buprenorphine patch on 9/3. Further, it revealed that the next buprenorphine patch was not applied until 9/10, seven days later. Additionally, the MAR indicated to refer to the nursing progress notes for the 9/3 entry.Review of a progress note dated 9/3/2025 at 10:53 AM revealed that the buprenorphine patch was not available to be administered. During a surveyor interview on 10/2/2025 at 11:21 AM with the Director of Nursing Services (DNS), she revealed that she would expect that the buprenorphine patch would be available to be administered to Resident ID #82.B. Record review revealed Resident ID #85 was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, type II diabetes.Review of a care plan focus area dated 9/26/2025, revealed that Resident ID #85 is being treated with vancomycin (an antibiotic) to treat Clostridium Difficile (C.diff).Record review revealed a physician's order for vancomycin 50 milligrams/milliliter (mL) to administer 2.5 mL, four times daily, for 10 days.Review of the September 2025 MAR revealed that Resident ID #85 was not administered his/her vancomycin on the following dates and times:-9/23: 5:00 PM and 9:00 PM-9/25: 9:00 AMDuring a surveyor interview on 10/1/2025 at 12:53 PM with the DNS, she revealed that she would expect that Resident ID #85 would have been administered his/her vancomycin, as ordered.C. Record review revealed Resident ID #30 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, Alzheimer's disease and dementia.Review of a care plan focus area dated 8/11/2025, revealed that Resident ID #30 has a history of agitation and physical aggression towards staff with an intervention to provide medication as ordered.Record review revealed a physician's order for divalproex sodium 125 milligrams (mg) to give three capsules, every 12 hours.Review of the October 2025 MAR revealed that Resident ID #30 was not administered his/her Depakote for the scheduled 8:00 AM dose on 10/1 or 10/2. Additionally, the MAR indicated to refer to the nursing progress notes.Review of the progress notes revealed the following:10/1/2025 at 9:11 AM: Depakote was reordered10/2/2025 at 7:12 AM: The facility is awaiting delivery of the Depakote from the pharmacyDuring a surveyor interview on 10/2/2025 at 1:41 PM with Licensed Practical Nurse, Staff D, she revealed that the facility has a Pyxis machine (an onsite medication dispensing machine that stocks commonly prescribed medications) and she would check it if the Depakote was unavailable to be administered. Additionally, she revealed that she was unaware that the resident did not receive his/her Depakote, as ordered, and would expect to be made aware if the resident did not receive his/her medication.Review of document provided by the facility revealed that the Pyxis machine stocks eight capsules of Depakote 125 mg.During a surveyor interview on 10/2/2025 at 2:00 PM with the DNS, she revealed that she would expect that Resident ID #30 would have received his/her Depakote, as ordered. Additionally, she revealed that she would expect staff to check the Pyxis machine for the medication first, then notify the provider if a resident does not receive his/her medication as ordered.

Based on surveyor observation, record review, staff, resident, and resident representative interview, it has been determined that the facility failed to ensure each resident is treated with respect and dignity relative to 2 of 3 residents reviewed who required staff assistance for incontinence, Resident ID #s 2 and 90.Findings are as follows:1. Record review revealed Resident ID #2 was re-admitted to the facility in March of 2025 with diagnoses including, but not limited to, hemiplegia and hemiparesis (weakness on one side of the body) affecting right dominant side and benign prostatic hyperplasia (noncancerous enlargement of the prostate gland) with lower urinary tract symptoms.Record review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed, the resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating s/he is cognitively intact. Additionally, s/he is always incontinent of bowel and is dependent on staff for toileting.During a surveyor interview with Resident ID #2 on 9/30/2025 at 11:44 AM, s/he revealed that s/he had soiled him/herself and needed assistance with care. The resident indicated that a staff member came in earlier around 11:00 AM and said that she would help him/her, but no one had come back or answered his/her call light.During continuous surveyor observations of Resident ID #2's room on 9/30/2025, the following was revealed: - 11:45 AM, the resident's call light was noted to be on. - 11:48 AM, Activity Aide, Staff A, brought the resident's lunch tray to his/her room. At that time, Resident ID #2 told her that s/he needed to have his/her brief changed. Staff A told Resident ID #2 to tell the nurse and the resident responded that s/he already told the staff, but no one had come in to help him/her. Staff A then left the room. - At approximately 12:00 PM, Resident ID #2 yelled Miss! I need to be changed to a staff member who walked by and did not address the resident's call light. During a subsequent surveyor interview with Resident ID #2 at this time, s/he revealed that an hour ago, s/he was allegedly told by Nursing Assistant, Staff B, that she would come back and assist him/her. Additionally, s/he stated that I sat here, ate my food while sitting on crap. - 12:20 PM, a staff member came in to drop off the resident's laundry and did not ask him/her if s/he needed anything. - 12:23 PM, Staff B came in to pick up the resident's lunch dishes. The resident told Staff B that s/he needed to be changed who replied, Just give me a minute and walked out with the resident's lunch dishes.During a surveyor observation on 9/30/2025 at 12:29 PM of the resident's incontinence care with Staff B, Resident ID #2 was observed to have had a large bowel movement.During a surveyor interview on 9/30/2025 at 12:44 PM, with Staff B, she indicated that the resident asked her to be changed at 11:45 AM but then she went on break. After informing Staff B that the surveyor had been observing the resident's room continuously for 45 minutes, she changed her story and denied that the resident had asked her to be changed prior to lunch. She acknowledged that waiting 45 minutes to be changed was unacceptable and that his/her call light should have been answered faster to assist him/her with changing his/her brief.During a surveyor interview with the Director of Nursing Services (DNS) in the presence of the Assistant Director of Nursing Services on 9/30/2025 at 2:05 PM, she indicated that the call light should be answered when it's on within reason, approximately 5 to 10 minutes, by any staff who is available to do so. Additionally, she would expect the resident to have been changed before being served his/her meal.2. Record review revealed Resident ID #90 was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, dementia with behavioral disturbance.Record review of a quarterly MDS assessment dated [DATE], revealed the resident has a BIMS score of 2 out of 15, indicating severe cognitive impairment. Additional review revealed s/he requires substantial/maximal assistance of staff for toileting and personal hygiene.During a surveyor interview with the resident's family member on 10/2/2025 at 11:39 AM, s/he indicated that when s/he arrived a few minutes ago, s/he was upset that the resident was still in bed and morning care had not been completed. During a surveyor observation immediately following the above interview in the presence of the resident's family member, the resident was seen lying in bed with a brown stain on his/her shirt, dried brown liquid on the side of his/her mouth and was still in his/her pajamas. Additionally, the resident's hair was unkempt, and the room was noted to have a strong urine odor. During the same observation, the resident's lunch tray was delivered. The resident's family member helped him/her out of bed. When s/he stood, there was a large wet stain covering the backside of the resident's pants, and a large yellow stain on his/her bed.During a surveyor interview with NA, Staff C, on 10/2/2025 at 11:42 AM, she revealed that the resident is on her assignment for the day and she did not perform the resident's morning care including incontinence care. Additionally, she was unaware that the resident was incontinent of urine and needed to be changed.During a surveyor interview with Licensed Practical Nurse, Staff D, in the presence of the DNS on 10/2/2025 at 11:45 AM, she acknowledged that the resident had stains on his/her clothing and face and was incontinent of urine. She further acknowledged that morning care was not done and should have been completed.During a surveyor interview with the DNS on 10/2/2025 at 12:03 PM, she revealed that she would expect that residents are toileted prior to being served a meal. Additionally, she was unable to provide evidence that each resident is treated with respect and dignity.

Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for each resident relative to urinary catheters for 1 of 3 residents reviewed, Resident ID #16. Findings are as follows:Review of a Clinical Competency dated 11/2017 states in part, Emptying a Urinary Drainage Bag.carefully measure urine in measuring cylinder.Record review revealed that Resident ID #16 was admitted to the facility in August of 2016 with diagnoses including, but not limited to, multiple sclerosis and neurogenic dysfunction of the bladder.Record review of a care plan revealed a focus area dated 9/18/2024 indicating, s/he has a suprapubic catheter with an intervention to monitor output for odor, color, consistency, amount, blood and sediment.Review of the Bladder Continence Task, question 3: catheter output for the last 30 days revealed 10 out of 30 days with no output documented.During a surveyor interview on 10/1/2025 at 8:10 AM with Nursing Assistant (NA), Staff C, she revealed that if a resident has a catheter the output is measured every shift and documented in the kiosk.During a surveyor interview on 10/1/2025 at 8:16 AM with Licensed Practical Nurse, Staff E, he revealed that if a resident has a catheter the Nursing Assistants measure the output every shift and report it to the nurse. Additionally, Staff E acknowledged the missing days of output documentation for Resident ID #16.During a surveyor interview on 10/1/2025 at 8:21 AM with the Director of Nursing Services, she acknowledged the missing days of output documentation for Resident ID #16. Additionally, she was unable to provide evidence that the facility followed the comprehensive care plan for Resident ID #16.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 2 residents observed for wound care, Resident ID #14. Findings are as follows: Review of a facility policy titled, Clean Dressing Technique, states in part, .Procedure: Check physician order for current, correct treatment.Sanitize hands and apply clean gloves. Remove old dressing and discard.Remove gloves, sanitize hands and apply clean gloves.Record review revealed the resident was admitted to the facility in September of 2025 with diagnoses including, but not limited to, type I diabetes and pressure wounds to his/her left heel, right foot, right hip, and sacrum (the lower back/base of the spine).Review of a care plan focus area dated 9/4/2025 revealed, the resident has multiple pressure wounds and that s/he is seen by the wound physician weekly. Additionally, it indicates to treat the wounds, as ordered.Record review revealed the following wounds and respective treatment orders:-Wound #1: Right hip - Cleanse with wound cleanser, apply collagen with silver (a wound treatment), and cover with a foam dressing daily and as needed.-Wound #2: Coccyx - Cleanse with wound cleanser, apply collagen with silver (a wound treatment), and cover with a foam dressing daily and as needed.-Wound #3: Right lateral foot - Skin prep (a skin protectant), and cover with a foam dressing every other day and as needed.-Wound #4: Right heel - Cleanse with wound cleanser, apply xeroform (a wound treatment) cut to size of wound bed, and cover with a bordered dressing twice daily and as needed.-Wound #5: Left heel - Skin prep twice daily.During a surveyor observation on 9/30/2025 at approximately 12:00 PM, with Licensed Practical Nurse, Staff J, she began dressing wound #1 and applied collagen powder to the wound, instead of collagen with silver as ordered, then applied the foam dressing. Staff J proceeded to wound #2 and again, applied collagen powder to the wound, instead of collagen with silver as ordered, then applied the foam dressing. Staff J then completed dressing changes for wounds #3 and #4. Staff J then proceeded to wound #5 and was noted to cleanse the wound, then removed her gloves and applied new gloves without first performing hand hygiene. Staff J then applied a clean dry dressing to the wound, which was observed to be open and had drainage. During surveyor interviews on 9/30/2025 at 12:50 PM and 1:11 PM, with Staff J, she acknowledged that she did not utilize collagen with silver for wounds #1 and #2. Additionally, she acknowledged that she did not perform hand hygiene in between removing the gloves used to cleanse wound #5 and before donning clean gloves to apply a clean dressing.During a surveyor interview on 10/1/2025 at 12:26 PM with the Wound Physician, she revealed that she would expect staff to have used collagen with silver because that is what was ordered.During a surveyor interview on 10/1/2025 at 12:49 PM with the Director of Nursing Services, she revealed that she would expect staff to have followed the wound treatment orders and perform hand hygiene between glove changes.

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 3 floors observed, the 3rd floor. Findings are as follows:1. During the medication storage and labeling task on 9/29/2025 at approximately 9:25 AM, in the presence of Certified Medication Technician (CMT), Staff K, observation of the 3rd Floor Northwest CMT medication cart revealed, 3 medication cups labeled with residents' room numbers containing multiple medications in each cup.During a surveyor interview at the time of the above observation with Staff K, he indicated that he pre-poured the resident's medications and that the residents were unavailable at the time they were prepared.During a surveyor interview on 9/28/2025 at 1:28 PM with the Director of Nursing Services (DNS), she indicated that pre-pouring medications is against the facility's policy and would expect the medications to be disposed of if the residents were unavailable. 2a. Review of a facility policy titled Medication Storage states in part, .Medication must be stored in accordance with manufacturer's specifications.all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself.During the medication storage and labeling task on 9/29/2025 at 8:56 AM, in the presence of Licensed Practical Nurse (LPN), Staff L, observation of the 3rd Floor Northwest Nurse medication cart revealed a bottle of Narcan with a manufacturer's expiration date of 6/2025. During a surveyor interview at the time of the above observation with Staff L, she acknowledged the expired Narcan and indicated that it should have been removed from the cart. 2b. During the medication storage and labeling task on 9/29/2025 at 8:49 AM, in the presence of LPN Staff L, observation of the 3rd floor medication fridge revealed, an open undated vial of a Tuberculin Purified Protein Derivative (an injectable test to aid in the diagnosis of tuberculosis,), 5 tuberculin units per 0.1 milliliters, opened and stored in the medication refrigerator. Additional observation failed to reveal evidence of a date when opened or an expiration date. Review of the Manufacturer's instructions for the Tuberculin Purified Protein Derivative solution revealed to discard the open medication after 30 days. During a surveyor interview at the time of the above observation with Staff L, she acknowledged the open undated bottle of Tuberculin Purified Protein Derivative, and acknowledged the medication was open and undated. Additionally, she was unable to identify when the medication expired. During a surveyor interview on 9/28/2025 at 1:28 PM with the DNS, she indicated that she would expect medications to be store and labeled properly in the medication cart and fridge, in accordance with the manufacturer's instructions.

Based on record review, resident and staff interviews, it has been determined that the facility failed to keep a resident free from physical abuse, for 1 of 4 residents reviewed, Resident ID #1.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 7/22/2025 revealed in part, Resident ID #2 (the perpetrator) was observed walking over to Resident ID #1 (the victim), in the dining room, and grabbed his/her left wrist, twisted it back and pulled his/her hair. Further review revealed Resident ID #2 was transferred to the hospital for a psychiatric evaluation and a STAT (immediate) X-ray was ordered for Resident ID #1.Review of a facility policy titled, RESIDENT ABUSE, NEGLECT, MISTREATMENT AND MISSAPROPRIATION PREVENTION, dated April 2015 states in part, .Each resident has the right to be free from abuse, neglect, mistreatment.'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.According to the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 4/25/2025, willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm.Record review revealed Resident ID #1, the victim, was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, Alzheimer's disease.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was unable to be completed, as the resident is rarely/never understood, indicating severe cognitive impairment.Record review revealed Resident ID #2, the perpetrator, was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, severe dementia with agitation.Review of an MDS assessment dated [DATE] revealed a BIMS was unable to be completed, as the resident is rarely/never understood, indicating severe cognitive impairment. Further review revealed Resident ID #2 displayed wandering and physical behavioral symptoms directed towards others, 1 to 3 days, during the 7-day look back period.Record review of a care plan last revised on 7/24/2025, for Resident ID #2, revealed s/he has a history of violent and aggressive behaviors and was involved in an altercation with a resident on 7/15/2025 and with Resident ID #1 on 7/22/2025. Record review for Resident ID #2 revealed a progress note dated 7/22/2025 which revealed Resident ID #2 was in the dining room when s/he approached Resident ID #1, grabbed him/her by the left wrist, twisted his/her left wrist, and pulled his/her hair. Further review revealed Resident ID #2 was placed on a 1 to 1 with staff for safety and was sent to the hospital for a psychiatric evaluation.Further record review for Resident ID #2 revealed a progress note dated 7/23/2025 which revealed s/he was admitted to geriatric psych at the hospital, on an emergency certification (a process that allows a physician to apply for the certification of a person who is believed to need immediate care due to psychiatric disability).Additional record review for Resident ID #2 revealed that earlier in the day on 7/22/2025, at approximately 2:21 PM, staff were attempting to redirect him/her from another resident's room, when Resident ID #2 responded by striking a Nursing Assistant in the chest.Record review for Resident ID #1 revealed the following progress notes: - 7/22/2025 at 9:56 PM, revealed Resident ID #1 was eating dinner in the dining room, when Resident ID #2 approached him/her, grabbed him/her by the left wrist, twisted his/her left wrist, and pulled his/her hair. Further review revealed Resident ID #1 did not do anything to provoke this incident. Additionally, upon initial assessment, no injuries were noted, however Resident ID #1 was administered Tylenol, 650 milligrams for left wrist pain, and a STAT X-ray of his/her left wrist was ordered, to rule out injury.- 7/23/2025 at 7:45 AM, revealed Resident ID #1 was noted to be guarding his/her left wrist/hand area and a bruise measuring approximately 1.5 x 2 inches was noted to be on his/her right hand.- 7/23/2025 at 10:39 PM, revealed that the following the physical altercation with Resident ID #2, the resident sustained a wrist fracture and was transported to the hospital.- 7/24/2025 at 1:22 AM, revealed Resident ID #1 returned to the facility with a diagnosis of a left distal radial fracture (wrist fracture) and a volar splint (a medical device used to immobilize and support the wrist and hand, particularly for injuries or conditions affecting the palm or volar aspect of the hand) was applied, with instructions to follow up with an orthopedic surgeon.During a surveyor interview on 8/6/2025 at 10:58 AM, with Nursing Assistant, Staff A, she revealed that she was in the dining room and witnessed Resident ID #2 approach Resident ID #1 at his/her table and attempted to take his/her food. She revealed that when she attempted to redirect Resident ID #2 away from Resident ID #1, Resident ID #2 reacted by grabbing Resident ID #1's wrist and twisted it, causing Resident ID #1 to scream. Further, she revealed that it took three staff members to separate Resident ID #2 from Resident ID #1, due to Resident ID #2 having a tight grip on Resident ID #1's wrist and s/he would not let go. Additionally, she revealed that Resident ID #2 has a history of being combative with staff, indicating that s/he can be unprovoked at times.During a surveyor observation and interview on 8/6/2025 at 1:00 PM, Resident ID #1 was noted to be sitting in the dining room, and a splint was observed on his/her left wrist. The resident was nonsensical in the interview and when asked how s/he was doing by the surveyor, s/he responded, I can do this another day.During a surveyor interview on 8/6/2025 at 1:07 PM, with the Director of Nursing Services, she revealed that Resident ID #2 would wander around the unit and touch things, indicating s/he required frequent redirection. She revealed that during this incident, Resident ID #2 attempted to touch Resident ID #1's meal tray, and when staff attempted to redirect Resident ID #2, s/he had a quick response and grabbed Resident ID #1's wrist and twisted it, resulting in a fracture. Additionally, she was unable to provide evidence that the facility kept Resident ID #1 free from physical abuse on 7/22/2025.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed who was administered antipsychotic medication (Clozaril) which was intended for another resident (Resident ID #2), Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/5/2024 indicated that Resident ID #1 was transferred to an acute care hospital due a change in his/her mental status related to a potential medication error. Review of the manufacturer's guidance, last revised September 2024, revealed that Clozaril (clozapine) is an antipsychotic medication used to treat severe psychotic disorders. The starting dose is 12.5 milligrams (mg) and the peak (when the medication reaches the highest concentration in a person's blood) time can occur between 1 - 6 hours after administration. Warnings, precautions, and adverse reactions include, but are not limited to the following: - Hypersalivation (too much saliva or difficulty with properly clearing the saliva a person produces). - Severe neutropenia (low white blood cells which can lead to serious or fatal infections). For this reason, Clozaril is only available through a restricted risk evaluation program. - low blood pressure - low heart rate - syncope (fainting) - myocarditis (inflammation of the heart muscle) - cardiomyopathy (disorder affecting the heart muscle) - QT prolongation (an irregular heart rhythm or a change in how the heart's bottom chambers send signals, resulting in a longer time for the heart to recharge between beats). According to the National Library of Medicine's online article, last updated 12/26/2022 titled, Long QT Syndrome, a QTc greater than 500 is associated with an increased risk of torsade de pointes (a specific type of abnormal heart rhythm that can lead to sudden cardiac death). Review of the facility's medication administration policy and procedure dated June 2015 revealed the following procedural steps in part: - Verify the medication order on the Medication Administration Record (MAR) and check against the physician's order. - Identify the resident. - Avoid distractions and interruptions when preparing and administering medications to reduce the risk of medication errors. - Only prepare medication for one resident at a time. Record review revealed that Resident ID #1 was admitted to the facility in July of 2019 with diagnoses including, but not limited to, cirrhosis (liver disease) and alcoholic cardiomyopathy (a type of heart disease caused by long-term alcohol consumption that weakens the heart muscle and impairs its ability to pump blood). Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 7 out of 15, indicating severely impaired cognition. Record review of a progress note authored by Licensed Practical Nurse (LPN), Staff A, dated 10/5/2024 created at 6:01 PM, indicates that the nurse suspected a possible medication error after the resident was noted to be difficult to arouse after s/he was administered his/her medications. Additionally, the note indicates that the physician was notified and gave an order for the resident to be transferred to the hospital. During surveyor interviews on 10/7/2024 at 12:20 PM and 12:40 PM, with Staff A, she stated the following: - She was assigned to care for and administer medications to Resident ID #s 1 and 2 on 10/5/2024 during the 7:00 AM - 3:00 PM shift. - At some time between 8:00AM - 9:00 AM, she prepared medications for both Resident ID #1 and Resident ID #2 at the same time, while they were out in the corridor near her medication cart and was interrupted by another resident who was yelling in the background. - Resident ID #1's medication was in a medication cup on top of the medication cart along with a medication cup containing Clozaril 125 mg for Resident ID #2. - Staff A stated that she administered Resident ID #1's scheduled medications, which included, but was not limited to, lorazepam 0.5 mg (antianxiety) and Lexapro 10 mg (antidepressant). - Staff A believes that during the interruption, she may have administered Clozaril to Resident ID #1, which was intended for Resident ID #2, because the cup containing the Clozaril was no longer there. - Staff A checked on Resident ID #1 several times and obtained his/her vital signs several times. - Staff A placed a call to the on-call provider line immediately at the time of suspecting she administered the Clozaril to Resident ID #1. She waited on hold for an hour, continued her medication pass then placed another call when Resident ID #1 was difficult to arouse. - Staff A received a physician's order to send the resident to the hospital via Emergency Medical Services (EMS). Additional record review for Resident ID #1 failed to reveal evidence of a physician's order for Clozaril 125 mg. Record review for Resident ID #2 revealed a physician's order dated 5/29/2024 for Clozaril 100 mg tablet to be administered along with a 25 mg tablet to total 125 mg twice daily at 8:00 AM and 8:00 PM. Record review of the EMS patient care report document dated 10/5/2024 revealed that dispatch was notified at 11:10 AM and the EMS Unit arrived at the nursing facility at 11:15 AM for a report of Resident ID #1 being administered the wrong medication. S/he was noted to be in his/her bed, unresponsive, alert to pain only. Additionally, the resident required oxygen via a non-rebreather mask (an oxygen mask that delivers high concentrations of oxygen when a person needs oxygen quickly in emergencies) because his/her blood oxygen level was found to be 85% on room air (normal blood oxygen level is greater than 92% on room air). Additionally, his/her airway required suctioning (mechanical removal) to clear his/her airway. His/her respirations (breathing rate) were noted to be 11 (normal range is 12 - 20) and s/he was transported to the hospital. Review of the hospital document dated 10/5/2024 revealed Resident ID #1 presented to the Emergency Department (ED) for an accidental Clozaril overdose. Additionally, s/he was noted to be minimally arousable, was unable to articulate speech and was making gurgling sounds. The document further indicates that s/he was transferred to the Critical Care Unit where s/he required intubation (a medical procedure when a breathing tube is inserted through the mouth or nose into the windpipe allowing air to get into the lungs. The tube connects to a machine for automated air delivery or a bag for manual air delivery) to protect his/her airway. Furthermore, s/he was noted to have a QTc of 520 (normal range is 360 to 460) which required a consult with poison control who recommended s/he be treated with a higher dose of intravenous (IV) Magnesium (magnesium is an electrolyte used to treat abnormal heart rhythms. IV Magnesium administration requires strict medical monitoring in the hospital setting). S/he was admitted for further management. The treatment plan included but is not limited to the following: acute toxic encephalopathy (altered mental status) secondary to Clozaril overdose, toxicity secondary to accidental overdose, and acute respiratory failure secondary to inability to protect airway. During a surveyor interview on 10/8/2024 at 10:59 AM, with Resident ID #1's Nurse Practitioner (NP) along with her Clinical Manager via the telephone, she reviewed the electronic documentation for weekend on-call provider log. The NP stated that on 10/5/2024 at 10:48 AM, Staff A left a voicemail reporting a medication error for Resident ID #1; s/he was very sleepy after s/he was administered Clozapine 125 mg, which s/he does not receive. Furthermore, the NP indicated that the resident's physician was notified and gave an order for the resident to be transferred to the hospital. During a surveyor interview on 10/8/2024 at 1:21 PM, with the Director of Nursing Services (DNS), she acknowledged that she would have expected Staff A to administer and prepare medications for one resident at a time, per the facility's policy. Additionally, she was unable to provide evidence that Resident ID #1 was kept free from significant medication error. As a result of this survey, it has been determined that Resident ID #1 was placed at risk for serious harm or injury due to Staff A's failure to administer medication according to the facility's policy, when she prepared and administered medications for both Resident ID #'s 1 and 2. Resident ID #1 was administered medication intended for Resident ID #2 which resulted in Resident ID #1 exhibiting adverse effects of Clozaril which required transfer to the hospital's Critical Care Unit.

Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from sexual abuse for 1 of 5 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled, Abuse Prohibition Policy dated September 2020, states in part, .It will be the facility's responsibility to identify, correct and intervene in situations where abuse, mistreatment, neglect, exploitation and/or misappropriation of resident property occur .sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident . Review of a facility reported incident submitted to the Rhode Island Department of Health on 9/30/2024 revealed that Resident ID #s 1 and 2 reported to a supervisor on 9/26/2024 that they were engaging in a consensual sexual relationship. On the morning of 9/30/2024, Resident ID #1 reported to the Director of Social Services that s/he had sex with Resident ID #2 three times since 9/27/2024 and all of these instances were without his/her consent. Record review revealed that Resident ID #1 (the alleged victim) was admitted to the facility in September 2022 with diagnoses including, but not limited to, paranoid personality disorder and anxiety. Review of a Minimum Data Set (MDS) Assessment for Resident ID #1 dated 8/26/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. Review of a progress note dated 9/27/2024, authored by the Director of Social Services, revealed that he met with Resident ID #1 relative to him/her being involved in a physical relationship with Resident ID #2. Resident ID #1 indicated that s/he felt safe and is happy with the relationship. Additionally, the progress note indicated that the Director of Social Services informed Resident ID #1 that if s/he ever felt unsafe or uncomfortable that staff are available to support him/her. Review of a progress note dated 9/30/2024, authored by the Director of Social Services, revealed that Resident ID #1 reported to him that Resident ID #2 had gotten into bed with him/her although s/he told him/her not to. Additionally, the progress note revealed that Resident ID #1 reported sexual activity occurred on Friday (9/27/2024), Saturday (9/28/2024), and Sunday (9/29/2024) without his/her consent. Further record review revealed that Resident ID #1 was transferred to an acute care hospital for an evaluation related to genital pain. Review of emergency room documentation dated 9/30/2024 revealed Resident ID #1 was being treated for a potential sexual assault. Additionally, it revealed that Resident ID #1 reported being penetrated with an object but was unable to identify what the object was. Additional review revealed that Resident ID #1 was forced to wear outfits and role play with Resident ID #2. The document further revealed that Resident ID #1 was experiencing dysuria (painful or difficulty with urination), pelvic pain and pain to his/her genital area. Lastly the documentation revealed that, while in the emergency room , Resident ID #1 was noted to be anxious and tremulous. Review of a facility provided statement authored by a laundry aide, Staff A revealed that on Sunday 9/29/2024 at around 10:30 AM Resident ID #1 was crying and told her that Resident ID #2 was trying to get into bed with him/her and s/he felt like Resident ID #2 was moving too fast. The statement further revealed that Resident ID #1 felt uncomfortable around Resident ID #2 because s/he was moving so fast and Resident ID #1 showed Staff A hickeys on his/her neck. The statement revealed that Staff A encouraged Resident ID #1 to speak to a Nursing Assistant and talk to the Director of Social Services on Monday. During a surveyor interview on 10/1/2024 at 12:11 PM with Staff A, she acknowledged that Resident ID #1 did tell her that s/he was uncomfortable with Resident ID #2 on Sunday 9/29/2024. Staff A acknowledged that she told Resident ID #1 to talk to the Director of Social Services the following day. Additionally, she revealed that she did not identify Resident ID #1's concerns as potential abuse at the time. Review of a facility provided statement authored by Nursing Assistant, Staff B revealed that on Sunday 9/29/2024 Resident ID #1 told her that Resident ID #2 was moving too fast and s/he wanted him/her to slow down. It further revealed that Resident ID #1 was having mixed emotions and did not know what to do. The statement revealed that Resident ID #1 wanted to tell Resident ID #2 but s/he was afraid and showed Staff B hickeys on his/her neck. During a surveyor interview via telephone on 10/1/2024 at 1:04 PM with Staff B, she revealed that Resident ID #1 told her that s/he felt that Resident ID #2 was moving too fast but s/he was afraid to talk to him/her about it. Staff B acknowledged that she encouraged Resident ID #1 to talk to the Director of Social Services the following day. Staff B revealed that she did tell Licensed Practical Nurse (LPN), Staff C about the concerns Resident ID #1 had with Resident ID #2. During a surveyor interview on 10/1/2024 at 1:45 PM with Staff C, she revealed that she did hear that Resident ID #1 felt that Resident ID #2 was moving too fast on 9/29/2024. Additionally, she acknowledged that she did not talk to Resident ID #1 and did not investigate his/her concerns. Resident ID #1 was unavailable for a surveyor interview due to being discharged to the hospital. Record review revealed that Resident ID #2 (the alleged perpetrator) was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, bipolar disorder. Review of an MDS Assessment for Resident ID #2 dated 7/31/2024 revealed a BIMS score of 13 out of 15 indicating intact cognition. Resident ID #2 was unavailable for a surveyor interview due to the resident requesting to be discharged home on 9/30/2024. Record review failed to reveal evidence that the facility staff initiated any interventions to ensure Resident ID #1's safety from Sunday 9/29/2024 at approximately 10:00 AM, when staff were made aware by Resident ID #1 that s/he was uncomfortable with Resident ID #2, as s/he was moving too fast for him/her within their relationship, until Monday 9/30/2024 when Resident ID #1 alleged that s/he was sexually assaulted. Resident ID #1 alleged that s/he was sexually assaulted on Sunday night 9/29/2024 after s/he expressed concerns to staff. During a surveyor interview on 10/1/2024 at approximately 12:05 PM with the Administrator he acknowledged that Resident ID #1 communicated concerns to the facility staff but that they did not identify it as abuse. Additionally, he was unable to provide evidence that the facility kept Resident ID #1 free from abuse on the evening of 9/29/2024. Cross reference F610

Based on record review and staff interview it has been determined that the facility failed to ensure that allegations made by residents are recognized as possible abuse by staff, all allegations are investigated, and that residents are kept free from experiencing further abuse during investigations for 1 of 1 Resident reviewed who expressed concerns to staff members regarding a consensual sexual relationship with another resident, Resident ID #1 (the alleged victim). Findings are as follows: Review of a facility policy titled, Abuse Prohibition Policy dated September 2020, states in part, .each resident has the right to be free from abuse .Procedure .identifying events, occurrences, patterns and trends of potential abuse for residents. Performing internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and reporting of the same to proper authorities. Protecting residents from harm during an investigation of alleged abuse . Review of a facility in-service on abuse dated 3/6/2023 states in part, .Identification of abuse .Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place or feelings of guilt or shame . Review of a facility reported incident submitted to the Rhode Island Department of Health on 9/30/2024 revealed that Resident ID #s 1 and 2 reported to a supervisor on 9/26/2024 that they were engaging in a consensual sexual relationship. On the morning of 9/30/2024, Resident ID #1 reported to the Director of Social Services that s/he had sex with Resident ID #2 (the alleged perpetrator) three times since 9/27/2024 and all of these instances were without his/her consent. Record review revealed that Resident ID #1 was admitted to the facility in September 2022 with diagnoses including, but not limited to, paranoid personality disorder and anxiety. Review of a Minimum Data Set (MDS) Assessment for Resident ID #1 dated 8/26/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. Review of a facility provided statement authored by a laundry aide, Staff A revealed that on Sunday 9/29/2024 at around 10:30 AM Resident ID #1 was crying and told her that Resident ID #2 was trying to get into bed with him/her and s/he felt like Resident ID #2 was moving too fast. The statement further revealed that Resident ID #1 felt uncomfortable around Resident ID #2 because s/he was moving so fast. The statement revealed that Staff A encouraged Resident ID #1 to speak to a Nursing Assistant and talk to the Director of Social Services on Monday. During a surveyor interview on 10/1/2024 at 12:11 PM with Staff A, she acknowledged that Resident ID #1 did tell her that s/he was uncomfortable with Resident ID #2 on Sunday 9/29/2024. Staff A acknowledged that she told Resident ID #1 to talk to the Director of Social Services the following day. Additionally, she revealed that she did not identify Resident ID #1's concerns as potential abuse at the time nor did she investigate any further. Review of a facility provided statement authored by Nursing Assistant, Staff B revealed that on Sunday 9/29/2024 Resident ID #1 told her that Resident ID #2 was moving too fast and s/he wanted him/her to slow down. It further revealed that Resident ID #1 was having mixed emotions and did not know what to do. The statement revealed that Resident ID #1 wanted to tell Resident ID #2 but s/he was afraid. During a surveyor interview via telephone on 10/1/2024 at 1:04 PM with Nursing Assistant (NA), Staff B, she revealed that Resident ID #1 told her that s/he felt that Resident ID #2 was moving to fast but s/he was afraid to talk to him/her about it. Staff B acknowledged that she encouraged Resident ID #1 to talk to the Director of Social Services the following day. Staff B revealed that she told Licensed Practical Nurse (LPN), Staff C about the concerns Resident ID #1 had with Resident ID #2. During a surveyor interview on 10/1/2024 at 1:45 PM with LPN, Staff C she revealed that she was made aware of Resident ID #1 telling Staff B about his/her concerns about Resident ID #2 moving too fast. Additionally, she acknowledged that she did not go talk to Resident ID #1 and did not further investigate any concerns. Review of emergency room documentation dated 9/30/2024 revealed Resident ID #1 was being treated for potential sexual assault. Additionally, it revealed that Resident ID #1 reported being penetrated with an object but was unable to identify what the object was. Further review revealed that Resident ID #1 was experiencing dysuria (pain or difficulty with urination), pelvic pain and pain to his/her genital area. While in the emergency room Resident ID #1 was noted to be anxious and tremulous. Resident ID #1 was unavailable for a surveyor interview due to being discharged to the hospital. Record review revealed that Resident ID #2 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, bipolar disorder. Review of an MDS Assessment for Resident ID #2 dated 7/31/2024 revealed a BIMS score of 13 out of 15 indicating intact cognition. Resident ID #2 was unavailable for a surveyor interview as the resident requested to be discharged home on 9/30/2024. During a surveyor interview on 10/1/2024 at approximately 12:05 PM with the Administrator he acknowledged that Resident ID #1 communicated concerns to the facility staff but that they did not identify it as potential abuse. Additionally, he was unable to provide evidence that the facility prevented further potential abuse from occurring to Resident ID #1 while an investigation was being conducted or that the facility initiated an investigation to determine if Resident ID #1 had been abused. Cross reference F600

Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan relative to monitoring and identifying a change in a resident's condition. Additionally, the facility failed to follow physician's orders relative to weekly weights, for 1 of 1 resident reviewed who exhibited increased swelling to his/her left leg and was diagnosed with a deep vein thrombosis (DVT- a blood clot). Resident ID #1. Findings are as follows: 1. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/19/2024, alleges in part, Resident ID #1's left leg doubled in size due to increased swelling, was not having his/her weight monitored, and the facility was not ruling out blood clots, despite him/her having a history. According to Lippincott Manual of Nursing Practice 10th edition, 2014 published by Wolters Kluwer, pages 118 - 119 indicates that standards of care guidelines relative to preventing and recognizing complications after a person has surgery includes, but are not limited to, .Providing measures to enhance circulation of the lower extremities, such as .compression .and assess [monitor] for tenderness, swelling, and red streaking which may indicate DVT . Additionally, clinical signs of DVT include swelling of the entire leg. Prevention and management include assessing the lower extremity for circulation and sensation by checking for pulses of the leg and foot and for pain in the calf when the foot is moved upwards [Homan's sign] which may indicate DVT. Record review revealed that the resident was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, surgical repair of a left hip fracture and history of DVT. Record review of a nursing admission assessment dated [DATE] revealed, the resident presented with 3+ non-pitting edema (swelling that occurs in your feet, ankles, or legs. Non-pitting edema refers to when the edema is pressed with a finger and there is no lasting indentation in the skin. 3+ edema indicates severe edema and can take up to 30 seconds or more to rebound) to his/her left leg. Further record review of the care plan revealed the following: 5/8/2024, A focus area that indicates s/he has a history of DVT with interventions including, but not limited to: - Apply compression stockings if ordered - Monitor for pain in the leg, tenderness in the calf, leg tenderness, swelling of the leg, increased warmth, redness, skin discoloration or discomfort when the foot is pulled upwards may indicate a DVT 6/4/2024, A focus area that indicates s/he has a left hip fracture with interventions including, but not limited to: - Monitor circulation, motion, and sensation as ordered Record review revealed the following physical therapy treatment notes authored by Physical Therapy Assistant, Staff B, which states in part: 6/10/2024 - .Pt [patient] has L [left] lower leg/pedal [foot] edema. Pt noted throbbing pain left hip at rest, constant 10/10 pain during gait [walking]. Pt also made comment that [s/he] felt like hip 'the bone' would pop out. Nursing notified . 6/13/2024 - .L LE [lower extremity] with excessive swelling, Nursing notified . 6/14/2024 - .Pt notes L LE feels 'heavy' during gait . 6/17/2024 - .Pt was up in w/c [wheelchair] at time of rx [treatment]. Pt noted left knee pain during gait. Pt continues with excessive L LE swelling . Additional record review revealed the following progress notes which states in part: 5/25/2024 9:00 PM - nursing admission note, .+3 nonpitting edema to LLE .Pedal pulses are present and regular . 5/26/2024 2:53 PM - .Resident has LE discolorations, 2-3+edema, left> [greater than] R [right] . 5/27/2024 5:33 PM - provider telemedicine note, .Physical Exam: Exam findings per nurse Physical Exam - Notes: General resting comfortably in no acute distress CARDIO no edema . 5/28/2024 1:18 PM - .bilateral LE edema . 5/29/2024 2:51 PM - .left hip swollen, 2+ bilateral LE edema . 6/13/2024 5:42 PM - authored by LPN, Staff A, .Swelling present to residents LLE, NP evaluated this shift. NO [new order] for Lasix [a medication used to remove a buildup fluid in the body; also referred to as a water pill] .x [times] 14 days . 6/18/2024 3:59 PM - authored by LPN, Staff C, .LLE remains swollen, follow up with the Surgeon today, returned .order STAT [immediate] U/S [ultrasound] of LLE to R/O [rule out] DVT . 6/18/2024 6:10 PM - authored by Staff A, .Resident ultrasound to LLE, + [positive] DVT. MD contacted, new orders to send resident out to ER [emergency room ] . Further record review failed to reveal evidence that the resident's left leg was monitored for increased warmth, redness, discoloration, or for discomfort when the foot is pulled upwards all of which would indicate the presence of a DVT, when s/he was noted with increased swelling. Additionally, the record failed to reveal evidence that an order was implemented for monitoring of circulation, motion, or sensation per the care plan. Lastly, the record failed to reveal evidence that the NP documented her evaluation of the resident on 6/13/2024. During a surveyor interview on 6/21/2024 at 11:41 AM with the NP, she revealed that she ordered the Lasix on 6/13/2024 when she was notified of the resident's increased left leg edema. She indicated that she evaluated the resident on 6/13/2024, however, she was unable to provide evidence of documentation of her assessment and findings. She indicated that she did not order an ultrasound on 6/13/2024 despite the resident having a history of DVT and recent surgery for the repair of a hip fracture. She acknowledged that she did not order the ultrasound until it was recommended by the resident's surgeon on 6/18/2024, 5 days after s/he was noted to have increased swelling of his/her left leg. During a surveyor interview on 6/21/2024 at 2:10 PM, with Licensed Practical Nurse, Staff A, the following was revealed: - On 6/13/2024 a physical therapist asked Staff A to see the resident because his/her left leg was swollen. Staff A indicated that she saw the resident's leg and notified the NP who gave an order for Lasix. - Additionally, Staff A was unable to provide evidence that she monitored the resident's circulation, motion, sensation, or for additional symptoms that may indicate a DVT. Furthermore, Staff A indicated that she was one of the nurses on duty when the resident was seen by his/her surgeon on 6/18/2024 for a follow up appointment. Staff A revealed that the resident returned to the facility with recommendations for an ultrasound to be completed immediately from the surgeon, to rule out a DVT. Staff A further revealed the ultrasound results were critical indicating multiple DVTs of the left lower extremity, which required the resident's transfer to an acute care hospital. Record review of the hospital documents revealed the following: - An ED triage note dated 6/18/2024 at 6:34 PM, indicates that the resident reported that s/he had been telling the nursing staff at the facility that his/her left leg was getting swollen. - An ultrasound of the resident's left lower extremity for DVT completed on 6/19/2024, which was positive for acute occlusive (blocked blood flow) blood clots in four major veins of the left lower extremity. S/he required high intensity intravenous blood thinning medication and transfer to a different acute care hospital for further management. - The resident was transferred to the other acute care hospital on 6/19/2024 and underwent a mechanical thrombectomy (medical procedure to remove blood clots). During a surveyor interview on 6/24/2024 at 10:21 AM with the Medical Director, he indicated that he would have expected the nurses would have monitored the resident for circulation, motion, and sensation in the residents left leg due to the increased swelling with his/her known history of DVT and recent surgery for a hip fracture. During surveyor interviews on 6/21/2024 at 12:12 PM and 6/24/2024 at 10:03 AM with the Assistant Director of Nursing (ADON), she revealed that she saw the resident before s/he left for his/her follow up appointment on 6/18/2024 and indicated that his/her left leg was discolored with increased swelling. She acknowledged and indicated that she would have expected the nurses to monitor the resident for signs that may indicate a DVT per the care plan and document the findings in the resident's medical record when s/he was noted with increased swelling on 6/13/2024. Additionally, the ADON was unable to provide evidence that the resident was monitored every shift since s/he was noted with increased swelling on 6/13/2024. Furthermore, she acknowledged that an ultrasound was not ordered until the surgeon recommended it on 6/18/2024, 5 days after the resident was noted with increased swelling. 2. Record review revealed a physician's order with a start date of 5/25/2024 indicating that the resident's weight should be obtained weekly for 4 consecutive weeks. Further record review of the May and June 2024 Treatment Administration Records revealed the following weights: 5/25/2024, 202.0 pounds (lbs.) 6/4/2024, 204.8 lbs. 6/11/2024, no evidence of a weight was documented. 6/18/2024, no evidence of a weight was documented. During a surveyor interview on 6/24/2024 at 10:03 AM, with the ADON, she was unable to provide evidence that the resident's weight was obtained as ordered on the above-mentioned dates. Additionally, she indicated that she would have expected the nurses to obtain the resident's weight as ordered. During a surveyor interview on 6/24/2024 at 10:21 AM with the Medical Director, he indicated that he would expect nursing staff to obtain the resident's weight as ordered. Additionally, he acknowledged that the resident's weight could have assisted in monitoring the change in his/her increased swelling and the effect of the water pill that the resident was prescribed.

Based on record review and staff interview, it has been determined that the facility failed to identify the care required by the resident population considering the types of disease, conditions, physical and cognitive disabilities. Additionally, the facility failed to ensure that staff has competencies that are necessary to provide the level and types of care needed for the resident population at risk and/or have limited range of motion (ROM). Furthermore, the facility failed to have necessary resources including a dementia care coordinator. Findings are as follows: Review of the Facility Assessment Annual Review dated 2/20/2022, reveals in the section titled, Part 1: Our Resident Profile, which indicates that the second floor is a secured dementia unit, which has a 60-bed capacity (average daily census is 59-60 residents). The Facility Assessment also indicates that Alzheimer's disease, stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts. In either case, parts of the brain become damaged or die. A stroke can cause [MEDICATION(S)] brain damage and/or long-term disability), [CONDITION(S)] (paralysis on one side of the body), and [CONDITION(S)] (another term for [CONDITION(S)]) are common resident diagnoses. Alzheimer's disease, stroke, [CONDITION(S)], and [CONDITION(S)] are all diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Further record review failed to reveal evidence that the facility developed or implemented a plan for residents who are at risk and/or have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Additionally, the Facility Assessment reveals under the section titled, Part 3: Facility Resource Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies indicates Staff type .Dementia care coordinator . and .Staffing plan .Dementia Care Coordinator -40 [hours/week] .Staff training/education and competencies . During the initial interview with the Director of Nursing (DON) on 11/1/2022 at 8:25 AM, she revealed that all residents residing on the second-floor secured dementia unit have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a surveyor interview with the Administrator and the DON on 11/4/2022 at 2:30 PM, they acknowledged that limited ROM was not included in the facility assessment or that there was a plan implemented to address the resident's requiring assistance with limited ROM. The DON revealed the facility has not had a Dementia Care Coordinator since 2020.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 residents with limited range of motion (ROM) who sustained an arm fracture during routine care, Resident ID #5. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a discharge summary from Physical Therapy (PT) dated 6/30/2021 stated in part, .Pt [patient] presenting with BUE [bilateral upper extremity] and LE [lower extremity] contracture, right side> [greater than] left side, pt's family requesting a evaluation for training for ROM to prevent further contracture . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Further review of the MDS quarterly assessments dated 1/5/2022, 4/5/2022, 10/4/2022, and an annual MDS assessment dated [DATE] revealed the resident had impairments on both sides of the upper and lower extremities relating to functional range of motion. The MDS assessments on the above-mentioned dates further revealed that the resident required extensive assistance of two or more persons relative to bed mobility (including turning side to side while in bed). Review of a care plan initiated 6/4/2021 revealed .has contracture of bilateral lower extremities. Further review of the care plan failed to identify any impairment to the upper extremities, specifically the left arm. Review of a progress note dated, 10/29/2022 at 9:30 AM, stated in part, .left arm became tight against [his/her] T-shirt and CNA [Certified Nursing Assistant] reported that [his/her] left arm made a popping sound .xray ordered, which showed a left humerus [bone of upper arm] fracture .Patient transferred to [hospital] for further evaluation . Review of the hospital note dated 10/29/2022, states in part, .[s/he] was combative with staff while they were attempting to change [him/her] when they think [s/he] dislocated or broke [his/her] left shoulder .patient complains of extreme pain .is contracted on [his/her] left side .noted to have hemi-paralysis to [his/her] left side which [s/he] is noted to be a baseline deficit from an old stroke . Further review of the of the X-ray results from the hospital on 10/29/2022 states in part, .mildly displaced spiral fracture [a fracture which is caused by a rotational, or twisting, force] . During a surveyor interview with Nursing Assistant (NA), Staff D, on 11/1/2022 at 1:22 PM, she acknowledged she was the person providing care for the resident when his/her arm broke. She revealed his/her left arm has been contracted since the resident was admitted . She revealed she usually dresses the bad arm (contracted left arm) first and then the right arm. Additionally, she revealed the resident usually requires one staff member for assistance with dressing but requires a two person assist if s/he becomes resistive or combative while receiving care. Additionally, she indicated that the resident requires two staff members for assistance with bed mobility. She acknowledged on the day the resident broke his/her arm; s/he was the only one providing care. She further revealed the resident was being combative while she was attempting to roll the resident (by herself) towards her to finish putting on a long sleeve shirt. She indicted that when she pulled on the shirt to get the sleeve over the resident's right arm is when she heard a pop from the left arm. Staff D revealed she would have asked for assistance while providing care on that day but revealed there was not enough staff available to help, and she was rushing to have the resident's care completed prior to his/her family members visiting that morning. She then indicated she would have done things differently that day considering the resident was combative and she should have asked for assistance from another staff member when rolling the resident. During a surveyor interview with NA, Staff E, on 11/2/2022 at 11:11 AM, she revealed the resident is difficult to turn with only one person. She further revealed his/her left arm is contracted making it difficult to put a shirt on. Additionally, she revealed while dressing the resident, you should dress the left arm first. During a surveyor interview with NA, Staff F, on 11/2/2022 at 11:22 AM, she indicated the resident is supposed to be two people relative to his/her daily care. She further revealed that Staff D approached her after hearing the popping noise and said to her I snapped this [resident's] arm. Staff F accompanied Staff D to the resident's room, and Staff F acknowledged she observed the resident's right arm was fully through the sleeve of the shirt, but the left arm (more contracted arm) was not in the sleeve - with the shirt only resting over the resident's shoulder. During an interview with the Administrator and the Director of Nurses on 11/10/2022 at approximately 3:00 PM they were unable to provide evidence that Resident ID #5 was provided care in accordance with professional standards of practice and his/her comprehensive person-centered care plan.

Based on record review, and staff interview, it has been determined that the facility failed to ensure nursing staff has the appropriate competencies and skill sets to provide nursing and related services to assure resident safety as identified through resident assessments and described in the plan of care for Resident ID #5. Findings are as follows: Record review revealed the resident was readmitted to the facility in December of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) quarterly assessments dated 1/5/2022, 4/5/2022, 10/4/2022, and an annual MDS assessment dated [DATE] revealed the resident had impairments on both sides of their upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities relating to functional range of motion. The MDS assessments on the above-mentioned dates further revealed that the resident required extensive assistance of two or more persons relative to bed mobility (including turning side to side and body positioning while in bed). Further record review revealed a nursing progress note dated, 10/29/2022 at 9:30 AM, states in part, .[his/her] left arm became tight against [his/her] T-shirt and CNA [Certified Nursing Assistant, Staff D] reported that [the resident's] left arm made a popping sound .xray ordered, which showed a left humerus [bone of upper arm] fracture . Additional record review of the radiology interpretation document dated 10/29/2022 of the left shoulder stated in part, .mildly displaced spiral fracture [occurs due to a rotational, or twisting, force] . During a surveyor interview with Staff D, on 11/1/2022 at 1:22 PM, she acknowledged she was the person providing care for the resident when his/her arm broke. She revealed his/her left arm has been contracted since the resident was admitted . Additionally, she revealed the resident usually requires one staff member for assistance with dressing but requires a two person assist if s/he becomes resistive or combative while receiving care. Additionally, she indicated that the resident requires two staff members for assistance with bed mobility. She acknowledged on the day the resident broke his/her arm; s/he was the only one providing care. She further revealed the resident was being combative while she was attempting to roll the resident (by herself) towards her to finish putting on a long sleeve shirt. She indicted that when she pulled on the shirt to get the sleeve over the resident's right arm is when she heard a pop from the left arm. Staff D revealed she would have asked for assistance while providing care on that day but revealed there was not enough staff available to help, and she was rushing to have the resident's care completed prior to his/her family members visiting that morning. She then indicated she would have done things differently that day considering the resident was combative and she should have asked for assistance from another staff member when rolling the resident. Record review of Staff D's personnel file failed to reveal evidence of the appropriate competencies and skill sets to provide nursing and related services to assure resident safety as identified through resident assessment and described in the plan of care relative to limited range of motion. During a surveyor interview with Nursing Assistant, Staff J, on 11/1/2022 at 4:25 PM, she revealed the resident requires a 2 person assist with repositioning while in bed. She further revealed that the resident requires a 2 person assist with care if s/he is combative. During an additional surveyor interview with Licensed Practial Nurse, Staff K, on 11/1/2022 at 4:20 PM, she revealed she has heard the resident yelling, especially during care, and most of the time the resident requires a 2 person assist with care and repositioning, due to both upper and lower extremity impairments. During an interview with the Staff Development Coordinator on 11/3/2022 at 2:38 PM, she was unable to provide evidence that in-services relative to limited range of motion were provided to nursing staff. During a surveyor interview with the Director of Nursing on 11/4/2022 at approximately 2:00 PM, she was unable to provide evidence that Staff D has the appropriate competencies and skill sets to provide nursing and related services to ensure resident safety as identified through resident assessments as described in the plan of care relative to limited range of motion.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to protect the resident's right to be free from sexual abuse for 1 of 6 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident that was submitted to the Rhode Island Department of Health on 5/19/2022 indicated a Certified Nursing Assistant, CNA, witnessed a resident standing beside another resident with his/her hand down another resident's pants. Review of the Abuse Prohibition Policy states in part, Every .facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation and misappropriation of his or her personal property .Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident . Record review revealed Resident ID #1 was admitted to the facility in May of 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident ID #2 was admitted to the facility in September of 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident ID #3 was admitted to the facility in March of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed a BIMS score of 9 revealing the resident has moderate cognitive impairment. Further review of the MDS reveals this resident has short term and long- term memory problems. Review of the progress notes for Resident ID #1 revealed the following: -11/24/2021, Resident ID #1 was found in Resident ID #3's room. Resident ID #3 was found sucking on resident's breast. -1/1/2022, Resident was found in an unoccupied room with Resident ID #3. Resident ID #3 was on top of Resident ID #1. -5/19/2022, At about 11:15 am CNA walked into Resident ID #2's room, CNA witnessed Resident ID #2's hand in Resident ID #1's pants. Resident family notified and made aware of incident. Record review of Resident ID #1's care plan initiated 11/29/2021 states in part, .Encourage .to be in common areas when out of [his/her] room .Provide specific diversional activity such as participating in the day room .Redirect resident with conversation, snack, change of environment, activity, etc . Further review of the care plan failed to reveal evidence that the care plan was updated to include new interventions to keep this resident free from sexual abuse after the incidents on 1/1 and 5/19/2022. The care plan further reveals that on 5/21/2021 the resident has progressed dementia and does not have the ability to understand or respect personal boundaries. Resident continues to wander aimlessly around the unit into other resident rooms. Interventions include but are not limited to: divert resident with eating, drinking, talking or music; medication/labs, psych evals as ordered; provide for the immediate safety of the resident or others. Additional intervention initiated on 9/27/2021 monitor resident when out of room. During a surveyor interview with CNA/Certified Medication Technician, Staff A, on 5/23/2022 at 12:15 PM, s/he stated Resident ID #1 wanders a lot during the daytime, walking into other resident rooms. Additionally, she revealed she is not always able to monitor the resident. During a surveyor interview with Resident ID #1's family member on 5/23/2022 at 2:12 PM, she revealed that when she was called on 5/19/2022 it was reported to her that her family member was wandering on the unit when another resident (Resident ID #3) grabbed Resident ID #1's hand. She stated that the facility did not tell her that anything inappropriate happened. She further stated she was not aware that her family member has had any sexually inappropriate behaviors. The family member revealed that she was shocked when the surveyor brought up the incidents from 11/24/2021, 1/1/2022 and 5/19/2022. She indicated that this is not ok and expects the facility to keep her family member safe. During a surveyor observation of Resident ID #1 on 5/24/2022 from 9:58 AM to 10:07 AM the surveyor witnessed the resident walking into two other resident rooms without staff supervision. During a surveyor interview with a Nurse, Staff D, on 5/24/2022 at 10:36 AM s/he revealed that on the day of the 5/19/2022 incident, Resident ID #1 had a podiatry appointment and when the podiatrist arrived, the staff were unable to locate the resident which prompted the search and discovery of Resident ID #1 in Resident ID #2's room. She further revealed that Resident ID #1 has wandering tendencies and will wander into other resident's rooms. She could not provide evidence that this resident was monitored per his/her care plan when out of the room. During a surveyor interview with the Nurse Practitioner on 5/24/2022 at 12:51 PM, he revealed that on 5/19/2022 the facility reported that Resident ID #1 was in his/her bed and Resident ID #'2 hands were found underneath the covers. He was not aware that Resident ID #2 had his/her hands down Resident ID #1's pants/underwear. During a surveyor interview with Nurse, Staff B, on 5/24/2022 at 8:24 AM s/he stated that on 1/1/2022 a CNA told him/her that when s/he walked in and observed Resident ID #3 on top of Resident ID #1. S/he stated, get off Resident ID #1. S/he further stated Resident ID #3 was ashamed stating sorry won't do it again. During a surveyor interview with the Assistant Director of Nursing, on 5/23/2022 at 10:58 AM, she stated she was not made aware of the incident on 1/1/2022, therefore, it was not investigated or reported. During a surveyor interview with the Director of Nursing on 5/24/2022 at 1:25 PM, she was unable to provide evidence that Resident ID #1 was kept free from abuse on 11/24/2021, 1/1/2022 and 5/19/2022. She was also unable to provide evidence of interventions to keep Resident ID # 1 safe after the incidents on 1/1/2022 and 5/19/2022. Additionally, she could not explain what exactly staff should have been doing to monitor Resident ID #1. During a surveyor interview with Resident ID #2 on 5/23/2022 at 11:30 AM, s/he acknowledged that s/he had his/her hand down another resident's pants. S/he stated that s/he was embarrassed, but that s/he has needs too.

Based on record review and staff interviews, it has been determined that the facility has failed to ensure that residents are free of any significant medication errors for 1 of 5 sample residents reviewed for medication, ID# 9. Findings are as follows: Record review for Resident ID #9 revealed that s/he was admitted on ,[DATE] and had [DIAGNOSES REDACTED]. Review of an Optum Medical Service - Behavioral Health-Evaluation and Management note dated 8/26/2019 revealed in part, . [MEDICAL CONDITION] with Hallucinations due to known Physiologic Condition-resident remains on [MEDICATION NAME] with no current aggression or elopement. No delusions or hallucinations noted on exam . Review of an Optum Medical Service - Behavior Health evaluation dated 9/25/2019, revealed in part, . Impression . resident remains on [MEDICATION NAME] with no current aggression or elopement. No delusions or hallucinations noted on exam. Based on history and symptoms would not recommend GDR of [MEDICATION NAME] due to concern for decompensation. Failed GDR 3/2019 . Review of Resident ID# 9's Medication Regimen Review dated 9/27/2019, revealed a recommendation to taper the [MEDICATION NAME] (an antipsychotic medication) dose from 25 milligram (mg) daily and 12.5 mg daily to [MEDICATION NAME] 25 mg once daily dosing or document the inability to do so. The Physician / Prescriber Response indicated Agree; Will do. Review of a Nursing progress note dated 10/10/2019 at 2:56 PM revealed, Received med rec to consider GDR (Gradual Dose Reduction) of [MEDICATION NAME], currently receiving 12.5mg Qam (every morning) and 25 mg in evening, recc (recommend) tapering to 25 mg QD (every day). NP (Nurse Practitioner) approved. Review of the Order Recap report revealed that on 10/10/2019 the order for [MEDICATION NAME] 25 mg in the evening and 12.5 mg one time daily was discontinued in error. There was no order to continue [MEDICATION NAME] 25 mg in the evening as ordered by the NP. Review of the manufacturer's instructions for [MEDICATION NAME] states in part .You should not stop using [MEDICATION NAME] suddenly. Stopping suddenly may make your condition worse. Review of a nursing progress note dated 10/16/2019 at 2:55 PM revealed, .Resident continues with GDR of [MEDICATION NAME], noted to have some increased confusion and fatigue . Review of a nursing progress note dated 10/17/2019 at 3:54 PM revealed that the facility was under the assumption that this resident was still taking the evening dose of the [MEDICATION NAME], despite it being discontinued on 10/10/2019 in error. The note states in part, .Resident is having increased bouts of depression and seems more withdrawn from baseline. (S/he) has had a recent dose reduction of (his/her) [MEDICATION NAME]. The NP (Nurse Practitioner) was notified of this change and decided that the benefits of the [MEDICATION NAME] scheduled as it was ordered before the reduction is what worked for the resident. The order for [MEDICATION NAME] 12.5 mg once a day between 7-11 am has been updated in PCC (PointClickCare an electronic health record software program). Review of the Order Recap report revealed that on 10/17/2019 an order for [REDACTED]. In review of the manufacturer's black box warning it indicated that taking [MEDICATION NAME] results in an increased risk of death in elderly people who are confused, have memory loss and have lost touch with reality. Review of the nursing notes below indicate that this resident had experienced increased confusion, incontinence and hallucinations which s/he did not previously exhibit while maintained on [MEDICATION NAME]. Review of a nursing progress note dated 10/18/2019 at 3:52 PM revealed that the facility remained under the assumption that this resident was back on the original [MEDICATION NAME] dose of 12.5 mg in the morning and 25 mg in the evening, failing to identify that the [MEDICATION NAME] had never been tapered rather than discontinued and that [MEDICATION NAME] was mistakenly started in error. This note states in part .Resident's [MEDICATION NAME] reinstated, resident continues with increased confusion, attempting to put underwear over pants and unable to understand simple commands, unlike baseline . Review of a nursing progress note dated 10/23/2019 at 4:05 PM revealed, .resident very confused compared to baseline this shift, unable to comprehend simple directions, incontinent, + hallucinations and increased fatigue . Review of a nursing progress note dated 10/28/2019 at 10:47 PM revealed, . Resident continues with increased confusion. Resident entered the elevator with another residents family and eloped to the 4th floor this evening . Review of a nursing progress note dated 10/29/2019 at 3:13 PM revealed, .Resident continues with increased confusion and occasional agitation and hallucinations. Resident now requires increased direction/queuing from staff and now incontinent .Resident was reported to have difficulty sleeping and was up all night on previous shift, very restless today. Review of a pharmacy consultant progress note dated 10/30/2019, revealed Medication Regimen Review. No Recommendations Made. There was no evidence that the consultant Pharmacist identified that the [MEDICATION NAME] was discontinued rather than tapered, or that [MEDICATION NAME] was added in place of the [MEDICATION NAME] that was ordered. Review of the Order Recap report revealed that on 11/05/2019 the [MEDICATION NAME] was discontinued. It further revealed that [MEDICATION NAME] 12.5 mg one time daily and [MEDICATION NAME] 25 mg one time a day in the evening was reinstated. Review of a nursing post event progress note dated 11/8/2019 at 9:40 PM, . The Med-tech came in the room and said, this resident was being aggressive and trying to get into the elevator .I asked the med-tech if the resident was redirected and in a safe place right now . I noticed the resident at the nursing station, (s/he) didn't appear aggressive and seemed calm .I then hear the Med-tech running out of the resident room yelling 'The resident fell out the window' I then began to yell for help and all the staff ran into (her/his) room. The other nurse then called 911. I called the supervisor. Resident was then placed back into (her/his) room from the window with the help of all staff . The facility failed to identify from 10/10/2019 to 11/05/2019 that this resident did not receive the appropriate medication potentially causing an increase in behaviors not previously exhibited such as climbing out the window on a second-floor unit onto the rooftop, putting the resident at risk for potential harm. During surveyor interview on 2/25/2020 at 2:29 PM with the Nurse Practitioner, he revealed that the 10/10/2019 order was to reduce the residents [MEDICATION NAME] by the morning dose of 12.5 mg and the 25 mg dosage at night was to remain the same. The facility nurse instead discontinued both dosages in error. Further, he revealed that on 10/17/2019 he was notified about the resident having increased behaviors and reordered the [MEDICATION NAME] 12.5 mg dose to be given in the AM thinking the resident was currently still receiving the 25 mg dosage at bedtime as order. During surveyor interview on 2/26/2020 at 1:50 PM with the DNS, she acknowledged the above errors.

Based on staff interviews and record review, it has been determined that the facility has failed to ensure that the resident's environment remains free of accident hazards relative to the use of a mechanical hoyer lift for 1 of 1 resident who was transferred with a mechanical lift, resident ID #1. Findings are as follows; The facility's policy and procedure entitled Safe Handling Program dated, (MONTH) 2013, states in part . 3. Mobilization support equipment includes the Total lift, . 4. Number of staff to operate the: . c. Total Lift: 2 or more . Record review for Resident ID #1 revealed a current care plan revised on 5/24/2019. The care plan indicates that the resident required assistance with activities of daily living related to intellectual disabilities, mental illness and poor understanding. The care plan stated Mechanical lift with an assist of 2. Review of a nursing note dated 6/18/2019 states in part the resident had a large bruise . with redness, 2 + [MEDICAL CONDITION] and severe pain upon movement to his/her lower left leg. The resident was subsequently sent to a hospital for x-rays of his/her left lower leg. This note indicates the resident had the x-rays done and was later transferred to another hospital for treatment of [REDACTED]. Review of the facility's investigation report dated 6/18/2019 revealed the Director of Nursing Servicers (DNS) interviewed with a nursing assistant (Staff B) who provided care to Resident ID #1 on the evening of 6/17/2019. Staff B revealed that he cared for Resident ID #1 and put the resident back to bed after supper via a total mechanical lift. Staff B admitted that he did the transfer alone during the lift transfer. When questioned by the DNS regarding the transfer, Staff B became very weepy and stated He was not sure but he thinks it happened during the transfer. According to this investigation report, it was concluded that injury was during transfer. During a phone interview with the unit nurse (Staff C) on 6/26/2019 at 11:36 AM, she revealed she worked on the night shift on 6/18/2019. She indicated that at approximately 1:00 AM, the resident was noted with a large bruise on a good portion of his/her left leg shin. The bruise was approximately 8 inches in length and 5 inches in width. She described the bruise as more black and blue than red .red around the bruise and hot to touch. During a phone interview on 6/26/2019 at 12:00 PM, Staff B revealed during the total mechanical lift transfer, Resident ID #1 hit his/her leg on the beam of the lift and the resident stated Ouch. When asked, Staff B stated the resident hit . the shin part on the beam of the lift while the resident was swung to the bed. During an interview with the DNS on 6/26/2019 at approximately 12:15 PM, she acknowledged that the plan of care was not followed and that Staff B used the total lift independently. Additionally, the DNS acknowledged that facility's policy for Safe Handing Program was not followed.

Based on record review and staff interview, it was determined that the facility failed to ensure that the resident is free of mistreatment, and abuse for 1 of 13 sample residents (ID #2). Findings are as follows: Review of resident ID # 2's record, reveals that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent (MDS) Minimum Data Set, indicates he/she was unable to complete a (BIMS) Brief Interview for Mental Status, and resides on the secured dementia unit. This resident requires assistance with care with all ADLs, is incontinent, non-ambulatory, uses a wheelchair and frequently needs to be redirected due to behaviors related to dementia. Review of the facilities Report dated 7/24/2015 revealed that on 7/24/2015 Staff F reported that while gathering residents on the 2nd floor dementia unit for an activity she noticed resident ID # 2 going into another residents room, she tried to redirect him, and asked him to come with her to the TV room, which he refused. She saw staff B in the hallway and asked her to come help with resident ID # 2. She states that Staff B, responded I'm already 40 minutes behind in my schedule and came into the room screaming you don't belong in here. She then pulled the resident's wheelchair from behind very hard and fast and he/she almost fell off of the chair. The resident was so scared and upset that he knocked items off of the TV stand with his hands and grabbed the walker that was near him and threw it at her, he tried to kick her, he was swearing. He then fell out of the wheelchair because she pulled the chair so hard and fast he had slid to the end of the seat. Review of the 7/24/2015 nurse's note documented at 11:50 PM revealed that resident ID #2 can make needs known, had a fall at 9:30 am, had no injury from fall, went to bed around 4 PM and stayed the rest of the shift. Denied any pain or discomfort Review of the 7/25/2015 nurse's notes documented at 2:00 AM revealed the resident has no apparent injuries noted after the fall. No complaints of pain or discomfort and has full range of motion to all extremities, and is pleasant and cooperative. On 7/24/2015, employee F reported to the (A DNS) that she witnessed Med tech Staff B yelling at the resident and abruptly pulling him backwards in his/her wheelchair,and the resident sliding forward in the chair and eventually falling out of the chair to the floor. Subsequently, the ADNS reported and investigated the allegation and staff F was sent home and removed from the schedule pending the investigation. On 3/11/2016 at approximately 10:30 AM, the surveyor interviewed the former DNS, who acknowledged that the report reveals that the staff (staff B) acted abruptly and inappropriately, and that the resident had become frightened. However, the report failed to report to the Department of Health that the resident fell from the chair subsequent to staff B's actions. The facility failed to ensure that the above resident was protected and free from mistreatment, and abuse . Upon further interview with the DNS, she indicated that the followings interventions were put in place; a) Med Tech Staff B has been terminated. b) The facility has provided abuse/neglect and in service education to employees.

Based on record review and staff interview, it was determined that the facility failed to provide adequate supervision and assistance for residents at risk for falls, for 2 of 2 sample resident (ID#'s 2 & 8). Findings are as follows: 1. Review of resident ID # 8's record reveals that he/she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The resident requires assistance with his/ her (ADL's) Activities of Daily Living, and scored a 7/15 on his/her most recent (BIMS) Brief Interview for Mental Status dated 12/2015. The resident was residing on the secured Dementia unit, and was noted to need assistance with transfers and ADLs. The resident has a care plan that was developed on 9/24/2013 and updated on 2/17/2016 for ADL Assistance, Falls, Anxiety, and ADL Deficit relative to cognitive loss, weakness and incontinence. During surveyor review of a community reported complaint and a facility reported fall, the care plan for resident ID #8, stated, resident at risk for falls, secondary to previous history of falls, decreased endurance/strength, [DIAGNOSES REDACTED]. Listed as an intervention dated 9/24/2013 the care plan states Do not leave in bathroom unattended. Review of the facilities report and investigation of the resident's fall on 12/24/2015, reveals that the resident requires extensive assist with ADLs, one assist with transfers, is non-ambulatory and self-propels in a wheelchair. The nursing assistant, assisted resident ID #8 to the toilet, and told her to call the light when she was done, that she would be right back as she heard someone else call for help. When she returned the resident was on the floor, and could not move her left leg. The resident was transported to the hospital and was admitted with a left femur fracture. During surveyor interview on 3/11/2016 at approximately 10:15 AM, with the Director of Nurses who conducted the investigation and reported the fall, she stated that the nursing assistant should not have left the resident on the toilet unattended, as the resident's care plan states do not leave resident in bathroom alone. She also informed the surveyor that the resident has had falls in the past trying to get up and do things on her own. She stated the the staff has been in-serviced relative to the above and the facilities policies. The surveyor interviewed the resident's daughter who had submitted a complaint to the Department of Health on 3/10/2016 at 12:10 PM. The complainant informed the surveyor that the resident had several falls while she was at the facility and that on 12/24/2015 when the resident fell , she had been left alone on the toilet even though the care plan required that the resident not be left alone. She stated that the resident fractured her hip when she fell , had surgery for [REDACTED]. 2. Review of resident ID # 2's record, reveals that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent (MDS) Minimum Data Set, he/she was unable to complete a BIMS, and resides on the secured dementia unit. This resident requires assistance with care with all ADLs, is incontinent, non-ambulatory, uses a wheelchair and frequently needs to be redirected due to behaviors related to dementia. During surveyor review of this facility reported allegation of staff to resident abuse the following was revealed. The facility reported that on 7/23/2015, resident ID # 2, went into another resident's room in his wheelchair and was trying to open the blinds in the room. The report failed to reveal that the resident had become so frightened that he/she fell to the floor out of the wheelchair. The Med Tech, Staff B went in to the room to help redirect the resident. She was observed yelling at the resident that he did not belong in that room and pulled the resident's wheelchair so abruptly that the resident slid towards the front of the chair. The resident became frightened by the action and knocked items off the TV stand and grabbed the walker and threw it at the med tech. As a result the resident fell from his chair onto the floor. Review of the resident's care plan dated 4/10/2014 and revised on 11/20/2014, list as a focus potential to be physically aggressive r/t Dementia, and as an intervention, . engage calmly in conversation On 3/11/2016 at approximately 10:30 AM, the surveyor interview the DNS, (at the time of the incident), who acknowledged that the report reveals that the staff (staff B) acted abruptly and inappropriately, however the report failed to reveal that the resident had become so frightened that he fell to the floor out of the wheelchair. The facility failed to ensure that the above resident's received adequate supervision and assistance to prevent falls. The facility has terminated the staff member (staff B) relative to ID #2, and provided in service for staff relative to caring for Dementia residents, following the plan of care, and appropriately dealt with staff who do not follow facility policies and practices in caring for resident's with dementia . You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions.