Every finding on record at AdviniaCare Orchard, LLC

Based on clinical record review and staff interview, the facility failed to provide and document sufficient preparation and orientation to ensure a safe and orderly discharge from the facility for 1 of 1 resident discharged , Resident ID #33. Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on 8/19/2026 alleged that Resident ID #33 was discharged to the hospital without an incident or medical reason. Additionally, the complaint alleged that the resident was not given a 30-day notice and the Rhode Island Alliance for Better Long-Term Care was not notified.Review of a facility policy titled, Discharge/ Transfer Process states in part, The facility will ensure a safe and proper transfer or discharge for all residents leaving the facility.Record review revealed that the resident was admitted to the facility in May of 2025 with diagnoses including, but not limited to, schizoaffective disorder and type II diabetes mellitus. Additional review revealed that Resident ID #33 was discharged from the facility in January of 2026 due to building closure and then readmitted in July of 2026.Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 of 15, indicating intact cognition. Further review of the MDS, Section E, Behaviors, revealed that the resident did not have any behaviors affecting other residents.Review of a care plan focus area dated 7/22/2026 revealed that Resident ID #33 wants to discharge to a lower level of care with interventions including, but not limited to, evaluate and record his/her abilities and strengths and determine gaps in his/her abilities which will affect discharge. Additional review revealed an intervention to make arrangements with required community resources to support independence post-discharge on ce discharge has been established.Review of a progress note dated 7/29/2026 authored by the Director of Nursing Services (DNS) states, Spoke to Medical Director regarding newly gained information about resident. Resident is a convicted sex offender with documented deviant behavior at another facility. Due to the conviction and our proximity to schools, our Medical Director will not assume care of this resident. An order was received to transfer to resident to the hospital. [S/he] is placed on 1:1 (one to one) observation until transfer occurs.Record review failed to reveal evidence that Resident ID #33 had any sexually inappropriate behavior at the facility.Further record review failed to reveal evidence of a 30-day notice of discharge, a discharge plan involving the interdisciplinary team, a written notice of discharge, or a discharge summary as required.Review of the, State of Rhode Island Executive Office of Health and Human Services Appeals Office Decision dated 8/20/2026 states in part, .Based on the foregoing Findings of Fact and Conclusions of Law, it is found that a final order be entered that the facility failed to comply with the requirements of an involuntary discharge from a long-term care facility. Specifically, the Facility failed to provide written notice of the intent to discharge.During a surveyor interview on 8/20/2026 at 8:17 AM with the Administrator and the DNS, they acknowledged that Resident ID #33 was discharged to the hospital without any medical reason. Per the DNS and Administrator, they discharged due to being made aware that the resident was a registered sex offender in the State of Florida. Both the DNS and Administrator acknowledged that the resident had been a resident of the facility from May of 2025 until January of 2026 when s/he was transferred due to facility wide closure. Additionally, both the DNS and Administrator acknowledged that they did not offer a 30-day notice, did not provide written notice of intent to discharge, did not attempt to transfer the resident to another nursing home, did not offer education to the resident regarding medication, did not report the discharge to the Alliance for Better Long-Term Care office, and did not attempt to make community referrals to aide in a successful discharge.

Based on surveyor observations and staff interviews between 1/22/2026 and 1/23/2026, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public. Active water leaks from the roof penetrated ceiling tiles and electrical fixtures on the second floor, causing brown water to pool on floors, collect in hallways accessible to cognitively impaired residents, and infiltrate the fire alarm panel. Despite awareness from maintenance, administration, and operations staff, no effective mitigation measures were implemented. These failures resulted in slippery, hazardous conditions, compromised life safety systems, and necessitated an evacuation directed by The Rhode Island Department of Health, placing 125 residents at immediate risk for serious harm or death.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 1/22/2026 alleged that the facility's roof was leaking and a large laundry cart and wastebasket full of dirty water was placed outside of a resident's room. During a surveyor observation of the Cortland and [NAME] Units, located on the second floor of the facility, with the Maintenance Assistant, on 1/22/2026 at approximately 11:10 AM, multiple areas within both units were observed with towels placed on the floor. The towels were visibly saturated with brown-colored water. Waste, laundry baskets, and buckets were placed in hallways and outside resident rooms, to collect water from the active leaks. Water was observed leaking from ceiling tiles and overhead light fixtures. [NAME] water staining was present on numerous ceiling tiles and wall surfaces. Floor surfaces were noted to be wet and slippery, especially around the water collection buckets. Further, many residents were observed to be sitting or ambulating near the active leaks and containers collecting the water. During a surveyor interview, immediately following the above observation, with the Maintenance Assistant, he acknowledged the leaking water on the second floor and indicated that it was leaking from the roof. He revealed that the leak had started the day prior and he had been instructed to remove the snow from the roof to prevent a continuous leak but stated that he had not removed it yet.During a surveyor interview on 1/22/2026 at 11:23 AM, with the Administrator, she acknowledged the water leaks on the second floor and revealed that the leak had become progressively worse throughout the morning, and the facility was in the process of obtaining a quote to have the roof fixed. During a surveyor interview on 1/22/2026 at 11:54 AM, with the Director of Operations, in the presence of the Administrator, he revealed that the leaking water was coming from the roof and indicated that they had placed a call to a contractor to assess the damage and fix the roof. Further, he revealed that he knew where the leak was coming from, however, he was unable to provide evidence of any immediate interventions that were put in place to mitigate the leak and ensure the environment is safe, functional, sanitary and comfortable for all residents, staff, and the public.During a surveyor observation on 1/22/2026 at 12:30 PM, the following individuals were dispatched and arrived at the facility to evaluate the situation: East Providence Fire Department, Chief of Fire for East Providence, East Providence Fire Marshall, Emergency Medical Services Coordinator and the Lieutenant Fire Prevention Coordinator. At this time, a directive was given by the City Fire Marshall to have the facility inspected by the following entities to determine if it was safe for all residents, staff, and the public: an electrical inspector, a roof inspector, a building inspector, and Servpro (a company that specializes in cleanup and restoration solutions).During a surveyor interview on 1/22/2026 at 3:00 PM, with RIDOH leadership, an order was given by the Director to evacuate the second floor of the facility, due to the water damage, active leaks, and to ensure that no residents remain on the affected units. During a surveyor interview on 1/22/2026 at 4:15 PM, with the City Fire Marshall, he revealed that the facility's fire panel on the second floor was noted to have water inside the panel. He indicated that the fire panel appears to have been tampered with. Due to these concerns, a fire watch was established at the facility by the East Providence Fire Department, to ensure all remaining residents were safe.During a follow-up surveyor interview on 1/22/2026 at 5:00 PM, with RIDOH leadership, a decision was made to evacuate the entire facility, as the health and safety of all residents and staff were at risk. All second-floor residents were evacuated on 1/22/2026 and the remainder of residents were to be evacuated on 1/23/2026.On 1/23/2026 the surveyor toured the second floor of the facility at approximately 12:10 AM and confirmed that all residents had been evacuated. Further, on 1/23/2026 at 10:20 PM, the surveyor toured the entire facility and confirmed that all residents had been evacuated.The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This failure resulted in active water leaking from electrical fixtures and the placement of water collection containers in resident care areas, including areas accessible to residents with mild to severe cognitive impairments. Additionally, water intrusion into the second-floor fire panel led to the panel potentially being compromised and deactivated for resident rooms on the affected units. These conditions placed residents at risk for serious injury, serious harm, serious impairment, or death.

Based on surveyor observation, record review, and staff interview, the facility failed to ensure the residents' environment remained as free of accident hazards as possible related to the storage and management of biohazardous waste (any material contaminated with infectious agents or potentially infectious substances that pose a risk to health, including blood and body fluids) and sharps (any instruments or devices with sharp points or edges that can puncture or cut skin, posing risks of injury and disease transmission). This failure resulted in unsecured, unlocked, and accessible biohazardous waste and sharps on four (4) of four (4) units observed, including a secured memory care unit, placing residents at risk for exposure to bloodborne pathogens, infectious disease, and physical injury. Findings are as follows:Review of a community-reported complaint submitted to the Rhode Island Department of Health on 1/7/2026 alleged that trash and biohazardous waste were blocking the entire back side/entrance of the facility. Further review of this complaint revealed that biohazardous waste was being stored in unlocked and unsecured rooms.Review of the facility policy dated April 2025 titled Storage of Sharps states in part, To maintain an avoidable accident-free environment, all sharps (scissors, razors, lancets, needles.) are stored and secured in designated areas at all times when not in use.Ensure that all sharps are placed in their designated locked storage containers at all times.Ensure that sharps are contained and stored in a secured manner.Do not allow residents/patients with functional and/or cognitive limitations to handle such objects as they may pose a hazard.1.During a surveyor observation on 1/8/2026 at 7:48 AM off the back entrance of the facility, a room was observed with the door half open. The room contained multiple boxes labeled Infectious Waste, Biohazard Medical Waste. The boxes were overflowing with sharps containers (containers used for the safe disposal of used needles, syringes, and other sharp medical items to prevent needlestick injuries and the spread of infection), along with red bags labeled Biohazard filled with sharps containers. Additional red biohazard bags filled with sharps containers were observed on the floor extending to the doorway and were visible from outside the room.2. During a surveyor observation on 1/8/2026 at 8:25 AM, in the presence of the Administrator, the same room was observed with the door half open and contained multiple boxes labeled Infectious Waste overflowing with sharps containers and red biohazard bags filled with sharps containers and other biohazardous waste.During a surveyor interview immediately following the above-mentioned observation with the Administrator, she acknowledged the room was unlocked and contained biohazardous waste.3. During a surveyor observation of the same room on 1/8/2026 at 8:44 AM, in the presence of the Assistant Maintenance Director, he acknowledged that the room was filled with biohazardous waste and that the door was unlocked. He further indicated that the room was filled because the contracted biohazard waste removal company had not picked up the waste due to non-payment by the facility.4. During surveyor observations on 1/8/2026, in the presence of the Director of Nursing Services (DNS), biohazardous waste was observed stored in unlocked and unsecured rooms on the following units where residents reside:a. At 9:13 AM, on the [NAME] Unit there was a box overflowing with sharps containers, with five additional sharps containers observed on top of the box. One of the sharps containers was observed open with needles and other sharp objects exposed.b. At 9:16 AM, on the [NAME] Unit there were boxes overflowing with sharps containers, with nine additional sharps containers observed on top of the boxes.c. At 9:24 AM, on the Cortland Unit there were fourteen (14) sharps containers observed on the floor. Additionally, there were multiple Intravenous lines (IV, a flexible tube used to deliver fluids, medications, nutrition, or blood products directly into a patient's bloodstream via the patient's vein) with blood visibly in the lines and the lines were hanging from the sharps' containers.d. At 9:27 AM, on the [NAME] Unit (memory care) there was a box overflowing with sharps containers, with five additional sharps containers observed on top of the box.During a surveyor interview with the DNS on 1/8/2026 at 9:33 AM, she acknowledged that the rooms on the above-mentioned units were unlocked and contained sharps containers and boxes of biohazardous waste. The DNS was unable to provide evidence that the biohazardous waste was stored in secured rooms not accessible to residents and acknowledged that the waste had not been removed from the units. Additionally, the DNS was unable to provide evidence the residents' environment remained as free of accident hazards as possible on the four units observed.During the above observations, multiple residents were observed ambulating and self-propelling in close proximity to the unsecured and unlocked rooms containing biohazardous waste. One of the units observed was a secured memory care unit with residents diagnosed with cognitive impairments.During a surveyor interview on 1/8/2026 at 9:35 AM with a representative from the contracted biohazard waste removal company, stated that services were placed on hold in May of 2025 due to non-payment by the facility and that the last biohazardous waste removal occurred on May 29, 2025.A review of facility records failed to reveal evidence that the facility's contacted biohazard waste removal company or any other licensed biohazardous waste removal company had been at the facility for the removal and disposal of biohazardous waste since May 2025.During an interview with the Administrator on 1/8/2026 at approximately 1:00 PM, she indicated that she was aware of the biohazardous waste disposal issues upon being hired in October 2025 and acknowledged that waste was not disposed of appropriately due to non-payment. The Administrator was unable to provide evidence that the facility ensured the residents' environment remained as free of accident hazards as possible related to the storage of biohazardous materials.As a result of these failures, the facility did not ensure biohazardous waste and sharps were secured, managed, and disposed of in accordance with the facility policy and safety standards, creating a hazardous environment with the potential for serious harm to residents.Cross reference F 880, F 814, and F 837

Based on surveyor observation, record review, and staff interview, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the transmission of communicable diseases and infections. Specifically, the facility failed to properly store, secure, and dispose of biohazardous waste (any material contaminated with infectious agents or potentially infectious substances that pose a risk to others) and overfilled sharps containers (used for the safe disposal of used needles, syringes, and other sharp medical items to prevent needlestick injuries and the spread of infection) in unsecured and unlocked areas on four (4) of four (4) units observed, including a secured memory care unit. These failures placed residents at risk for exposure to bloodborne pathogens, infectious diseases, and physical harm. Findings are as follows:Review of a community-reported complaint submitted to the Rhode Island Department of Health on 1/7/2026 alleged that trash and biohazardous waste were blocking the entire back side of the building. Further review revealed that biohazardous waste was being stored in unlocked and unsecured rooms.Review of the facility's policy dated April 2025 titled Storage of Sharps states in part, .To maintain an avoidable accident-free environment, all sharps (scissors, razors, lancets, needles.) are stored and secured in designated areas at all times when not in use.Ensure that all sharps are placed in their designated locked storage containers at all times.Ensure that sharps are contained and stored in a secured manner.Do not allow residents/patients with functional and/or cognitive limitations to handle such objects as they may pose a hazard.1.During a surveyor observation on 1/8/2026 at 7:48 AM off the back entrance of the facility, a room was observed with the door half open. The room contained multiple boxes labeled Infectious Waste, Biohazard Medical Waste overflowing with sharps containers, along with red bags labeled Biohazard. Multiple red biohazard bags filled with sharps containers were also observed on the floor extending to the doorway and were visible from outside the room.2. During a surveyor observation on 1/8/2026 at 8:25 AM, in the presence of the Administrator, the same room was observed with the door half open and contained multiple boxes labeled Infectious Waste overflowing with sharps containers and red biohazard bags filled with sharps containers and other biohazardous waste. During an interview immediately following the observation, the Administrator acknowledged the room was unlocked and contained biohazardous waste.3. During a surveyor observation on 1/8/2026 at 8:44 AM, in the presence of the Assistant Maintenance Director, he acknowledged the room was filled with biohazardous waste and that the door was unlocked. He further indicated that the contracted biohazard waste removal company had not picked up the waste due to non-payment by the facility.4. During surveyor observations on 1/8/2026, in the presence of the Director of Nursing Services (DNS), biohazardous waste and sharps containers were observed stored in unlocked and unsecured rooms on the following units, where residents reside:a. At 9:13 AM, on the [NAME] Unit there was a box overflowing with sharps containers, with five additional sharps containers observed on top of the box. One sharps container was observed open with needles and other sharp objects exposed.b. At 9:16 AM, on the [NAME] Unit there were boxes were overflowing with sharps containers, with nine additional sharps containers observed on top of the boxes.c. At 9:24 AM, on the Cortland Unit there were fourteen (14) sharps containers observed on the floor. Additionally, there were multiple Intravenous lines (IV, a flexible tube used to deliver fluids, medications, nutrition, or blood products directly into a patient's bloodstream via the patient's vein) with blood visibly in the lines and the lines were hanging from the sharps' containers.d. At 9:27 AM, on the [NAME] Unit (memory care) there was a box overflowing with sharps containers, with five additional sharps containers observed on top of the box.During an interview with the DNS on 1/8/2026 at 9:33 AM, she acknowledged that the rooms on the above-mentioned units were unlocked and contained sharps containers with biohazardous waste. The DNS was unable to provide evidence that the sharps containers were stored in secured areas not accessible to residents to help prevent the transmission of communicable diseases and infections.During the above observations, multiple residents were observed ambulating and self-propelling in close proximity to the unsecured and unlocked rooms containing biohazardous waste. One of the units observed was a secured memory care unit housing residents diagnosed with cognitive impairment.During a surveyor interview on 1/8/2026 at 9:35 AM with a representative from, the facility's contracted biohazard waste removal company, the representative stated that services were placed on hold in May 2025 due to non-payment by the facility and that the last biohazardous waste removal occurred on May 29, 2025.A review of facility records failed to reveal evidence that the facility's contacted biohazard waste removal company or any other licensed biohazardous waste removal company had been at the facility for the removal and disposal of biohazardous waste since May 2025.During an interview with the Administrator on 1/8/2026 at approximately 1:00 PM, she stated that she was aware of the biohazardous waste disposal issues upon being hired in October 2025 and acknowledged that biohazardous waste was not disposed of appropriately due to non-payment. The Administrator was unable to provide evidence that the facility maintained a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections.As a result of these failures, the facility did not implement and maintain an effective infection prevention and control program related to the safe storage and disposal of biohazardous waste and sharps, creating a risk for transmission of infectious diseases and potential serious harm to residents.Cross reference F 689, F 814, and F 837

Based on surveyor observation, record review, and staff interview, the facility failed to ensure the proper disposal and management of garbage, resulting in an accumulation of garbage at the back of the facility that obstructed exit routes and posed an immediate hazard to residents' safety. This failure placed residents at risk in the event of an emergency evacuation. The facility was found to be in past noncompliance.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 1/7/2026 alleged that large amounts of trash were blocking the entire back side of the facility. Further review of the complaint revealed that the accumulation of garbage obstructed exit doors, resulting in blocked fire exits for residents to use in the event of an emergency evacuation, posing an extreme risk and immediate hazard to resident safety.Record review of photographs obtained from the complainant, dated 1/7/2026 at 2:13 PM, revealed a significant accumulation of garbage at the back of the facility. The photographs showed multiple black and white trash bags containing garbage, including yellow personal protective gowns. The garbage was observed blocking exit doors at the back entrance shared with the facility's main kitchen and extended the full length of the entrance. The accumulation covered the entire platform surface, extended to the ground below, and obstructed the exit ramp. Multiple large garbage bins filled to capacity with trash bags were also observed.During a surveyor interview on 1/8/2026 at 9:39 AM with a representative from the facility's contracted garbage removal company, the representative indicated that garbage removal services were placed on hold after November 28, 2025 due to non-payment by the facility. The representative confirmed that November 28, 2025, was the last scheduled garbage pickup prior to services resuming on 1/7/2026. The representative further stated that the company was contracted to remove garbage weekly on Thursdays.During a surveyor interview on 1/8/2026 at 10:28 AM with the Assistant Director of Maintenance, he acknowledged that garbage had not been picked up by the contracted garbage removal company from November 2025 until 1/7/2026 due to non-payment by the facility. After reviewing the photographs with the surveyor, he confirmed that the images accurately depicted the accumulation of garbage and waste at the back of the facility blocking exit routes. He further acknowledged that garbage removal was scheduled weekly but had not occurred as scheduled due to non-payment.During a surveyor interview on 1/8/2026 at approximately 1:00 PM, the Administrator acknowledged the photographs depicting the large accumulation of garbage at the back entrance of the facility. She indicated that the garbage was removed by the contracted garbage removal company after the issue was brought to the facility's attention by the complainant on 1/7/2026.During a surveyor observation of the back entrance of the facility on 1/8/2026 at 7:48 AM, no garbage accumulation was observed. Two large blue dumpsters were present and covered, and exit routes were unobstructed.Based on observation, interview, and record review, the facility failed to ensure the timely removal and proper management of garbage, resulting in blocked exit routes and hazardous conditions. As the conditions were corrected prior to the surveyor observations, the facility was determined to be in past noncompliance.Cross reference F 880, F 689, and F 837

Based on surveyor observation, record review, and staff interview, the facility's governing body failed to ensure the effective implementation and oversight of policies related to the management and operation of the facility. Specifically, the governing body failed to ensure the proper disposal and management of biohazardous waste and garbage, resulting in unsecured biohazardous waste stored in the facility and an accumulation of garbage at the back of the building that obstructed exit routes and posed an immediate hazard to the residents' safety.Findings are as follows: Review of the Facility assessment dated [DATE], states in part, Resources: The physical environment, services and other physical plant considerations are reviewed to ensure [the facility] meet the needs of our residents.assuring the safety and well-being for each resident.Waste management, hazardous waste management.Review of a community-reported complaint submitted to the Rhode Island Department of Health on 1/7/2026 alleged that large amounts of biohazardous waste were stored in unsecured rooms and that garbage was blocking the entire back side of the facility. Further review revealed that the accumulation of garbage obstructed exit doors, resulting in unavailable fire exits for residents to use in the event of an emergency evacuation, posing an extreme and immediate risk to resident safety.Review of photographs obtained from the complainant dated 1/7/2026 at 2:13 PM revealed a significant accumulation of garbage at the back of the facility. The photographs showed multiple black and white trash bags containing refuse, including yellow personal protective gowns. The garbage was observed blocking exit doors at the back entrance shared with the facility's main kitchen and extended the full length of the entrance. The accumulation covered the entire platform surface, extended to the ground below, and obstructed the exit ramp. Multiple large garbage bins filled to capacity with trash bags were also observed. 1. During a surveyor observation on 1/8/2026 at 7:48 AM off the back entrance of the facility, a room was observed with the door half open. The room contained multiple boxes labeled Infectious Waste, Biohazard Medical Waste overflowing with sharps containers, along with red bags labeled Biohazard. Multiple red biohazard bags filled with sharps containers were observed on the floor extending to the doorway and visible from outside the room.a. During a surveyor observation on 1/8/2026 at 8:25 AM, in the presence of the Administrator, the same room was observed with the door half open and contained multiple boxes labeled Infectious Waste overflowing with sharps containers and red biohazard bags filled with sharps containers and other biohazardous waste. During an interview immediately following the observation, the Administrator acknowledged the room was unlocked and contained biohazardous waste.b. During a surveyor observation on 1/8/2026 at 8:44 AM, in the presence of the Assistant Maintenance Director, he acknowledged that the room was filled with biohazardous waste and that the door was unlocked. He further stated that the contracted biohazard waste removal company had not removed the waste due to non-payment by the facility.2. During surveyor observations on 1/8/2026, in the presence of the Director of Nursing Services (DNS), biohazardous waste and sharps containers were observed stored in unlocked and unsecured rooms on the following units:a. At 9:13 AM, on the [NAME] Unit there was a box overflowing with sharps containers, with five additional sharps containers observed on top of the box. One sharps container was observed open with needles and other sharp objects exposed.b. At 9:16 AM, on the [NAME] Unit there were boxes overflowing with sharps containers, with nine additional sharps containers observed on top of the boxes.c. At 9:24 AM, on the Cortland Unit there were fourteen (14) sharps containers observed on the floor. Additionally, there were multiple Intravenous lines (IV, a flexible tube used to deliver fluids, medications, nutrition, or blood products directly into a patient's bloodstream via the patient's vein) with blood visibly in the lines and the lines were hanging from the sharps' containers.d. At 9:27 AM, on the [NAME] Unit (memory care) there was a box overflowing with sharps containers, with five additional sharps containers observed on top of the box.During an interview with the DNS on 1/8/2026 at 9:33 AM, she acknowledged that the rooms on the above-mentioned units were unlocked and contained sharps containers with biohazardous waste. She further stated that the biohazardous waste had not been removed due to non-payment to the waste removal company by the facility owner.During a surveyor interview on 1/8/2026 at 9:35 AM with a representative from the facility's contracted biohazard waste removal company, the representative stated that services were placed on hold in May of 2025 due to non-payment and that the last biohazardous waste removal occurred on May 29, 2025.A review of facility records failed to reveal evidence that the facility contracted biohazard waste removal company, or any other licensed biohazardous waste removal company had been to the facility for removal or disposal of biohazardous waste since May 2025.During a surveyor interview on 1/8/2026 at 9:39 AM with a representative from the facility's contracted garbage removal company, the representative stated that garbage removal services were placed on hold after November 28, 2025, due to non-payment. The representative confirmed that November 28, 2025, was the last scheduled garbage pickup prior to services resuming on 1/7/2026.A review of email communications dated 11/19/2025 and 1/5/2026 between the Administrator and the Regional Director of Operations (governing body) revealed that the Administrator informed the governing body that both the biohazardous waste and garbage removal accounts were on credit hold.During a surveyor interview on 1/8/2026 at 10:28 AM, the Assistant Director of Maintenance acknowledged that garbage was not removed from November 2025 until 1/7/2026 due to non-payment and that biohazardous waste had not been removed due to lack of space, as the designated biohazard room was filled to capacity. He further stated that biohazardous waste had not been removed from the facility since the summer of 2025.During surveyor interviews on 1/8/2026 at 10:30 AM and on 1/9/2026 at 10:49 AM, the Administrator acknowledged that the corporation owning the facility is the governing body and is responsible for authorizing payments for contracted services. She further acknowledged that the governing body was aware that biohazardous waste and garbage removal services were suspended due to non-payment.As a result of the governing body's failure to ensure adequate oversight and provision of essential services, the facility did not maintain safe waste management practices, resulting in hazardous conditions that placed residents at risk for serious harm.cross reference F 689, F 880, and F 814

Based on record review, resident, family, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed who sustained a fall, Resident ID #2.Findings are as follows:During the investigation of a community reported complaint on 9/24/2025, a surveyor interview was completed at 8:38 AM with Resident ID #2's family member. The family member alleged that Resident ID #2 fell on Friday, 9/19/2025, and was sent to the hospital on 9/21/2025, where s/he was diagnosed with a spinal fracture. The family further revealed that when they questioned the nurse on Sunday about the fall, the nurse revealed that there was no fall documented in Resident ID #2's medical record.Review of a policy titled, Fall Management states in part, .A fall risk evaluation will be conducted by the 'nurse on duty/supervisor' on any resident/patient sustaining a fall with or without injury.Post fall, once a resident/patient is clinically evaluated as being stable, vital signs, neurological signs, range of motion, and evaluation of cognitive status will be documented. Neurological checks are to be documented on the neurological flow sheet for 72 hours in the following circumstances: resident/patient states that he/she hit head, physical evidence resident hit head, and unwitnessed fall. Resident/patient should continue to be monitored for 72 hours after a fall evaluation for latent injury, with documentation in the medical record.Review of a policy titled, Condition: Significant Change states in part, .The physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition.This notification shall be documented in the clinical record.Record review revealed the resident was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, unsteadiness on feet and history of falling. Record review revealed a Minimum Data Set assessment dated [DATE] which revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.During a surveyor interview with the resident on 9/24/2025 at 10:31 AM, s/he revealed that on Friday, 9/19/2025 s/he had fallen from his/her wheelchair to the floor, landed on his/her butt and staff members picked him/her back up. S/he further revealed s/he did not have pain at that moment but that it developed the next day. Lastly, s/he revealed that s/he went to the hospital on Sunday because s/he was in so much pain it hurt to move. Record review of the resident's medical record from Friday, 9/19/2025 failed to reveal documentation of a fall occurring, an assessment of the resident including initial vital signs and initial neurological checks, 72-hour vital signs and neurological checks, 72-hour monitoring after a fall for latent injury and/or notification to a provider about a fall per the facility policy. Review of the Medication Administration Record revealed that the resident received Acetaminophen 1000 milligrams (mg) for pain of a six out of ten on 9/20/2025 and nine out of ten pain on 9/21/2025.Review of a progress note dated 9/21/2025 at 9:34 AM Central Standard Time, authored by an on-call provider, revealed that the resident had a fall on Friday where s/he fell from his/her wheelchair and onto the floor on his/her bottom. At that time, s/he reported no pain. The progress notes further revealed that on 9/20 and 9/21/2025, the resident was having pain when moving and complained of 10 out of 10 pain to his/her lower back. Additionally, the progress note revealed that the resident is not able to get out of bed or lift his/her head up without excruciating pain to the back area. His/her baseline is up and out of bed often. The resident is almost in tears on exam from pain.Review of a progress note dated 9/21/2025 at 11:45 AM, authored by Licensed Practical Nurse, Staff A, revealed she overheard the resident screaming in his/her room. Upon entry, the resident stated that s/he had back pain. Staff A revealed that, .upon entering the room resident was lying in bed crying, reports pain localized to lower back rated 10/10. When asked what happened resident stated [s/he] had slipped and fell out of wheelchair Friday 9/19/25. Residents' roommate also stated '[s/he] fell out of [his/her] wheelchair the other day'. [range of motion] in lower extremities elicits pain/discomfort during flexion and extension. Redness and warmth area noted in lower back. No swelling or open areas noted.Review of a hospital Discharge summary dated [DATE], revealed that the resident had a compression fracture (a type of break in the vertebrae that causes the bone to collapse) of the L2 vertebrae (a bone in your lumbar region). Further review of the discharge summary revealed that the cause of a compression fracture includes, but is not limited to, a fall or trauma.Record review revealed a physician's order dated 9/23/2025 for tramadol (a narcotic medication used for pain management) 25 mg, to be administered twice daily for pain for 1 week.Review of a statement provided by Nursing Assistant (NA), Staff B, revealed that Resident ID #2 fell on the floor on 9/19/2025 and she helped him/her up to his/her chair with another NA and nurse.During a surveyor interview on 9/24/2025 at 10:19 AM with Staff B, she revealed that on Friday, 9/19/2025, she was standing at the nurse's station when she heard screaming. She entered Resident ID #2's room and found him/her on the floor. The resident stated to Staff B that s/he had fallen and landed on his/her butt. The resident did not complain of pain at that time.During an interview on 9/24/2025 at 12:04 PM, with Registered Nurse, Staff C, she stated that she was the assigned nurse for Resident ID #2 on 9/19/2025. She reported that Staff B informed her the resident was found on the floor but claimed the resident had not fallen. When the surveyor asked whether she had questioned the resident about the incident, Staff C admitted she had not, noting that the resident was crying and appeared frightened. She further acknowledged that she did not perform an assessment or notify the provider regarding the incident.During a surveyor interview on 9/24/2025 at 12:56 PM, with the Director of Nursing Services, she revealed that regardless of if the resident fell from his/her wheelchair or was placed on the floor, that it is still considered a fall. Additionally, she was unable to provide evidence that the resident was evaluated following the fall on 9/19/2025, per the facility policy. Further, she was unable to provide evidence that the provider was notified of the resident's fall until the resident was observed in excruciating pain two days after the fall occurred.

Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that filters waste and excess fluid from your blood when your kidneys are failing) receive services consistent with professional standards of practice, for 2 of 2 residents reviewed who receive dialysis, Resident ID #s 1 and 3. Findings are as follows: According to the manufacturer's instructions for Sevelamer Carbonate states in part, .1 INDICATIONS AND USAGE Sevelamer Carbonate is indicated for the control of serum phosphorus [elevated levels can develop weak and broken bones and cause damage to blood vessels] in adults .with chronic kidney disease (CKD) on dialysis. 2 DOSAGE AND ADMINISTRATION .administered orally with meals .12.1 By binding phosphate in the gastrointestinal tract and decreasing absorption, sevelamer carbonate lowers the phosphate concentration in the serum (serum phosphorus).1. Record review revealed Resident ID #1 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, CKD. Additionally, the resident receives dialysis three times a week.Record review revealed the following physician's orders:-8/28/2025, Sevelamer Carbonate 1600 milligrams (mg) by mouth three times a day. -1000 milliliter (ml) fluid restriction (the limitation of daily fluid intake for patients who can't maintain their body's fluid balance) per day; 600 ml from dietary and 400 ml from nursing Review of the August 2025 Medication Administration Record (MAR) from 8/23/2025 through 8/31/2025 revealed the administration times for Sevelamer were scheduled for 6:30 AM, 3:00 PM and 8:00 PM. Further review of the MAR revealed documentation of a code 3, indicating the resident was absent from the facility and that s/he was not administered his/her Sevelamer on 8/26/2025 and 8/27/2025 at 3:00 PM.Further review of the September 2025 MAR revealed the administration times for Sevelamer are scheduled for 8:00 AM, 12:00 PM and 5:00 PM. Further review of the MAR revealed documentation of a code 3, indicating the resident was not administered his/her Sevelamer on the following dates and times:-9/3/2025 at 12:00 PM-9/5/2025 at 8:00 AM-9/10/2025 at 12:00 PM-9/15/2025 at 12:00 PMRecord review of the September 2025 MAR revealed the resident exceeded his/her ordered fluid intake specific to nursing administration, on the following dates:-9/13/2025, 1400 ml-9/14/2025, 1210 ml-9/15/2025, 1010 ml2. Record review revealed Resident ID #3 was readmitted to the facility in August of 2021 with a diagnosis including, but not limited to, CKD. Additionally, the resident receives dialysis three times a week.Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact.Record review revealed the following physician's orders:-8/13/2025, Sevelamer Carbonate 1600 mg by mouth three times a day before meals. -1000 ml fluid restriction per day; 720 ml from dietary and 280 ml from nursing. Review of the August 2025 MAR from 8/13/2025 through 8/31/2025 and the September 2025 MAR revealed the administration times for Sevelamer are scheduled for 7:00 AM, 11:30 AM and 4:30 PM. Further review of the MAR revealed documentation of a code 3, indicating the resident was not administered his/her Sevelamer on the following dates at 11:30 AM:-8/14/2025-8/16/2025-8/19/2025-8/21/2025-8/23/2025-8/26/2025-8/28/2025-9/2/2025-9/4/2025-9/6/2025-9/9/2025-9/11/2025-9/13/2025Record review of the September 2025 MAR revealed the resident exceeded his/her ordered fluid intake specific to nursing administration, on the following dates:-9/8/2025, 1090 ml-9/12/2025, 1040 ml-9/14/2025, 1510 mlDuring a surveyor interview on 9/17/2025 at 5:16 PM with Resident ID #3, s/he revealed that s/he is supposed to receive the Sevelamer before meals and that usually does not happen. The resident further revealed that s/he is good at following his/her fluid restriction. During surveyor interviews with the Director of Nursing Services on 9/17/2025 at 4:19 PM and at 5:30 PM, she was unable to provide evidence that Resident ID #s 1 and 3 received his/her Sevelamer, as ordered, or that the residents' fluid restrictions were followed, as ordered.

Based on record review and staff interview it has been determined that the facility failed to provide or obtain radiology services to meet the needs of its residents relative to obtaining a STAT (diagnostic or therapeutic procedure that is to be performed immediately) X-ray for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Record review of a facility reported incident dated 8/11/2025 revealed that Resident ID #1 sustained a fall on 8/9/2025 and was admitted to the hospital on [DATE] with a hip fracture.Record review revealed that the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, dementia, anxiety, unsteadiness on feet and lack of coordination.Record review of a progress note dated 8/9/2025 authored by the Doctor of Osteopathic Medicine (DO), Staff A, at 4:40 PM revealed that the resident sustained an unwitnessed fall. Additionally, it revealed that the resident complained of right groin pain and demonstrated a leg length discrepancy (right leg shorter than the left). The note further stated, High possibility of right hip fracture and revealed new orders to obtain a STAT right hip X-ray and to remain on bed rest pending results. Record review revealed an order was entered on 8/9/2025 at 4:49 PM for a STAT X-Ray of the resident's right hip.Record review of a nursing progress note dated 8/10/2025 at 6:39 AM revealed that the resident asked what they were going to do for his/her leg, and s/he was told by nursing staff that the facility was going to obtain an X-ray and that s/he was to stay in bed.Record review of a nursing progress note dated 8/10/2025 at 9:29 AM revealed that the contracted company used for X-rays was contacted regarding the STAT X-ray and was told that they would have a technician call the facility with an estimated time of arrival.Record review of a progress note dated 8/10/2025 authored by the Advanced Practice Registered Nurse (APRN), Staff B, at 12:34 PM revealed that they were contacted by nursing staff related to the resident experiencing an acute onset of malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify) and fever.Record review of a nursing progress note dated 8/10/2025 at 3:51 PM revealed that the resident had an elevated temperature, and his/her oxygen level was at 75% on room air (normal oxygen levels range from 95%-100%), the resident was placed on oxygen at 2 liters (L) and was given Tylenol which had no effect as the resident continued to have an elevated temperature after one hour. The note further revealed that the provider gave orders for a medical work-up that included lab work, a chest X-ray and a urine analysis.Additional review revealed that while attempting to wash the resident, [s/he] was screaming in pain and unable to roll over to place brief under. when rechecking [resident's] vitals low grad fever persist, and [resident] remained at 90% 3L Nasal Canula. On call provider called again to update on [resident's] status orders were given to send [resident] to Hospital.Review of an ED Provider Note dated 8/10/2025 states, .Per [his/her] nursing facility, [s/he] fell.around 4pm yesterday. This was an unwitnessed fall.was supposed to get an x-ray done of [his/her] right hip but the facility was unable to get this done. They also noted.a low-grade fever this morning.here for evaluation.walks with a walker at baseline and has not been ambulatory since the fall.does have significant hip pain in the setting of an acute hip fracture.During a surveyor interview on 8/13/2025 at approximately 10:40 AM with Licensed Practical Nurse, Staff C, she revealed that that a STAT X-ray should be performed within 4 hours of being ordered by the provider. She further revealed that if the X-ray is not performed in a few hours that the provider would be updated, and the resident could be sent to the hospital.During a surveyor interview on 8/13/2025 at 11:40 AM with the NP, Staff D, he revealed that he would expect the x-ray to be performed the same day if ordered STAT. Additionally, he would expect to be notified if the X-ray could not be performed and if there was a concern for injury the resident would be sent to the hospital for treatment.During a surveyor interview on 8/13/2025 at approximately 11:25 AM with the Director of Nursing Services, she was unable to provide evidence that the facility obtained radiology services to meet the needs of Resident ID #1. Additionally, she acknowledged that the staff did not notify the provider of the delay in obtaining the STAT X-ray on 8/9/2025 resulting in the residents prolonged pain and requiring hospitalization on 8/10/2025. She further revealed that timeliness of X-rays and services has been an ongoing problem with the current contracted company.

Based on surveyor observation, record review, resident 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 for the use of methadone (a medication prescribed to reduce cravings and withdrawals from opiates and to treat chronic and severe pain), Resident ID #330. Findings are as follows: Record review of an untitled facility medication reconciliation policy last revised August 2022, states in part, .This facility reconciles medication frequently throughout a resident's stay to ensure the resident is free of significant medication errors .medication reconciliation refers to the process of verifying the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident .medication reconciliation involves collaboration with the resident/representative and multiple disciplines .admission process .Compare orders to the hospital record, etc. Obtain clarification orders as needed . Review of the [NAME] Drug Guide for Nurses last revised January 2021, states in part, .methadone .the duration of methadone withdrawal varies from person to person but may last anywhere from two to three weeks to up to six months .initial withdrawal symptoms are usually mild and may include anxiety, restlessness, a runny nose, sweating, tiredness, and watery eyes .other withdrawal symptoms such as muscle cramps .diarrhea and depression are likely to be at their worst over the first week . During surveyor observations and simultaneous interviews with the resident on 6/24/2025 at 9:45 AM and 6/26/2025 at 10:23 AM, s/he was observed sitting in a chair in his/her room holding his/her back. The resident indicated that his/her pain medication was abruptly changed by NP, Staff H and that s/he was experiencing withdrawal symptoms and increased pain which s/he felt was abusive and harmful. When asked what symptoms s/he was experiencing, s/he indicated that s/he experiencing withdrawal symptoms that included increased body aches, depression, diarrhea, abdominal pains, and sweating. Record review revealed Resident ID #330 was admitted to the facility on [DATE] with diagnoses including, but not limited to, osteomyelitis of vertebra (an infection and inflammation of the bone and bone marrow that affects the spine), opiate dependence, anxiety, and depression. Record review of a Brief Interview of Mental Status assessment dated [DATE], revealed a score of 13 out of 15, indicating intact cognition. Record review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 6/18/2025 revealed that the resident presented to the hospital with low back pain and was found to have recurrent osteomyelitis. Additionally, s/he was to continue on oxycodone (an opioid medication prescribed to treat moderate to severe pain), 10 milligrams (mg) every six hours as needed for severe pain, and a daily dose of Methadone 105 mg upon discharge from the hospital. -6/19/2025 documented as a late entry and authored by NP, Staff I, states in part, The patient had requested to speak with the provider discussed pain management .confirmed with the patient that .was discharged to the facility to be given oxycodone every 6 hours PRN .became notably upset, started crying; stated I cannot function because of the pain' .provider compromised with patient to give oxycodone every 4 hours as needed for short term basis .there were some questions regarding the actual dose and they were reaching out to the pain clinic to confirm the dose .patient will continue on ordered dose for now we will continue to monitor for acute changes/signs and symptoms of withdrawal at the facility .continue methadone 52 MG given by mouth every 12 hours . Additional record review failed to reveal evidence that the order for methadone 52 mg every 12 hours was transcribed on 6/19/2025 as ordered. Record review revealed the methadone order was transcribed to administer 52 mg by mouth one time a day in error, rather than every 12-hours as ordered by the provider. Further record review failed to reveal evidence that the resident was being monitored for withdrawal symptoms. Review of the June 2025 Medication Administration Record (MAR) revealed the resident did not receive 52 mg of methadone every 12 hours as ordered on the following dates: 6/19/2025 6/20/2025 Record review revealed a physician's order with a start date of 6/19/2025 for oxycodone 10 milligrams every four hours as needed. Additional review of the June 2025 MAR revealed the resident received the oxycodone 10 mg for pain on the following dates and times: -6/19/2025 at 8:16 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 12:16 AM, Pain documented as 10 out of 10, indicating severe pain. -6/20/2025 at 6:00 AM, Pain documented as 10 out of 10, indicating severe pain. -6/20/2025 at 12:24 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 5:30 PM, Pain documented as 7 out of 10,indicating severe pain. -6/20/2025 at 9:40 PM, Pain documented as 7 out of 10, indicating severe pain. -6/21/2025 at 2:27 AM, Pain documented as 7 out of 10, indicating severe pain. Review of a progress note dated 6/20/2025 revealed that the resident was seen by NP, Staff H, and an order was provided to increase the resident's dose of methadone to 105 mg daily, which reflects the intended dose upon the resident's admission. During a surveyor interview 6/25/2025 12:02 PM with NP, Staff I, she revealed that on 6/19/2025 she gave a verbal order for methadone 52 mg every 12 hours and it was her expectation that the resident was to receive the methadone as ordered. Further, she indicated she would have expected the facility to monitor the resident for signs and symptoms of withdrawal symptoms. During surveyor interviews on 6/25/2025 at 12:15 PM and 6/26/2025 at approximately 4:00 PM, with the Director of Nursing Services, she indicated it would be her expectation that the resident would have received methadone 52 mg twice daily as ordered by NP, Staff I. Additionally, she was unable to provide evidence that the resident was kept free from significant medication errors. Cross reference F697 and F835.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1. Record review of Rhode Island Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or below for a maximum of 7 days. The day of preparation shall be counted as Day 1 . During the initial tour of the kitchen on 6/23/2025 at approximately 8:20 AM in the presence of the Food Service Director (FSD), the following was observed without a label or a date: In the walk-in refrigerator: - one 3 pounds (lbs.) bag containing potatoes. - seven individually wrapped round packages containing sliced deli turkey meat, approximately 1 lb. each. In the walk- in freezer: -one bag containing approximately 12 frozen skinless, boneless chicken breasts. - one individually wrapped frozen vanilla [NAME] cake. - one clear plastic bag containing approximately 24 frozen raw cookie dough pieces. - a clear bag containing four individual frozen pie crusts. - one tray of 24 frozen biscuits. - one box of 60 frozen individual assorted chocolate candies. - two and a half cylindrical shaped packages, approximately 18 inches long and 3 inches in diameter containing an unidentified food product. In the main kitchen: - one 20-liter clear plastic container with a lid, containing approximately 5 liters of an unidentified white powder. During a surveyor interview with the FSD immediately following the above observations, he acknowledged that the items were not labeled or dated as required per the Food Code. 2. Record review of The Rhode Island Food Code 2022 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight . During a surveyor observation of the facility ice machine located in the main kitchen during the initial tour on 6/23/2025 at approximately 8:50 AM, revealed black matter approximately 3 inches long on the white shield located on the inside of the machine where the ice is dispensed. During a surveyor interview with the FSD immediately following the above observations, he acknowledged the presence of the black matter inside of the ice machine.

Based on staff interview and record review, it has been determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. Findings are as follows: During the resident council meeting on 6/25/2025 at 10:00 AM, the residents reported the following: - Resident ID #117 complained that someone told him/her that there were cockroaches and ants in his/her room. - Resident ID #s 38 and 95 have seen ants eat their leftover food in their rooms. The following observations were made after the resident council meeting: - 6/25/2025 at 11:03 AM, ants were observed to be present in the rear stairwell. - 6/25/2025 at approximately 12:00 PM and 2:00 PM, ants were observed in the second-floor dining room. - 6/26/2025 at approximately 8:00 AM and 2:00 PM, ants were observed in the second-floor dining room. During a surveyor interview on 6/26/2025 at 2:49 PM with the covering Administrator, he revealed that the facility has not had pest control services since February of 2024. Additionally, he was unable to provide evidence that the facility is kept free of pests.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE), for 1 of 1 resident observed on neutropenic precautions (a set of measures taken to prevent infections for individuals with neutropenia, a condition where there is an abnormally low number of white blood cells, increasing the risk of infection), Resident ID #2, and for 1 of 1 resident reviewed who was readmitted to the facility with an order for Enhanced Barrier Precautions (EBP; infection control measures which require putting on a gown and gloves during high-contact resident care activities), Resident ID #43. Findings are as follows: 1. Review of a facility policy titled, Neutropenic Precautions states in part, .if an order is received to place a resident on neutropenic precautions, the nurse will clarify what restrictions are necessary .staff members will wear a mask with any direct contact with the resident .provide a supply of masks, gowns, gloves .needed to maintain isolation precautions . Record review revealed Resident ID #2 was admitted to the facility in February of 2023. Record review revealed a physician's order dated 3/29/2023 for Neutropenic Precautions every shift for neutropenia. During a surveyor interview on 6/23/2025 at 10:45 AM with Licensed Practical Nurse (LPN), Staff D, she indicated that she was unaware of the reason why Resident ID #2 was on neutropenic precautions. She further indicated that staff are expected to wear a mask, gown, and gloves upon entering the resident's room. During a surveyor observation on 6/23/2025 at 10:52 AM, Nursing Assistant (NA), Staff K, entered Resident ID #2's room. Staff K failed to perform hand hygiene or put on a gown or gloves. Additionally Staff K, wore her mask on her chin, leaving her nose and mouth exposed while assisting the resident in bed. During a surveyor interview on 6/23/2025 at 10:56 AM with Staff K, she acknowledged that she did not wear a gown or gloves and wore her mask below her nose and mouth while assisting Resident ID #2 in bed. She further indicated that the resident was not on any precautions, however, acknowledged that there was signage and a precautions bin outside of the resident's room. During a subsequent surveyor observation on 6/23/2025 at 11:09 AM following the above interview, Staff K re-entered the resident's room without performing hand hygiene, putting on a mask, gown or gloves, and leaned over the resident to talk to him/her and delivered a cup of ice. During a surveyor interview on 6/23/2025 at 11:25 AM with LPN, Staff D, she acknowledged that the resident is immunocompromised and that the neutropenic precautions are in place to protect the resident from infections. During a surveyor interview on 6/25/2025 at approximately 11:20 AM with the Infection Preventionist (IP) in the presence of the Director of Nursing Services (DNS), she indicated that she would expect all staff to wear a mask, gown, and gloves each time they enter Resident ID #2's room. 2. Review of a facility policy titled, .Policy for Enhanced Barrier Precautions states in part, .implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms [MDROs] .additional epidemiological important MDROs may include, but are not limited to .ESBL-producing Enterobacterales [a group of bacteria that commonly cause infections .are resistant to common antibiotics and may require complex treatments] .require the use of gown and gloves .during specific high-contact resident care activities in which there is an increased risk for transmission of [MDROs]. High-contact resident activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care . Record review revealed Resident ID #43 was readmitted to the facility in June of 2025 with diagnoses including, but not limited to, ESBL. Record review revealed a physician's order dated 3/2/2025 for EBP every shift related to a history of ESBL. During surveyor observations on 6/24/2025 at 9:13 AM and at 12:27 PM, of the resident's room failed to reveal a precautions sign or a precautions bin containing personal protective equipment (PPE). During a surveyor observation on 6/24/2025 at 12:28 PM, NA, Staff M, was observed assisting Resident ID #43 in the shower wearing only gloves. During an additional surveyor observation on 6/24/2025 at 12:51 PM, Staff M was observed getting a brief out of the resident's drawer and then grabbing dirty linens off of the resident's bed without wearing a gown or gloves. The dirty linens were observed to be touching Staff M's body as she picked them up and carried them across the room to put them into a bag. During a surveyor interview on 6/24/2025 at 12:52 PM with Staff M, she indicated that she was unaware that the resident was on any precautions. During a surveyor interview on 6/24/2025 at 1:00 PM with LPN, Staff D, she acknowledged that the resident had an active order for EBP related to a history of ESBL. She further acknowledged that the resident did not have a precautions sign or bin outside of his/her room. Additionally, she indicated that she would expect staff to wear a gown and gloves when performing high contact activities such as assisting the resident with a shower or when touching dirty linens. During a surveyor interview on 6/25/2025 at approximately 11:30 AM with the IP, in the presence of the DNS, she acknowledged that Resident ID #43 has an active order for EBP and that she would expect a precaution sign and bin to be placed by the resident's door. She further indicated that she would expect staff to utilize PPE as required.

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for the exhaust hood in the main kitchen. Findings are as follows: NFPA (National Fire Protection Association) 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition section 11.2 states in part, .11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person (s) acceptable to the authority having jurisdiction at least every 6 months . During a surveyor observation of the main kitchen on 6/23/2025 at 8:20 AM revealed that the exhaust hood over the stove was last cleaned on 6/26/2024. The next required semiannual cleaning would have been due on 12/26/2024, which indicates the cleaning was past due by more than 5 months. During a surveyor interview with the Food Service Director following the above observation, he acknowledged that the exhaust hood failed to receive cleaning at least every 6 months, as required.

Based on surveyor observation and staff interview, it has been determined that the facility failed to have handrails securely affixed to the walls on 3 of 4 units in the facility. Findings are as follows: Surveyor observations on 6/23/2025 revealed the following handrails were not securely affixed to the wall: 1. [NAME] Unit - The handrail between rooms A7 and A9 was falling off the wall, with the screws exposed. - The handrail on right side of the door of room A9 was loose. Resident ID #12 was observed utilizing the handrails in the hallway while self-propelling in a wheelchair to get to his/her room. During a surveyor interview on 6/23/2025 at 2:58 PM with Nursing Assistant, Staff C, she acknowledged that the above-mentioned handrails were loose and not securely affixed to the wall. During a surveyor interview on 6/23/2025 at 3:01 PM with Licensed Practical Nurse (LPN), Staff D, she revealed that she was aware of the broken handrail between rooms A7 and A9, and has notified the maintenance department about it. Additionally, she indicated that repair requests are documented in the maintenance log. Staff D was unable to provide evidence that she had submitted a request for the repair of the hand rail to the maintenance department. Review of the maintenance log, failed to review evidence that a repair request had been submitted. 2. [NAME] Unit - The handrail between rooms B6 and B8 was loose. - The handrail between rooms B10 and B12 was loose. During a surveyor interview on 6/23/2025 at approximately 3:00 PM, LPN, Staff O, she acknowledged that the above-mentioned handrails were loose and indicated they should be secured. 3. Cortland Unit - The handrails outside rooms C18, C20, and C22 were loose. During a surveyor observation and interview on 6/23/2025 at 2:53 PM with the Maintenance Director, he acknowledged that the above-mentioned handrails were loose and needed to be fixed right now. During a surveyor interview on 6/24/2025 at 12:17 PM with the Director of Nursing Services, she revealed that she was aware that the above-mentioned handrails in the facility were broken and loose, and that she would follow up with the Maintenance Director to complete an audit to ensure that all of them are fixed and secured.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for 3 of 4 shower rooms observed relative to safety rails (rails that provide a sturdy handhold to help users maintain balance and avoid slips and falls, especially on wet or slippery surfaces). Findings are as follows: 1a. During a surveyor interview on 6/24/2025 at approximately 1:15 PM with Resident ID #71, s/he stated that the shower rails are loose and when s/he went to stand in the shower the other day, the safety rail gave out. Record review revealed Resident ID #71 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, lack of coordination and unsteadiness on feet. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of the task documentation revealed that the resident is frequently independent with showers. During a simultaneous surveyor observation of the [NAME] Unit shower room and interview with Nursing Assistant (NA), Staff A, on 6/24/2025 at 1:27 PM, he acknowledged that two of the three shower stalls had safety rails that were detached from the shower walls. He indicated that he had been aware of the unstable shower safety rails since he started working on that unit, approximately one month ago. During a subsequent surveyor observation on 6/25/2025 at 3:23 PM, of the shower room on the [NAME] Unit, the safety rail to the right side of the toilet was observed to be loose. During a surveyor interview immediately following the above observation with NA, Staff B, she acknowledged that the safety rail to the right side of the toilet was loose. 1b. During a surveyor observation on 6/24/2025 at 1:22 PM of the shower room on the [NAME] Unit, two of the three shower stalls were observed to have loose safety rails, which were rusted. Additional observations revealed the safety rail to the left side of the toilet was loose. During a surveyor interview on 6/24/2025 at 1:26 PM with NA, Staff C, she indicated that all three of the shower stalls are utilized by the residents. Additionally, she acknowledged that two of the shower stalls had safety rails that were loose, as well as the safety rail near the toilet. During a surveyor interview on 6/24/2025 at 1:29 PM with Licensed Practical Nurse (LPN), Staff D, she indicated that at least one resident on the unit prefers to stand in the shower and may use the loose bars. Additionally, she indicated that she was unaware of the unstable safety rails in the shower room. 1c. During a surveyor observation on 6/24/2025 at approx. 2:35 PM, of the shower room on the Cortland Unit, two of three shower stalls were observed to have loose safety rails, which were rusted, one of which was completely detached from the wall. During a surveyor interview on 6/24/2025 at 2:40 PM with NA, Staff E, she indicated that two of the three shower stalls had loose safety rails. She further indicated that at least two residents on the unit prefer to stand in the shower. During a surveyor interview on 6/24/2025 at 2:48 PM with Registered Nurse, Staff F, she acknowledged that the safety rails are loose in two of the shower stalls and one is detached in the middle shower stall. Additionally, she acknowledged that some residents prefer to stand while utilizing those showers. During a surveyor interview on 6/25/2025 at 3:32 PM, with Maintenance Staff, Staff G, he acknowledged the loose and detached safety rails in the shower rooms on the [NAME], [NAME], and Cortland Units. Additionally, he indicated that he was unaware of the loose and detached rails, and would have expected staff to notify maintenance of anything in disrepair within the facility.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that adequate pain management was provided to a resident who required such services, for 1 of 1 resident reviewed for pain, Resident ID #330. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 6/25/2025 indicates the resident reported to the state surveyor s/he was abused by the Nurse Practitioner (NP), Staff H, related to changes in his/her medications. Record review of an untitled facility policy relative to medication reconciliation, last revised in August of 2022, states in part, .This facility reconciles medication frequently throughout a resident's stay to ensure the resident is free of significant medication errors .medication reconciliation refers to the process of verifying the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident .medication reconciliation involves collaboration with the resident/representative and multiple disciplines .admission process .Compare orders to the hospital record, etc. Obtain clarification orders as needed . Review of the [NAME] Drug Guide for Nurses last revised January 2021 states in part, .methadone .the duration of methadone withdrawal varies from person to person but may last anywhere from two to three weeks to up to six months .initial withdrawal symptoms are usually mild and may include anxiety, restlessness, a runny nose, sweating, tiredness, and watery eyes .other withdrawal symptoms such as muscle cramps .diarrhea and depression are likely to be at their worst over the first week . Record review revealed Resident ID #330 was admitted to the facility on [DATE] with diagnoses including, but not limited to, osteomyelitis of the vertebra (an infection and inflammation of the bone and bone marrow that affects the spine), opiate dependence, anxiety, and depression. Record review of a Brief Interview of Mental Status assessment dated [DATE], revealed a score of 13 out of 15, indicating intact cognition. During surveyor observations and simultaneous interviews with the resident on 6/24/2025 at 9:45 AM and 6/26/2025 at 10:23 AM, s/he was observed sitting in a chair in his/her room holding his/her back. The resident indicated that his/her pain medication was abruptly changed by NP, Staff H and that s/he was experiencing withdrawal symptoms and increased pain which s/he felt was abusive and harmful. When asked what symptoms were experienced, s/he indicated she was experiencing withdrawal symptoms that included increased body aches, depression, diarrhea, abdominal pains, and sweating. Review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 6/18/2025 revealed that the resident presented to the hospital with low back pain and was found to have recurrent osteomyelitis. Additionally, s/he was to continue oxycodone (an opioid medication prescribed to treat moderate to severe pain) (10 milligrams [mg]) one tablet every six hours as needed for severe pain, and a daily dose of Methadone 105 mg upon discharge from the hospital. Record review of a progress note dated 6/19/2025 documented as a late entry and authored by NP, Staff I, states in part, The patient had requested to speak with the provider discussed pain management .confirmed with the patient that .was discharged to the facility to be given oxycodone every 6 hours PRN .became notably upset, started crying; stated 'I cannot function because of the pain' .provider compromised with patient to give oxycodone every 4 hours as needed for short term basis .there were some questions regarding the actual dose and they were reaching out to the pain clinic to confirm the dose .patient will continue on ordered dose for now we will continue to monitor for acute changes/signs and symptoms of withdrawal at the facility .continue methadone 52 MG given by mouth every 12 hours. Record review revealed a physician's order dated 6/18/2025 for Methadone 52 mg by mouth one time a day. Indicating the order was not transcribed to be administered every 12 hours as intended by the provider. Additional record review failed to reveal evidence that the resident was being monitored for withdrawal symptoms. Review of the June 2025 Medication Administration Record (MAR) revealed the resident received 52 mg of methadone once daily on the following dates and times: 6/19/2025 at 8:00 AM 6/20/2025 at 8:00 AM Record review revealed a physician's order with a start date of 6/19/2025 for oxycodone 10 mg one tablet every four hours as needed Additional review of the June 2025 MAR revealed the resident received the oxycodone 10 mg for pain on the following dates and times: -6/19/2025 at 8:16 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 12:16 AM, Pain documented as 10 out of 10, indicating severe pain. -6/20/2025 at 6:00 AM, Pain documented as 10 out of 10, indicating severe pain. -6/20/2025 at 12:24 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 5:30 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 9:40 PM, Pain documented as 7 out of 10, indicating severe pain. -6/21/2025 at 2:27 AM, Pain documented as 7 out of 10, indicating severe pain. Review of a progress note dated 6/20/2025 revealed that the resident was seen by NP, Staff H, and an order was provided to increase the resident's dose of methadone to 105 mg daily, which reflects the intended dose upon the resident's admission. Additional review of the June 2025 Medication Administration Record (MAR) revealed the resident received an as needed dose of methadone 52 mg on 6/21/2025. Further review failed to reveal evidence that the order for the resident to receive 105 mg daily was transcribed into his/her record. Lastly an order for the resident to receive 52 mg of methadone every 12 hours was entered into their MAR on 6/22/2025 at 8:00 AM. During a surveyor interview 6/25/2025 12:02 PM with NP, Staff I, she revealed that on 6/19/2025 she gave a verbal order for methadone 52 mg every 12 hours and it was her expectation that the resident was to receive the methadone as ordered. Further, she indicated she would have expected the facility to monitor the resident for signs and symptoms of withdrawal symptoms. During surveyor interviews on 6/25/2025 at 12:15 PM and on 6/26/2025 at approximately 4:00 PM, with the Director of Nursing Services, she indicated it would be her expectation that the resident would have received methadone 52 mg twice daily as ordered. Additionally she was unable to provide evidence that the facility managed Resident ID #330's pain adequately. Cross reference F760 and F835.

Based on record review and staff interview, it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to 1 of 1 resident reviewed with an order for methadone (a medication prescribed to reduce cravings and withdrawals from opiates and to treat chronic and severe pain), Resident ID #330. Findings are as follows: Record review of an untitled facility policy relative to medication reconciliation, last revised in August of 2022 states in part, .This facility reconciles medication .to ensure that the resident is free of any significant medication errors .'Medication reconciliation' refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident .Medication reconciliation involves . multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff .Pre-admission Process .obtain current medication list from referral source .obtain current medication/admission orders .forward to nursing unit accepting the resident .admission Process .Compare orders to hospital records .Obtain clarification orders as needed .Transcribe orders in accordance with procedures for admission orders .have a second nurse review transcribed orders for accuracy .order medications from pharmacy in accordance with facility policy for ordering medications .Verify medications received match the medication orders . Review of the facility's Memorandum of Agreement with Codac (an outpatient supplier who provides methadone for residents residing in this facility), states in part, .Duties and Responsibilities .Ensuring that referrals made, one to the other, are appropriate, and supported by an accurate summary of .recommendations .Once the patient has arrived at the Offsite facility, the Offsite facility will fax Referral/Discharge form . Review of the [NAME] Drug Guide for Nurses last revised January 2021, states in part, .methadone .the duration of methadone withdrawal varies from person to person but may last anywhere from two to three weeks to up to six months .initial withdrawal symptoms are usually mild and may include anxiety, restlessness, a runny nose, sweating, tiredness, and watery eyes .other withdrawal symptoms such as muscle cramps .diarrhea and depression are likely to be at their worst over the first week . Record review revealed Resident ID #330 was admitted to the facility in June of 2025 with a diagnosis including, but not limited to, opioid use. Record review revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. During a surveyor interview on 6/24/2025 at 9:45 AM with Resident ID #330, s/he indicated that his/her pain medication was abruptly changed after their admission to the facility. The resident further indicated that s/he experienced symptoms of withdrawals due to this change and that s/he felt this was abusive and harmful. Record review of the Printable Discharge Form dated 6/18/2025 revealed communication between a hospital employee and the Admissions Coordinator, an unlicensed employee of the facility, at 9:57 AM, prior to Resident ID #330's admission. Further review of this document revealed the hospital employee wrote, .last methadone today at 8:54 am 52.5 mg [milligrams] . Record review of a form completed by the Admissions Coordinator dated 6/18/2025 revealed the .Amount of Last Methadone Dose was written is as 52.5 mg. Other Pertinent Information was left blank. The physician's order was not included on this communication form. Record review revealed this form was faxed to Codac on 6/18/2025 at 9:12 AM and at 9:16 AM. Record review of the hospital Continuity of Care form dated 6/18/2025, revealed the resident was ordered 105 mg of Methadone daily. Record review of the hospital discharge medication list dated 6/18/2025 revealed a physician's order for Methadone 105 mg daily. Record review of the June 2025 Medication Administration Record revealed that the resident received Methadone 52.5 mg once on 6/18 (in the hospital) and Methadone 52 mg on 6/19 and 6/20 in the facility, less than half of his/her prescribed dose. Record review of a facility document titled, Reconciliation of New admission Medication from Continuity of Care Form dated 6/18/2025 revealed two nurses signed that the medications had been reviewed with a physician. Further review revealed a handwritten note to Confirm Methadone Dosage. During a surveyor interview on 6/25/2025 at 12:02 PM with Nurse Practitioner, Staff I, she indicated that she was unaware that the resident was only receiving half of the ordered dose of Methadone. She further indicated that she ordered 52 mg twice daily and would have expected the resident to receive that dose. During a surveyor interview on 6/25/2025 at approximately 12:10 PM with the Admissions Coordinator, she indicated that she communicated with the care manager at the hospital via telephone and requested the resident's Methadone order. She further indicated that the hospital sent what she thought was the Methadone order electronically, which indicated the resident's last dose was 52.5 mg. Additionally, she indicated that she completed the form with the dose of 52.5 mg and sent it to Codac for the prescription to be filled. Furthermore, she indicated that she is not a licensed nursing professional and transcribed the resident's last dose of Methadone that had not been reconciled by a nurse or provider. During a surveyor interview on 6/25/2025 at 12:15 PM with the Director of Nursing Services, she acknowledged that the Admissions Coordinator, an unlicensed employee, transcribed what she thought to be, the resident's Methadone order on the form that was sent to Codac to be filled and delivered to the facility. Additionally, she acknowledged that this is the practice of the facility. Furthermore she acknowledged that the resident was not present in the facility prior to his/her prescription being sent to Codac to be filled, which does not align with the facility's Memorandum of Agreement with Codac. Lastly, she acknowledged that the Methadone prescription was not reconciled by a physician or a licensed nurse prior to being forwarded to Codac to be filled on 6/18/2025, per the facility's policy. The facility's failure to follow the Memorandum of Agreement with Codac and to have a licensed nurse and/or a provider reconcile the Methadone order prior to it being forwarded to Codac to be filled, resulted in the resident receiving half of their prescribed dose of Methadone. This failure caused the resident to experience withdrawal symptoms. Cross reference F697 and F760

Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure a resident received a therapeutic diet as ordered by the physician for 1 of 2 residents reviewed who had orders for a therapeutic diet, Resident ID #1. Findings are as follows: Resident ID #1 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, acute and chronic respiratory failure and diastolic heart failure (when the left ventricle of the heart becomes stiff and does not beat properly). Record review of a physician order with a start date of 3/26/2025 revealed a Low Sodium Diet (2-4 grams of Sodium) diet. During a surveyor observation of the resident on 4/2/2025 at approximately 12:30 PM, revealed that the lunch meal that was served to the resident contained a double portion of ham. Record review of the tray ticket that was on the resident's tray revealed the following in part: - Regular Texture, Low Sodium - Notes: Double Portions - No Ham During a surveyor interview on 4/2/2025 at approximately 2:00 PM with the Dietitian, Staff B, she acknowledged that the prescribed diet was not served to the served to the resident. She further revealed that s/he should have received baked chicken. B. Record review of a physician order dated 3/26/2025 revealed a 2000 milliliters (ml) daily fluid restriction, dietary to provide 830 ml of the 2000 ml fluid restriction. Record review of the tray ticket for 4/2/2025 revealed the following in part: Breakfast: 4 ounces (oz) of Milk 8 oz of Orange Juice Lunch: 8 oz of Cranberry Juice 8 oz of Ginger Ale Dinner 8 oz of Cranberry juice 8 oz of Ginger Ale This indicates that a total fluid amount provided to the resident by the dietary department was 1320 ml's, which exceeded the 830 ml's that is allotted to be provided by the dietary department in a 24 hour period. During a surveyor observation on 4/2/2025 at 12:30 PM of the resident's lunch tray, revealed the resident was provided with 8 ounces of gingerale, that was placed in a 16 ounces styrofoam container of ice, and 8 ounces of cranberry juice. During a surveyor interview with the resident immediately following the above mentioned observation, s/he revealed that s/he placed the gingerale that was on his/her lunch tray into the cup of ice. Additionally, s/he acknowledged that s/he was on a fluid restriction. During a surveyor interview on 4/2/2025 at 1:30 PM, with the Dietitian, Staff B, she indicated that the Dietary staff provide the beverages that are listed on the meal tickets. She acknowledged that beverages listed on Resident ID #1's meal ticket indicates that s/he exceeds his/her daily dietary fluid allotment, as she was receiving 1320 ml from dietary, and should only be receiving 830 ml.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality, relative to following a physician's order to obtain daily weights for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed a physician's order with a start date of 3/27/2025 for the resident to be weighed daily. Record review failed to reveal evidence of documented weights from 3/28/2025 through 4/1/2025. Additional, record review failed to reveal evidence that the physician was notified of the missed weights. During a surveyor interview on 4/2/2025 at approximately 11:30 AM, with the DNS she was unable to provide evidence that daily weights were obtained for Resident ID #1 from 3/28/2025 through 4/1/2025.

Based on surveyor observation, record review and staff interview it has been determined that the facility failed to ensure that residents receive adequate supervision for 1 of 1 resident reviewed who attempted suicide, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/9/2024 alleges that Resident ID #1 tried to commit suicide on 9/7/2024. S/he had a belt around his/her neck and the family was not informed. Review of a facility policy titled, Suicide Attempt or Threats last revised in November of 2019 states in part, In the event a resident/patient attempts or is threatening suicide: Take all allegations seriously. Ensure the resident's/patient's immediate safety. Place the resident on 1:1 [constant supervision]. The charge nurse will notify the supervisor and attending physician. The supervisor or charge nurse will notify nursing administration. A staff member will be assigned to stay with the resident/patient on a one-to-one basis until the resident/patient is seen by psychiatry or sent to the Emergency Department. The staff member must be in close proximity to the resident/patient. Do not leave the resident/patient alone . Record review revealed that the resident was originally admitted to the facility in June of 2024 with diagnoses including but not limited to; chronic post-traumatic stress disorder, vascular dementia with agitation, major depressive disorder, insomnia and depression. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15, indicating that s/he has moderate cognitive impairment. Review of a care plan dated 6/26/2024 revealed the resident has a history of major depression and post-traumatic stress disorder (PTSD). Interventions include but are not limited to, provide emotional support as needed, encourage verbalization, and psychiatric consult or follow up as needed. Review of a progress note dated 9/7/2024 at 7:39 AM states in part, resident had a sleepless night .Resident was found later with belt tied to [his/her] neck, it took three of us to take it from [him/her]. During a surveyor interview on 9/10/2024 at approximately 9:00 AM with the Day Nursing Supervisor, Staff A, she revealed that she was aware of the resident's suicide attempt that was made during the early morning hours of 9/7/2024. She revealed that the resident was on frequent checks on 9/7/2024, but not on one-to-one supervision. Record review failed to reveal evidence that Resident ID #1 was placed on one-to-one supervision per the facility's policy or frequent checks, as indicated by Staff A. During a surveyor interview on 9/10/2024 at 10:36 AM with the Night RN/Nursing Supervisor, Staff D, she revealed that the resident's room is directly across from the nurse's desk and that on the night of 9/6/2024 into 9/7/2024, the resident was awake, in and out of his/her room, and very restless. Staff D indicated that between 2:00 AM and 3:00 AM, the resident came out of his/her room with a belt wrapped around his/her neck. Staff D indicated that she immediately approached the resident and called out for help as she tried removing the belt from around the resident's neck. She revealed that it took three staff members to get the resident to release the belt from his/her neck. Additionally, she revealed that following the incident, she did not place the resident on one-to-one supervision and instead placed him/her on frequent safety checks. Record review failed to reveal evidence that Resident ID #1 was placed on one-to-one supervision per the facility's policy or frequent checks, as indicated by Staff D. During a surveyor interview on 9/10/2024 at approximately 9:15 AM with Nursing Assistant (NA), Staff B, she revealed that on 9/7/2024 between 2:00 AM and 3:00 AM, she heard the nurse calling out that Resident ID #1 had a belt around his/her neck and that help was needed. Staff B indicated that it took three staff members (including herself) to talk the resident into releasing the belt and handing it to them. Additionally, Staff B revealed that she took the belt and placed it back in the resident's drawer where other belts were located. Staff B indicated she kept the resident safe the remainder of the shift by checking his/her room for sharp objects like scissors and razors and that the resident was checked on a lot. Staff B indicated the resident was not provided with one-to-one supervision. Record review failed to reveal evidence that Resident ID #1 was placed on one-to-one supervision per the facility's policy or checked on a lot, as indicated by Staff B. During a surveyor interview with Licensed Practical Nurse, Staff C, on 9/10/2024 at 10:50 AM, she revealed that the resident attempted to hang him/herself on the 11:00 PM to 7:00 AM shift on 9/7/2024 and was placed on frequent checks but was not on one-to-one supervision. Record review failed to reveal evidence that Resident ID #1 was placed on one-to-one supervision per the facility's policy or was placed on frequent checks, as indicated by Staff C. Record review failed to reveal evidence that, per the facility policy, the resident was placed on one-to-one supervision, the charge notified the physician and/or nursing administration, a staff member was assigned to stay with the resident on a one-to-one basis until s/he was sent to the emergency room , and that the responsible party/family was notified. During a surveyor interview with the resident's family member on 9/11/2024 at approximately 9:30 AM she revealed that she arrived at the facility at approximately 12:30 PM on 9/7/2024 and that she observed the resident crossing the parking lot without his/her walker. The resident was alone without a staff member present and greeted her at the car. Additionally, she revealed the resident was wearing a belt after attempting to hang him/herself with a belt earlier that morning. During a surveyor interview on 9/11/2024 at approximately 1:00 PM with Staff E, Social Worker, she revealed that she saw the resident on 9/7/2024 when she arrived at work on 9/7/2024 between 10:00 -11:00 AM. Staff E revealed that the resident was outside and unattended by a staff member. She immediately went up to the resident's unit to notify the nurse, Staff C, who then sent a restorative aid outside to return the resident into the facility. Additionally, she indicated that she called the DON to report her findings of the resident being outside alone, indicating that the facility was not aware of the resident's whereabouts after s/he had attempted suicide earlier that day. A surveyor observation of the resident's room on 9/11/2024 at approximately 12:45 PM revealed the resident's drawers and closet contained several pairs of shorts/pants and jackets with removable string ties. The resident's call light was attached to the resident's bed side rail and a phone with a long phone cord was observed on the resident's bedside table. Review of the facility's surveillance footage of 9/7/2024, in the presence of the Administrator, DON, and Assistant Director of Nursing (ADON), revealed the following occurrences: - 2:48 AM to 2:57 AM- The resident was observed ambulating in and out his/her room multiple times. S/he was also observed to sit in a chair for a few moments but then would get up. - 2:58 AM- The resident came out of his/her room with a belt wrapped around his/her neck and proceeds to sit at a chair outside of his/her room which was visible from the nurse's station. Staff D approached the resident and attempts to remove the belt. - 2:59 AM- Two NAs arrived to help the nurse to remove the belt from the resident's neck. The NAs and Staff D were then observed walking the resident back into his/her room. - 3:00 AM to 7:00 AM- Revealed staff intermittently enter and exit the resident's room. - 10:40 AM- Revealed the resident exiting the facility unattended and is out of line of sight of facility staff. Indicating, s/he was not receiving any supervision at that time. - 11:15 AM - The Resident was observed walking back into the facility with the restorative aid. - 12:28 PM- The Resident was observed exiting the facility a second time unattended with his/her walker, crossing the parking lot and approached a parked car. Indicating, s/he was not receiving any supervision for a second time. Further review revealed, the resident and his/her family member, who was in the parked car, made their way to and sat at a picnic table until 1:44 PM. They were then observed entering the facility together. The resident was observed wearing a belt. - 2:20 PM- The Resident was observed being brought out of the facility to an ambulance. During a follow-up surveyor interview on 9/12/2024 at approximately 10:45 AM with Staff C, after the surveyor had viewed the surveillance footage, Staff C acknowledged that the first time the resident was observed outside at approximately 10:40 AM she realized the resident was missing from the unit and asked a restorative aid to search for him/her. She revealed that the second time the resident was observed outside at approximately 12:28 PM, she was not aware of his/her whereabouts, indicating that the resident was not receiving any type of supervision both times s/he was able to leave the unit s/he resided on and the facility. During a surveyor interview with the DON on 9/10/2024 at 9:45 AM she revealed that she was not made aware of the events that occurred with Resident ID #1 on 9/7/2024 until approximately 10:00-10:30 AM, 7 hours after the incident had occurred. She indicated that she directed the staff to perform frequent checks until they sent the resident out to the hospital for a psychiatric evaluation. Furthermore, she revealed that she was initially unaware of the facility's Suicide Attempt or Threats policy and was unaware of the unsafe items that remained in the resident's room, prior to him/her being sent out to the hospital. Additionally, the DON acknowledged that the facility failed to place the resident on one-to-one supervision or assigning a staff member to stay with him/her on a one-to-one basis until s/he was sent to the emergency room , following his/her suicide attempt. Furthermore, the DON revealed that there was no documentation available to demonstrate that the facility had placed the resident on frequent checks for his/her safety. The facility's failures to ensure the resident received adequate supervision following an elopement attempt is evidenced by: - the failure to follow their own Suicide Attempt or Threats policy and not placing the resident on one-to-one supervision or assigning a staff member to stay with the resident on a one-to-one basis until s/he was sent to the emergency room . - the failure to supervise the resident after s/he tried to hang him/herself, as s/he was left unsupervised in his/her room where multiple ligature risks were accessible to him/her. - the failure to monitor his/her whereabouts after making a suicide attempt, as s/he was observed being outside of the facility unsupervised twice that same day. These failures had the potential to place the resident at risk for more than minimal harm, death, or impairment. Cross reference F600

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to keep a resident free from neglect for 1 of 1 resident reviewed who attempted suicide, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/9/2024 alleges that Resident ID #1 tried to commit suicide on 9/7/2024. S/he had a belt around his/her neck and the family was not informed. Review of a facility policy titled, Suicide Attempt or Threats last revised in November of 2019 states in part, In the event a resident/patient attempts or is threatening suicide: Take all allegations seriously. Ensure the resident's/patient's immediate safety. Place the resident on 1:1 [constant supervision]. The charge nurse will notify the supervisor and attending physician. The supervisor or charge nurse will notify nursing administration. A staff member will be assigned to stay with the resident/patient on a one-to-one basis until the resident/patient is seen by psychiatry or sent to the Emergency Department. The staff member must be in close proximity to the resident/patient. Do not leave the resident/patient alone . Record review revealed that the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, vascular dementia (dementia caused by a series of strokes that restricts blood flow to the brain) with agitation, depression, insomnia, and chronic post-traumatic stress disorder (PTSD). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 12 out of 15 indicating, moderate cognitive impairment. Review of a progress note dated 9/7/2024 at 7:39 AM states in part, resident had a sleepless night .Resident was found later with belt tied to [his/her] neck, it took three of us to take it from [him/her]. During a surveyor interview on 9/10/2024 at approximately 9:00 AM with the Day Nursing Supervisor, Staff A, she revealed she was aware of the resident's suicide attempt that was made during the early morning hours of 9/7/2024. She revealed that the resident was on frequent checks on 9/7/2024, but not on one-to-one supervision. Additionally, she revealed that the resident's family member called the unit on 9/7/2024 at approximately 10:00 -10:30 AM, after the family member had spoken to the resident. The resident told the family member that s/he tried hanging him/herself overnight. The family member was questioning what the resident had just told them and called the facility to confirm. The family member spoke with Staff A, who confirmed what occurred overnight to the caller and told them that the facility wanted to send the resident out for a psychiatric evaluation. The caller then requested that the facility wait to send the resident out because they were on their way. Staff A further indicated that she checked the room for safety and when asked what the room check entailed, she revealed that she checked the room for sharp objects. During a surveyor interview on 9/10/2024 at 10:36 AM with the Night RN/Nursing Supervisor, Staff D, she revealed that the resident's room is directly across from the nurse's desk and that on the evening of 9/6/2024 into 9/7/2024, the resident was awake, in and out of his/her room, and very restless. Staff D indicated that between 2:00 AM and 3:00 AM, the resident came out of his/her room with a belt wrapped around his/her neck. Staff D indicated that she immediately approached the resident and called for help as she tried removing the belt from around the resident's neck. She revealed that it took three staff members to get the resident to release the belt from his/her neck. Additionally, she revealed that following the incident, the resident was placed on frequent safety checks and not on one-to-one supervision as stated in the facility's Suicide Attempts or Threats policy. Staff D indicated that she did not notify the resident's physician, the Director of Nursing (DON), or the resident's family. Furthermore, she acknowledged that she did not send the resident to the Emergency Department for a psychiatric evaluation following his/her suicide attempt. During a surveyor interview on 9/10/2024 at approximately 9:15 AM with Nursing Assistant (NA), Staff B, she revealed that on 9/7/2024 between 2:00 AM and 3:00 AM, she heard the nurse calling out that Resident ID #1 had a belt around his/her neck and that help was needed. Staff B indicated that it took three staff members (including herself) to talk the resident into releasing the belt and handing it to them. Additionally, Staff B revealed that she took the belt and placed it back in one of the resident's drawers where other belts were located. Staff B indicated she kept the resident safe the remainder of the shift by checking his/her room for sharp objects like scissors and razors and that the resident was checked on a lot. Staff B indicated the resident was not provided with one-to-one supervision. During a surveyor interview with Licensed Practical Nurse, Staff C, on 9/10/2024 at 10:50 AM, she revealed that the resident attempted to hang him/herself on the 11:00 PM to 7:00 AM shift on 9/7/2024 and was placed on frequent checks but was not on one-to-one supervision. Record review failed to reveal evidence that, per their facility policy, the resident was placed on one-to-one supervision, that the charge notified the physician and/or nursing administration, that a staff member was assigned to stay with the resident on a one-to-one basis until s/he was sent to the emergency room , and that the responsible party/family was notified. During a surveyor interview with the resident's family member on 9/11/2024 at approximately 9:30 AM, she revealed that she arrived at the facility at approximately 12:30 PM on 9/7/2024 and that she observed the resident crossing the parking lot without his/her walker. The resident was alone without a staff member present and greeted her at the car. Additionally, she revealed the resident was wearing a belt after having attempted to hang him/herself with a belt earlier that morning. During a surveyor interview on 9/11/2024 at approximately 1:00 PM with Staff E, Social Worker, she revealed that she saw the resident on 9/7/2024 when she arrived at work on 9/7/2024 between 10:00 -11:00 AM. Staff E revealed that the resident was outside alone, unattended by a staff member. She immediately went up to the resident's unit to notify the nurse, Staff C, who then sent a restorative aid outside to get him/her. Additionally, she indicated that she called the DON to report her findings of the resident being outside alone, indicating that the facility was not aware of the resident's whereabouts after s/he had attempted suicide earlier that morning. During a surveyor observation of the resident's room on 9/11/2024 at approximately 12:45 PM, the following was identified, resident's closet and dresser contained several pairs of shorts/pants and jackets with removable string ties. The resident's call light was attached to the resident's bed side rail and a phone with a long phone cord was observed on the resident's bedside table. Review of the facility's surveillance footage of 9/7/2024, in the presence of the Administrator, DON, and Assistant Director of Nursing (ADON), revealed the following occurrences: - 2:48 AM to 2:57 AM- The resident was observed ambulating in and out his/her room multiple times. S/he was also observed to sit in a chair for a few moments but then would get up. - 2:58 AM- The resident came out of his/her room with a belt wrapped around his/her neck and proceeds to sit in a chair outside of his/her room, visible from the nurse's station. Staff D approaches the resident and attempts to remove the belt. - 2:59 AM- Two NAs arrived to help the nurse remove the belt from the resident's neck. The NAs and Staff D were then observed walking the resident back into his/her room. - 3:00 AM to 7:00 AM- Revealed staff intermittently would enter and exit the resident's room. - 10:40 AM- Revealed the resident exiting the facility unattended and then goes out of view. - 11:15 AM - The Resident was observed walking back into the facility with the restorative aid. - 12:28 PM- The Resident was observed exiting the facility a second time unattended with his/her walker, crossing the parking lot and approached a parked car. The resident and his/her family member, who was in the parked car, then made their way to and sat at a picnic table until 1:44 PM. They were then observed entering the facility together. The resident was observed wearing a belt. - 2:20 PM- The Resident was observed being brought out of the facility to an ambulance. During a follow-up surveyor interview on 9/12/2024 at approximately 10:45 AM with Staff C, after the surveyor had viewed the surveillance footage, she acknowledged that the first time the resident was observed outside at approximately 10:40 AM, she realized the resident was missing and asked a restorative aid to search for him/her. She revealed that the second time the resident was observed outside at approximately 12:28 PM, she was not aware of his/her whereabouts. During a surveyor interview with the DON on 9/10/2024 at 9:45 AM, she revealed that she was not made aware of the events that occurred with Resident ID #1 on 9/7/2024 until approximately 10:00-10:30 AM, 7 hours after the incident had occurred. She indicated that she directed the staff to perform frequent checks until they sent the resident out to the hospital for a psychiatric evaluation. Furthermore, she revealed that she was initially unaware of the facility's Suicide Attempt or Threats policy and unaware of the unsafe items that remained in the resident's room, prior to him/her being sent to the hospital. Additionally, the DON acknowledged that the facility failed to place the resident on one-to-one supervision, notify the physician and/or nursing administration, assign a staff member to stay with the resident on a one-to-one basis until s/he was sent to the emergency room , and notify the responsible party/family of the incident. The facility failed to keep the resident free from neglect as evidenced by: - the failure to follow their own Suicide Attempt or Threats policy by not placing the resident on one-to-one supervision until s/he was sent to the hospital, notifying the physician and/or nursing administration, and notifying the responsible party/family of the incident. - the failure of staff members caring for the resident to identify that the cords, belts and ties in the resident's room were potential hazards and were left accessible to a resident who had just had a belt around his/her neck. - the failure to monitor the resident's whereabouts after making a suicide attempt, as s/he was observed outside of the facility unsupervised twice on the same day of the incident. These failures had the potential to place the resident at risk for more than minimal harm, death, or impairment. Cross reference F689

Based on record review and staff interview it has been determined that the facility failed to ensure a resident receives adequate supervision to prevent accidents for 1 of 4 residents reviewed who successfully eloped from the facility and for whom interventions and assessments were not implemented, Resident ID #4. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/18/2024 alleges that Resident ID #4 had eloped from the facility successfully twice. Review of the facility policy titled Elopement states in part, .Elopement is defined as the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way . - The licensed nurse will conduct an elopement screen on admission, re-admission, annually, upon change of condition. Residents identified at risk for elopement will have their photo maintained in a confidential manner at the main entrance to the facility. - A care plan will be developed and implemented for any resident at risk of elopement . Review of a facility policy titled Discharge Against Medical Advice (AMA) states in part, .Procedure (MA/RI) . - An order for AMA will be written. - Documentation will be made in the clinical record with details of the discharge to include persons notified, statement of reason for discharge, if known, the date and time of discharge. - The resident/patient and or legal representative will sign the AMA form and it will be placed in the clinical record. - Appropriate agencies will be notified by the Social Worker or member of center to provide additional services to the resident, if necessary, in the community . Record review revealed the resident was admitted to the facility in September 2023 with diagnoses including, but not limited to, schizoaffective disorder, adjustment disorder, traumatic brain injury, developmental delay, mild intellectual disability, and type 2 diabetes mellitus. Record review of a document titled Psychiatric Evaluation and Consult dated 2/1/2024, revealed the resident has, .schizoaffective disorder, bipolar type .[S/he] demonstrated AVH [auditory verbal hallucinations] and paranoia at today's visit but did not appear as agitated as last visit. I will continue to monitor. Mild-intellectual disability may complicate medication teaching . 1a. Record review of a progress notes revealed on 2/2/2024, the resident went to a behavioral health appointment in the community. Additional review of this progress note revealed that s/he was accompanied by facility staff, Nursing Assistant (NA), Staff A, and that the resident ran out of the provider's office. Staff A and the staff at the provider's office pursued the resident but were unable to reach him/her as s/he fled the building. The note further revealed that the facility assumed the resident left AMA, the resident's family was contacted and it was indicated that if the resident were to be found, s/he would need to go to the Emergency Department to be medically cleared before s/he could return to the facility, as the resident has a history of substance abuse. Review of a statement authored by Staff A on 2/2/2024 states, I went in to the appointment with the resident, while we were in the waiting room, [s/he] started to get aggravated saying [s/he] 'was going to leave and if the cops came looking for [him/her], [s/he] would kick their a**,' [s/he] was pacing back and forth. The doctor came and took us into her office, the resident wasn't answering her questions she was asking [him/her]. [S/he] just kept saying 'I don't want to talk about it' She was trying to find out what was bothering [him/her], then [s/he] stood up and took off out the door. The doctor followed [him/her] trying to redirect [him/her], but [s/he] had left the building. Cops were called and I gave my description of [him/her]. During a surveyor interview with Staff A on 4/19/2024 at 10:50 AM, she indicated that she usually accompanies residents that are not alert and oriented to their appointments. Additionally she indicated that she was asked to accompany Resident ID #4 to his/her behavioral health appointment in the community on the morning of 2/2/2024. She further revealed that the doctor's office called the local police department to locate the resident as they were unable to find him/her after s/he ran off. During a surveyor interview with Registered Nurse (RN), Staff B, on 4/19/2024 at approximately 2:15 PM, she revealed that on 2/2/2024 at approximately 4:00 PM, she was looking out the window and happened to see the resident outside of the facility with Emergency Medical Services (EMS). Staff B indicated that this was the first time that the resident was seen at the facility after running out of the doctor's office that morning. Staff B acknowledged it was unclear how the resident made it back to the facility. EMS informed her that the resident had called 911, and they were taking him/her to the hospital. She further revealed that the resident informed her that s/he was made aware by his/her sister, that in order for him/her to be able to return to the facility, s/he needed to go to the hospital for medical clearance first. Record review of a document titled RI EMS Patient Care Report dated 2/2/2024 at 4:03 PM indicated the resident was agitated standing outside the nursing home. A nurse reported the resident is eloping from nursing home. The resident is at the nursing home due to his/her inability to self-medicate properly, and that s/he has a history of schizoaffective disorder, traumatic brain injury, bipolar disorder, and diabetes. Record review of a document titled Continuity of Care Consultation and Referral Form dated 2/2/2024, revealed the resident eloped from [provider's office] after refusing to participate in [his/her] appointment with psychiatrist. The local Police have been informed and will attempt to locate the client and bring [him/her] to the ED [Emergency Department] for further evaluation. During a surveyor interview with the Director of Nursing Services (DNS), in the presence of Staff B, on 4/19/2024 at approximately 2:20 PM, she unable to explain how the resident returned to the facility on [DATE], s/he fled from the provider's office, approximately 6.7 miles away from the facility. Additionally, she was unable to explain where the resident had been for approximately 6 hours from the time after s/he fled from the provider's office unsupervised and presented him/herself back to the facility. During a surveyor interview with Staff A on 4/22/2024 at 11:30 AM, she revealed she was unaware if the resident had a cell phone or wallet on him/her at the time s/he fled from the provider's office on 2/2/2024. During a surveyor interview with the Regional Director of Nursing (RDNS), on 4/19/2024 at approximately 11:10 AM, in the presence of the DNS, she revealed that on 2/2/2024, the resident left the provider's office of his/her own will and that s/he is alert and oriented, therefore it was her interpretation that the resident had left AMA from the facility and had not in fact eloped. Additionally, she was also unable to provide evidence of a completed AMA discharge from the facility nor was she able to provide evidence that an Elopement & Wandering Risk Assessment had been completed for the resident following the above-mentioned incident when s/he was left unsupervised in the community. Record review failed to reveal evidence that the facility analyzed the events of 2/2/2024 or discharged the resident AMA on 2/2/2024. As the resident's record did not contain an order for an AMA discharge, documentation was not found in the clinical record with details of such a discharge to include persons notified, statement of the reason for discharge was not documented, the date and time of discharge was not documented, the resident or his/her legal representative had not signed an AMA form, an AMA form was not found in his/her clinical record, appropriate agencies were not notified by the Social Worker or a member of the facility to provide additional services to the resident, per the facility's AMA policy. Record review of a document dated 3/18/2024, titled Elopement & Wandering revealed the resident was not at risk for elopement, despite the above-mentioned incident that took place on 2/2/2024 with police involvement. Record review of the resident's care plan failed to reveal evidence that s/he was assessed for elopement risks or that interventions were put in place as a result of the incident on 2/2/2024. 1b. Record review of a progress note dated 4/6/2024 revealed the resident had called 911 and walked by the nurse stating, I'm leaving and I'm not coming back. The nurse then watched the resident leave the premises and then the nurse informed her supervisor. Record review of a document titled Orchard View Manor Security Log dated 4/6/2024 through 4/7/2024, revealed that on 4/6/2024, at 7:50 PM, the resident walked out of the building and was heading towards [NAME] farms on Wampanoag Trail, a [nurse] and [security guard] tried to get [him/her] to come back but [s/he] refused. [Nurse] called the police and they took [him/her] to the hospital. Record review of a document titled, RI EMS Patient Care Report dated 4/6/2024 revealed an emergent call was received at 7:52 PM, for Psychiatric Problem/Suicide Attempt/Suicide threats with primary symptoms of altered mental status. The report revealed the resident was found standing with the local police, approximately 0.5 miles away from the facility and was transported to the hospital for further evaluation. The report further reveals the resident has a history of schizophrenia, and past medical history including, but not limited to, schizoaffective disorder, altered mental status, acute kidney failure, traumatic brain injury as well as alcohol abuse. Further review revealed s/he presented with a blood pressure of 161 systolic and 79 diastolic, (a normal range for an adult is 120-129 systolic and less than 80 diastolic) and s/he had with pulse rate of 124 beats per minutes (normal range is 60 to 100 beats per minute). The report also indicates that s/he was in distress and was noted to be verbally confused upon assessment. Further record review revealed an additional RI EMS Patient Care Report dated 4/6/2024 at 10:19 PM which revealed that EMS was dispatched to the hospital to transport the resident back to the facility as the resident required ambulance transportation for medical supervision for safety of self due to cognitive impairment after being brought to the hospital's emergency department for eloping from the facility with reported behavioral changes. The resident was secured to a stretcher with 5 safety belts in place. Record review failed to reveal evidence that the facility analyzed the events of 4/6/2024 or that the resident was assessed for elopement behaviors relative to this incident. During a surveyor interview with the DNS on 4/19/2024 at approximately 2:20 PM, she revealed she was not aware of the resident's successful elopement on 4/6/2024 until 4/8/2024. She revealed that the facility staff should have followed the facility's policy and should have conducted an elopement assessment. 1c. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/7/2024, revealed the resident had eloped from the facility following a verbal altercation with another resident which escalated to a physical incident. The police were notified, and the resident was transported to the hospital for further evaluation. Record review of the resident's progress notes revealed that on 4/7/2024 at 3:44 PM, the resident has had two incidents of elopements within 24 hr. The first one was on 4/6 with no known triggering factors. Second incident happened 4/7 after the resident got into a verbal altercation with another resident that turned physical . Record review of a document titled RI EMS Patient Care Report dated 4/7/2024 at 3:19 PM states in part, .were dispatched for a mental health evaluation .found patient in parking lot with police . Record review revealed that the resident had not returned to the facility as of 4/23/2024. Record review revealed that the resident's care plan was updated sometime on 4/7/2024 which indicates the .Resident is at risk to to try to leave nursing facility Attempting to leave the facility, Expressed desires to go home., Pacing, roaming 4/6 and 4/7 attempted to leave facility . With interventions that include, If resident is seen at an exit encourage to come with staff. During a surveyor interview with the resident's physician on 4/23/2024 at approximately 11:37 AM, he revealed that he was unable to recall if he was made aware of the incidents regarding Resident ID #4 on 2/2/2024 when s/he eloped from the behavioral health center and returned unsupervised to the facility several hours later. Additionally, he was unable to recall if he was made aware of the successful elopements from the facility on 4/6/2024 and 4/7/2024. He indicated that the Administrator informed him of these incidents the morning of 4/23/2024. He indicated it was his expectation that the facility would have conducted elopement behavior assessments. The facility's failure to follow their own policy relative to elopements and AMA discharges, to properly assess and identify the resident as an elopement risk and provide interventions for added safety measures for a resident who has diagnoses of schizoaffective disorder, adjustment disorder, traumatic brain injury, developmental delay, and a mild intellectual disability placed him/her at risk for serious injury, harm, impairment, or death.

Based on record review and staff interview if has been determined that the facility failed to promptly identify and intervene during an acute change in a resident's condition, related to a mental status change and a fall, for 1 of 1 resident reviewed for a change in condition, Resident ID #1. Findings are as follows: Review of a facility policy titled Condition: Significant Change states in part, .staff will communicate with the physician, resident/patient, and family regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management . Review of a facility policy titled, Hypoglycemia- Clinical Management Of states in part, Hypoglycemia is defined as finger stick or serum glucose less than 60 mg./dl [milligram per deciliter] .if symptoms of a low blood sugar (hypoglycemia) are present, immediate intervention is necessary . Symptoms of hypoglycemia include, but are not limited to, lethargy, confusion, and a change in mental status. Record review revealed Resident ID #1 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, diabetes mellitus type 2, heart failure, chronic obstructive pulmonary disease (COPD), and a history of falling. Record review failed to reveal a care plan in place to include instructions needed to provide effective and person-centered care. Record review of the admission progress note revealed the resident was alert and oriented times 4 (person, place, time, and situation), verbally responsive, and able to make needs known. Record review revealed on 2/6/2024 the resident fell while independently ambulating to the bathroom, resulting in a laceration to his/her head and significant bleeding from the wound. Further review revealed the resident was sent to the hospital for an evaluation following the fall; staples were placed to close the laceration to his/her head. Record review reveled the resident sustained a subsequent unwitnessed fall on 2/14/2024 at approximately 2:00 AM. Record review of a nursing progress note dated 2/14/2024 at 8:43 AM revealed the resident was found on the floor by his/her wheelchair and was alert and oriented times 2. Further review revealed the resident sustained an injury to his/her toe with minimal bleeding noted. The resident was transferred from the floor back to bed. Additional review failed to reveal that the resident's blood sugar was obtained at the time of the fall. Record review of a nursing progress note dated 2/14/2024 at 11:26 AM states in part, Resident is S/p [status post] fall from 2 AM 2/14/24, resident was noted to be lethargic, weak, unable to answer questions correctly, and appears confused, not responding to verbal stimuli, resident is alert and oriented at baseline .resident b/s [blood sugar] was noted to be 57 mg/dl .1 dose of glucagon [emergency medication to increase blood sugar] IM [intramuscularly] administered and b/s rechecked noted 88 mg/dl after 30 minutes, resident started being responsive to verbal stimuli but appears lethargic, fatigued and confused .DNS/MD [Director of Nursing Services/ Medical Doctor] made aware . Further review revealed the resident was sent to the hospital for an evaluation via 911. Record review of the hospital documentation dated 2/15/2024 revealed the resident's glucose on admission was 56, indicating s/he was hypoglycemic. During a surveyor interview on 2/15/2024 at 1:27 PM with Registered Nurse, Staff B, she revealed that she assessed the resident after she was alerted by a Nursing Assistant that the resident was found on the floor in his/her room. She further revealed that upon assessment the resident was able to recall his/her name and that s/he was at a facility however, s/he was unaware of the date and stated that s/he had been sitting there on the floor all day. Additionally, Staff B indicated that she was unaware of the resident's mental status change at that time and she didn't think to obtain his/her blood sugar. Furthermore, she revealed that she did not contact the physician at the time of the fall and indicated several hours later, after 7:00 AM, she left a message for the on call physician. During a surveyor interview on 2/15/2024 at 12:46 PM with Registered Nurse, Staff C, she indicated that she entered the resident's room at approximately 9:00 AM to obtain his/her scheduled vital signs and blood sugar, as ordered. She indicated that when she entered the resident's room, s/he was not responding. Staff C further indicated that the resident's blood sugar was 57 mg/dl at that time. Additionally, Staff C indicated that she administered glucagon IM, as ordered, for hypoglycemia and obtained an order from the physician to send the resident to the hospital for further evaluation. During a surveyor interview on 2/15/2024 at 12:23 PM with the DNS, she acknowledged that the resident had a change in condition at the time of the fall as evidenced by his/her mental status change and could not provide evidence that the resident's blood sugar was obtained at that time. Additionally, she indicated that she would expect a change in mental status to be identified and that the physician be notified timely.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to a nurse transcribing an order for NPO (nothing by mouth) without a physician's order and discontinuing a medication without physician authorization for 1 of 1 resident reviewed, Resident ID #99. Additionally, the facility failed to follow a physician's order for 1 of 3 residents reviewed for blood sugar monitoring, and for 1 of 2 residents observed for wound care, Resident ID #11. 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. 1. Record review revealed Resident ID #99 was admitted to the facility in May of 2023 with diagnoses of, but not limited to, malignant neoplasm of the brain (brain cancer) and mild protein calorie malnutrition. Record review revealed a physician order dated [DATE] states in part, Regular diet, Regular Consistency texture, Thin (Regular) Liquids consistency. Record review revealed a care plan dated [DATE] revealed the resident has no dietary restrictions. It further revealed that Staff will provide House regular diet .Staff will provide favorite foods and beverages on request as comfort measure. S/he eats a variety of foods, except fish & shellfish and cereal. S/he enjoys most other foods. [Resident ID #99] is open to suggestions for snacks and beverages between meals, and will request as desired. S/he enjoys most types of snacks . Record review revealed an order was transcribed on [DATE] which states, NPO entered by Licensed Practical Nurse (LPN), Staff D. Additional record review revealed the resident did not consume food or fluids for 6 days after the order for NPO was initiated. This order was entered into the medical record by Staff D without authorization by a physician. During a surveyor interview on [DATE] at 8:14 AM with Registered Nurse (RN), Staff B, she revealed that the resident was NPO because the resident was receiving hospice services. During a surveyor interview on [DATE] at 11:15 AM with Hospice RN, Staff C, she revealed that hospice would not have recommended a resident to be NPO. She further revealed that hospice would encourage a resident to eat. During a surveyor interview on [DATE] at 1:47 PM with the resident's physician, he revealed that he would not make a resident on hospice services NPO, and further revealed he would expect the staff to encourage a resident on hospice to eat and drink for comfort. Further record review revealed the resident had a physician's order for Dexamethasone (a medication to provide temporary symptomatic relief of symptoms related to increased pressure and edema secondary to brain cancer) twice a day. This order was also discontinued on [DATE] by Staff D without authorization by a physician. During a surveyor interview on [DATE] at 2:00 PM with Staff D, she acknowledged that she discontinued the Dexamethasone and entered the order for Resident ID #99 to be NPO. She revealed that she did not obtain a physician's order for NPO or to discontinue the Dexamethasone. During a subsequent surveyor interview on [DATE] at 8:38 AM with Staff B, she revealed that Resident ID #99 had expired on [DATE]. During a surveyor interview with the Director of Nursing Services (DNS) on [DATE] at 9:34 AM, she revealed that Staff D entered the order for Resident ID #99 to be NPO and discontinued the Dexamethasone without obtaining a physician's order. This failure resulted in Resident ID #99 not eating or drinking for 6 days leading up to his/her death. The system failures of the facility staff entering and following physician orders for its residents, without prior authorization from a physician, unequivocally placed Resident ID #99 at risk for serious harm, impairment or death as food, hydration and significant medications were withheld from him/her for the 6 days that led up to his/her death. 2a. Record review revealed Resident ID #11 was admitted to the facility in January of 2014 with a diagnosis including, but not limited to, type 1 diabetes mellitus. Record review revealed a physician order dated [DATE] which states in part, If blood sugar is over 400 administer standing order and sliding scale, recheck in 2 hours, if still over 400 call VA [Veteran Affairs] . Further record review revealed that the resident received scheduled insulin three times a day along with a sliding scale insulin based on the resident's blood sugar, if needed. Record review of the [DATE] Medication Administration Record revealed that the resident's blood sugar exceeded 400 on the following dates and times, which would require that staff recheck the resident's blood sugar in 2 hours as per the physician order: [DATE] - 11:30 AM, blood sugar 417 [DATE] - 11:30 AM, blood sugar 413 [DATE] - 11:30 AM, blood sugar 449 [DATE] - 11:30 AM, blood sugar 425 [DATE] - 07:30 AM, blood sugar 450 Record review failed to reveal evidence that the resident's blood sugar on the above dates and times were rechecked per the physician order. During a surveyor interview on [DATE] at 9:51 AM with the DNS, she acknowledged that the above mentioned blood sugar levels were above 400 and would expect the resident's blood sugar to be rechecked per the physician's order and documented in the medical record. 2b. Record review revealed Resident ID #11 was admitted to the facility in January of 2014 with a diagnosis including, but not limited to, type 1 diabetes mellitus. Record review of a facility policy titled Clean Dressing Technique states in part, .Check physicians order for current and correct treatment . Record review revealed the resident has a wound to the bottom of his/her foot (plantar aspect). Record review revealed the following physician orders relative to wound care: - [DATE]: Plantar wound - apply a saline soaked Hydrofera blue (improves growth or formation of wound while wicking drainage and debris from the wound bed) once every other day During a surveyor observation on [DATE] at 9:20 AM, of the resident's wound dressing change, performed by RN, Staff E, revealed the following: - The resident's existing plantar wound dressing was dated [DATE]. This treatment was documented as being completed on [DATE] per the [DATE] Treatment Administration Record (TAR). This indicates that the dressing was not changed on [DATE] as documented. - Staff E applied Iodosorb to the resident's plantar wound, which was not ordered. During a surveyor interview on [DATE] at 9:20 AM with Staff E, she acknowledged that she did not follow the physician order for the plantar wound dressing. Additionally, she acknowledged that the resident's existing plantar dressing was dated [DATE]. During a surveyor interview on [DATE] at 9:40 AM with the DNS, she acknowledged that Staff E did not follow the physician's order for the plantar wound dressing. Additionally, she was unable to explain why the existing plantar wound dressing was dated [DATE] when it was documented as being changed on [DATE] on the TAR. Refer to Tags:F 684, F 692, F 710. 47939

45263 46715 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative for 1 of 4 residents reviewed for hospice services, Resident ID #99. Additionally, the facility failed to follow physician's recommendations for 2 of 3 residents reviewed for wounds, Resident IDs #8 and 330, and not following the comprehensive care plan for 1 of 1 resident reviewed for the use of arm sleeves, Resident ID #82. Findings are as follows: 1a. Review of a facility policy titled, Comfort Measures dated [DATE] states in part, .The plan of care will include interventions developed to promote pain management and to address the actual and/or potential physical/emotional/spiritual comfort needs of the resident/patient. According to National Library of Medicine, Adult Dehydration, last updated 2022, indicated that dehydration may complicate other medical problems and may cause significant illness. A resident may appear with dark urine or decreased urine output and may be lethargic upon observation in severe cases of dehydration. Failure to treat dehydration in older adults may lead to significant mortality. The Centers for Disease Control and Prevention does not have defined water intake recommendations, however, adults are encouraged to maintain between 2,000 - 3,000 milliliters per day. Record review of Resident ID #99 revealed that s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, malignant neoplasm of the brain (brain cancer) and mild protein calorie malnutrition. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident requires limited assistance with meals of one staff member. Review of a care plan dated [DATE] states in part, .[resident] has no dietary restrictions . Record review revealed a Hospice Care Coordination Note dated [DATE] that revealed the resident is a 1 to 1 feed on a regular, thin liquid diet and ate 100% of breakfast and 75% of lunch. Additionally, it revealed that the resident intermittently refuses meals. Record review revealed an order was transcribed on [DATE] which states, NPO [nothing by mouth]entered by Licensed Practical Nurse (LPN), Staff D. Additional record review revealed the resident did not consume food or fluids for 6 days after the order for NPO was initiated. This order was entered into the medical record by Staff D without authorization by a physician. Review of the resident's meal intake dated [DATE] through [DATE] revealed the following: - [DATE] revealed ,d+[DATE]% of breakfast eaten, lunch refused by resident and dinner NPO. - [DATE] revealed all three meals charted as not applicable. - [DATE] revealed breakfast and lunch charted as NPO, and dinner charted as not applicable. - [DATE] revealed breakfast and dinner charted as not applicable, and lunch is charted as ,d+[DATE]% intake. - [DATE] revealed all three meals charted as ,d+[DATE]% intake. - [DATE] revealed all three meals charted as not applicable. - [DATE] revealed all three meals charted as not applicable. Record review of a progress note dated [DATE], 4 days following the resident being NPO, revealed that the resident had 200 milliliters of concentrated urine output and noted with a terminal ulcer (Kennedy ulcer, wound that occurs during the dying process). Record review of a Hospice Care Coordination Note dated [DATE] revealed the resident was voiding clear, yellow urine via foley catheter. Further review of a hospice progress note dated [DATE], 5 days following the resident being NPO, revealed s/he was now voiding amber urine, which is indicative of dehydration. Record review of a progress note dated [DATE], 6 days following the resident being NPO, revealed the resident expired at 8:20 AM. During a surveyor interview on [DATE] at 11:15 AM with the Hospice Nurse, Staff C, revealed that she did not and would not recommend that a resident at the end of life to be NPO. Additionally, she revealed that hospice would encourage a resident to eat but not force feed the resident. During a surveyor interview on [DATE] at 12:53 PM with the Dietitian, she revealed that she did not recommend the resident to be NPO and that it is not the facility's practice to discontinue food or fluid intake for a resident at the end of life. Additionally, she revealed that she would expect the staff to offer food and fluids for comfort at the end of life. 1b. Review of Mosby's Drug Guide for Nursing Students, Tenth Edition, states in part, dexamethasone .corticosteroid [medication used to stimulate cortisol, an anti-inflammatory hormone produced by the adrenal glands] .Uses: Inflammation .neoplasms, cerebral edema .teach to not discontinue abruptly . Further record review revealed the resident had a physician's order for Dexamethasone twice a day, dated [DATE]. This order was also discontinued on [DATE] by Staff D without authorization by a physician. During a surveyor interview on [DATE] at 2:00 PM with Staff D, she acknowledged that she discontinued the Dexamethasone for Resident ID #99. She revealed that she did not obtain a physician's order to discontinue the Dexamethasone. During a surveyor interview on [DATE] at 1:47 PM, and again on [DATE] at 9:06 AM, with the resident's physician, he revealed that he did not give an order to any staff member for the resident to be NPO and did not discontinue the Dexamethasone. Additionally, he revealed that he would not give an order for a resident to be NPO at the end of life and would expect staff to encourage fluid intake as a means of comfort. Furthermore, the physician revealed that he would expect a nurse to obtain orders from him prior to entering it into the medical record. During a surveyor interview on [DATE] at 2:00 PM with Staff D, she revealed that she did not speak to the physician regarding the resident being NPO and did not obtain an order for NPO, or to discontinue the Dexamethasone. Furthermore, Staff D acknowledged that it is not in her scope of practice to write an order without physician authorization. During a surveyor interview on [DATE] at 9:34 AM with the DNS, she acknowledged that Staff D transcribed an order for the resident to be NPO and discontinued the Dexamethasone without obtaining an order from the physician. The system failures of the facility staff entering and following physician orders for its residents, without prior authorization from a physician, unequivocally placed Resident ID #99 at risk for serious harm, impairment or death as food, hydration and significant medications were withheld from him/her for the 6 days that led up to his/her death. 2a. Record review revealed Resident ID #330 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, osteomyelitis (bone infection) and end stage renal disease. Record review revealed a visit report of a wound physician consultation for an evaluation of the resident's wounds dated [DATE] that revealed the resident has an unstageable pressure ulcer to his/her right heel and a diabetic ulcer to his/her right third toe. Further record review of the wound consultation dated [DATE] revealed the following wound physician's recommendations: - The left heel: apply skin prep daily - The right heel: cleanse with Vashe wash (cleansing solution), apply santyl followed by alginate with silver (wound treatment), skin prep to the peri wound, cover with an ABD pad (dressing) and secure with rolled gauze daily. - The right third toe: cleanse with Vashe wash, apply alginate with silver, followed by Medihoney (wound treatment), cover with an ABD pad, and secure dressing with rolled gauze daily. Further record review revealed the following wound treatment orders were entered into the medical record and that did not reflect the wound physician's recommendations: - [DATE] The left heel: cleanse with normal saline, apply santyl to calcium alginate, cover the wound, skin prep peri wound, apply ABD pad, and wrap with kerlix daily - [DATE] The right heel: skin prep to eschar (a slough or piece of dead tissue that sheds off from the surface of the skin after an injury and leave open to air) twice daily - [DATE] The right third toe: cleanse with normal saline, apply Medihoney to calcium alginate, cover the wound, skin prep peri wound, apply ABD pad, and wrap with kerlix daily Record review of the [DATE] Treatment Administration Record (TAR) revealed that the wound treatment orders listed above, which do not reflect the wound physician's recommendations from [DATE], were being documented as completed on the following dates and times: - The left heel: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE]. - The right heel: ,d+[DATE] morning and afternoon ,d+[DATE] afternoon ,d+[DATE] morning and afternoon ,d+[DATE] morning and afternoon ,d+[DATE] morning and afternoon ,d+[DATE] morning - The right 3rd toe: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE]. Additionally, no treatment was completed on ,d+[DATE] During a surveyor interview on [DATE] at 12:03 PM with the DNS, she acknowledged that the resident's current wound treatment orders do not reflect the wound physician's recommendations, including the reversed heel treatments for the left and right heel wound, and the lack of cleansing with Vashe wash and omitting of silver in the right 3rd toe wound treatment. The DNS further acknowledged that the resident's physician was not contacted regarding the wound physician recommendations. Additionally, she revealed the resident's physician always follows the wound physician's recommendations for wound care. 2b. Record review revealed that Resident ID #8 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, type 2 diabetes and muscle wasting. Record review revealed a visit report of a physician wound consultation for an evaluation of the resident's wounds dated [DATE], revealed that the resident has an unstageable pressure ulcer of the left heel and an unstageable pressure ulcer of the buttocks. Further record review of the wound physician consultation dated [DATE] revealed the following wound treatment recommendations: - The left heel: Apply Medihoney Alginate, skin prep eschar, and cover with bordered foam dressing daily - The buttocks: Cleanse with Vashe wash, apply alginate rope (wound treatment), apply Medihoney, and cover with bordered foam dressing daily. Further record review revealed the following wound treatment orders entered that do not reflect the wound physician's recommendations as listed above: - [DATE] The left heel: Apply betadine and leave open to air - [DATE] The buttocks: Remove existing dressing, if existing prisma (wound treatment) is present and is dry, moisten with saline, cover with kerra max bordered dressing (wound dressing), but if the existing prisma is absorbed then apply saline moistened prisma and cover with kerra max bordered dressing once every other day. Record review of the [DATE] TAR revealed that the wound treatment orders listed above, which do not reflect the wound physician's recommendations from [DATE], were being documented as completed on the following dates and times: - The left heel: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] - The buttocks: ,d+[DATE], ,d+[DATE], ,d+[DATE] During a surveyor interview on [DATE] at 11:39 AM with LPN, Staff G, she acknowledged that the current wound treatment orders do not reflect the most recent wound physician's recommendations. Additionally, she revealed that the resident's physician would follow the wound physician's recommendations. During a surveyor interview on [DATE] at 11:53 AM with the DNS, she acknowledged that the current orders for the resident's left heel and buttocks wounds do not reflect the most recent wound physician's recommendations. She further acknowledged that the resident's physician was not contacted regarding the wound physician's recommendations. Additionally, she revealed that the resident's physician always follows the wound physician's recommendations for wound care. Additional record review revealed that the DNS updated the resident's wound orders to reflect the wound physician's recommendations after it was brought to her attention by the surveyor. 3. Record review revealed that Resident ID #82 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, heart failure and hypertension. Review of a care plan revealed that the resident is at risk for skin breakdown and has left arm edema with bruising. Additionally, the interventions include, but are not limited to, a sleeve to the left arm to protect the skin. During multiple surveyor observations, the resident was observed without a left arm sleeve on the following dates and times: - [DATE] at 10:45 AM and 12:07 PM - [DATE] at 9:06 AM During a surveyor interview on [DATE] at 9:09 AM with LPN, Staff H, she acknowledged that the resident was not wearing the left arm sleeve. During a surveyor interview on [DATE] at 11:30 AM with the DNS, she was unable to provide evidence that the resident was utilizing the left arm sleeve as per the care plan.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 residents reviewed for hydration, Resident ID #99. Findings are as follows: According to National Library of Medicine, Adult Dehydration, last updated 2022, indicated that dehydration may complicate other medical problems and may cause significant illness. A resident may appear with dark urine or decreased urine output and may be lethargic upon observation in severe cases of dehydration. Failure to treat dehydration in older adults may lead to significant mortality. The Centers for Disease Control and Prevention does not have defined water intake recommendations, adults are encouraged to maintain between 2,000 - 3,000 milliliters per day. Review of an article published by Medical News Today, titled, How long you can live without water, states in part, .The body needs lots of water to carry out many essential functions, such as balancing the internal temperature and keeping cells alive. As a general rule of thumb, a person can survive without water for about 3 days . Record review for Resident ID #99 revealed that s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, malignant neoplasm of the brain (brain cancer) and mild protein calorie malnutrition. Further record review revealed a physician's order dated [DATE] which states in part, Regular diet, Regular Consistency texture, Thin (Regular) Liquids consistency. Review of a care plan dated [DATE] revealed the resident has no dietary restrictions. Additionally, the care plan further stated in part, Staff will provide House regular diet .Staff will provide favorite foods and beverages on request as comfort measure. S/he eats a variety of foods, except fish & shellfish and cereal. [S/he] enjoys most other foods. [Resident ID #99] is open to suggestions for snacks and beverages between meals, and will request as desired. [S/he] enjoys most types of snacks . Record review revealed an order was transcribed on [DATE] which states, NPO [nothing by mouth] documented as administered daily. Record review of the resident's progress notes revealed two notes, dated [DATE] and [DATE], which revealed the resident was documented as being alert and responsive and his/her NPO status was maintained. Further record review of a progress note dated [DATE], authored by the Director of Nursing Services, revealed the resident has had no intake. Record review of the resident's daily intake revealed the resident was documented as NPO or ,d+[DATE]% intake from [DATE] through [DATE], the day the resident expired. Record review of the resident's urine output revealed the urine output decreased after the NPO order was initiated: [DATE] - 1200 milliliters (mL) [DATE] - 650 mL [DATE] - 625 mL [DATE] -750 mL [DATE] - 420 mL [DATE] - 700 mL [DATE] - 500 mL [DATE] - 150 mL [DATE] - 175 mL [DATE] - 50 mL Record review of a Hospice Care Coordination Note dated [DATE] revealed that the resident had yellow clear urine (indicative of adequate hydration). Record review of the progress note dated [DATE] at 11:01 PM, revealed the resident had concentrated urine (darker urine is indicative of dehydration). Record review of a Hospice Care Coordination Note dated [DATE] revealed that the resident had amber urine (a concentrated urine) and was unresponsive to voice/touch. During a surveyor interview on [DATE] at 8:14 AM, with Registered Nurse (RN), Staff B, she revealed that the resident was NPO due to the resident being on hospice services. During a surveyor interview on [DATE] at 11:15 AM with Hospice RN, Staff C, she revealed that hospice would not have recommended NPO for the resident. She further revealed that hospice would encourage a resident to drink, indicating it is not their practice to recommend NPO status. During a surveyor interview with the Dietitian on [DATE] at 12:53 PM, she revealed that she would expect staff to attempt to offer fluids to the resident. She further revealed that it is not the facility's practice to make a hospice resident NPO. During a surveyor interview on [DATE] at 1:47 PM, with the resident's physician, he revealed that he would not make a resident on hospice NPO. He further revealed he would expect the staff to encourage a resident on hospice to drink for comfort. During a surveyor interview on [DATE] at 2:00 PM, with Licensed Practical Nurse, Staff D, she revealed that she did not obtain a physician's order to change the resident's diet from his/her prescribed regular diet to an NPO status. She acknowledged that she wrote an order for NPO for this resident without contacting the physician. Additionally, she acknowledged it is not within her scope of practice to write an order without a physician's authorization. During a surveyor interview with the Director of Nursing Services on [DATE] at 9:34 AM, she revealed that she would expect staff not to transcribe a physician's order unless it was obtained from a physician. Additionally, she acknowledged that Staff D put in the order for NPO status without obtaining a physician's order, resulting in the resident not eating or drinking for 6 days, and ultimately expiring on [DATE]. Furthermore, she was unable to provide evidence that the facility offered sufficient fluid intake to maintain proper hydration for Resident ID #99 as evidence by the resident having decreased concentrated urine output, increase lethargy and ultimately expiring. The system failure of the facility staff entering and following a physician order for its residents, without prior authorization from a physician, unequivocally placed Resident ID #99 at risk for serious harm, impairment or death as nutrition and hydration were withheld from him/her for the 6 days that led up to his/her death. Refer to Tags:F 658, F 684, F 710.

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 4 residents reviewed for end-of-life care, Resident ID #99. Findings are as follows: 1. Record review revealed Resident ID #99 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, malignant neoplasm of the brain (brain cancer) and mild protein calorie malnutrition. Record review of an order dated 6/22/2023 entered by Licensed Practical Nurse (LPN), Staff D, for NPO [nothing by mouth]. Further record review of the order dated 6/22/2023 for NPO entered by Staff D, was electronically signed through a web application by the resident's physician on 6/24/2023. During a surveyor interview on 6/27/2023 at 1:47 PM, and then again on 6/30/2023 at 9:06 AM with the resident's physician, he revealed that he did not give an order for the resident to be NPO. Additionally, he revealed that the order was digitally signed by him in a batch of orders. Furthermore, he indicated that the orders are not reviewed individually, but are electronically signed all at once via the electronic medical record. Further record review revealed the resident had a physician's order for Dexamethasone (a medication to provide temporary symptomatic relief of symptoms related to increased pressure and edema secondary to brain cancer) twice a day. This order was also discontinued on 6/22/2023 by Staff D without authorization by a physician. Furthermore, the lack of fluid intake paired with the discontinuation of Dexamethasone increases the likelihood of the resident experiencing discomfort from increased intracranial (within the head) pressure secondary to his/her brain cancer. During a surveyor interview on 6/28/2023 at 2:00 PM with Staff D, she acknowledged that she discontinued the Dexamethasone and entered the order for Resident ID #99 to be NPO. She revealed that she did not obtain a physician's order for NPO or to discontinue the Dexamethasone. Additionally, she further acknowledged that it is not in her scope of practice to write an order without physician authorization. During a surveyor interview with the Director of Nursing Services (DNS) on 6/28/2023 at 9:34 AM, she revealed that Staff D entered the order for Resident ID #99 to be NPO and discontinued the Dexamethasone without obtaining a physician's order. Additionally, this failure resulted in Resident ID #99 not consuming food or fluids for 6 days leading up to his/her death. The system failure of having the facility's physicians sign batch orders, rather than individually reviewing them, prevented the resident's physician from reviewing this order two days after it was entered into the resident's medical record in error, which would have allowed the resident to resume eating and drinking prior to his/her death. Additionally, this failure also resulted in the resident not receiving his/her Dexamethasone which was ordered to control the edema and swelling of his/her brain, which placed him/her at risk for an increase in intracranial pressure (can cause headaches and injure your brain or spinal cord). Refer to Tags: F 658, F 684, F 692

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 3 residents reviewed with an indwelling catheter, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 2/20/2023 revealed that there was an accident that resulted in a hospital admission. Per the report the resident rolled out of bed and was admitted to the hospital with a diagnosis of right rib fractures. Record review of a facility policy titled, .Urinary Catheter states in part, .Urinary Catheter Change Policy .Urinary catheters should be changed when a urinary tract infection is suspected .A sample for urine culture and sensitivity should be obtained from the new catheter once it is inserted . Record review revealed Resident ID #1 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, acute respiratory failure and was readmitted in February of 2023 after a hospitalization that revealed the resident tested positive for a urinary tract infection (UTI). Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Record review of the hospital discharge summary document dated 2/22/2023 states in part, .Rib fractures .Compression fracture of T8 vertbra [bone of mid-spine] .Called [facility] .They did not know why [s/he] has a foley [indwelling catheter] or when it was last changed . Further review of the hospital documentation indicated the resident's existing foley had been in place for a total of 78 days prior to the hospital replacing the foley catheter. Record review of a care plan focus area initiated on 12/28/2022 revealed the resident has a foley catheter and is at risk for infection with one of several interventions to change the foley and bag per physician order. Review of the record failed to reveal evidence of a physician's order to change the foley catheter. Record review of the hospital continuity of care (COC) document dated 2/24/2023 revealed a medication list that included Bactrim DS (an antibiotic medication) 800-160 milligrams (mg) to be given 2 times daily for a urinary tract infection beginning on 2/23/2023 at 8:00 PM through 2/28/2023 at 11:59 PM. Additionally, the document indicated the last dose of Bactrim DS administered to the resident was at the hospital on 2/24/2023 at 11:02 AM. Furthermore, it indicated the resident was to receive the next dose of the medication on 2/24/2023 at 8 PM. Record review of the February Medication Administration Record (MAR) failed to reveal evidence that the order for Bactrim DS was transcribed as ordered per the hospital COC document indicating the resident did not receive the remaining 9 doses of the antibiotic for his/her urinary tract infection. Record review revealed the following progress notes preceding the hospitalization : - 2/1/2023 at 6:57 PM .very confused .thinks [s/he] is at .sons house .hearing kids playing downstairs .does not know where [s/he] is . - 2/2/2023 at 11:20 AM .lab results reported .start Ciprofloxacin [antibiotic] .x 7 days .continue to monitor. - 2/4/2023 at 8:03 PM .noted confusion .Cipro [ciprofloxacin] .r/t [related to] UTI [urinary tract infection] . - 2/17/2023 at 7:35 AM .found on floor .was trying to get [his/herself] back into bed despite already being in bed already .sent out to [hospital] . Record review of the February 2023 MAR revealed the resident was treated with antibiotics for a UTI beginning on 2/2/2023 after the facility obtained a urine specimen without replacing the catheter per the facility policy for a suspected UTI. Further review of the February MAR failed to reveal evidence the resident received his/her antibiotic on 2/3/2023 at 8:00 PM. Additional record review indicated the resident continues with increased confusion and hallucinations and revealed the following nursing progress notes: - 2/24/2023 at 10:31 PM .had a rough night .very confused .[s/he] though [sic] [s/he] was in [his/her] old house . - 2/26/2023 at 6:10 AM .Patient agitated .exhibited extreme poor safety awareness .reaching towards floor from the bed .confused and hallucinating .combative . During a surveyor interview on 2/28/2023 at 11:00 AM with the Director of Nursing Services (DNS), she revealed only the foley catheter bag is changed prior to obtaining a urine specimen from an indwelling catheter. She was unable to provide evidence the foley catheter was changed prior to obtaining the urine specimen as per policy. During a subsequent interview on 3/1/2023 at 11:35 AM with the DNS, she revealed the resident had completed his/her antibiotic course for the UTI in the hospital and no longer required the medication. During a surveyor interview on 2/28/2023 at 2:18 PM with the physician, he revealed he would expect long term foley catheters to be changed at least monthly. During a follow up surveyor interview on 3/1/2023 at 1:44 PM with the physician, he revealed he was unaware the resident was to continue antibiotics for a UTI upon return to the facility and missed a total of 9 doses until brought to his attention by the surveyor. Additionally, he revealed he would order another urine specimen if the patient continued to exhibit symptoms.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such a usual body weight or desirable body weight and failed to follow their policy relative to weights, for 1 of 3 residents reviewed, Resident ID #5. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/28/2023 alleges in part, Pt [patient] allege .lost 30 lbs [pounds] in the last two months . Review of the facility policy titled, WEIGHTS states in part, .weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale, with a licensed nurse present. Weights are documented in the resident's/patient's medical record and/or weight book. If a significant weight loss/gain is identified (>5% [greater than] in 30 days or >10% in 6 months), the IDT[Interdisciplinary Team], Dietitian, Physician and Family are notified. All residents with a significant weight loss are reviewed by the Interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly. Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, malnutrition and symptoms and signs concerning food and fluid intake. Record review revealed current physician's orders for: - 11/29/2022 Weekly Weight . - 12/2/2022 Ensure Enlive .two times a day .Supplement . Record review of a document titled Weights and Vitals Summary, dated 3/1/2023 revealed the following weights: - 12/6/2022 179.4 Lbs [pounds] - 12/27/2022 166.6 Lbs - 1/31/2023 162.2 Lbs - 2/7/2023 158.4 Lbs - 2/14/2023 155.5 Lbs Additional record review revealed the resident lost 12.8 pounds between 12/6/2022 through 12/27/2022, indicating a significant weight loss of 7.1% in 3 weeks. Further review revealed s/he continued to lose weight, a total of 23.9 pounds between 12/6/2022 through 2/14/2023, indicating a significant weight loss of 13.3% in total in approximately 2 months. Record review revealed the following progress notes: - 2/16/2023 at 10:31 PM authored by the Dietitian .had significant wt [weight] loss of 23.9#[pounds] since admission .Cont [continue] on weekly wt .Intakes vary 0-100% meals .May benefit from use of remeron [medication] to help stimulate appetite . - 2/22/2023 at 2:46 PM authored by the Nurse Practitioner .23.9 lb [pound] weight loss since admission. Weight loss likely attributed to decreased PO [oral] intake .assessed by dietitian with recommendation for Ensure Enlive [supplement] bid [twice daily] .Will strongly consider remeron . Further review of the record failed to reveal evidence that the resident was reweighed for verification, all appropriate parties were notified, that interventions were implemented as per facility policy for significant weight loss or that the remeron was initiated. During a surveyor observation on 3/1/2023 at 12:57 PM revealed the resident asleep in bed with his/her lunch tray on the bedside table untouched. Further observation revealed the diet slip on the tray indicating standing orders for the lunch meal to include 8oz [ounces] of whole milk and 4oz of orange juice, both absent from the tray. During a surveyor interview on 3/1/2023 at 2:27 PM with the Dietitian, she acknowledged the resident has had significant weight loss since admission. She further revealed she was unaware of the significant weight loss of 12.8 pounds between 12/6/2022 and 12/27/2022. Additionally, she revealed she would not implement another intervention because the resident was already started on a supplement prior. Furthermore, she revealed the only additional dietary intervention put in place was a selective menu for the resident after the continued significant weight loss was identified on 2/14/2023. During an additional surveyor interview on 3/1/2023 at 2:40 PM with the Director of Nursing Services in the presence of the Administrator, she was unable to provide evidence the facility adhered to the weight policy or the above-mentioned intervention for remeron was implemented.

Based on record review and staff interview, it has been determined that the facility failed to meet the needs of the residents regarding timeliness of reporting laboratory results relative to a positive wound culture for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review revealed the resident was readmitted in February of 2023 after a hospitalization that revealed s/he sustained 2 rib fractures and a vertebral (bone of spine) fracture after an unwitnessed fall in the facility. Record review of a care plan focus area revised on 2/25/2023 revealed s/he has pressure ulcers to the coccyx and left heel and is followed by a wound MD (medical doctor) and wound nurse. Further review revealed interventions including, but not limited to, monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx [signs and symptoms] of infection, monitor wound healing and report declines to MD. Record review of several progress notes revealed the following: - 2/2/2023 at 7:03 PM .Weekly wound assessment completed by [wound] MD .STAGE 4 [most severe pressure wound and may expose muscle, tendons, ligaments, cartilage, and/or bone] PRESSURE WOUND COCCYX .Wound progress: Improved. - 2/8/2023 at 9:35 AM .Wound culture from coccyx wound obtained . - 2/10/2023 at 3:52 PM .Wound culture resulted - no new orders . Record review of the resident's coccyx wound culture obtained on 2/8/2023 revealed it was positive for infection. Additional review of the progress notes revealed the resident's coccyx wound had deteriorated as evidenced by the following progress notes: - 2/11/2023 at 5:18 PM authored by the Infection Preventionist, .PRESSURE WOUND COCCYX .Exudate [drainage]: Heavy Purulent [thick, milky discharge containing pus, often indicating infection] .Wound progress: Deteriorated. - 2/14/2023 at 12:55 PM .Weekly wound rounds completed .Wound to coccyx .Surrounding area red .warm to touch .purulent drainage .tender to touch . Additional review of the progress note on 2/14/2023 at 12:55 PM indicated the doctor would be in the facility the following day to assess the wound. Further review of the record failed to reveal evidence that staff reported the deterioration of his/her coccyx wound per the plan of care after staff identified the decline of the resident's wound as noted by the above-mentioned progress notes. Further review of the progress notes revealed the following: - 2/15/2023 at 9:04 AM .Patient complained of increased pain to wound site .MD also reviewed wound culture, would like [wound doctor] to review. - 2/15/2023 at 1:27 PM .Wound culture to coccyx .positive .Reported to Wound MD .Start cipro [antibiotic] . Review of the record revealed the resident began his/her antibiotic treatment for his/her coccyx wound infection on 2/15/2023, indicating that 5 days had elapsed since the facility first discovered the resident's coccyx wound was positive for infection. Additional review of the progress notes revealed the following: - 2/28/2023 at 12:40 PM .Readmit from hospital on risk for wounds . - 3/2/2023 at 10:23 AM authored by the Infection Preventionist, .PRESSURE WOUND COCCYX .Wound progress: Deteriorated .starting abx [antibiotic] therapy r/t [related to] suspected osteomyelitis [infection in a bone] . - 3/2/2023 at 10:59 AM .assessed by Wound Doctor .new orders .DX [diagnosis]: Osteomyelitis to Coccyx Bone Culture Obtained STAT [immediate] STAT labs .Referral for infectious disease faxed .as a high priority . During a surveyor interview on 3/8/2023 at 7:51 AM with the Director of Nursing Services (DNS), she revealed the resident was transferred to the hospital. She further revealed his/her sacral (coccyx) wound is infected and s/he needed a intravenous catheter placed and intravenous antibiotics. During a follow up interview on 3/8/2023 at approximately 1:30 PM with the DNS, she was unable to provide evidence that the wound physician, who ordered the wound culture, was notified in a timely manner to prevent a delay in treatment. Additionally, she was unable to provide evidence that staff reported the deterioration of the coccyx wound to the physician when it was identified per the plan of the care.

Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 3 resident's reviewed for medication administration, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/20/2022 alleges in part, .the facility did not order [the resident's] suboxone [a medication used to treat opioid dependence, abrupt discontinuation may cause withdrawal symptoms including, but not limited to, nausea, vomiting, and anxiety]. He had to go to the ER [emergency room ] in order to receive his required dose . Record review revealed the resident was admitted to the facility in November of 2021 with diagnoses including, but not limited to, pain in right knee, pain in right lower leg, opioid use, and post-traumatic stress disorder. Review of the resident's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMs) score of 15/15, indicating intact cognition. Record review of the resident's care plan dated 12/8/2021 revealed .potential for pain .Administer pain medications as ordered. Review of a hospital document dated 12/20/2022 states in part, presents to the emergency department with withdrawal and in need of [his/her] suboxone dose .At present, pt [patient] reports [s/he] is starting to go through withdrawals now with abdominal pain [s/he] appears to be in withdrawal .will check urine and give [him/her, his/her] Suboxone dose . Review of the resident's progress notes revealed the following: -12/20/2022 8:19 AM- .no buprenorphine [a medication used to treat opioid use disorder and chronic pain] available for this resident. pharmacy called and [prescribing physician] called again regarding script this morning. Resident states he is going to call 911 and go to the hospital for his dose at this time. -12/20/2022 13:34- .resident to return from [hospital] .Buprenorphine dose given in the ED [emergency department]. [prescribing physician] will send script to pharmacy this afternoon and facility will have next dose on hand. Review of the resident's December Medication Administration Record (MAR) revealed an order with a start date of 9/21/2022 for Buprenorphine HCL Tablet Sublingual [under the tongue] 8MG [milligram] Give 24 mg sublingually in the morning for pain. Further review of the MAR failed to reveal evidence the resident received Buprenorphine HCL tablet at the facility on 12/20/2022 as ordered. Record review of the unit narcotic count book revealed that on 12/19/2022 the quantity remaining was zero for Buprenorphine 8 mg tablets and it was not delivered to the facility until 12/21/2022. Review of a document provided by the facility titled, Controlled Substance Ordering states in part, Please anticipate your needs- do not wait until the patient is completely out of medication to start the process in the case of chronic use controlled substances. Record review failed to reveal evidence any effort was made to obtain the medication Buprenorphine prior to being completely out of the medication on 12/19/2022. During a surveyor interview with the complainant on 12/22/2022 at 9:45 AM, she indicated that because the facility failed to provide the resident with his/her medication resulting in the resident going to the hospital for the medication. During a surveyor interview with the resident on 12/22/2022 at approximately 10:10 AM, s/he revealed that s/he did not receive Buprenorphine on the morning of 12/20/2022 which resulted in him/her feeling sick and vomiting. Additionally, s/he revealed this missed medication dose was stressful and s/he felt that there was no choice but to go to the hospital for the medication on 12/20/2022. During a surveyor interview on 12/22/2022 at 10:40 AM with Licensed Practical Nurse (LPN) Staff A, he revealed the facility did not have Buprenorphine on hand on 12/20/2022 and that the resident's dose was not administered as ordered. During a surveyor interview on 12/22/2022 at 1:04 PM with the office manager at the prescribing physician's office, she revealed the first time the facility attempted to contact the doctor to refill this prescription was on 12/19/2022. She further revealed she would have expected the facility to contact the office to request a refill prior to running out of the medication. During a surveyor interview with the Director of Nursing Services on 12/22/2022 at 2:56 PM, she acknowledged the resident did not receive his/her dose of Buprenorphine at the facility on 12/20/2022 as ordered. She further acknowledged that the facility did not have the medication available at the time it was due to be administered on 12/20/2022. Additionally, she was unable to provide evidence that Resident ID #1 was free from any significant medication errors.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents were free from significant medication errors related to the administration of [MEDICATION(S)] (a medication used to treat blood clots and to lower the chance of blood clots forming in your body) for 1 of 4 residents reviewed for medication administration, Resident ID # 1. Findings are as follows: A Patient's Guide to Taking [MEDICATION(S)], https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/a-patients-guide-to-taking-[MEDICATION(S)], states in part, .[MEDICATION(S)] (brand names [MEDICATION(S)] and [MEDICATION(S)]) is a prescription medication used to prevent harmful blood clots from forming or growing larger. Beneficial blood clots prevent or stop bleeding, but harmful blood clots can cause a heart attack, stroke, [CONDITION(S)] or pulmonary embolism[PE] .The goal of [MEDICATION(S)] therapy is to decrease the clotting tendency of blood, not to prevent clotting completely .The blood test used to measure the time it takes for blood to clot is referred to as a prothrombin time test, or [MEDICATION(S)] (PT). The PT is reported as the International Normalized Ratio (INR) .It is important to monitor the INR (at least once a month and sometimes as often as twice weekly) to make sure that the level of [MEDICATION(S)] remains in the effective range. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding. This is why those who take [MEDICATION(S)] must have their blood tested so frequently . Record review of a community reported complaint submitted to the Rhode Island Department of Health dated 4/26/2022, indicated that the resident was admitted to the nursing home after being admitted to an acute care hospital. The facility did not properly care for the resident and failed to ensure that all his/her medications were transcribed. During the time at the nursing home s/he never received his/her blood thinner ([MEDICATION(S)]) which resulted in a re- hospitalization . Record review revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a discharge summary from an acute care hospital dated 4/13/2022, which states in part, .Discharge Medications and Instructions .CONTINUE these medications .[MEDICATION(S)] ([MEDICATION(S)]) 5 MG (milligrams) .[MEDICATION(S)] PLAN .is being discharged on [MEDICATION(S)] .for [CONDITION(S)] .should remain on [MEDICATION(S)] indefinitely .has been given a prescription for [MEDICATION(S)] 5 milligram (mg) .Last dose of [MEDICATION(S)] was 5 mg on 4/13/2022 .Goal INR is 2.0-3.0 . Further review revealed a Continuity of Care (COC) form dated 4/13/2022, that included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet by mouth at the same time every evening for 30 days. Record review revealed on 4/14/2022 a PT/INR was drawn. The facility was unable to determine who ordered this lab draw. Additionally, on 4/14/2022 at 3:45 PM there was a nursing note that indicated that the resident's labs were drawn and contained high values. The note indicated that this was reported to Registered Nurse [NAME] and to place the laboratory results in folder for the physician to review. During an interview with the Licensed Practical Nurse, Staff A, on 4/29/2022 at 10:55 AM, the writer of the above nurses note, indicated that [NAME] was the Registered Nurse of the attending physician for the facility (Staff B). Staff A, indicated that she placed the labs in a folder for the Nurse Practitioner of the attending physician to review. She indicated that she did not transcribe a [MEDICATION(S)] order on 4/14/2022. Record review of the April 2022 Medication Admission Record (MAR) failed to reveal evidence that the 5 mg of [MEDICATION(S)] was administered to the resident on 4/14, 4/15, 4/16, 4/17, 4/18, 4/19 and 4/20/2022. On 4/21/2022 the resident went to a scheduled cardiology appointment. Record review of a progress note dated 4/21/2022 indicated that while the resident was at his/her cardiology appointment the Nurse Practitioner for the cardiologist called the facility to question the [MEDICATION(S)] order for the resident. However, the resident subsequently was having complaints of shortness of breathe, his/her oxygen saturation was 92% (normal oxygen saturation is 95-100%) and the Nurse Practitioner suspected fluid overload and therefore, s/he was sent via rescue directly from the cardiology appointment to the emergency room . Record review of an acute care hospital admission summary dated 4/21/2022 revealed in part, .Per patient and chart review .has not been receiving [his/her] [MEDICATION(S)] since arrival to rehab facility. [His/her] cardiologist referred [him/her] to the ED [Emergency Department] with concern for PE .admitted with CHF [Congestive Heart Failure] exacerbation, recurrent bilateral pleural effusions .On exam the pt [patient] appears volume overloaded .is tachypneic [rapid respiration], [CONDITION(S)] [rapid heart rate] and edematous [swollen with accumulation of fluid]. EKG showed sinus [CONDITION(S)] . Further record review of hospital documents revealed that s/he was admitted to hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . S/he underwent Cardioversion, which is a medical procedure by which an abnormally fast heart rate or other cardiac arrhythmia is converted to a normal rhythm using electricity or medication. S/he also was in [CONDITION(S)] flutter which is an abnormal heart rhythm. S/he also received a thoracentesis, which is a procedure to remove fluid or air from around the lungs. The thoracentesis removed approximately 700 milliliters of pleural fluid. During a surveyor interview on 4/29/2022 at 11:05 AM with Registered Nurse of the resident's attending physician, Staff B, she revealed that the attending physician was not aware that the resident was on [MEDICATION(S)] and denied receiving a call regarding the PT/INR lab results which were drawn on 4/14/2022. During a surveyor interview with the Director of Nurses on 4/28/2022 at 12:20 PM she acknowledged that the resident did not receive his/her [MEDICATION(S)] on 4/14, 4/15, 4/16, 4/17, 4/18, 4/19 and 4/20/2022. During an interview on 5/3/2022 at 11:55 AM with Registered Nurse, Staff C, she indicated that she completed the admission for this resident. She acknowledged that she did not transcribe the [MEDICATION(S)] order and she could not recall who gave her the order for the PT/INR.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the medical care of each resident is supervised by a physician related to anticoagulant therapy for 1 of 4 residents reviewed. Resident ID # 1. Findings are as follows: A Patient's Guide to Taking [MEDICATION(S)], https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/a-patients-guide-to-taking-[MEDICATION(S)], states in part, .[MEDICATION(S)] (brand names [MEDICATION(S)] and [MEDICATION(S)]) is a prescription medication used to prevent harmful blood clots from forming or growing larger. Beneficial blood clots prevent or stop bleeding, but harmful blood clots can cause a heart attack, stroke, [CONDITION(S)] or pulmonary embolism[PE] .The goal of [MEDICATION(S)] therapy is to decrease the clotting tendency of blood, not to prevent clotting completely .The blood test used to measure the time it takes for blood to clot is referred to as a prothrombin time test, or [MEDICATION(S)] (PT). The PT is reported as the International Normalized Ratio (INR) .It is important to monitor the INR (at least once a month and sometimes as often as twice weekly) to make sure that the level of [MEDICATION(S)] remains in the effective range. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding. This is why those who take [MEDICATION(S)] must have their blood tested so frequently . Record review of a community reported complaint submitted to the Rhode Island Department of Health, dated 4/26/2022 revealed the facility failed to ensure his/her [MEDICATION(S)] (a medication used to treat blood clots and to lower the chance of blood clots forming in your body) orders were transferred to the MAR (Medication Administration Record) as prescribed. Additionally, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a community reported complaint submitted to the Rhode Island Department of Health dated 4/26/2022, indicated that the resident was admitted to the nursing home after being admitted to an acute care hospital. The facility did not properly care for the resident and failed to ensure that all his/her medications were transcribed. During the time at the nursing home s/he never received his/her blood thinner ([MEDICATION(S)]) which resulted in a re- hospitalization . Record review revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a discharge summary from an acute care hospital dated 4/13/2022, which states in part, .Discharge Medications and Instructions .CONTINUE these medications .[MEDICATION(S)] ([MEDICATION(S)]) 5 MG (milligrams) .[MEDICATION(S)] PLAN .is being discharged on [MEDICATION(S)] .for [CONDITION(S)] .should remain on [MEDICATION(S)] indefinitely .has been given a prescription for [MEDICATION(S)] 5 .mg .Last dose of [MEDICATION(S)] was 5 mg on 4/13/2022 .Goal INR is 2.0-3.0 . Further review revealed a Continuity of Care (COC) form dated 4/13/2022, that included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet by mouth at the same time every evening for 30 days. Record review of the resident's April 2022 MAR failed to reveal evidence that the [MEDICATION(S)] was administered to the resident since his/her admission. Record review revealed that the Nurse Practitioner (NP)saw the resident on 4/18/2022. The record failed to reveal evidence that when the NP assessed the resident's current medical issues that she reviewed the clinical record to discover the medication error. On 4/21/2022 the resident went to a scheduled cardiology appointment. Record review of a progress note dated 4/21/2022 indicated that while the resident was at his/her cardiology appointment the NP for the cardiologist called the facility to question the [MEDICATION(S)] order for the resident. However, the resident subsequently had complaints of shortness of breath, oxygen saturation was 92% (normal oxygen saturation is 95-100%) and suspected fluid overload and was sent via rescue to the emergency room . Record review of an acute care hospital admission summary dated 4/21/2022 revealed in part, .Per patient and chart review .has not been receiving [his/her] [MEDICATION(S)] since arrival to rehab facility. [His/her] cardiologist referred [him/her] to the ED [Emergency Department] with concern for PE .admitted with CHF [Congestive Heart Failure] exacerbation, recurrent bilateral pleural effusions .On exam the pt [patient] appears volume overloaded .is tachypneic [rapid respiration], [CONDITION(S)] [rapid heart rate] and edematous [swollen with accumulation of fluid]. EKG showed sinus [CONDITION(S)] . During a surveyor interview on 4/29/2022 at 11:05 AM with Registered Nurse of the resident's attending physician, Staff B, she revealed that the attending physician was not aware that the resident was on [MEDICATION(S)] and denied receiving a call regarding the PT/INR lab results which were drawn on 4/14/2022. During a surveyor interview with the Director of Nurses on 4/28/2022 at 12:20 PM she acknowledged that the resident did not receive his/her [MEDICATION(S)] on 4/14, 4/15, 4/16, 4/17, 4/18, 4/19 and 4/20/2022.

Based on surveyor record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 4 of 4 residents reviewed for nutrition (ID #'s 1, 3, 5, 6) and offer sufficient fluid intake to maintain proper hydration for 1 of 1 residents reviewed for hydration (ID #3). Findings are as follows: Review of the facility's policy titled, Weights, states in part: If a significant weight loss/gain is identified (> 5% in 30 days or > 10% in 6 months), the IDT (Interdisciplinary Team), Dietitian, Physician and Family are notified. All residents with a significant weight loss are reviewed by the Interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly. Review of the facility's document titled, COVID-19 ACTION PLAN, recommended by a consultant pharmacy company, states in part . 2. D/C (discontinue) SUPPLEMENTS: Wherever possible and appropriate, D/C vitamins and supplements (Multivitamins, Vitamins B, C, D, and E, Calcium, Folate, and other OTC supplements) unless part of COVID-19 regimen a. Consider a 14 day (or longer) hold order if permanent D/C is not appropriate. b. Work with dietician to assess and eliminate Ensure and other supplements given as part of the med pass whenever possible and clinically appropriate . 1. Resident ID #1 was admitted to the facility in January 2015 and has [DIAGNOSES REDACTED]. Review of the resident's advanced directives, signed and dated by the resident's physician on 8/30/2019, indicates that the resident wishes to be a Full Code with indication for artificial nutrition and hydration, if required. Review of the resident's Minimum Data Set (MDS), dated [DATE], indicates that the resident had a weight loss of 5% or more in the last month or 10% or more in the last six months, while not on physician-prescribed weight-loss regimen. Review of the resident's nutrition care plan reveals an intervention, initiated 3/22/2018, to Monitor/evaluate energy intake and/or food/beverage intake via meal intake records and observation. An additional intervention, revised on 7/1/2019, states, Obtain weights q (every) week as per physician order [REDACTED]. Review of the physician's orders [REDACTED]. - Order dated 9/10/2019-6/5/2020: Weekly weights on Tuesdays - Order dated 9/5/2020-6/5/2020: HiCal (high calorie oral supplement), 60 ml by mouth, two times a day - Order dated 12/16/2019-6/5/2020: HiCal, give 60 ml by mouth, every day in the afternoon - Order dated 3/1/2020-6/5/2020: Liquacel (supplement given for extra protein), give 30 ml by mouth (mix w/ 30-90 ml of beverage), every day at bedtime Further review of the physician's orders [REDACTED]. Review of the resident's intake documentation from 4/12/2020 to 4/26/2020 revealed 29 out of 45 opportunities where the resident's meal intake was not documented. Review of the resident's weights from 1/7/2020 (169.6# (pounds)) to 4/7/2020 (149#) reveals that the resident lost 20.6# or 12% of body weight (classified as severe weight loss) in 3 months. Review of the resident's weekly weights from 4/7/2020 until 6/5/2020 revealed the following: - 4/7/2020: 149# - 4/14/2020: no weight obtained - 4/21/2020: documented unable to obtain - 4/28/2020: documented will obtain next shift - 5/5/2020: 139.6# - 5/12/2020: no weight obtained - 5/19/2020: documented unable to obtain - 5/26/2020: 138# - 6/2/2020: documented unable to obtain The resident lost 9.4 pounds or 6.7 % of body weight (classified as severe weight loss) from 4/7/2020 to 5/5/2020. During this time, the facility failed to obtain three weekly weights in a row. Additionally, during this time the resident's above supplements were held from 4/12/2020 to 4/26/2020. The facility continued to fail to obtain weekly weights on 5/12/2020, 5/19/2020, and 6/2/2020. Further record review revealed that the resident had a Stage 3 pressure ulcer to the coccyx on 3/25/2020. As of 5/11/2020, the resident's pressure ulcer was documented as an unstageable pressure ulcer with 100% unhealthy tissue. Refer to F686. Review of the Registered Dietitian's (RD) progress note, dated 5/15/2020, states the following: Risk note - wt (weight) on 5-5-20 .139.6# more recent wgt (weight) n/a (not available) Wt shows 9.4# loss x past month due to poor intakes. Wt loss may also be attributed to increased kcal (calorie) needs for wound healing .Intakes appear to have declined, consumes <50% meals per flow sheet documentation. Rec'ng (receiving) supplements 6x qd (daily) - res (resident) usually consumes . The RD recommended to continue current interventions. No additional recommendations were noted. Review of the resident's labs, dated 6/1/2020, reveals the following: - [MEDICATION NAME] (a protein made in the liver; the lab tests the amount of [MEDICATION NAME] in the blood) = 2.5 gm/dl (grams/deciliter) (normal range = 3.5-5.2 gm/dl) - [MEDICATION NAME] (a protein made in the liver; the lab tests the amount of [MEDICATION NAME] in the blood) = 6.6 mg/dl (milligrams/deciliter) (normal range = 20.0-40.0 mg/dl) Resident ID #1 was admitted to the hospital in June 2020. Review of the hospital documentation from 6/4/2020 indicates that s/he meets criteria for severe protein calorie malnutrition. During a surveyor interview with the RD on 6/17/2020 at 11:40 AM and 6/25/2020 at 3 PM and 4:40 PM, she revealed that she was unaware that the resident's supplements were held from 4/12/2020 to 4/26/2020. Additionally, she indicated that she was out of work from 4/2/2020 to 5/1/2020 and that there was no other RD covering for her. The RD acknowledged that the resident was a Full Code, with indications for artificial nutrition, if necessary. The RD revealed that she did not discuss pursuing the use of artificial nutrition with the doctor or family after the resident experienced severe weight loss in May 2020. During a surveyor interview with the Medical Director (resident's primary physician) on 6/24/2020 at 9:49 AM and 6/25/2020 at 2:15 PM, he indicated that he would not have agreed to discontinuing the resident's HiCal and Liquacel supplements given her history of weight loss and present pressure ulcer. While reviewing the resident's overall weight loss since January, and further weight loss during the month of April/May, with the MD, he revealed he was not aware of the amount of weight loss the resident had and could not recall if the nursing staff called him specifically about his/her weight loss. He was unaware that the resident's weekly weights were not being obtained and intake was not being documented. Additionally, he could not recall if a discussion was held regarding artificial nutrition for this resident. During a surveyor interview with the Director of Nursing Services (DNS) on 6/26/2020 at 9:12 AM, he could not provide evidence that a discussion related to artificial nutrition was had with the resident's physician or resident's representative after the resident had severe weight loss in May 2020. During a surveyor interview with the Director of Clinical Services on 6/18/2020 at 2:35 PM, she revealed that only life-sustaining medications were given while the facility was in crisis due to Covid-19. Furthermore, she indicated that there was not enough time to evaluate on an individual basis which residents' supplements were clinically appropriate to be put on hold when initiating the Covid-19 Action Plan. 2. Resident ID #3 was admitted to the facility in November of 2017 with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS), dated [DATE], indicates that the resident had a weight loss of 5% or more in the last month or 10% or more in the last six months, while not on physician-prescribed weight-loss regimen. Review of the nutrition care plan, initiated 5/26/2020, indicates Staff will monitor (resident's) food and beverage intake using observations and meal intake record. Review of the resident's intake documentation from 4/10/2020 to 4/26/2020 revealed no record of intake for breakfast or lunch, and for dinner there were 17 opportunities to document intake, 5 opportunities no intake was documented, there were 8 opportunities where it was documented that the resident refused, and the remaining 5 opportunities intake varied for dinner from 0-75%. Review of the physician's orders [REDACTED]. - Order dated 3/20/2018: Weekly weight on Tuesday - Order dated 5/19/2020: Continue weekly weight on Tuesday Review of the resident's weights from 4/8/2020 to 6/23/2020 revealed the following: - 4/08/2020: 227.8# - 4/15/2020: weight not documented - 4/21/2020: documented resident refusal - 4/29/2020: resident at the hospital - 5/06/2020: resident at the hospital - 5/13/2020: readmission weight not obtained - 5/19/2020: 214.2# - 5/27/2020: documented resident refusal - 6/02/2020: 213.2# - 6/09/2020: weight not documented - 6/17/2020: weight not documented - 6/23/2020: 217.2# The resident lost 13.6 pounds or 5.97 % of body weight from 4/8/2020 to 5/19/2020. During this time, the facility failed to obtain 2 weekly weights in April. In addition, upon readmission from the hospital on [DATE], the resident's readmission weight was not obtained until 5/19/2020. Weekly weights were missed on 6/09/2020 and 6/17/2020. Review of the dietitian's note on 5/15/2020, states in part, Supplements: will add 60 cc Hical bid due to decreased intakes .readmission Wt. not obtained, continue weekly wgt a/o (as ordered) last available wgt 4-8-20 .227.8# Hosp wgt 220# .supplements to be initiated .continue to monitor intakes, weights and labs prn (as needed). Review of the dietitian's note on 5/26/2020, states in part, Risk note - wt on 5-19-20 .214.2# Wt shows significant loss of 13.6# x past 6 weeks. Wt loss due to recent hospital stay and poor intakes. Continue Cont. weekly wgt a/o (as ordered) . Further review of the nursing progress notes from 4/12/2020- 4/28/2020 revealed the resident had experienced intermittent low-grade temperatures, with periods of lethargy, and requiring oxygen use. Of note, resident was positive for COVID as of 4/18/2020. Further review of the nursing note dated 4/28/2020 reveals the resident was lethargic; the physician was made aware and new orders for a chest x-ray and labs were obtained. Lab results revealed an elevated BUN (a test to see how well your kidneys are working) of 166, a critically elevated creatinine (a test to see how well your kidneys are working) of 8.06, and a critically elevated Sodium (an electrolyte) level of 161, all results suggest dehydration. Lab results were reported to the physician and the resident was sent out to the hospital for an evaluation. Review of a nursing progress note dated 5/12/2020 revealed the resident was readmitted from the hospital with [DIAGNOSES REDACTED]. Review of the resident's Advanced Directive, dated 3/07/2018, revealed a code status of DNR/DNI (do not resuscitate/do not intubate). In addition, the advanced directive revealed s/he would want Intravenous Hydration. Record review revealed at no time in the month of April was Intravenous Hydration administered. 3. Resident ID #5 was admitted to the facility in March of 2016 with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS), dated [DATE], indicates that the resident had a weight loss of 5% or more in the last month or 10% or more in the last six months, while not on physician-prescribed weight-loss regimen. Review of the nutrition care plan, initiated 3/20/2019, indicates Staff will monitor (resident's) food and beverage intake using observations and meal intake record. Review of the resident's intake documentation from 4/12/2020 to 4/26/2020 revealed 33 out of 45 opportunities where the resident's meal intake was not documented. Review of the physician's orders [REDACTED]. - Order dated 1/4/2019-6/1/2020: Monthly weight on 4th of every month - Order dated 5/12/2020-6/1/2020: Weekly weight on Tuesday Review of the resident's weights from 3/4/2020 to 5/26/2020 revealed the following: - 3/4/2020: 92.2# - 4/4/2020: documented as see nurses notes, no reasoning documented in notes - 5/7/2020: 82.6# - 5/12/2020: progress note indicating resident refused to get out of bed - 5/19/2020: progress note indicating resident refused to get out of bed - 5/26/2020: 76.0# The resident lost 9.6 pounds or 10.4 % of body weight (classified as severe weight loss) from 3/4/2020 to 5/7/2020. During this time, the facility failed to obtain a monthly weight in April. Record review revealed that the resident was put on weekly weights starting on 5/12/2020; however, the resident refused to be weighed on 5/12/2020 and 5/19/2020. There is no evidence that the facility re-attempted to get a weight at a different time/date. The resident lost another 6.6# or 7.9% of body weight in less than 1 month, for a total weight loss of 16.2# or 17.6 % weight loss (classified as severe weight loss) in less than 3 months. Review of the dietitian's note on 5/12/2020, states in part, Risk note - wt on 5-7-20 .82.6# Wt shows 9.6# loss x past 2 months due to poor intakes .Intakes vary - consumes 0-75% meals per flow sheet documentation . The RD recommended to continue current interventions. No additional food interventions were put into place at this time. Review of the dietitian's note on 5/28/2020, states in part, Risk note - wt on 5-26-20 .76.0# wt shows 6.6# loss x past 3 weeks. Res continues with decreased intakes - consumes 25-75% meals per flow sheet documentation with most meals <50% eaten .Granddtr called this writer - Granddtr also updated re: above. Res usually drinks health shakes and currently rec'ng 120cc 5x qd (daily). Will increase to 240cc with meals and continue 120cc bid (twice daily) with med pass. Cont to follow on risk for wgt. During a surveyor interview with the RD on 6/25/2020 at 3 PM, she revealed that she did not increase the resident's supplement on 5/12/2020 after the initial 9.6-pound weight loss as the resident was already getting supplements 5 times a day. The RD further indicated that she increased the resident's supplement on 5/28/2020, after speaking with the resident's family. 4. Resident ID #6 was admitted to the facility in November of 2018 with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS), dated [DATE], indicates that the resident had a weight loss of 5% or more in the last month or 10% or more in the last six months, while not on physician-prescribed weight-loss regimen. Review of the nutrition care plan revealed a goal, revised on 12/4/2019, to consume greater than 75% of nutrition supplements through next review. Review of the physician's orders [REDACTED]. - 10/8/2019-current: Supplemental House Milkshake in the morning, give 120 ml. Review of the April administration record revealed that this supplement was held from 4/12/2020 to 4/26/2020. Review of the resident's intake documentation from 4/12/2020 to 4/26/2020 revealed 27 out of 45 opportunities where the resident's meal intake was not documented. Review of the resident's weights from 4/2/2020 to 5/5/2020 revealed the following: - 4/2/2020: 127.4# - 5/5/2020: 119.8# The resident lost 7.6 pounds or 5.9 % of body weight from 4/2/2020 to 5/5/2020. Additionally, during this time the resident's above supplements were held from 4/12/2020 to 4/26/2020. Record review revealed that the resident was not seen by the RD until 5/19/2020. During a surveyor interview with the RD on 6/25/2020 at 3 PM, she revealed that she typically sees a resident 1-2 days after s/he experiences significant weight loss; however, she was playing catch up from being out from 4/2/2020 until 5/1/2020 and was unable to see the resident until that time. During a surveyor interview with the DNS on 6/26/2020 at 9:12 AM, he acknowledged that they did not have a dietitian covering from 4/2/2020 until 5/1/2020 while the RD was on leave. Furthermore, he indicated that he would expect nursing to monitor intake and notify the physician if there was a change in weight. During a surveyor interview with the Director of Clinical Services on 6/28/2020, she indicated that the facility was in crisis due to Covid-19 during the time of the above resident's weight loss.

Based on record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent infections from developing for 1 of 3 residents who have actual pressure ulcers (ID # 1). Findings are as follows: A review of the facility's policy titled, Prevention and Management of Pressure Injuries, states in part: Residents with pressure injuries .are identified, assessed and provided appropriate treatment to encourage healing or maintain skin integrity .ongoing monitoring and evaluations are provided to ensure optimal resident outcomes . Assessment: Ulcer/Risk Factors . 5. Pressure injuries are assessed and documented on at least weekly and with a significant change in the wound until it is resolved. Pressure ulcer assessment includes: · Location · Measurement in centimeters- Length, width and depth, undermining and tunneling · Stage · Presence of tunneling or undermining · Drainage Amount · Drainage Color · Odor - If present after cleaning · Appearance of wound bed · Appearance of wound edges · Appearance of peri wound · Pain · Effectiveness of treatment. Clinical record review for ID #1 revealed the resident has [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] revealed the resident had an unstageable pressure ulcer. A care plan, dated 3/18/2020, revealed a pressure area to her coccyx with interventions to monitor nutritional status and to follow facility policies and protocols for the prevention and treatment of [REDACTED]. A review of the Wound Physician's report, dated 3/18/2020 and 3/25/2020, revealed a description of the wound under the heading of Other visible tissues stating, this wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of biofilm (overgrowth of bacteria embedded in the tissue fluid of a wound). An order was added on 3/18/2020 for Santyl (used as a chemical debridement) treatment once daily with a foam silicone border dressing and to apply skin prep daily. Review of the resident's weekly pressure injury evaluations from 3/18/2020 until 5/11/2020 revealed the following: - 3/18/2020: Stage 3 pressure ulcer (full-thickness tissue loss, subcutaneous fat may be visible) to the right coccyx; measurements of 1.0 cm (centimeter) in length x 0.6 cm in width x 0 cm in depth; the wound bed has 50% granulation tissue (pink or red tissue with a bumpy appearance), 50 % Dermis (skin), and 0% unhealthy tissue with no drainage. Under the heading current treatment it states, Santyl treatment order in place. - 3/25/2020: Stage 3 pressure ulcer to the right coccyx, now measuring 1.3 cm in length x 0.8 cm in width x 0 cm in depth with moderate serous (clear or pale-yellow fluid) exudate (accumulation of fluid); wound bed has 50% granulation tissue and 20% slough (non-viable yellow/white/ or brown tissue that impedes wound healing); wound bed has 25% unhealthy tissue; no odor. - 5/11/2020: coccyx wound is Unstageable (full thickness wound where the entire wound bed is completely obscured by slough and or eschar); wound measurements are 5 cm in length x 4 cm in width x 0.2 cm in depth. The evaluation continues to describe the wound as white to tan and dark green slightly firm slough noted to upper wound bed going to mid wound bed with areas of white slough .100 % unhealthy tissue, wound edges described as unhealthy, irregular, rolled under, red hard/indurated, macerated. The wound was documented as having 25-75% of purulent (pus production in infected tissue)-thin/thick tan to yellow drainage, and the surrounding skin was documented as red-warm-swollen-macerated/white-abraded/denuded. The evaluation further stated that the current treatment was effective and to continue current treatment, which was Santyl ointment to wound bed followed by an [MEDICATION NAME] dressing daily. - 5/19/2020: the coccyx wound is Unstageable, measuring 3 cm in length x 4 cm in width x 0.3 cm in depth, with small areas of pink tissue noted with dark red areas of tissue .75% unhealthy tissue with yellow slough to the wound bed, wound edges described as unhealthy, irregular, rolled under, red hard/indurated, macerated. The wound was documented as having < 25% of serosanguinous (yellow drainage with small amounts of blood) drainage, and the surrounding skin was documented as red-warm-swollen-macerated/white-abraded/denuded. Further documentation states the current treatment was effective and to continue current Santyl and [MEDICATION NAME] treatment. - 5/24/2020: the coccyx wound is Unstageable, measuring 3 cm in length x 2 cm in width x 0.5 cm in depth, with loose fibrous green slough noted throughout wound bed .100 % unhealthy tissue, wound edges described as unhealthy, irregular, rolled under, red hard/indurated, macerated. The wound was documented as having < 25% of serosanguinous drainage. Further documentation states to apply Santyl to the wound bed then lightly pack with gauze followed by a dry clean dressing. - 5/29/2020: the coccyx wound is Unstageable, measuring 4 cm in length x 2 cm in width x depth unknown, and the wound now has undermining (the destruction of tissue or ulceration extending under the skin edges, pressure ulcer larger at base than at skin surface) noted at 7 o'clock to 12 o'clock, measuring 0.8 cm. The wound bed has 100 % unhealthy tissue with dark green fibrous loose slough, wound edges described as unhealthy, irregular, rolled under, red hard/indurated, macerated. The wound was documented as having 25-75% of purulent thin/thick tan to yellow drainage, and the surrounding skin was documented as red-warm-swollen-macerated/white-abraded/denuded. Documentation further states to start Silver Alginate followed by a dry clean dressing twice daily. - 6/04/2020: the coccyx wound is Unstageable, measuring 3.1 cm in length x 4.0 cm in width, the wound now has undermining from 11-1 o'clock measuring 3.1 cm, 4-5 o'clock, measuring 4.0 cm and 7-8 o'clock, measuring 3.1 cm. The wound now has presence of tunneling (a passageway of tissue destruction under the skin level under the wound) at the center of the wound measuring 3.1 cm. Further description of the wound states in part, 100 % Eschar (dead tissue either hard or soft in texture; usually black, brown, or tan in color) to the wound bed and draining 75% of purulent-thin/thick tan to yellow drainage, wound edges described as unhealthy, irregular, rolled under, red hard/indurated, macerated, and the surrounding skin was documented as red-warm-swollen-macerated/white-abraded/denuded. Documentation further states that the current treatment is effective, although [MEDICATION NAME] (antibiotic to treat an overgrowth of bacteria) was added to the treatment. Instructions were to crush [MEDICATION NAME] and put in wound bed with Santyl ointment daily. Record review revealed no evidence of a weekly pressure ulcer assessment, including location, measurement in centimeters (length, width and depth), stage, presence of tunneling or undermining, drainage amount, drainage color, odor (if present), appearance of wound bed, wound edges, and peri wound, pain, and effectiveness of treatment from 3/25/2020 to 5/11/2020 (6 weeks). During this time the resident's wound progressed from a Stage 3 with 25% unhealthy tissue, moderate drainage, and no odor to an unstageable wound with 100% unhealthy tissue, purulent drainage, and an unhealthy odor. Additionally, weekly wound rounds by the Wound Team Physician and Nurse were not conducted from 4/1/2020 until 6/4/2020. During a surveyor interview on 6/22/2020 at 11:05 AM with nurse, Staff A, who is filling in for the Wound Nurse, revealed that the last time the Wound Physician came to the facility for wound rounds was on 3/25/2020. The last time wound rounds was conducted by the Wound Team was 3/25/2020. Additionally, she stated that she began conducting weekly wound rounds without the Wound Physician starting on 5/11/2020 and the physician returned on 6/4/2020. Further record review revealed that the resident lost 9.4 pounds or 6.7 % of body weight (classified as severe weight loss) from 4/7/2020 to 5/5/2020. During this time, the facility failed to obtain three weekly weights in a row. Additionally, during this time the resident's HiCal (high calorie oral supplement) (60 ml by mouth three times a day) and Liquacel (supplement given for extra protein) (30 ml by mouth once daily) were held from 4/12/2020 to 4/26/2020 due to a recommendation by pharmacy to discontinue supplements as clinically appropriate (as part of the Covid-19 Action Plan). This weight loss occurred during the time frame in which pressure ulcer assessments were not completed weekly. Refer to F692. Review of the nursing progress note, dated 5/28/2020 at 1:16 PM, revealed the MD was notified of the resident's temperature of 99 and worsening wound, which was described as copious (abundant) amounts of purulent drainage noted to dressing and foul odor/warmth/redness to area. A new stat order was given to give [MEDICATION NAME] (antibiotic used to treat bacterial infections) 1 gram x 1 intramuscular (IM), obtain a wound culture, lab work and to [MEDICATION NAME](antibiotic used to treat bacterial infections) 500 mg BID (twice daily) x 7 days. Review of the lab work results, dated 5/28/2020, revealed an elevated white blood cell count (WBC - cells of the immune system involved in protecting the body against infectious disease) of 20.0 (normal range 4-10), and an elevated [DIAGNOSES REDACTED] (type of WBC involved in body's immune response) count of 86.8 (normal range 40-70). A nurse's note on 5/29/2020 at 12:03 PM revealed the resident was noted to have a decrease in intake and a decrease in activity. The physician was made aware and new orders were given for STAT labs, a STAT x-ray of the sacrum, coccyx and chest, a STAT U/A C&S (urinalysis with culture and sensitivities), and an order was given to place a Foley catheter (helps to drain urine). A Foley catheter was placed, x-rays were completed, and urine was obtained for testing. The physician was called to report results and was unable to be reached so a message was left. A nursing progress note, dated 6/1/2020 at 3:23 PM, revealed the physician was made aware of the wound culture results, UA C&S results, and chest x-ray results. A new order was given to start [MEDICATION NAME] (initiated 6/2 in the morning) (antibiotic used to treat bacterial infections) 500 mg twice daily x 7 days, [MEDICATION NAME](initiated 5/29) for elevated WBC's as previously ordered. A review of the 6/1/2020 lab results revealed a low [MEDICATION NAME] (a protein made in the liver; the lab tests the amount of [MEDICATION NAME] in the blood) of 2.5 (normal range 3.5-5.2), a low [MEDICATION NAME] (a protein made in the liver; the lab tests the amount of [MEDICATION NAME] in the blood) of 6.6 (normal range 20-40), and an elevated white blood cell count of 21.9. Further clinical review of the sacral/coccyx x-ray report, dated 5/29/2020, revealed soft tissue ulceration posterior/inferior to the coccyx. A follow up bone scan or MRI was recommended. The UA C&S report, dated 6/1/2020, revealed positive results for Ecoli (bacteria) and confirmatory test for Extended Spectrum Bata Lactamase (ESBL) (bacteria) in the urine. The wound culture results on 5/29/2020 revealed gram-negative bacteria. Review of a nursing progress note, dated 6/3/2020 at 9:54 AM, revealed the physician was made aware of the sacral/coccyx x-ray results with no new orders ([MEDICATION NAME] in place). Review of a nursing progress note, dated 6/4/2020 at 11:07 AM, revealed the physician was made aware of purulent exudate with odor and tunneling in the wound. A new order was given to crush and add [MEDICATION NAME] to the wound bed with the Santyl treatment. A subsequent nursing progress note, for that same day at 12:05 PM, revealed that the resident's son was updated on the resident's status, wound progression, intake, code status, and possible Hospice Consult. Further noting resident's son agreed to sending resident out to (hospital) for second opinion on wound to coccyx. POA (Power of Attorney) is not ready to change code status or ready for a Hospice Consult. A subsequent nursing progress note dated 6/4/2020 at 1:20 PM revealed the resident's physician was contacted about resident's condition and son requesting a second opinion for the resident's wound. An order was given to send the resident to the hospital. Review of the hospital documentation, dated 6/4/2020, revealed that the resident had an elevated White Blood Count of 24.8 and that a CT scan showed a large sacral decubitus ulcer with changes involving the coccyx, concerning for osteo[DIAGNOSES REDACTED] (bone infection). While in the Emergency Department, the resident had a surgical consult, an incision and drainage were performed, and a wound culture was obtained. After the surgical consult, there was concern that the sacral ulcer was a stage 4 and would require a bone biopsy. Additionally, neurosurgical was consulted due to CT findings of possible involvement of spinal canal at distal sacrum. Intravenous fluids were initiated for hydration. Broad spectrum Intravenous [MEDICATION NAME] (an antibiotic used to treat infections) and [MEDICATION NAME] (antibiotic used to treat infections caused by bacteria) were initially started due to the stage 4 sacral ulcer and osteo[DIAGNOSES REDACTED] of the sacrum. The physicians report states in part, recent COVID +, PNA (pneumonia) and ESBL infection .(the resident) presented from SNF (skilled nursing facility) with an infected stage 4 sacral decubitus ulcer found to have osteo[DIAGNOSES REDACTED] of sacrum .her sacral decubitus likely took significant time to form, as it tracks and probes to bone, not just the past week (per SNF documents) .consult with plastic surgery for [REDACTED]. Patient started on Intravenous Ertapenem (antibiotic used to treat bacterial infections) every day for 6 weeks. Palliative Hospice was consulted. During a surveyor interview on 6/22/2020 at 12:05 PM, with the Director of Clinical Operations, she revealed that beginning on 4/11/2020 to the end of April or beginning of May evaluations had stopped due to the pandemic, including weekly pressure evaluations, as the facility had many cases of Covid-19. She further stated that they were focused on keeping patients safe and sustaining life. During a surveyor interview with the resident's Physician (also the Medical Director) on 6/24/2020 at 9:49 AM, he revealed that he was unaware that evaluations were stopped, including weekly pressure evaluations. Additionally, he stated he would have expected weekly assessments, measurements, and description of the wound to be done by nursing in absence of the Wound Physician and Wound Nurse. The physician also added that with the Wound Nurse and Wound Physician being out, he would have hoped that wounds would have been checked remotely by the Wound Team. When asked if he was aware of the resident's status of his/her wound prior to leaving the facility, he revealed he was unaware of the specific description or stage of the wound. During a subsequent surveyor interview with the resident's physician at this time, he was asked about the Covid-19 Action Plan, recommended by pharmacy, that was put into place regarding supplements being held. The MD could not recall the recommendations made from pharmacy relative to supplements being held during the COVID outbreak at the facility. He further stated that he would not have held Resident ID #1's nutritional supplements with his/her ongoing weight loss and active wound. While reviewing the resident's overall weight loss since January, and further weight loss during the month of April/May, with the MD, he revealed he was not aware of the amount of weight loss the resident had and could not recall if the nursing staff called him specifically about his/her weight loss.

Based on surveyor observations, staff interview and medical record review, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care for 1 of 18 residents on narcotic pain medications, resident ID# 4 . Findings are as follows: Resident ID# 4, was readmitted from the hospital on [DATE] and has [DIAGNOSES REDACTED]. This resident was not able to complete a brief mental status score (BIMS) due to severe cognitive impairment and is unable to express basic needs or desires. During an observation of this resident on 3/28/2017 at approximately 1:55 PM he/she was noted in a cardiac chair in the common TV area. The resident was moaning. A Care Plan developed for pain, which was last updated on 3/17/2017 states,monitor and report to nurse symptoms of pain or worsening pain. Administer and monitor for effectiveness of pain medication. Nursing staff on the unit reported that the resident's pain is identified by using a non-verbal pain evaluation tool which identifies pain by facial grimacing, moaning, behaviors or restlessness. This tool identifies the pain scale as follows: 0 indicates no pain 1-3 mild pain 4-6 moderate pain 7-10 severe pain A review of the physician's orders [REDACTED]. Additionally, there is an order dated 2/24/2017 which states, [MEDICATION NAME] 5 mg every 6 hours as needed for pain. A review of the Medication Administration Record [REDACTED] Level 4 pain - 3/4, 3/5 Level 5 pain - 3/4, 3/14, 3/22, 3/23 Level 6 pain - 3/26 Level 7 pain - 3/20, 3/24 Level 8 pain - 3/6, 3/12 A review of the nursing progress notes from 3/1 through 3/27 reveals there was one note to indicate that pain had been addressed. Further review revealed no evidence of interventions to address the residents pain during the 10 other times pain had been identified. During an interview with the unit nurse (staff D) on 3/31/2017 at approximately 10:05 AM, she revealed that the resident's power of attorney was not in agreement with using narcotic medications, therefore the medication was not administered nor had the resident's physician been notified to consider alternatives. During an interview with the Assistant Director of Nursing on 4/1/2017 at approximately 1:00 PM, she could not explain why this resident had not been medicated for moderate to severe pain.