Every finding on record at Adviniacare Pawtucket Pleasant Rehab Center, LLC

Based on clinical record review and staff interviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with a physician's order for fluid restrictions, Resident ID #1.Findings are as follows:Record review revealed Resident ID #1 was re-admitted to the facility in December of 2025 with a diagnoses including, but not limited to, hypo-osmolality (a lower than normal concentration of sodium, electrolytes and proteins in the blood) and hypernatremia (when the sodium level in blood is low, which occurs when there's too much water or not enough sodium).Record review of the resident's care plan initiated on 11/21/2025 revealed the resident has a potential for fluid overload related to polydipsia (excessive thirst) and hyponatremia.Record review of the physician's orders revealed an order dated 12/12/2025 Encourage resident to limit fluid intake, every shift for monitoringRecord review of a progress note dated 12/22/2025 revealed that the resident was found on the floor in the bathroom with a large lump on his/her forehead. The resident was sent emergently to the hospital for an evaluation. Subsequently, the resident was admitted to the hospital with a diagnosis of hyponatremia.Record review of a hospital summary dated 12/22/2025 revealed the resident was admitted due to psychogenic polydipsia (excessive drinking of water ) and was found to be hyponatremic. Lab results revealed hyponatremia of 119 (a normal blood sodium range is between 135 and 145 millimoles per liter (mmol/L) with a serum osmolality (the concentration of solutes in the liquid part of the blood) sodium of 252 (a normal range is 275-295). With a recommendation of a 1500 ml fluid restriction.Record review of a progress note dated 12/24/2025 revealed that the resident's Nurse Practitioner (NP) reviewed the fluid restriction with the resident and the importance of following it and for him/her to alert staff to any urinary retention. Additionally, the NP requested that Nursing staff to continue to monitor the resident's daily fluid intake and report acute changes to the provider, as the resident was hospitalized . The NP reinforced adherence to a 1500 mL per day fluid restriction. Record review of the physician's orders revealed an order dated 12/24/2025 Fluid Restriction 1500 ml Serve 1080 ml Dietary/Day. Dietary Amount per Meal: Breakfast: 480 ml Lunch: 240 ml Dinner: 360 ml Serve 420 ml for Nursing/Day Amount per Shift: 7-3 shift = 200 ml, 3-11 shift = 120 ml, 11=7 shift = 100 ml. every shift for Fluid RestrictionDuring a surveyor interview on 1/22/2026 at 8:36 AM with Nursing Assistant (NA), Staff A, he revealed that the NA's do not document or communicate with nursing, the amount of fluids consumed for any of the residents.During a surveyor interview on 1/22/2026 at 8:45 AM with Licensed Practical Nurse, Staff B, she revealed that the fluid intake for Resident ID #1 had been monitored and completed in his/her electronic record by the NA's and is signed off as completed by the nursing staff in his/her Treatment Administration Records (TAR). She acknowledged that there was no record of the amount of fluid that was provided per shift to the resident or the amount of the resident's fluid intake per shift as indicated by the physician's order for monitoring.Record review of the resident's TAR for December 2025 and January 2026 revealed the resident's orders for fluid restrictions were documented as completed with a check mark.Further review of the record failed to reveal documentation of the amount of fluid the resident consumed per shift daily as ordered. During a surveyor interview on 1/22/2026 at 10:26 AM with the Medical Director, she revealed that she would expect the resident's fluid intake to be monitored and the amount s/he consumed would documented per shift as indicated in the physician's order.During a surveyor interview on 1/22/2026 at 10:44 AM with the Administrator, she acknowledged that the facility failed to monitor the resident's fluid intake per the physician's order.

Based on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice for 2 of 3 residents reviewed relative to skin conditions, Resident ID #s 111 and 3.Findings are as follows:1) Record review revealed Resident ID #111 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, diabetes mellitus type 2, morbid obesity, and osteoarthritis. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. During a surveyor interview on 8/12/2025 at 2:30 PM with Resident ID #111, s/he indicated that s/he had black stuff on his/her toes and that s/he had not been seen by the podiatrist in months. The resident further indicated that his/her feet were painful.Record review of a care plan dated 3/27/2024 revealed the resident had the potential for skin alteration related to decreased mobility with interventions including, but not limited to, complete weekly skin checks and to follow the physician's orders for skin care and treatments. Record review revealed the following physician's orders:-3/3/2025- weekly skin evaluation on Fridays during the evening shift, must complete weekly skin monitoring.-6/9/2025- diabetic foot care every evening shift for monitoring Record review of a Weekly Skin Check assessment dated [DATE] revealed that the resident's skin was intact and without foot concerns.Further record review failed to reveal evidence that a Weekly Skin Check assessment was completed on 8/8/2025 as ordered.During a surveyor interview on 8/13/2025 at 2:20 PM with Nursing Assistant (NA), Staff F, she stated that she cared for Resident ID #111 that day and did not observe anything wrong with the resident's feet. During a surveyor observation of the resident's feet on 8/13/2025 at 2:22 PM in the presence of Staff F, a buildup of dark colored tissue and matter was observed on the left great toe and on the right great and second toes. During this observation, Staff F indicated that the resident's feet appear to be normal and have looked like that for over a week, at least. During a surveyor interview on 8/13/2025 at 2:22 PM with Licensed Practical Nurse (LPN), Staff G, she indicated that she was unaware of any skin alterations with Resident ID #111's feet. During a surveyor observation of the resident's feet on 8/13/2025 at 2:23 PM, in the presence of Staff G, she acknowledged the buildup of dark colored tissue and matter. Staff G indicated that she had not been made aware of the skin alterations of the resident's feet until it was brought to her attention by the surveyor. Record review of a podiatry exam note dated 3/31/2025 revealed the resident's skin color was normal with no ulcers, and house lotion was recommended twice daily to both feet to boost skin integrity. Record review failed to reveal evidence that house lotion was being applied to the resident's feet twice daily. During a surveyor interview on 8/13/2025 at 2:27 PM with the Assistant Director of Nursing Services (ADNS), she indicated that she follows the wounds in the facility and that she was not aware of any areas of concern to Resident ID #111's feet. Additionally, she assessed the resident's feet after the surveyor brought the issue to her attention and she acknowledged the buildup of tissue and matter with dark discoloration. Record review revealed the following physician's orders were obtained after the above-mentioned skin alterations were brought to the facility's attention by the surveyor:-Left first toe- cleanse with normal saline, pat dry, apply bacitracin to wound bed followed by a bordered gauze every evening shift for skin alteration care-Right first toe- cleanse with normal saline, pat dry, apply bacitracin to wound bed followed by a bordered gauze every evening shift for skin alteration care-Soak feet at bedtime with warm water, pat dry followed by lotion to feet every evening shift for foot care. Record review revealed the resident was seen by the podiatrist on 8/14/2025, after the alterations of the resident's feet were brought to the facility's attention. Further review revealed ingrown toenails with pyogenic granuloma (a skin condition characterized by a buildup of immune cells that form a localized raised area) and pain were noted on both of the resident's left and right great toes. Further review revealed red, beefy granulation tissue (new tissue that forms on the surface of wounds during the healing process) was noted to the nail fold. Additionally, silver nitrate (a topical chemical compound that is used to cauterize and remove excess granulation tissue) was applied to both nail folds to cauterize the granuloma.During a surveyor interview and observation of the resident's feet on 8/15/2025 at 1:30 PM with the ADNS, she stated that the buildup on the resident's feet would not have occurred if diabetic foot care had been completed daily as ordered. She further noted that the buildup on the resident's right second toe was able to be removed. Additionally, she reported that after the resident received treatment from the podiatrist, new open areas were identified. The open areas were measured as follows: left great toe, 5 millimeters (mm) by 2 mm; right great toe, 13 mm by 5 mm.During a surveyor interview on 8/15/2025 at 1:36 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the weekly skin check assessment for 8/8/2025 had been completed as ordered. She also acknowledged that Resident ID #111 was found to have new skin alterations on his/her feet after it was brought to the facility's attention by the surveyor, which required physician intervention and resulted in open areas. 2. Record review revealed Resident ID #3 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), and morbid obesity. Review of the MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, indicating the resident's cognition was intact. Record review of a Weekly Skin Check assessment dated [DATE] indicated that the resident's skin was intact with no concerns. During a surveyor interview on 8/15/2025 at 10:45 AM with Resident ID #3, s/he indicated that s/he had a wound on his/her abdomen. The resident further indicated that s/he had picked at an old scar and sometimes they put a bandage on it. During a surveyor observation at the time of the above interview, a superficial wound was observed to the resident's upper left area of his/her abdomen measuring approximately 3 centimeters (cm) by 2 cm. During a surveyor interview on 8/15/2025 at 10:53 AM with LPN, Staff G, she indicated that she was made aware of the open area on the resident's abdomen yesterday, 8/14/2025 on the 7:00 AM to 3:00 PM shift; however, she did not notify the provider for an intervention or complete the skin assessment. During a surveyor interview on 8/15/2025 at 10:57 AM with the DNS, she indicated that she would expect that the provider would be notified of a new open area and that the wound would be reflected on the skin assessment.

Based on record review, staff and resident interview, it has been determined that the facility failed to provide specialized rehabilitation services such as physical therapy and occupational therapy, that are required per the resident's comprehensive plan of care for 2 of 2 residents reviewed with a decline in activities of daily living (ADL) functional abilities, Resident ID #s 8 and 42.Findings are as follows: 1. Record review revealed Resident ID #8 was readmitted to the facility in October of 2024 with diagnoses including, but not limited to, hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side following a stroke and left foot drop (the inability to lift the front part of your foot causing it to drag).During a surveyor interview with the resident on 8/13/2025 at 8:49 AM, the resident reported that they had not received therapy in several months and expressed that they are unable to do as much as they were previously able to.Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating s/he is cognitively intact. Further review revealed the resident was coded as a 6 for functional abilities, indicating s/he does not require assistance for eating, oral and personal hygiene, toileting hygiene, shower/bathing, dressing, and putting on footwear.Record review of a subsequent Quarterly MDS assessment dated [DATE] revealed the resident is now coded as a 4 for functional abilities indicating that s/he requires verbal cues and/or touching/steadying and/or contact guard assistance for eating, oral and personal hygiene, toileting hygiene, shower/bathing, dressing, and putting on footwear.Record review of the care plan revised on 8/4/2025, indicates the resident requires assistance with ADL's related to weakness and stroke with a goal that the resident's ADL status will improve through the next review date. Further review revealed interventions, including, but not limited to, providing one staff member for assistance with personal care, personal hygiene and mouth care and to monitor for changes in status. Record review failed to reveal evidence that a screening for therapy services was completed following an identified decrease in ADL functioning.During surveyor interviews on 8/15/2025 at 9:55 AM and 12:25 PM with the Director of Rehabilitation, Staff A, she revealed that the resident was last discharged from Physical Therapy (PT) and Occupational Therapy (OT) services as of 5/20/2025 and has not received therapy services since. Additionally, she indicated that residents are screened for the need for therapy services during the Quarterly and Annual MDS assessment periods and when nursing notices a decline in residents' functional abilities. Staff A was unable to provide evidence that a therapy screen or referral for therapy was completed after a decline was identified in the Quarterly MDS assessment dated [DATE].2. Record review revealed Resident ID #42 was admitted to the facility in October of 2024 with diagnoses including, but not limited to, urinary retention and coronary artery disease. During a surveyor interview with the resident on 8/13/2025 at 8:50 AM s/he revealed that s/he hasn't had therapy in many months and has not walked. The resident further revealed that s/he wants to walk daily.Record review of an Annual MDS assessment dated [DATE], revealed a BIMS score of 14 out of 15, indicating s/he is cognitively intact. Further review of the MDS failed to reveal evidence that the resident ambulated 10, 50, or 150 feet during the assessment period. Record review of the PT Discharge Summary document dated 6/27/2025 revealed the following short and long-term goals: -Increase the ability to stand supported for 15 minutes to initiate gait activities-Once standing, the resident will improve the ability to safely ambulate 50 feet and make two turns with partial/moderate assistance while using a two-wheeled walker-Once standing, the resident will improve the ability to safely ambulate 150 feet in a corridor with partial/moderate assistance while using a two-wheeled walkerFurther review of the discharge summary document revealed the resident met his/her short and long-term goals and has made consistent progress with skilled interventions. The document indicates that the resident and staff were in-serviced relative to ambulation with contact guard assist and a two-wheeled walker. Additionally, the document indicates the resident's prognosis to maintain his/her current level of functioning is excellent with consistent staff support.Record review of an undated in-service document completed for the resident by the Physical Therapist revealed that a skills demonstration was provided to staff to ambulate the resident with contact guard assistance with a two-wheeled walker, up to 150 feet. During a surveyor interview on 8/13/2025 at approximately 9:00 AM with Licensed Practical Nurse, Staff D, she indicated she was unable to recall the last time the resident ambulated with staff. She further revealed that the last time the resident was assisted with ambulating, s/he was unable to ambulate due to being unsteady and shaking. Additionally, Staff D confirmed that the resident has not had physical therapy since 6/27/2025.During a surveyor interview on 8/15/2025 at 1:10 PM with NA, Staff E, she revealed that the resident always asks to walk, but she is unsure if the resident is supposed to walk. During a surveyor interview on 8/15/2025 at 9:55 AM with Director of Rehabilitation, Staff A, she acknowledged that the resident has not received therapy since s/he was discharged on 6/27/2025. She further revealed that on 8/14/2025 the Physical Therapist completed an evaluation for PT services, after the resident's concerns were brought to nursing by the surveyor. Additionally, she acknowledged that the PT evaluation indicated that the resident had a decline in function since s/he was discharged from therapy services on 6/27/2025.Record review of the PT Evaluation and Plan of Treatment dated 8/14/2025, indicates that the resident presented with significant decrease in muscle strength and balance, decreased safety awareness, and a decrease in activity intolerance with prolonged activities. During a surveyor interview on 8/15/2025 at 1:15 PM with the Director of Nursing Services, she revealed that if the MDS indicates a decline in functional abilities, then she would expect that a request for a therapy screen would be completed. Additionally, the DNS was unable to provide evidence Resident ID#'s 8 and 42 were screened or evaluated by physical therapy after a decrease in ADL function.

Based on surveyor observation, and staff and resident interviews, it has been determined that the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to help prevent the transmission of communicable diseases and infections for 3 of 4 nursing staff, Staff IDs K, L, and M, interviewed regarding contact precautions (infection control measures which require specific personal protective equipment (PPE)); Resident ID #2 requires the use of infection control measures of donning a gown and gloves when entering the resident's room. Findings are as follows:Review of a facility policy titled, Isolation Precautions states in part, .Implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment.Place ‘isolation' sign at door of resident's room.Record review revealed Resident ID #2 was readmitted to the facility with a diagnosis including, but not limited to, ESBL (a multidrug resistant organism) infection in the urine.Record review revealed a physician's order dated 8/7/2025 for contact precautions every shift related to ESBL in the urine. During a surveyor observation on 8/14/2025 at approximately 12:00 PM signage on the resident's door stated, Contact Precautions Everyone Must Clean their hands including before entering and when leaving the room. Providers and Staff Must Also: Put on glove before room entry.Put on gown before room entry.During a surveyor observation on 8/14/2025 at 12:10 PM, Nursing Assistant (NA) Staff K, entered Resident ID #2's room without performing hand hygiene and without putting on a gown or gloves. She assisted the resident with his/her glasses then exited the room without performing hand hygiene. She then entered another resident's room across the hall for a short time then re-entered Resident ID #2's room, without performing hand hygiene and without putting on a gown or gloves. While in the room, Staff K went over to Resident ID #2 and was behind the privacy curtain.During a surveyor interview on 8/14/2025 at approximately 12:15 PM with Staff K, she indicated that she was unaware Resident ID #2 was on contact precautions. She further indicated that she did not see the sign indicating the need for contact precautions. Additionally, she acknowledged that the signage on Resident ID #2's door indicates to perform hand hygiene before entering and exiting the room, and to put on a gown and gloves before entering the room. Furthermore, she indicated that she thought contact precautions only required putting on a gown and gloves when touching the resident. During a surveyor interview on 8/14/2025 at 12:01 PM with Certified Medication Technician, Staff L, she indicated that you only need to wear a gown and gloves when touching a resident on contact precautions.During a surveyor interview on 8/14/2025 at 12:16 PM with Licensed Practical Nurse (LPN), Staff M, she was unable to answer any questions relative to contact precautions. During a surveyor interview on 8/14/2025 at 12:30 PM with the Assistant Director of Nursing Services and Infection Preventionist, Staff H confirmed that Staff K, L, and M had completed competencies related to infection control practices. However, she was unable provide evidence these staff members were able to demonstrate knowledge of the appropriate competencies and skills for caring for a resident on contact precautions. Cross Reference F 880

Based on surveyor observation, record review, and resident and staff interviews, it has been determined that the facility failed to ensure that a resident received adequate supervision for 1 of 1 resident reviewed who was assessed to be at risk for elopement and failed to ensure that a resident is provided assistive devices to prevent accidents relative to smoking for 1 of 1 resident reviewed, Resident ID #31.Findings are as follows:Record review of a facility policy titled Elopement Prevention dated 10/2022, states in part, .The facility maintains a process to assess all residents for risk for elopement, implement prevention strategies for those identified as an elopement risk, Elopement is 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 harm's way.interventions that may be used for residents identified at risk for elopement includes.frequent monitoring of the resident's whereabouts to assure he or she remains in the facility.utilize a sign out book on units for all activities off unit.disciplines working with residents who are at risk for elopement will take into consideration to alert other staff member when resident is left unattended.Record review revealed the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, schizophrenia (a serious mental health condition that affects how people think, feel and behave), anxiety, and tobacco use.Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0 out of 15, indicating s/he has severely impaired cognition.1a. Record review of an elopement evaluation dated 9/6/2024 revealed the resident scored a two; a score value of one or higher indicates the resident is at risk for elopement. Record review revealed a physician's order dated 6/23/2025 to check the resident's wander guard placement (a device used to monitor and prevent individuals from wandering, particularly in environments where safety is a concern. The device is typically worn as a bracelet or ankle band by the individual, and it is equipped with sensors that trigger alarms or alerts if the person moves beyond a designated area. This helps to ensure that people do not accidentally leave a secure environment or wander into potentially dangerous situations) to right wrist, every shift for safety.Review of a care plan, last updated on 4/4/2024, indicates that the resident is at high risk for elopement due to a pattern of wandering behavior. Interventions to address this risk include, but are not limited to, ensuring the resident is always supervised when outside and the use of a wander guard placed on their right wrist.During a surveyor observation on 8/13/2025 at 8:36 AM, the resident was seen entering the 2nd floor elevator with Staff I, a contracted worker performing maintenance on the building.Immediately following the above observation, the resident was observed by the surveyor on the ground floor level outside of the facility in the rear patio area unsupervised by staff. During this observation another resident alerted Nursing Assistant (NA), Staff F, that Resident ID #31 was outside unsupervised. During a surveyor interview on 8/13/2025 at 11:16 AM with Staff F, she acknowledged that another resident brought to her attention that the resident was outside unsupervised and s/he should not have been.During a surveyor interview on 8/13/2025 at 8:54 AM with Licensed Practical Nurse (LPN), Staff J, she acknowledged that the resident was found outside unsupervised and should not have been. During a surveyor interview with Staff I, he indicated that he escorted the resident to the first floor so s/he could smoke. He further indicated that the resident entered the rear patio area after he entered the code into the wander guard keypad system which disabled the alarm to the external door, to allow the resident outside. Additionally, he indicated he was not aware that the resident required supervision while outside of the facility.1b. Review of a facility policy titled Smoking and Safety Evaluation Last revised 10/2022 states in part, An individualized plan of care should be developed for the resident to ensure their smoking safety based on the outcome of their smoking assessment.Safety equipment such as but not limited to smoking apron will be provided as needed based on the outcome of the residents smoking assessment.residents are not permitted to hold their smoking materials.resident smoking materials will be stored by the facility in a locked area.Review of a Smoking and Safety Evaluation dated 8/5/2025 revealed that the resident is a current smoker and requires the use of a smoking apron when s/he smokes tobacco products.Review of a care plan last revised on 7/19/2025 revealed that the resident is a smoker with interventions including, but not limited to, smoking materials to be held by staff, cigarettes and or lighting material to be given by staff at designated times. During a surveyor observation on 8/13/2025 at 8:40 AM the resident was observed sitting outside the facility on the patio with a cigarette and lighter, s/he lit the cigarette, and was observed to be smoking not utilizing a smoking apron per his/her smoking assessment.During surveyor interviews on 8/13/2025 at 8:54 AM and 10:58 AM with LPN, Staff J, she acknowledged that the resident's smoking assessment revealed that the resident should be utilizing a smoking apron and acknowledged the resident had a lighter in his/her procession and should not have.During a surveyor interview on 8/13/2025 at 11:18 AM with the Administrator, she acknowledged that the facility's contracted workers should not have escorted the resident off the unit. Additionally, she indicated that it would be her expectation that the resident would not have been outside unattended, as s/he is an elopement risk. Further, she revealed the resident should not have any smoking implements and requires a smoking apron while smoking.

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 reviewed with an order for contact precautions (infection control measures which require donning a gown and gloves upon entering the resident's room) for Extended-spectrum beta-lactamase producing bacteria (ESBL- an antibiotic resistant bacteria), Resident ID #2.Findings are as follows:Review of a facility policy titled, Isolation Precautions states in part, .Implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment.Place ‘isolation' sign at door of resident's room.Record review revealed Resident ID #2 was readmitted to the facility in June of 2025 with a diagnosis including, but not limited to, ESBL in the urine. Record review revealed a physician's order dated 8/7/2025 for contact precautions every shift related to ESBL in the urine. During a surveyor observation on 8/14/2025 at approximately 12:00 PM revealed signage on Resident ID #2's door stating, Contact Precautions Everyone Must Clean their hands including before entering and when leaving the room. Providers and Staff Must Also: Put on glove before room entry.Put on gown before room entry.During a surveyor observation on 8/14/2025 at 12:10 PM, Nursing Assistant (NA), Staff K, entered Resident ID #2's room without performing hand hygiene and without putting on a gown or gloves. She assisted the resident with his/her glasses then exited the room without performing hand hygiene. She then entered another resident's room across the hall for a short time then reentered Resident ID #2's room again, without performing hand hygiene and without putting on a gown or gloves. While in the room, Staff K went over to Resident ID #2 and was behind the privacy curtain. During a surveyor interview in 8/14/2025 at approximately 12:15 PM with Staff K, she indicated that she was unaware that Resident ID #2 had an order for contact precautions. She further indicated that she did not see the sign on the door indicating contact precautions were in place. Additionally, she acknowledged that the signage on Resident ID #2's door indicates to perform hand hygiene before entering and exiting, and to put on a gown and gloves before entering the room. Furthermore, she indicated that she thought contact precautions only required putting on a gown and gloves when touching the resident. During a surveyor interview on 8/14/2025 at 12:18 PM with Licensed Practical Nurse (LPN), Staff P, she indicated that Resident ID #2 was actively being treated for ESBL and had an order for contact precautions. Additionally, she indicated that she would expect staff to put on a gown and gloves upon entering the resident's room. During a surveyor interview on 8/14/2025 at 12:30 PM with the Assistant Director of Nursing Services and the Infection Preventionist, Staff H, she acknowledged that Resident ID #2 was actively being treated for ESBL in his/her urine and had a physician's order for contact precautions. Additionally, she indicated that she would expect staff to perform hand hygiene before and after entering a resident's room and put on a gown and gloves upon entering a resident's room. Cross reference F-726

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 3 residents reviewed for wound treatment orders, Resident ID #2. Findings are as follows: Review of a facility policy titled, Wound Care, last revised in January of 2023, states in part, .Procedure: 1. Verify that there is a physician's order for this procedure .Steps in Procedure .13. Dress wound .Mark tape with initials, time, and date and apply to dressing . Review of the resident's record revealed s/he was admitted to the facility in October of 2022 with diagnoses which include, but are not limited to, dementia and moderate protein-calorie malnutrition. 1. Record review of a Wound Evaluation & Management Summary dated 4/2/2025, authored by the Wound Physician, revealed the resident has a non-pressure wound (open sore caused by poor circulation or other underlying condition other than prolonged pressure) of the left, anterior (top) shin. Further record review of the above document revealed a treatment order recommendation by the wound physician for the above mentioned wound to apply a collagen sheet (wound dressing to promote healing) with calcium alginate (a dressing that absorbs excess exudate [cells and fluid that seep out of blood vessels, pus], creating a moist wound bed to promote healing) followed by a gauze island with bordered dressing twice daily for 30 days. Record review failed to reveal evidence a physician order was in place for the non-pressure wound on the resident's left shin. During a surveyor observation of the resident on 4/7/2025 at 2:40 PM, in the presence of Registered Nurse, Staff A, the resident had a dressing applied to the top of his/her left shin. The dressing was not labeled with a date or initials. During a surveyor interview with Staff A immediately following the above observation, she revealed that she did not apply the dressing to the resident's left shin and was not aware of who did. She acknowledged that the dressing was not dated or initialed and that there was not a physician's order in place for the treatment of the wound on the shin. 2. Record review revealed the resident has an unstageable pressure wound (full thickness pressure injury where the base of the wound is obscured by slough [yellowish tissue] or eschar [brown, leathery tissue] making it impossible to determine depth or stage of the wound) to his/her left posterior (back) calf. Record review revealed a physician order dated 3/13/2025 to apply Santyl (an ointment used to debride wounds) topically to the left posterior calf every day shift. The order was discontinued on 4/3/2025 at 9:44 AM. Record review revealed a physician order dated 4/5/2025 to cleanse the wound on the left posterior calf with normal saline, pat dry, apply a collagen sheet followed by a calcium alginate sheet to the wound bed followed by a gauze island dressing every day and evening shifts. Additional record review of the Wound Evaluation & Management Summary dated 4/2/2025, revealed a treatment order recommendation to discontinue Santyl and begin applying a collagen sheet to the wound followed by calcium alginate and a gauze island dressing twice daily. Record review of the April 2025 Treatment Administration Record failed to reveal evidence that a treatment order for the left posterior calf wound was in place on the following dates/times: - 4/3/2025, evening shift - 4/4/2025, day and evening shift - 4/5/2025, day shift During surveyor interviews with the Wound Nurse in the presence of the Administrator on 4/7/2025 at 2:55 PM and 3:24 PM, she revealed the wound physician's treatment orders are transcribed by the nurse when received. If they are received after hours she completes them herself the following day. She acknowledged that there was not a treatment order in place for Resident ID #2's non-pressure wound on his/her left anterior calf as ordered by the wound physician. Additionally, she would expect the dressing to be dated and initialed, per facility policy. Further, she acknowledged that there was no treatment in place for the resident's unstageable pressure ulcer on his/her posterior calf on the above-mentioned dates and times, as recommended by the wound physician.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, relative to 3 of 3 units observed for the condition of resident bathrooms and shower rooms. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/24/2025 alleges that areas of the nursing home appear to be under construction, but appear to be sitting in a state of disrepair . In addition, the complainant revealed his/her loved one's room smells overwhelmingly of urine, and that s/he mentioned this on 3/14/2025 and was told that they would have housekeeping do a deep cleaning. When s/he returned on 3/21/2025, the room still smelled of urine. 1. Surveyor observations on 3/26/2025 at approximately 9:00 AM of the 1st floor revealed the following: - The 1st floor shower room had black matter inside and around the base in the shower stall to the left. The grout in the corners of the stall had black and pink matter extending halfway up the tile. - The bathroom in resident room [ROOM NUMBER] had an odor of urine. Additionally, the inside of the toilet bowl was discolored with brown stains. 2. Surveyor observations on 3/26/2025 at approximately 9:20 AM of the 2nd floor revealed the following: - The 2nd floor shower room revealed pink and black matter all along the base of the shower stall. The grout in the corners of the stall had pink and black matter extending halfway up the grout in one of the shower stalls. - The bathroom identified in the above mentioned community reported complaint had an odor of urine. Additionally, the inside of the toilet bowel was discolored with brown stains. - The bathroom in resident room [ROOM NUMBER] had an odor of urine. Additionally, the inside of the toilet bowl was discolored with brown stains. - The bathroom in resident room [ROOM NUMBER] had a fairly large hole at the bottom of the wall across from the toilet. It measured approximately 12-15 inches. 3. Surveyor observations on 3/26/2025 at approximately 9:40 AM of the 3rd floor revealed the following: - The 3rd floor shower room had black matter all along the base of the middle shower stall. The grout had black and pink matter extending halfway up the tile. Additionally, when the curtain to the stall was opened, multiple small flies were observed to fly out. - Resident room [ROOM NUMBER] had a strong odor of urine and the bed closest to the window had 2 urinals, half full, hanging off the foot of the bed. - The bathroom in resident room [ROOM NUMBER] had a strong odor of urine. Additionally, the inside of the toilet bowl was discolored with brown stains. - The inside of the toilet bowl in resident room [ROOM NUMBER] was stained with a brown substance. - On the [NAME] unit, a wall was observed to be partially plastered with three visible holes. - Multiple wheelchairs, recliners, a bed frame, and small table were stored in the [NAME] unit common area. During surveyor observations and simultaneous interview with the Administrator, Director of Nursing, and Maintenance Director on 3/26/2025 at approximately 10:00 AM, they acknowledged the above mentioned observations and indicated that they would remedy the issues by replacing toilet bowls, cleaning, and fixing the areas that are in disrepair.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for antibiotic use, Resident ID #1. Findings are as follows: Review of community reported complaint submitted to the Rhode Island Department of Health on 10/1/2024 alleges that the resident was admitted to the facility from the hospital. Additionally, 3 days later the resident had returned to the hospital due to a fever and infection. Record review revealed the resident was admitted to the facility in September of 2024 with diagnoses including, but not limited to, urinary tract infection (UTI), bacteremia (the presence of bacteria in the blood which can be serious and require antibiotics), and sepsis (a life-threatening reaction to an infection). Review of a hospital document titled, Continuity of Care - Post-Acute Facility dated 9/24/2024 revealed that the resident was to continue receiving an antibiotic, Sulfamethoxazole-trimethoprim (Bactrim) 200-40 milligrams (mg)/5 milliliters (mL) oral suspension (liquid), 20mL (to equal 800-160mg) twice daily for 21 days for bacteremia. Additional review of the hospital document revealed that the resident last received his/her Bactrim on 9/24/2024 at 8:39 AM and was scheduled to receive his/her next dose of Bactrim on 9/24/2024 at 8:00 PM. Record review of a progress note dated 9/24/2024 authored by Licensed Practical Nurse, Staff A, revealed that the resident arrived on the unit at 5:30 PM and all medications were verified with a provider without any changes to the resident's medications. Record review revealed a physician's order for Bactrim oral suspension 200-40mg/5mL and to give 20mL (to equal 800-160mg) with a start date of 9/25/2024 at 8:00 PM. Additional review of the order revealed the start date was transcribed incorrectly for 9/25/2024 instead of 9/24/2024 at 8:00 PM which caused the resident to miss 2 doses of his/her Bactrim on 9/24/2024 (evening dose) and 9/25/2024 (morning dose). Review of the September 2024 Medication Administration Record (MAR) revealed that the resident did not receive his/her Bactrim on 9/25 (evening dose) or 9/26 (morning dose), the reasoning documented as other. Review of the progress notes revealed the following relative to the Bactrim: -9/25/2024: .on order -9/26/2024: .waiting for pharmacy. Additional review of the September 2024 MAR revealed that the resident did not receive 4 consecutive doses of his/her Bactrim. Record review failed to reveal evidence that a provider was made aware of the missed Bactrim doses. Review of a progress note authored by the Physician dated 9/26/2024 at 5:22 PM, revealed the resident was to complete a course of Bactrim for bacteremia. Additionally, the resident's vital signs were reviewed and s/he was considered stable at present. Further review of the progress notes revealed that the resident had experienced a change in condition as evidenced by the following: -9/27/2024 at 1:59 PM: The resident complained of severe abdominal pain, increased weakness and fatigue, difficulty urinating, chills, and was noted to have the following abnormal vital signs: Blood pressure (BP):144/89 (Normal BP 120/80) Heart rate (HR): 137 (Normal HR 60-100) Respiratory rate (RR): 24 (Normal RR 12-20) Temperature (T): 103.9 (Normal T 98.6) Additionally, a provider ordered the resident to be transferred to the hospital for an evaluation. Review of the hospital Emergency Department notes dated 9/27/2024 revealed that the resident presented with findings consistent with urosepsis (a serious condition that happens when a UTI spreads to the kidneys causing sepsis). Additionally, the resident required 2 intravenous antibiotics, intravenous fluids, and placement of a urinary catheter (a flexible tube that drains urine from the bladder). During a surveyor interview on 10/2/2024 at 12:49 PM with LPN, Staff B, she revealed that the facility has a Pyxis machine (a machine securely stores an emergency supply of medication) that nursing staff has access to in the event that a resident requires medication that has not been delivered by the pharmacy or if a medication runs out. She further revealed that the Pyxis machine currently has 16 tablets of Bactrim 800-160mg tablets and she indicated that she would have called a provider to ask if the Bactrim tablet form could have been substituted for the liquid Bactrim to prevent the resident from missing a dose. Additionally, she revealed that she would notify a provider if the resident missed a dose of medication, especially an antibiotic, and would also document it. During a surveyor interview on 10/2/2024 at 2:43 PM with Staff A, she was unable to explain why the Bactrim order start date was transcribed incorrectly and revealed that she did not notify the provider to inquire if the Bactrim tablet form, which was available to administer, could be substituted for the Bactrim liquid form (the resident was receiving other medications in tablet form). An attempt to reach the Nurse Practitioner and Physician were made on 10/2/2024 at 2:51 PM and 3:18 PM, respectively, and voice messages were left. No return calls were received. During a surveyor interview on 10/2/2024 at approximately 1:00 PM with the Director of Nursing Services and the Administrator, they revealed that they would have expected the resident to receive his/her Bactrim as ordered or notify a provider if the Bactrim was not administered to the resident.

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 2 of 2 residents reviewed for an indwelling catheter (foley; a flexible tube that drains urine from the bladder), Resident ID #s 1 and 2. Findings are as follows: 1) According to the 2022 Brunner & Suddarth's Textbook of Medical-Surgical Nursing 15th Edition, page 1542 states, .the average person voids 1-2 L [Liters, equal to 1000 milliiters (mL) - 2000 mL] of urine in 24 hours . Review of a community report complaint submitted to the Rhode Island Department of Health on 10/1/2024 alleges that Resident ID #1 was admitted to the facility and accidentally removed his/her foley the following day. Additionally, Resident ID #1 was transferred to the hospital 3 days after admission to the facility for a fever and infection. Review of a facility policy titled, INTAKE AND OUTPUT last revised 12/2019 states in part, .Record any output as soon as possible after collecting .Resident should be provided a hat [urinary collection device for measuring] for accurate output measurement .At the end of your shift, total the amounts .and any amount of output obtained .Documentation .The date and time the resident's intake and output was measured and recorded . a) Record review revealed Resident ID #1 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, urinary tract infection (UTI), bacteremia (the presence of bacteria in the blood which can be serious and requires antibiotics), and sepsis (a life-threatening reaction to an infection). Record review revealed that the resident was admitted to the facility with a foley. Record review revealed the following progress notes: -9/25/2024 at 6:46 AM the resident removed his/her foley and a provider was made aware -9/25/2024 at 1:22 PM the Nurse Practitioner was notified of the foley removal and ordered staff to monitor urinary output Record review revealed the following physician's orders relative to urinary output monitoring: -9/25/2024 Monitor urinary output every shift -9/26/2024 Monitor urinary output and use a hat to measure every shift due to foley removal Review of the September 25th through September 27th, 2024, Treatment Administration Record (TAR) revealed the following relative to urinary output: -9/25 Evening shift (3:00 PM - 11:00 PM): Documented as completed without a measurement -9/25 Night shift (11:00 PM - 7:00 AM): Documented as completed without a measurement -9/26 Morning shift (7:00 AM - 3:00 PM): Documented as completed (600mL output per a progress note) -9/26 Evening shift: Documented as completed without a measurement -9/26 Night shift: 200 mL output documented -9/27 Morning shift: 200 mL output documented (progress note indicated one wet brief) Additional record review revealed the resident's total urinary output on the following days: -9/25/2024: No output recorded -9/26/2024: 800 mL -9/27/2024: 200 mL (prior to the resident being transferred to the hospital at approximately 2:00 PM) Record review failed to reveal evidence that a provider was made aware of the resident's low urinary output on the above-mentioned dates until the resident had a change in condition and was transferred to the hospital. Review of the hospital Emergency Department notes dated 9/27/2024 revealed that the resident required a foley to be placed for strict urinary intake and output monitoring. During a surveyor interview on 10/2/2024 at 12:49 PM with Licensed Practical Nurse, Staff B, she revealed that she would contact the provider if a resident's urinary output was less than 200-300 mL in one shift (8 hours). b) Record review revealed Resident ID #2 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, neuromuscular dysfunction of the bladder. Review of a care plan focus area dated 9/13/2024 revealed that the resident has a foley with an intervention to monitor and document intake and output. Record review revealed a physician's order dated 9/13/2024 to monitor urinary output every shift due to a foley catheter. Review of the September 13th through September 25th, 2024, TAR revealed the resident's urinary output was not documented on the following dates and shifts: -9/20 morning shift -9/21 morning shift -9/22 evening shift An attempt to reach the Nurse Practitioner and Physician were made on 10/2/2024 at 2:51 PM and 3:18 PM, respectively. Voice messages were left; however, no return calls were received. During a surveyor interview on 10/2/2024 at approximately 1:00 PM with the Director of Nursing Services (DNS) and the Administrator, they revealed that they would have expected the resident's urinary output to be measured and documented as ordered. Additionally, the DNS would not acknowledge that a provider should have been notified for Resident ID #1's low urinary output.

46715 46241 Based on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 4 of 4 residents reviewed for tobacco use, Resident ID #s 26, 40, 44, and 86 and 1 of 3 residents reviewed for limited range of motion, Resident ID #16. Findings are as follows: 1. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October 2023 states in part, .Current Tobacco Use .Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. 3. If the resident is unable to answer or indicated that they did not use tobacco of any kind during the 7-day look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Coding Instructions Code 0, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicated that the resident used tobacco in some form during the look-back period . 1a. Record review revealed Resident ID #26 was readmitted to the facility in September of 2023 with a diagnosis including, but not limited to type two diabetes mellitus, with diabetic neuropathy (nerve damage). Review of a progress note dated 3/12/2024 states in part, Smoking status: Resident uses tobacco products . Review of a facility provided document titled Quality Review - Smoking Program last revised 7/11/2024 revealed Resident ID #26 is an independent smoker. Review of a Minimum Data Set (MDS) assessment dated [DATE], Section J, titled, Health Condition revealed the resident was coded a 0 for tobacco use, indicating they did not use tobacco products during the 7-day look-back period. 1b. Record review revealed Resident ID #40 was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, type two diabetes mellitus, with diabetic neuropathy. Review of a progress note dated 2/19/2024 states in part, Smoking status: Resident uses tobacco products . Review of a facility provided document titled Quality Review - Smoking Program last revised 7/11/2024 revealed Resident ID #40 is an independent smoker. Review of a MDS assessment dated [DATE], Section J, titled, Health Condition revealed the resident was coded a 0 for tobacco use, indicating they did not use tobacco products during the 7-day look-back period. 1c. Record review revealed Resident ID #44 was readmitted to the facility in September of 2022 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of a progress note dated 3/27/2024 states in part, Smoking status: Resident uses tobacco products . Review of a facility provided document titled Quality Review - Smoking Program last revised 7/11/2024 revealed Resident ID #44 is an independent smoker. Review of a MDS assessment dated [DATE], Section J, titled, Health Condition revealed the resident was coded a 0 for tobacco use, indicating they did not use tobacco products during the 7-day look-back period. 1d. Record review revealed Resident ID #86 was readmitted to the facility in July of 2024 with a diagnosis including, but not limited to, type one diabetes mellitus with hyperglycemia (high blood sugar). Review of a progress note dated 5/14/2024 states in part, Smoking status: Resident uses tobacco products . Review of a facility provided document titled Quality Review - Smoking Program last revised 7/11/2024 revealed Resident ID #86 is an independent smoker. Review of a MDS assessment dated [DATE], Section J, titled, Health Condition revealed the resident was coded a 0 for tobacco use, indicating they did not use tobacco products during the 7-day look-back period. During a surveyor interview on 7/17/2024 at 2:01 PM, with the MDS Coordinator, she indicated that she does not interview the residents about their smoking status. Additionally, she was unable to provide evidence of why the above-mentioned resident's tobacco use was not accurately coded on the MDS Assessments. 2. Record review revealed Resident ID #16 was admitted to the facility in November of 2023 with a diagnosis including, but not limited to, left hand contracture. Record review revealed a care plan focus area initiated on 6/13/2024 relative to him/her having a left-hand contracture. Review of a MDS assessment dated [DATE], Section GG, titled, Functional Abilities and Goals revealed the resident was documented as having no impairments to his/her range of motion. During a surveyor interview on 7/18/2024 at 8:10 AM, with the MDS Coordinator, she was unable to provide evidence that the 5/21/2024 MDS Assessment for Resident ID #16 was coded accurately, to reflect his/her impaired range of motion, due to his/her left hand contracture. During a surveyor interview on 7/18/2024 at 9:42 AM, with the Director of Nursing Services, she was unable to provide evidence that Resident ID #s 16, 26, 40, 44, and 86's MDS Assessments were completed accurately.

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 for 2 of 2 residents reviewed relative to Multi-drug Resistant Organisms (MDRO), Resident ID #s 17 and 86, 1 of 1 resident reviewed for enhanced barrier precautions Resident ID #38, 2 of 2 residents reviewed for humidified oxygen storage, Resident ID #s 45 and 58, and 1 of 2 residents reviewed for Bilevel positive airway pressure (BiPAP; a treatment that uses mild air pressure to keep your airways open while you sleep) cleaning schedule, Resident ID #11. Findings are as follows: 1. Review of the Center for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug resistant Organisms (MDROs) last updated 7/12/2022 revealed in part, .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions [gown and glove upon entering the room] do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization [the bacteria is living on or in the body not causing symptoms but can the bacteria can be spread to others] as well as for residents with MDRO infection or colonization .Summary of Personal Protective Equipment (PPE) Use and Room Restriction When Caring for Residents in Nursing Homes .Enhanced Barrier Precautions .All residents with any of the following .Infection or colonization with an MDRO when Contact Precautions do not otherwise apply . Review of a facility policy titled Enhanced Barrier Precautions states in part, .Enhanced Barrier Precautions is applicable for residents with any of the following: Infection or colonization with a MDRO when contact precautions do not apply . 1a. Record review revealed Resident ID #17 was admitted to the facility in May 2024 with diagnoses including, but not limited to, paraplegia and type 2 diabetes mellitus. Review of Resident ID #17's discharge summary from the hospital dated 5/17/2024 revealed that the resident was on contact isolation precautions related to a diagnosis of Methicillin-Resistant Staphylococcus Aureus (MRSA; a MDRO). Record review failed to reveal evidence that the resident was on Contact Precautions or Enhanced Barrier Precautions related to the diagnosis of MRSA. Surveyor observations on 7/16, 7/17, and 7/18/2024 failed to reveal evidence that the resident was on Contact or Enhanced Barrier Precautions relative to the diagnosis of a MDRO, per the facility policy or CDC. 1b. Record review revealed Resident ID #86 was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, type 1 diabetes mellitus and adjustment disorder. Record review revealed the resident was hospitalized in May of 2024 and returned from the hospital on contact precautions related to the diagnoses of MRSA and Extended-spectrum beta-lactamase (ESBL; MDRO). Review of the above-mentioned document revealed that the facility was notified that the resident was returning to the facility on MRSA/ESBL precautions. Record review revealed that the resident was hospitalized in June of 2024 and returned to the facility on contact precautions from the hospital. Additionally, it reiterated that the resident received a MRSA diagnosis on 5/14/2024. Review of Resident ID #86's July 2024 hospital documentation revealed that the resident was on contact precautions related to having a MDRO. Further review revealed that the resident was diagnosed with pneumonia with a history of MRSA and was started on antibiotics. Surveyor observations on 7/16, 7/17, 7/18 and 7/19/2024 failed to reveal evidence that the resident was on Contact or Enhanced Barrier Precautions relative to the diagnosis of a MDRO, per the facility policy or CDC. Further record review failed to reveal evidence the facility retested the resident for MRSA or ESBL prior to removing him/her from the precautions that s/he was placed on while in the hospital. During a surveyor interview on 7/18/2024 at 1:14 PM and 7/19/2024 at 10:24 AM with the Director of Nursing Services (DNS), she was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of communicable diseases. 2. Review of a facility policy titled Enhanced Barrier Precautions states in part, .Enhanced Barrier Precautions is applicable for residents with any of the following: Infection or colonization with a MDRO when contact precautions do not apply .wounds .and or indwelling medical devices (e.g., central lines, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) regardless of MDRO colonization status. Record review revealed that Resident ID #38 was readmitted to the facility in January of 2024 with a diagnosis including, but not limited to, gastrostomy status (a tube that provides direct access to the stomach for supplemental feeding, hydration or medication). During a surveyor observation on 7/18/2024 at 8:45 AM revealed Licensed Practical Nurse (LPN), Staff A, was administering Resident ID #38's medications via a feeding tube without wearing a gown. Further observation revealed signage posted at the resident's door which indicated to wear a gown during device care or with care of the feeding tube. During a surveyor interview on 7/18/2024 at 9:10 AM with Staff A, she acknowledged that she did not wear a gown while the administration the medications via the feeding tube. During a surveyor interview on 7/18/2024 at 10:35 AM with the DNS, she revealed that she would have expected the nurse to have worn a gown when administering medications via a feeding tube. 3a. Record review revealed that Resident ID #45 was admitted to the facility in March of 2018 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and heart failure. Record review revealed that the resident utilized oxygen via nasal cannula (a device that delivers oxygen through two prongs into your nostrils). During surveyor observations on 7/17 and 7/18/2024 revealed the resident was receiving humidified oxygen via nasal cannula. Further observation revealed that the oxygen humidifier container was placed on the floor instead of the shelf of the oxygen concentrator. During a surveyor interview on 7/18/2024 at 2:52 PM with LPN, Staff D, she acknowledged that the humidifier was on the floor in the resident's room and not on the shelf of the concentrator. Additionally, she revealed that it should not be on the floor. 3b. Record review revealed that Resident ID #58 was admitted to the facility in September of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and heart failure. Record review revealed that the resident utilized oxygen via nasal cannula. During surveyor observations on 7/17 and 7/18/2024 revealed the resident was receiving humidified oxygen via nasal cannula. Further observation revealed that the oxygen humidifier container was placed on the floor and not on the shelf of the oxygen concentrator. During a surveyor interview on 7/18/2024 at 2:45 PM with Staff D, she acknowledged that the humidifier was on the floor on the resident's room and not on the shelf of the oxygen concentrator. Additionally, she acknowledged that it should not be on the floor. During a surveyor interview on 7/18/2024 at 3:32 PM with the DNS, she revealed that she would expect the humidifier bottles would not be stored on the floor. 4. Review of a facility policy titled Respiratory - Pap Equipment states in part, .Equipment cleaning Daily .place the .BIPAP tubing, nasal mask or pillow and headgear into a sink with warm soapy water. (Use a small amount of mild dish detergent) Agitate these supplies in the water for approximately 5 minutes. Rinse well with warm water and allow to dry until all moisture is gone .humidifier care .clean once weekly with warm soapy water and rinse thoroughly. To disinfect, place vinegar/water solution (1 part vinegar 3-5 parts water) in clean humidifier. Soak for 30 minutes and rinse thoroughly . Record review revealed that Resident ID #11 was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and heart failure. Record review revealed a physician's order with a start date of 6/4/2022 for a BIPAP to be used at night. Record review failed to reveal evidence of an order for daily cleaning of the BIPAP or weekly cleaning of the humidifier. Review of the July 2024 Medication Administration Record revealed that Staff D documented that she performed a cleaning of the BIPAP filter on 7/17/2024. During a surveyor observation on 7/18/2024 at 1:24 PM of the residents BIPAP machine revealed the door that holds the filter in place for the BIPAP was broken and the filter was missing. During a surveyor interview on 7/18/2024 at 3:32 PM with LPN Staff D, She revealed that she documented that she completed the filter cleaning on 7/17/2024 but acknowledged to the surveyor that she did not complete the cleaning. During a surveyor interview on 7/19/2024 at 12:18 PM with the DNS, she revealed that she would have expected the BIPAP machine to be cleaned. Additionally, she was unable to provide evidence that the resident's BIPAP was cleaned to according to the facility policy. 47939

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for assistance with meals, Resident ID #42. Findings are as follows: Record review revealed that the resident was admitted to the facility in October of 2021 with diagnoses including but not limited to Parkinson's disease, dysphagia (difficulty swallowing) and, contractures of both hands (shortening or hardening of the muscles). Record review revealed a care plan, last revised on 8/16/2022, which revealed the resident has a nutritional problem related to obesity and requires the physical assistance of staff for meals and fluids. Record review revealed a physician's order dated 7/16/2022 for one to one assistance with feeding and to position the resident upright at 90 degrees during meals. During surveyor observations of the resident failed to reveal s/he was upright at 90 degrees while being assisted with his/her meal, on the following dates and times: -7/17/2024 at 12:35 PM -7/18/2024 at 8:40 AM -7/18/2024 at 12:37 PM During a surveyor interview on 7/18/2024 at 12:37 PM with Nursing Assistant, Staff C, he acknowledged that the resident was not upright at 90 degrees while being assisted with his/her meal and indicated that s/he should have been. During a surveyor interview on 7/18/2024 at 2:52 PM with Licensed Practical Nurse, Staff D, she acknowledged that the resident has a physician's order to be upright at 90 degrees at mealtimes. She revealed she was not aware that the resident's head of the bed was not at 90 degrees during the above-mentioned mealtimes and indicated s/he should have been. During a surveyor interview with the Director of Nursing Services on 7/18/2024 at 3:37 PM, she was unable to provide evidence that the resident's head of the bed was upright at 90 degrees during mealtimes per the physician's order. 46539

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with an indwelling foley catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #11. Findings are as follows: According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Volume 2, 10th Edition, page 252 states, .the usual daily urine volume in the adult is 1-2 Liters or 1000-2000 cubic centimeters (cc). Additionally, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage . Record review revealed the resident was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, acute heart failure and obstructive uropathy (a structural or function hindrance of the normal flow of urine). Review of a care plan dated 1/6/2024, revealed the resident requires an indwelling foley catheter with interventions including, but not limited to, monitor, record and report signs and symptoms of a urinary tract infection including no urine output. Record review of a hospital discharge summary dated 7/10/2024 revealed the resident was discharged following his/her hospitalization with a diagnosis of complicated urinary tract infection with bacteremia (bacertia in the blood), septic shock (life-threatening condition caused by severe localized or system wide infection), and acute kidney injury. Record review of the documented urinary output from 7/1/2024 through 7/17/2024, failed to reveal evidence that the output was measured and recorded each shift for 46 of 51 opportunities. During a surveyor interview with the Director of Nursing Services on 7/19/2024 at approximately 12:15 PM, she revealed it would be her expectation for urinary output to be documented every shift for a resident with a foley catheter. Additionally, she was unable to provide evidence that the facility provided appropriate treatment and services for a resident with a urinary catheter, including documenting the urinary output to assess for adequacy of renal function.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed receiving nutrition and medications via a gastrostomy tube (g-tube; (a tube that provides direct access to the stomach for supplemental feeding, hydration or medication), Resident ID #38. Findings are as follows: Review of a facility provided policy titled, Enteral Tube Medication Administration dated 12/2019 states in part, The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes .check for proper tube placement using air and auscultation [listening] .check gastric content for resident feeding. Return residual volumes to the stomach . Record review revealed that the resident was readmitted to the facility in January of 2024 with a diagnosis including, but not limited to, gastrostomy status. Record review revealed a physician's order dated 7/21/2023 to check g-tube placement every shift before and after any feeds and before and after any medication administration. During a surveyor observation of the medication administration task on 7/18/2024 at 8:45 AM with Licensed Practical Nurse, Staff A, she was observed to disconnect the resident's feeding. She then administered the medications and reconnected the tube feeding to the resident. Staff A, failed to check for proper g-tube placement after disconnecting the feeding, prior to administering medications or before reattaching the feeding to the resident. During a surveyor interview on 7/18/2024 at 9:10 AM with Staff A, she acknowledged that she did not check for proper g-tube placement at any time during the medication administration task. Additionally, she acknowledged that she did not follow the physician order to check for placement. During a surveyor interview of 7/18/2024 at 10:35 AM with the Director of Nursing Services she was unable to provide evidence that the resident received the appropriate treatment and services to prevent complications relative to checking for placement of the tube prior to medication administration.

Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders Based on record review and staff interview it has been determined that the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the treatment of mental disorders for 1 of 2 residents reviewed for trauma informed care, Resident ID #40. Findings are as follows: Record review revealed that the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, post-traumatic stress disorder, bipolar disorder, major depressive disorder, and anxiety disorder. Review of a document titled PSYCHIATRIC EVALUATION & CONSULTATION dated 3/26/2024 revealed that the resident endorses flashbacks and spoke openly about a trigger. It further revealed a plan to increase his/her buspirone 15 milligrams (mg) twice a day (BID) (anxiety medication) and add hydroxyzine 25mg as needed (PRN) for anxiety to manage acute symptoms. Review of a progress note dated 3/26/2024 authored by the Nurse Practitioner (NP), states in part, .agree to increase buspirone to 15mg bid and start hydroxyzine 25mg bid prn for anxiety . Record review revealed a physician's order with a start date of 3/26/2024 for buspirone 15 mg once a day for anxiety. Further review revealed a physician's order for hydroxyzine 25 mg every 12 hours as needed for anxiety with a start date and end date of 3/26/2024. Record review failed to reveal evidence that the resident was receiving buspirone 15mg BID and hydroxyzine 25mg BID PRN for anxiety as ordered. Record review revealed that the resident had a Patient Health Questionnaire (PHQ-9; a tool for screening, diagnosing, monitoring, and measuring the severity of depression) completed on the following dates, which resulted in the following scores: - 1/12/2024 with a score of 9 indicating mild depression - 4/5/2024 with a score of 12 indicating moderate depression - 5/16/2024 with a score of 10 indicating moderate depression - 5/18/2024 with a score of 15 indicating moderately severe depression - 6/10/2024 with a score of 19 indicating moderately severe depression Further review of the progress notes revealed on the following dates the resident was experiencing anxiety or depressive symptoms: -3/4/2024 baseline anxiety present -4/9/2024 I'm having a hard time with sleep, anxiety and depression. [S/he] also scored positive for little interest in doing things, feeling tired, low appetite and feeling bad about [him/herself]. [S/he] states [s/he] feels this way due to [his/her] health and adjustment to the facility. [S/he] also reported ongoing daily flashbacks of the trauma [s/he] has experienced in [his/her] past -5/20/2024 [S/he] is unable to tolerate imaging without medication due to anxiety, has taken Ativan [anxiety medication] in the past for anxiety r/t [related to] imaging -6/7/2024 At 2pm [the resident] called writer into room to state [s/he's] having increased anxiety r/t urine specimen. writer asked [him/her] to elaborate to which [s/he] then stated, 'can you have psych talk to me this week'. writer placed resident on Psych list -6/10/2024 [Social Worker] reached out to supportive care .to inform her of high PHQ9 and .stating [the resident] was having nightmare and panic attacks causing [the resident] not to sleep. She states she will come in tomorrow to see [the resident] . 7/16/2024 .new recommendations Clonidine 0.1 mg BID PRN for anxiety/panic x28days (pt [patient] has taken in past with good effect). reported to .NP with approval of recommendations . During a surveyor interview on 7/18/2024 at 9:40 AM with the Director of Nursing Services, she was unable to explain why the medications were not transcribed as ordered. Additionally, she was unable to provide evidence that the resident was provided with the necessary behavioral health care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Review of an additional PSYCHIATRIC EVALUATION & CONSULTATION dated 7/16/2024 revealed that the psychiatric provider documented that the resident was currently receiving buspirone 15 mg twice a day and hydroxyzine 25 mg every 12 hours as needed for anxiety when the resident was not, the resident wasonly receiving buspirone 15 mg once a day. During a surveyor interview with the Psychiatric provider on 7/19/2024 at 9:37 am, she revealed that the resident was started on clonidine on 7/16/2024 as the as needed because the hydroxyzine was ineffective. She was unaware that the order for hydroxyzine was not transcribed correctly, resulting in the resident only receiving it for one day. Additionally, she revealed that she was unaware that the resident was only receiving buspirone 15mg once daily, not twice a day as ordered. A surveyor interview was attempted with the NP on 7/18 and 7/19/2024, but were unsuccessful as the NP did not return the phone calls. 46539

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 30 opportunities for errors observed during the medication administration task, there were 5 errors resulting in an error rate of 16.67% relative to enteral medication administration via gastrostomy tube (g-tube; (a tube that provides direct access to the stomach for supplemental feeding, hydration or medication). Findings are as follows: Review of a facility policy titled, Enteral Tube Medication Administration dated 12/2019 states in part, The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes .Administer each medication separately and flush the tubing between each medication .Pour dissolved/dilute medication in syringe and unclamp tubing, allowing medication to flow by gravity . Record review revealed Resident ID #38 has the following physician orders: - Nortriptyline HCl Oral Capsule 10 milligrams (MG) via g-tube one time a day for depression - Cyanocobalamin Tablet 1000 micrograms (MCG) 1 tablet via g-tube one time a day for supplement - Cholecalciferol Tablet 1000 UNIT Give 2 tablets via g-tube one time a day for supplement - Folic Acid Tablet 1 MG Give 1 tablet via g-tube one time a day for supplement - Metoprolol Tartrate Tablet 25 MG give one tablet via g-tube two times a day for hypertension During a surveyor observation of the medication administration task on 7/18/2024 at 8:45 AM with Licensed Practical Nurse, Staff A, she was observed to crush all of the above mentioned medication together. She was then observed to administer the mixed medications to the resident via his/her g-tube. Staff A, was also observed to push medication with a piston syringe into the g-tube and not via gravity per the facility's policy. During a surveyor interview on 7/18/2024 at 9:10 AM with Staff A, she acknowledged that she did not administer each medication separately and did not flush the tubing between each medication. Additionally, she revealed that she did not let the medication flow via gravity and pushed all the medications. During a surveyor interview of 7/18/2024 at 10:35 AM with the Director of Nursing Services (DNS) she revealed that she would have expected Staff A, to administer each medication separately via the g-tube and allow the medication to run via gravity per the facility policy. The DNS was unable to provide evidence that the facility ensured each resident's medication regimen is free from a medication error rate of 5% or greater.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to accommodate residents' food preferences for 1 of 1 resident reviewed, Resident ID #42. Findings are as follows: Record review revealed that the resident was admitted to the facility in October of 2021 with diagnoses including, but not limited to, Parkinson's disease, dysphagia, (difficulty swallowing) and contractures of both hands (shortening or hardening of the muscles). Record review of a care plan, last revised on 8/16/2022, which revealed the resident has a nutritional problem related to obesity and requires physical assistance of staff for meal and fluids. The intervention includes, but is not limited to, identify and honor food preferences. Record review revealed a progress note, authored by the Registered Dietitian, dated 7/18/2024 which revealed, the resident will have soft salad sandwiches offered at lunch and dinner, per the resident's preference. Review of the resident's tray ticket revealed Notes: Soft salad sandwich and large portions. Surveyor observations of the resident during the lunch meals revealed the following: -7/17/2024 at 12:35 PM the sandwich was crossed off of the tray ticket and the resident did not receive a sandwich -7/18/2024 at 12:37 PM the sandwich was listed on the tray ticket, but there was no sandwich on the resident's lunch tray During a surveyor interview on 7/17/2024 at 12:40 PM with Licensed Practical Nurse, Staff B, she acknowledged that the sandwich was not provided to the resident and should have been. Additionally, she could not explain why the sandwich was crossed off of the resident's meal tray ticket. During a simultaneous interview and observation of the resident while being assisted with eating by Nursing Assistant, Staff C, on 7/18/2024 at 12:37 PM revealed with the resident was being fed chicken. The resident revealed s/he likes a sandwich because s/he often does not eat chicken because it does not taste good to him/her. The resident further revealed s/he would like a sandwich and was unaware of why s/he did not receive one for his/her lunch meal that day. Staff C acknowledged that the resident did not receive a sandwich on his/her lunch tray and continued to feed the resident the chicken that was on his/her tray and did not provide him/her with a salad sandwich, although s/he expressed his/her displeasure with the meal. During a surveyor interview with the Registered Dietitian on 7/18/2024 at approximately 1:00 PM, she revealed that the resident prefers sandwiches, and indicated that she added this preference into the meal tray system, to print to his/her meal tray ticket, so s/he would receive the sandwiches. Additionally, she revealed that the facility has sandwiches available for the lunch meal. During a surveyor interview with the Administrator on 7/18/2024 at 2:52 PM, he was unable to provide evidence that the resident received meals according to his/her preference.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice related to notifying the physician of a change in condition and implementing hospice recommendations without physician approval for 1 of 1 hospice residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/5/2024 alleged in part, that the resident was found to be in extreme pain, however, due to his/her dementia, s/he was unable to verbalize where the pain was originating from. The complaint further alleges that a bruise was discovered on his/her genital area and thigh, and that the physician had not been notified. Review of a facility policy titled, Change in Condition Notification states in part, .monitor residents for changes in their condition .and to notify the physician .of changes . Record review revealed Resident ID #1 was originally admitted to the facility in February of 2022 with diagnoses including, but not limited to, dementia with behavioral disturbance, thrombophilia (a blood clotting disorder), anxiety disorder, and hypertension (high blood pressure). Review of a Minimum Data Set assessment dated [DATE] revealed the resident had severe cognitive impairment and required maximum assistance from staff for activities of daily living and transfers. Record review revealed a care plan dated 5/2/2022, indicating the resident was at risk for bleeding with interventions including, but not limited to, monitoring for signs and symptoms of abnormal bleeding .(skin bruising .). Record review revealed a physician's order dated 12/15/2022 for Rivaroxaban 20 milligrams daily (an anticoagulant medication). Further review revealed a physician's order dated 3/15/2024 to monitor for side effects of anticoagulant medications including, but not limited to, excessive bruising and if symptoms are observed to notify the physician and document in the progress note. Record review revealed a progress note dated 6/1/2024 at 8:15 PM that bruises were noted on the genital area and inner thigh, Nursing Assistant (NA) noticed during care and the nurse assessed the area, the resident yelled when the area was touched, Tylenol was administered, vital signs were at baseline, and the Director of Nursing Services (DNS), hospice nurse, Staff A, and spouse were made aware. Staff A ordered to hold the anticoagulant medication for 24 hours. Record review of a hospice visit note dated 6/2/2024 and authored by Staff A, revealed .significant bruising to posterior thigh all the way down to behind [his/her] knee .resistance during ROM [range of motion] .Please consider the following .Do not send out to the hospital, mobile X-ray of left hip/pelvis, schedule morphine 5mg Q [every] 8 [hours] for 24 hrs [hours] due to pain at left hip, withhold blood thinner for 24 hrs .call with results of Xray . Record review of the June 2024 Medication and Treatment Administration Records revealed the above-mentioned hospice recommendations were entered as physician's orders and completed. Although, the record failed to reveal evidence that the provider was notified. During a surveyor interview on 6/6/2024 at 1:08 PM with Licensed Practical Nurse, Staff B, she indicated that the NA alerted her to a reddened area to the resident's left leg on 6/1/2024 at approximately 6:30 AM. She further indicated that a bruise was noted to that area on 6/1/2024 on the 3:00 PM - 11:00 PM shift. Additionally, she indicated that she notified the hospice nurse who gave multiple recommendations including to hold the anticoagulant medication however Staff B acknowledged that she did not notify the physician of the bruising or of the hospice recommendations and put these recommendations in the electronic medical record as orders without provider authorization. During a surveyor interview on 6/6/2024 at 1:19 PM with the Nurse Practitioner, Staff C, she indicated that she would have expected the provider to be notified on 6/1 and 6/2/2024 of the resident's condition and the hospice recommendations prior to them being implemented as orders. She further indicated that she was unaware of the resident's condition until 6/3/2024, while she was routinely at the facility. During a surveyor interview on 6/6/2024 at approximately 2:48 PM with the DNS, she was unable to provide evidence that the provider was notified or authorized the hospice recommendations that were entered on 6/2/2024 prior to implementing them. She further indicated that she would consider the injury a change of condition and would expect that the provider to be notified.

Based on record review, surveyor observation and staff interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, relative to 4 of 5 units observed for the condition of floors, ceilings, and walls. Findings are as follows: Record review of an anonymous community reported complaint submitted to the Rhode Island Department of Health on 10/4/2023 alleges in part, .center is 'filthy, abandoned . 1. During a surveyor observation of the 3rd floor Subacute Unit on 10/4/2023 at approximately 11:00 AM revealed, an old worn carpet with extensive dirt build up, brown in color, which was present throughout the unit. 2. During a surveyor observation of the 3rd floor, [NAME] Unit on 10/4/2023 at approximately 11:15 AM, the following was observed: -Several floor tiles along the threshold to the unit which were visibly worn. -Several floor tiles adjacent to rooms [ROOM NUMBERS] with extensive cracking. -Four ceiling tiles in the common area noted with gray and brown staining. -On the wall adjacent to the stained tiles, there was a large crack that extended down the wall approximately 6 feet from the ceiling. -On the wall adjacent to the social worker's office the paint was peeling and appeared blistering. During a surveyor interview on 10/4/2023 at approximately 11:48 AM with the Director of Operations (DOO), he revealed that there were no repairs scheduled to be completed to the interior of the building at this time. During an additional surveyor interview on 10/4/2023 at approximately 11:52 AM with the DOO in the presence of the Director of Nursing Services and the Administrator in Training, he acknowledged that the above-mentioned areas on the 3rd floor needed repairs. Additionally, he stated that the condition of the floors and carpet were unacceptable and outdated and needed to be replaced. 3. During a surveyor observation of the 2nd floor T Unit on 10/4/2023 at approximately 12:40 PM revealed, an old warn carpet with visible dirt that extended throughout the unit. 4. During an additional surveyor observation of the 2nd floor Harbor Unit on 10/4/2023 at approximately 12:55 PM revealed the following: -Old carpet throughout the unit was old, worn and visibly dirty. -A heavy accumulation of brown dirt on the carpet adjacent to the threshold to the common area. During a surveyor interview on 10/4/2023 at approximately 2:30 PM, with the Administrator in Training, she acknowledged the above observations on the 2nd floor and indicated that they needed attention.

Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that a cognitively impaired resident received adequate supervision to prevent elopement from the facility for 1 of 5 resident reviewed for elopement, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/7/2023 alleges that a resident went missing between 6:00 AM and 8:00 AM on 2/7/2023. Police contacted and resident still missing as of 1:00 PM on 2/7/2023. Review of an additional community reported complaint submitted to the Rhode Island Department of Health on 2/7/2023 alleges in part, An elderly [resident] .went missing out of this facility which is supposed to be locked down, The [resident] was able to leave the facility and Police were not notified til after 2 hours. Review of a document titled RI EMS (Emergency Medical Services) Patient Care Report dated 2/7/2023 revealed in part, that on 2/7/2023 at approximately 12:47 PM the police called EMS to alert of a resident outside the post office located in Woonsocket that matched the missing resident in Pawtucket with his/her walker and wanderguard attached. Further review revealed the resident was able to state the buses that s/he took to get to Woonsocket. Review of a facility education titled Elopement Prevention states in part, .It is EVERY persons responsibility to respond to a door alarm. Go through the door to ensure a resident has not exited the building DO NOT ASSUME it was a staff member triggering the alarm YOU MUST CHECK!! Record review revealed the resident was readmitted to the facility in February of 2021 with diagnoses including, but not limited to, dementia, diffuse traumatic brain injury (head injury causing damage to the brain), and seizure disorder. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating the resident's cognition is impaired. Record review revealed an elopement assessment was completed on 1/9/2023 with a score of 14, indicating the resident was a high risk for elopement. Record review of a care plan dated 2/4/2022 states in part, Resident exhibits potential risk for elopement Exit Seeking,Wandering Behavior .The resident will not leave facility unattended . Record review revealed a physician's order dated 1/9/2023 states in part, Check Wanderguard placement to (walker) Every Shift and functionality daily . documented as administered daily from 2/2/2023 through 2/6/2023. Record review revealed the resident resided on a secured locked unit with a wanderguard system and a wanderguard on his/her walker until 2/1/2023, when the resident tested positive for COVID-19. S/he was then transferred to a non-secured unit that was not equipped with wanderguard sensors on 2/1/2023. Wanderguard remained attached to his/her walker. Record review of the resident progress notes revealed the following entries: -2/4/2023 at 3:04 PM which states in part, Date/Time of actual observation .02/04/2023 8:00 AM Resident was non compliant with quarantine. [S/he] got dressed .walked to the nursing [sic] station stating that [s/he] is going to woonsocket to court. [s/he] got on the elevator and satin [sic] the lobby apparently waiting for transport. This writer tried to redirect [him/her] but was uneffective. This writer called residents [family member] and after [s/he] spoke with her [s/he] decided to com [sic] back to the unit. [S/he] ambulated safetly to [his/her] room and had [his/her] meds and breakfast. [S/he] settled in and satyed [sic] in [his/her] bed. Staff will continue to monitor. - 2/4/2023 at 12:13 PM which states, Date/Time of actual observation .02/04/2023 12:00 PM .[S/he] then got dressed up again and said [s/he] is getting late for court. [S/he] then got on the elevator and sat in the lobby again. Staff was able to bring [him/her] back upstairs. [S/he] had [his/her] lunch and pm medications. No issues at this time -Further review of the progress notes dated 2/5/2023 revealed the resident was having increase aggressive behaviors with the staff and was sent to the emergency room for evaluation. Additionally, the resident returned to the facility around 4:00 PM on 2/5/2023 with a diagnosis from the hospital of a urinary tract infection (UTI) and was started on an antibiotic. - 2/7/2023 at 9:35 AM which states in part, .Resident cant be found in [his/her] room or the unit. An immediate code gray [missing resident] was cold[called]. Residents count on all units done. Facility premises searched. Police notified. NP [Nurse Practitioner] .and family .notified. During a surveyor interview on 2/7/2023 at approximately 12:45 PM with the Administrator he revealed the resident was still missing. During a surveyor interview on 2/7/2023 at 1:24 PM, the Director of Nursing Services notified the surveyor that the resident had been located in Woonsocket and was being transported to the local hospital for evaluation. During a surveyor interview on 2/7/2023 at 1:59 PM with Licensed Practical Nurse (LPN) Staff A, and LPN Staff B, they revealed that at around 7:30 AM on 2/7/2023 the medication technician alerted the nurse that the resident was not in his/her room. They further revealed that they started looking for the resident on the unit and then expanded the search to the entire building. A code gray was called indicating the resident was missing from the building. During a surveyor interview on 2/7/2023 at 2:04 PM with the resident's roommate s/he revealed that on 2/7/2023 s/he was just waking up when s/he saw the roommate grab his/her coat and leave their room. Record review of a hospital document titled After Visit Summary dated 2/7/2023, states in part, .Patient left [his/her] Pawtucket nursing home and was found wandering in [his/her] gown after taking a bus to Woonsocket . During a surveyor interview on 2/8/2023 at 8:16 AM with the resident s/he had no recollection of events of the prior day. During a surveyor interview on 2/8/2023 at 8:42 AM, with the Administrator, he revealed that the time line of events that occurred is as follows; - approximately 6:00 AM the resident received his/her medication - approximately 6:00 AM to 6:30 AM the 11PM to 7AM LPN, Staff C silenced the front door wanderguard alarm - approximately between 7 AM and 8 AM the facility noticed the resident was missing and conducted a search of the building - approximately 8:30 AM to 8:45 AM the Administrator notified the police During a surveyor interview on 2/8/2023 at 11:04 AM with Staff C, she revealed that she silenced the wanderguard alarm on 2/7/2023 after calling the 3rd floor nurse for assistance. Additionally, she revealed she did not go outside per the facility provided education. During a surveyor interview on 2/8/2023 at 11:09 AM with LPN Staff D, she revealed that on 2/7/2023 at approximately 6:00 AM she administered Resident ID #1 his/her medication. She further revealed she received a call from the 1st floor nurse related to the front door wanderguard alarm sounding. She revealed she assisted the staff in silencing the alarm over the phone and did not go downstairs as per the facility provided education. Additionally, SHe revealed that once the resident could not be located on the 3rd floor unit she moved her search to the 2nd floor secured unit where the resident had been going downstairs a lot the last few days. During a surveyor interview on 2/8/2023 at approximately 1:20 PM, with the Administrator, he acknowledged the staff failed to follow the facility provided education resulting in Resident ID #1 leaving the building on 2/7/2023 between 6:00 AM to 6:30 AM and being located approximately 18 miles away in Woonsocket. Resident ID #1 was missing for approximately 6 and a half hours, found at around 12:47 PM. Additionally, he was unable to provide evidence that the facility provided adequate supervision to a cognitively impaired resident resulting in Resident ID #1 leaving the facility. The facility failed to implement interventions after Resident ID #1 wandered off the unsecured unit twice on 2/4/2023. Additionally, facility staff failed to follow the facility education regarding elopement prevention and turned off the wandergaurd alarm without going through the doors to ensure a resident had not exited the building. These failures resulted in a resident who was identified by the facility as a high risk of elopement with a diagnoses of dementia eloping from the facility, taking a bus approximately 18 miles to Woonsocket and being located 6 1/2 hours later by the police.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings are as follows: According to 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident was admitted to the facility in June of 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ 75 ml/hr [milliliter per hour] -keep Iv in case more fluids are needed. four times a day for abnormal lab. Record review of the facility's policy titled IV- PERIPHERAL CATHETER INSERTION revised 1/2022 revealed IV documentation should include, .date and time of procedure, site location and assessment, dressing type, patient response to procedure and/or medication, and patient teaching on appropriate nursing document. Record review of the medical record failed to reveal documentation that an IV was inserted or that Normal saline was given via the IV as ordered. Further review of the medical record revealed the resident was sent to the hospital on 8/22/2022 with altered mental status and low blood pressure. Record review of hospital records dated 8/22/2022 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record further revealed the resident required multiple liters of IV fluid in the emergency room . Record review of the Nurse Practitioner (NP) note dated 8/22/2022 states in part, Ordered IV NS [Normal Saline] 1000 ML 8/19/22 .unsure if given IV given because unable to find any documentation. -no IV order in PCC [electronic medical record program] -no Normal Saline Order- no notes in PCC from LPN (Licensed Practical Nurse) staff- AM Monday 08/22 .osmolarity 288 to 303 over the w/e [weekend] (osmolality increases when someone is dehydrated, higher osmolality means lower water concentration) . During a surveyor interview on 8/24/2022 at 2:24 PM with the NP, she revealed that on 8/19/2022 she gave a telephone order to Staff A for oral and IV fluids to be given to the resident. She stated that she would have expected an IV to be placed and IV fluids given as ordered. Additionally, she revealed that the resident was sent to the hospital on 8/22/2022 due to dehydration as evidence of his/her labs. During a surveyor interview on 8/24/2022 at 3:00 PM with Licensed Practical Nurse (LPN), Staff A, she acknowledged that she received the above mentioned telephone order from the NP on 8/19/2022 and entered it into PCC. She further acknowledged she did not contact Pharmerica regarding an IV, an IV was not started and IV fluids were not given as ordered. During a surveyor interview on 8/24/2022 at 2:05 PM with LPN, Staff B, she indicated that when the resident was sent out to the hospital for evaluation on 8/22/2022, s/he did not have an IV in place. She failed to provide evidence that s/he received IV fluid as ordered. During a surveyor interview on 8/24/2022 at 4:32 PM with the Director of Nursing Service in training and the Administrator, they acknowledged that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences for 1 of 5 residents reviewed for quality of care, Resident ID #1. Findings are as follows: Review of the facility's policy titled, Change in Resident's Condition dated 5/2019 revealed a 'significant change' of condition is a major decline .in the resident's status that: will not normally resolve itself without intervention by staff .the nurse will make detailed observations .will record in the resident's medical record information relative to changes in the resident's medical condition . Review of a community reported complaint sent to The Rhode Island Department of Health on 7/21/2022 alleges that the resident's daughter reported that after an interdisciplinary meeting on 7/21/2022 at approximately 9:30 AM, she found [the resident] slumped over .[his/her] mouth was placed at a crooked position .[s/he] was slurring [his/her] words . This allegation further revealed that the daughter alerted a nurse of the change in condition and that the resident was not assessed until approximately 2:40 PM, after another family member arrived at the facility. Record review revealed the resident was admitted to the facility in July of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of theNursing Admission Evaluation dated 7/9/2022 states in part, .Resident's grasp is equal bilaterally . Record review of the physical therapy notes dated 7/11/2022 revealed the resident ambulated with a rolling walker with moderate staff assistance at baseline. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required one person physical assistance for walking in his/her room and corridor. Record review revealed an interdisciplinary team meeting was held on the morning of 7/21/2022 with social services, rehab/therapy, the resident and the resident's daughter. Record review of an interdisciplinary team note dated 7/21/2022 revealed that the resident .was walking yesterday but today [s/he] was having trouble walking, holding [his/her] head up and holding on to left side of walker . During a surveyor interview with the Social Worker, Staff A on 7/25/2022 at 12:18 PM, she revealed that during the interdisciplinary team meeting on 7/21/2022 at approximately 9:45 AM, the resident was not at his/her baseline and couldn't grab the left side of his/her walker. During a surveyor interview with Occupational Therapy Assistant on 7/25/2022 at 12:44 PM, she revealed that during the interdisciplinary team meeting on 7/21/2022 the resident seemed a little weaker. She was going to tell the nurse on the unit about the weakness but did not as the Social Worker had left to inform the nurse. During a surveyor interview with the Director of Nursing Services (DON) on 7/25/2022 at 2:33 PM she revealed that she was made aware of the resident's change in condition by Staff A on 7/21/2022 at approximately 10:00 AM. She further revealed she notified the Nurse Practitioner (NP) describing the resident's change in condition as extreme confusion and weakness at 10:03 AM via text message. She further revealed the NP ordered multiple labs and a urinalysis at that time. She acknowledged that she did not assess Resident ID #1 on 7/21/2022, put the order in the system or alert the unit nurse of the NP orders. During a surveyor interview with the NP on 7/25/2022 at 3:17 PM, she revealed that she was notified of the resident's change in condition on 7/21/2022 at approximately 10:00 AM. She further revealed that she was not in the facility at that time and ordered multiple labs via a text message sent to the DNS. She revealed that due to the resident's change in condition, she would have expected a nurse to complete and document an assessment of the resident and obtain the labs as ordered. The NP further stated she would have expected the labs to be obtained .STAT, usually within an hour. Additionally, she acknowledged that the resident's change in condition .may have been representative of a stroke. During a surveyor interview with License Practical Nurse/ nurse on the unit, Staff B on 7/25/2022 at 12:31 PM, she indicated that at approximately 10:00 AM the resident's daughter notified her that the resident was experiencing a change in condition. Record review failed to reveal evidence that an assessment was completed after the interdisciplinary meeting or after notification by the resident's family on 7/21/2022 at approximately 10:00 AM. Additional record review failed to reveal evidence that the NP's order were transcribed and put into the system for the facility to obtain the lab work or urinalysis. Further record review revealed a nursing progress note dated 7/21/2022 at 2:24 PM indicating that Resident ID #1 was visiting with his/her sister. The sister had alerted Staff B and indicated that she felt that her sister was having a stroke. Per the note Staff B observed Resident ID#1 to have had left sided weakness, facial drooping, and difficulty speaking. Additionally, the note revealed that the nurse then called 911 and the resident was transferred to the hospital. Review of the hospital medical record revealed Resident ID #1 arrived to the hospital at approximately 2:47 PM on 7/21/2022 presenting with .significant worsening of his/her L [left] sided weakness and new onset facial droop . A code stroke was activated. Further record review revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the record states in part, the resident was .out of window for tPA [a medication that when administered within 3 hours of a stroke, may limit the risk of damage and functional impairment] . During a surveyor interview with License Practical Nurse, Staff B on 7/25/2022 at 12:31 PM, she acknowledged she failed to document an assessment of the resident after being notified of the residents change in condition by the resident's daughter at approximately 10:00 AM. During a surveyor interview with the DNS on 7/25/2022 at 2:33 PM, she acknowledged that she failed to assess the resident's change of condition, notify the unit nurse of the concerns, or obtain the labs as ordered.

Based on surveyor observation, record review and staff and interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 3 residents reviewed for weight loss, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Department of Health on 3/14/2022 revealed allegations concerning weight loss for Resident ID #1. Record review for the resident revealed that s/he was admitted to the facility in November of 2021 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a hospital discharge summary dated 11/30/2021 revealed that s/he was admitted with generalized weakness and listed unplanned weight loss as a problem. The discharge summary further recommended adding Ensure pudding (a nutritional supplement) as well as to set up and assist the resident with meals. Review of the facility's policy titled Weight Assessment and Interventions last revised in May of 2019 revealed in part, POLICY: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents PROCEDURE: Obtaining weights . 2. Monthly weights will be obtained by the 7th of each month or as ordered by physician . 4. a. Any weight change of 5 lbs in a month and 3 lbs in a week since their last weight assessment will be retaken within 48 hrs [hours] for confirmation and verified by Nursing . 5. The Dietician/Diet Tech will review the Resident's weights monthly to follow individual weight trends over time. Negative trends will be evaluated to determine whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight change will be based on the following criteria: a. 1 month- 5% weight change is significant; greater than 5% is severe. 3 months- 7.5% weight change is significant; greater than 7.5% is severe . Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Ensure Plus three times a day 237ml [milliliters] .-order date-12/23/2021 . - Ensure pudding two times a day .-order date- 01/19/2022 . - Weigh on Admission/Readmission x 1, then weekly x 4 .-start date-12/06/2021 . - Weigh weekly x 4 weeks every day shift every 7 day(s) for 4 weeks re-weigh for change of 5 lbs. (+ or -) in last 7 days -start date-01/24/2022 . Record review of the resident's documented weights in the electronic medical record (EMR) revealed the following: - 11/30/2021 (standing) 147.0 lbs. - 12/01/2021 (standup scale) 132.7 lbs. - 12/02/2021 (standup scale) 132.0 lbs. - 12/15/2021 (standup scale) 106.6 lbs. - 12/23/2021 (standup scale) 105.6 lbs. - 12/31/2021 (standup scale) 103.8 lbs. - 1/03/2022 (standing) 105.8 lbs. - 1/13/2022 (standing) 104.2 lbs. - 2/03/2022 (sit down scale) 93.0 lbs. - 2/07/2022 (sit down scale) 92.0 lbs. Indicating a weight loss of 55 lbs. or -37.41% in less than a 3-month period. Review of the resident's documented weights in the EMR failed to reveal evidence that the resident was weighed weekly per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Registered Dietician's progress notes revealed the following: -12/3/2021- .significant weight loss is noted .Wt [weight]: possibly 132 lbs, but requested a re-weight .For now, will monitor wt change . -12/13/2021- .Wt loss noted. Wt is being monitored. Resident will be weighed again this week. Will add intervention if there is significant wt loss . - 12/23/2021- .A recent weight was obtained and verified at 105.6 lbs. Resident is aware [s/he] has lost weight. No updates for food preferences, but resident agreed to receiving Ensure Plus TID [3 times a day] (chocolate) to help stabilize/maintain weight. Will continue to monitor for supplement intake and wt. change . - 1/04/2022- .Wt loss noted. Resident has been told of weight loss. Ensure supplements are in place and diet preferences have been updated. Resident will remain on weekly weights until weight is stabilize/gained. - 1/18/2022- .Resident has protein-calorie malnutrition and .weight continues to decrease.; more interventions are in place of adding Ensure/boost pudding BID [twice a day] .will monitor weight change, PO [by mouth] intake, supplement intake . - 2/04/2022- .Resident continues to lose weight .will follow up with unit manager/family to discuss further interventions to encourage PO intake . - 2/07/2022- .An appetite stimulant is being ordered as well. Will continue to monitor PO intake and weight changes. Review of the resident's December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional record review failed to reveal evidence of an appetite stimulant being ordered per Dietician recommendation on 2/04/2022. During a surveyor interview with the Registered Dietician on 3/21/2022 at approximately 9:00 AM, she revealed that the resident was on weekly weights, had weight loss, and was started on supplements. She further indicated that she was not sure if the resident was put on double portions for meals, but that s/he should have been. Additionally, she revealed that she did recommend an appetite stimulant, but knowing that the resident was admitted on [MEDICATION(S)] for depression, she would have expected an increase in dosage or a new medication to have been put into place. Additionally, she revealed that when she makes a recommendation for a resident, she documents it in a progress note and verbally reports them to the interdisciplinary team, including the Director of Nursing Services (DNS) and Administrator (ADM), as well as to the unit manager. During a surveyor interview with the DNS and the ADM on 3/21/2022 at approximately 2:30 PM, they acknowledged that the resident had significant weight loss and revealed that they would expect that the nutritional supplements should have been administered as ordered, weights and re-weights should have been obtained as ordered, and if the dietician recommended an appetite stimulant, then one should have been ordered. Additionally, they were unable to provide evidence that the hospital's recommendations for nutritional supplements and assistance with meals were implemented upon the resident's admission to the facility.

Based on record review and staff interview it has been determined that the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 1 of 3 sample residents reviewed for medications, Resident ID #9. Findings are as follows: Review of the Manufacturer's information regarding [MEDICATION(S)] reveals in part, . a synthetic adrenocortical steroid .Warnings .Cardio-renal: Average and Large doses of Corticosteroids can cause elevation of blood pressure, sodium and water retention. These effects are less likely to occur with the synthetic derivatives except when used in large doses .Adrenocortical insufficiency [adrenal glands don't make enough of the hormone [MEDICATION(S)]] may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage. This type of relative insufficiency may persist for months after discontinuation of therapy .Patients who are on corticosteroids are more susceptible to infections than are healthy individuals. There may be decreased resistance and inability to localize infection when corticosteroids are used. Infection with any pathogen .in any location of the body may be associated with the use of corticosteroids alone or in combination with other immunosuppressive agents .Precautions .The lowest possible dose of corticosteroids should be used to control the condition under treatment. When reduction in dosage is possible, the reduction should be gradual. Since complications of treatment with corticosteroids are dependent on the size of the dose and the duration of treatment .As sodium retention with resultant [CONDITION(S)] and potassium loss may occur in patients receiving corticosteroids these agents should be used with caution in patients with [CONDITION(S)], hypertension, or renal insufficiency .corticosteroids may increase blood glucose concentrations .Geriatric use .the increased risk of diabetes mellitus, fluid retention and hypertension in elderly patients treated with corticosteroids should be considered .Adverse reactions .the following adverse reactions have been reported with [MEDICATION(S)] .Cardiovascular .[CONDITION(S)] .Endocrine .[CONDITION(S)] .Fluid and Electrolyte disturbances .[CONDITION(S)] in susceptible patients, fluid retention .sodium retention .Other .decreased resistance to infection .Dosage and Administration .The initial dosage varies from 0.75 to 9 mg a day depending on the disease being treated .If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly . Resident ID #9 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Hospital's Continuity of Care paperwork dated 12/27/2021 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . With a start date of 12/28/2021. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order has a start date of 12/28/2021 and was not discontinued until 2/17/2022. Record review of the Medication Administration Records revealed the resident was receiving the [MEDICATION(S)] every other day from 12/28/2021 through 2/16/2022. This resulted in 24 doses of the medication administered throughout January and February. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked evidence that the resident required these interventions prior to 2/17/2022. Review of the Resident's progress notes and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The normal blood sugar range is between 70-120 mg/dl. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's lab work revealed the following: 12/20/2021- ProBrain Natriuretic Peptide- 436.00 PG/ML (picograms per milliliter) reference range is 0-300. For a patient in the range of 50-[AGE] years old a PG/ML of greater than 900 indicates a high probability of heart failure. Sodium- 141MEQ/L (milliequivalents per liter) reference range 135-146. 2/17/2022- ProBrain Natriuretic Peptide- 1806.00 PG/ML. For a patient in the range of 50-[AGE] years old a PG/ML of greater than 900 indicates a high probability of heart failure. Sodium- 151 MEQ/L 2/18/2022- ProBrain Natriuretic Peptide- 888.00 PG/ML Sodium-149 MEQ/L Hemoglobin A1C (test that measures your average blood sugar levels over the past 3 months)- 11.2% reference range is less than 5.7%. A reading of over 6.4% is consistent with diabetes 2/20/2022- ProBrain Natriuretic Peptide- 771.20 PG/ML Sodium- 147 MEQ/L Record review of a progress note dated 2/18/2022 by Nurse Practitioner B, revealed in part, .seen today for drug or chemical induced diabetes mellitus with [CONDITION(S)], Hyperosmolality [a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances] and [CONDITION(S)] [rise in serum sodium concentration], Chronic diastolic (congestive) heart failure .CXR [chest x-ray] noted interstitial [CONDITION(S)], cardiomegaly, pulmonary vascular redistribution .Of note, during medication review [s/he] was noted to be on a [MEDICATION(S)] taper that was not discontinued .in late December 2021 . During a surveyor interview on 2/21/2022 at approximately 1:00 PM with Nurse Practitioner B, he revealed that he went to see the resident on 2/17/2022 by request of the nurse for a change in status and realized that the [MEDICATION(S)] which should have ended at the end of December continued to be given until 2/16/2022. He further revealed that after the [MEDICATION(S)] had been discontinued, he hoped his/her lab work, including ProBrain Natriuretic Peptide and blood sugars would improve. He further revealed that due to continued high blood sugars, which was not a previous issue for the resident, and the question of CHF versus infiltrate, the resident was sent to the hospital for evaluation on 2/21/2022. Review of the hospital paperwork dated 2/21/2022 under History of Present Illness revealed in part, .On Thursday [s/he] had acute respiratory failure with at chest x-ray showing CHF with [CONDITION(S)] to greater than 375 as patient was on [MEDICATION(S)] for Covid since December. [MEDICATION(S)] has been discontinued. Blood sugar treated with sliding scale [MEDICATION(S)] . The paperwork further revealed the following, .Assessment and Plan .Fevers of unknown origin .Patient's fevers were rather significant at [Skilled Nursing Facility] reaching nearly 102. Unfortunately [s/he] has been on longstanding [MEDICATION(S)] [[MEDICATION(S)]] for nearly 2 months which was stopped on 2/17, therefore leukocytosis may be suppressed .Differential is broad including infectious, metabolic, potential med effect .In terms of metabolic, adrenal insufficiency could cause acute [CONDITION(S)] in the setting of suddenly stopped steroids .Blood sugars have been very elevated and patient has been on prolonged steroids . During a surveyor interview on 2/21/2022 at approximately 1:45 PM with the Director of Nursing Services, she revealed that a medication transcription error was made for [MEDICATION(S)] causing the resident to get the medication until 2/16/2022 instead of the December completion date.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to subcutaneous hydration therapy for 1 of 1 sample residents, Resident ID #1. Findings are as follows: Record review of a community reported complaint reported to the Rhode Island Department of Health on 2/3/2022 states in part, .Attempted to hydrate patient through subcutaneous clysis .they noted a dime shaped wound on the abdomen .when the patient first presented to [hospital name redacted] the wound was much larger and draining purulent (containing pus [thick material produced in infected tissue]) material .the patient also has an abdominal wall infection. There is an additional ulceration to the lower left quadrant of the abdomen. There is surrounding [CONDITION(S)](reddening of the skin), significant concern for abdominal wall infection and concern of potential necrotizing (serious bacterial infection that destroys tissue under the skin) infection. Furthermore, concern for [CONDITION(S)] (potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues). Surgery has been consulted. Surgery has concern for potential gas forming bacterial infection .On arrival the patient needed surgical debridement (removal of damaged tissue from a wound) at bedside. Given the extensive large wound, the patient should have been brought into the hospital earlier . Review of the facility's policy titled, HYPODERMOCLYSIS (clysis)THERAPY (SUB Q HYDRATION) [technique by which fluids are infused into the subcutaneous space via small-gauge needles] states in part, .Subcutaneous fluids should be considered carefully and then reviewed every 48 hours .Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Insertion sites must be changed every 7 days . Record review revealed the resident was admitted to the facility in February of 2020 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed an order dated, 1/18/2022, Dextrose-NaCl Solution 5-0.45 % (Dextrose-Sodium Chloride)[solution for fluid and electrolyte restoration and caloric supply] Use 75 ml/hr [milliliters/hour] intravenously every shift for Dehydration. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, this order indicated that this resident was receiving intravenous fluids when the resident was actually receiving fluids through a clysis. Record review revealed following: - Nursing note dated 1/18/2022 at 10:20 AM, .place Clysis to RLQ (right lower quadrant) . - Nursing note dated 1/27/2022 at 3:00PM, .Clysis site was leaking .new Clysis site to LUQ (left upper quadrant). Upon removal of previous site to RLQ the area below site was macerated (when skin is in contact with moisture for too long) . - Initial Wound assessment dated [DATE] revealed in part, .Units of measure: centimeters(cm) .Site .RLQ .Length 5.5cm Width 4cm Depth 0.2cm .Cause of wound Removal of clysis, [MEDICATION(S)] (transparent dressing) lifted epidermis and dermis .Surrounding Tissue Wound Edges .Maceration .Hardness/induration . - A new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Santyl Ointment (cream use to debride necrotic [death of cells] tissue) 250 UNIT/GM (gram) .Apply to RLQ topically one time only for non-pressure injury for 1 Day . - Nursing note dated 1/28/2022 at 11:25 AM, .NP [nurse practitioner] also assessed resident's wound site to RLQ and requested for wound MD (Medical Doctor) to follow-up w/ resident next week . - A new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply to RLQ topically every day shift for wound care cleanse wound with normal saline, pat dry, apply santyl to slough (necrotic tissue) and cover with dry protective dressing once daily . -Nursing note dated 2/1/2022 at 1:00 PM, .Resident .lethargy; refusing PO intake; RLQ wounds presents large amount of purulent drainage; NP ordered resident out to the ER (emergency room ) for evaluation . Further record review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Discussed with nursing staff. Patient has abdominal wound due to clysis. Discussed about wound care . Record review of a facility physician report dated 2/1/2022 states in part, .change in condition .Unstageable ulcer (tissue loss in which actual depth of the ulcer is completely obscured by slough) ulcer to RLQ, noted slough with purulent odorous drainage .ulcer to previous clysis site which was draining purulent, odorous drainage with question of underlying abscess . Record review of a hospital Emergency Department note dated 2/1/2022 revealed in part, .presents to the emergency department from nursing facility for concerns of decrease mental status .has an abdominal wall infection that has occurred and progressed over the weekend. Per nursing facility, patient had been receiving clysis at that location. On physical exam patient has a purulent wound to the right lower quadrant abdominal wall as well as an additional ulceration of the left lower quadrant abdomen. There is surrounding [CONDITION(S)] . Additional review of hospital #1's record revealed a surgical consult that states in part, .Transfer to [hospital #2] for surgical intervention . Record review of hospital #2's documentation to which the resident was transferred and dated 2/2/2022 revealed in part, .Findings suggestive of .wounds on abdomen with I/D (incision and drainage) [procedures to release pus built up under the skin] and packing performed . Further review of the Summary Order Report and the MAR failed to reveal that the method and site of the infusion administration. Additionally, it failed to reveal that the dressing at the insertion site was monitored or that the subcutaneous fluid therapy was reviewed every 48 hours. During a surveyor interview on 2/4/2022 at 10:55 AM with the Director of Nursing, she was unable to provide evidence that the provider included an end date and an insertion site for the clysis. She also acknowledged that the resident was receiving fluids via subcutaneous clysis and not intravenously. The DNS revealed that her expectation is that a resident who is receiving clysis, that his/her insertion site should be monitored and rotated. Additionally, she acknowledged that there was no order to rotate the site until 1/27/2022, nine days after the clysis was originally applied to the site on 1/18/2022.

Based on surveyor observation, record review and staff interview it has been determined that the facility failed to provide services to avoid physical harm and emotional distress, defined as neglect for 1 of 44 sample residents, Resident ID # 84. Findings are as follows: 1. Surveyor observation on 12/14/2017 at 5:55 AM of the second floor nursing unit revealed Staff A, the unit nurse, in a dark area adjacent to the nursing station, stretched out on a small couch, eyes closed, not responding to verbal cues made by the surveyor. Surveyor interviewed nursing assistant, Staff B, at the time of the observation, who was present on the unit. Staff B approached the nurse on the couch, turned the light on and called his name. Staff A got up off the couch and proceeded to the bathroom. When he was questioned after the time of the observation, the nurse stated he was on his break. He stated he did not leave the unit because there was no one who could cover his break. He could not explain why he did not respond to verbal cues when laying on the couch with his eyes closed. Subsequent surveyor observation during medication pass with Staff A on 12/14/2017 at 6:40 AM revealed Resident ID # 84, sitting on the edge of the bed, short of breath, gasping for air with abnormal audible breath sounds, anxious and in respiratory distress. The nurse took a pulse oximetry reading which measures the blood oxygen level and it was 88% on 5 Liters (L) of oxygen via nasal cannula. Lippincott Manual of Nursing Practice, eighth edition, 2006, defines Respiratory Assessment as, assessment of respiratory status when administering inhalation medications. It states in part . Auscultate (listen to) the chest after administration of aerosol [MEDICATION NAME] to assess improvement in aeration and reduction in adventitious (abnormal) breath sounds. Review of the Medication Administration Record [REDACTED]. Staff A proceeded to administer the breathing treatment at 6:40 AM, but he did not perform a complete Respiratory Assessment following administration. The resident's pulse oximetry was assessed after the treatment and was 90% on 5 L of oxygen via nasal cannula. Neglect is defined at 483.5 as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Staff failed to conduct a respiratory assessment and to administer a necessary breathing treatment at 4:00 AM as was ordered by the physician. Failure to provide this necessary service resulted in the resident experiencing respiratory distress, as evidenced by the resident visibly gasping for air, abnormal breath sounds, a decreased blood oxygen saturation and anxiety. The failure of the nurse to provide these services and the resulting harm constitutes neglect. An interview was conducted with Staff A immediately following the observation, he could not explain why he did not administer the breathing treatment or perform a Respiratory Assessment at 4:00 AM as scheduled, nor could he explain why he did not perform a Respiratory Assessment after he administered the breathing treatment at 6:40 AM. Refer to F-695 for more information.

Based on surveyor observation, 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 healing and prevent new ulcers from developing for 2 of 7 residents who triggered an investigation for the risk of developing pressure ulcers or who have actual pressure ulcers (ID #s 2 and 85). Findings are as follows: 1. Resident ID #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a Braden Scale for Predicting Pressure Ulcers on 12/06/2017 which assessed the resident as at high risk for pressure. Record review for resident ID #2 revealed an admission assessment dated [DATE] which revealed that the resident has a pressure ulcer to the coccyx. There was no documentation of the size, exudate (wound drainage), pain, and description of wound bed and wound edges. Review of the resident's progress notes revealed a physician admission note dated 11/24/2017 which indicates the resident had a Stage 2 pressure ulcer (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red/pink wound bed, without slough) to the coccyx. Additional record review revealed a physician's orders [REDACTED].¼ side rails to both sides of bed which is medically appropriate to increase bed mobility and positioning. Further record review revealed a Physical Therapy progress note dated 11/24/2017 stating, patient requires bed ¼ siderails for bed mobility and transfers in and out of bed. Observations on the following dates and times revealed no evidence of ¼ side rails on the resident's bed: - 12/13/17 10:20 AM - 12/14/17 08:36 AM - 12/15/17 02:50 PM - 12/18/17 10:16 AM - 12/18/17 01:21 PM During a surveyor interview with the Physical Therapist, Staff G, on 12/18/2017 at 10:17 AM he stated that ¼ side rails may help to reduce skin breakdown as it can help to shift pressure when used for positioning and/or mobility purposes. Additionally, the resident has a care plan initiated on 11/30/2017 stating that the resident is at risk for pressure ulcer development with an intervention to monitor nutritional status. The facility failed to follow the resident's plan of care to monitor nutritional status and physician's orders [REDACTED]. Refer to F-692. Record review of the resident's care plan dated 11/23/2017 reveals a care plan for alteration in skin integrity related to the resident having an actual stage 2 pressure ulcer to the coccyx. Interventions include: Assess wound weekly, document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue. Record review revealed that the facility failed to follow the plan of care for alteration in skin integrity as they did not assess the wound weekly, document wound measurements, wound bed appearance, odor, drainage, and the surrounding tissue. The Assistant Director of Nursing Services (ADNS), who is also the wound nurse, provided an undated wound assessment which he stated was completed the first week of December. This staged the pressure ulcer as a stage 2 to the sacrum. During a surveyor interview with the wound nurse on 12/13/2017 at 10:15 AM, he could not provide evidence that the wound was assessed upon admission on 11/22/2017 until an unspecified date in the first week of December. At this time, the surveyor requested to observe the wound in the presence of the wound nurse. During surveyor observation of the resident's pressure ulcer on 12/13/2017 at 10:20 AM with the wound nurse, there was a pressure ulcer on the sacrum with small amounts of slough (non-viable yellow tissue) in the wound bed, indicating a stage 3 pressure ulcer (full thickness tissue loss and slough may be present). After the above observation with the surveyor, record review of the Registered Nurse weekly wound assessment, dated 12/13/2017, documented a stage 3 pressure ulcer to the sacrum, indicating that the wound had worsened. Additional record review revealed a care plan, initiated 11/23/2017, with an intervention dated 11/30/2017 to place heel protectors (used to prevent pressure ulcers) on resident. During a surveyor observation on 12/13/2017 at 10:20 AM, resident ID #2 was observed lying in bed, with no heel protector on either heel. During an observation of the resident's heels on 12/14/2017 at 8:32 AM with two surveyors and Staff Nurse C, it was observed that the resident had a discolored, nonblanchable area to the right heel and a nonblanchable redness with a darkened area to the left heel. The resident was not wearing heel protectors and the heels were resting directly on the bed. During a surveyor interview with Staff Nurse C on 12/14/2017 at 8:35 AM, she was unaware that the resident had heel protectors in the care plan and acknowledged that there were no heel protectors in the resident's room. After an immediate jeopardy related to pressure ulcers was brought to the attention of the facility on 12/14/2017, an outside wound care consultant was brought into the facility to perform an assessment of the wounds. Review of the outside wound care consultant initial evaluation dated 12/14/2017 revealed the following assessment and measurements of the wounds: - A stage 3 pressure wound to the sacrum (wound size: 2 x 3 x 0.2 centimeters) - An unstageable Deep Tissue Injury (DTI) on the right heel (wound size: 1.1 x 11 x not measurable centimeters). - An unstageable DTI on the left heel (wound size: 1.2 x 1 x not measurable centimeters). The above documentation confirms the wound to the sacrum progressed to a stage 3 and that the resident developed a new pressure ulcer on each heel. 2. Resident ID # 85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a significant change assessment dated [DATE] revealed that the resident was at risk for developing pressure ulcers. The Care Area Assessment states will proceed to care plan. A Braden Scale for Predicting Pressure Ulcers score was obtained on 11/19/2017 indicating high risk for pressure ulcers. An interview was conducted with the resident on 12/13/2017 at 9:00 AM. The resident stated he/she prefers to stay in bed and does not get out of bed. Observations on 12/13/2017 at 9:00 AM, 12/14/2017 at 2:30 PM and on 12/19/2017 at 9:15 AM revealed the resident in bed with heels flat on the bed and both feet pressing up against the foot board of the bed. Further record review revealed no evidence of a plan of care addressing pressure ulcer prevention. An interview was conducted with the Administrator on 12/19/2017 at approximately 1:00 PM. She was unaware that the resident did not have a plan of care for preventing pressure ulcers and could not provide evidence that a plan of care was developed.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition for 1 of 2 sample residents with significant weight loss (ID #2). Findings are as follows: Resident ID #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review for resident ID #2 revealed a physician's orders [REDACTED]. Review of the resident's record revealed a weight of 111.2 lbs (pounds) on 11/23/2017, a weight of 100.4 lbs on 12/12/2017, and a re-weight of 99.8 lbs on 12/13/2017. This indicates a 10.3% significant weight loss in 20 days. Further record review revealed that the resident's Power of Attorney (POA) signed a Medical Orders for Life Sustaining Treatment (MOLST) on 11/30/2017 identifying the resident as a Full Code, with indications of long-term artificial nutrition (feeding tube), if needed. Review of the dietary progress notes revealed a note by the Registered Dietitian on 12/13/2017 noting a 10.3% change in weight and a response will monitor and remain available PRN. During a surveyor interview with the 3rd floor Unit Manager on 12/13/2017 at 10:20 AM, she acknowledged that the resident should have been weighed twice a week. During a surveyor interview with the Registered Dietitian on 12/15/2017 at 1:45 PM, she acknowledged that the resident was not being weighed twice a week. Additionally, she revealed that she was aware of the resident's Full Code status; however, could not explain why new interventions were not added until brought to the attention of the facility on 12/14/2017.

Based on surveyor observation, staff interview and record review it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 residents reviewed for respiratory care, ID # 84 who was observed to be in respiratory distress. Lippincott Manual of Nursing Practice, eighth edition, 2006, defines Respiratory Assessment as, Assessment of respiratory status when administering inhalation medications. It states in part . Auscultate (listen to) the chest after administration of aerosol [MEDICATION NAME][MEDICATION NAME] to assess improvement in aeration and reduction in adventitious (abnormal) breath sounds. Record review revealed that ID # 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. 1. An order dated 11/13/2017 for [MEDICATION NAME] Nebulizer Solution (a [MEDICATION NAME] for inhilation) 2.5 milligrams (mg) in 3 milliliters (ml) every 4 hours (4 AM, 8 AM, 12 PM, 4 PM, 8 PM and 12 AM). 2. An order dated 11/14/2017 which reads, Respiratory Assessment with nebulizer treatment. 3. An order dated 12/01/2017 for Oxygen 1-3 liters (L) via nasal cannula (NC) continuous 4. An order dated 12/04/2017 stating O2 (oxygen) sats (saturation) greater than or equal to 92%. Surveyor observation during medication pass with Staff Nurse A on 12/14/2017 at 6:40 AM revealed resident ID # 84, sitting on the edge of the bed, anxious, short of breath, gasping for air with abnormal audible breath sounds, in respiratory distress. The resident's respirations were shallow and were counted at 33 per minute (normal adult range is 12-22 per minute). The resident stated I need the bag, get me the bag, holding the nebulizer mask to his/her face attempting to get air from the mask. Surveyor observed oxygen infusing at 5 L via nasal cannula. Staff A placed the medication, [MEDICATION NAME], into the administration set up, then left the room to get a pulse oximetry monitor (a monitor to measure the oxygen level in the blood). The resident stated to the surveyor, please don't leave me. Staff A returned to the resident's room and obtained a pulse oximetry reading which was 88 % on 5 L of oxygen. The resident remained anxious and continued to be short of breath. The resident's pulse oximetry reached 90% on 5 L after the breathing treatment was complete. Staff A stated that he was satisfied with the pulse oximetry reading of 90%. No further respiratory assessment was performed at this time. The resident remained anxious and short of breath. The nurse proceeded to leave the room and he did not return. When interviewed immediately following the observations, Staff A could not explain why he did not administer the treatment at the time it was due or why he did not perform a respiratory assessment as ordered. An interview was conducted with the Administrator 12/14/2017 at 7:45 AM. She was made aware of the observations and acknowledged that a respiratory assessment should have been performed and that the nebulizer breathing treatment should have been administered at 4:00 AM as ordered.

br>For findings see survey Event ID # *459S12, Fed - F - 0353 Sufficient 24 Hour Nursing Staff

Based on surveyor observation, record review and staff interviews, it was determined the facility has failed to ensure that each resident receives adequate assistive devices to prevent accidents for 2 of 3 sample residents (ID #'s 3 and 4) who have impaired safety awareness and when indicated on the plan of care. Findings are as follows: 1. Resident ID# 3 has a facility readmission date of [DATE] with primary [DIAGNOSES REDACTED]. Review of the resident's plan of care with a revision date on 7/9/2015 indicates the resident is at risk for falls secondary to urinary retention, decreased strength/endurance, use of cardiovascular agents, diuretics, narcotic analgesia and pain with an approach to keep bed in low position when the resident is in bed. Surveyor observations on 7/15/2015 between 9:00 AM and 9:45 AM and 1:00 PM to 2:30 PM revealed the resident lying in his/her bed. The bed was not in low position (approximately 2 feet from the floor). During an interview on 7/15/2015 at 4:00 PM with the Director of Nursing Services (DNS), she indicated the bed is supposed to be in the lowest possible position while the resident is in bed. Following the above interview, with the DNS present, the resident was observed lying in his/her bed with the bed not in low position (approximately 2 feet from the floor). Immediately, the DNS put the resident's bed in the lowest position which was approximately 1 foot from the floor. When interviewing the DNS, she was unable to explain why the resident's bed was not in lowest possible position. 2. Resident ID #4 has a facility readmission date of [DATE] with primary [DIAGNOSES REDACTED]. Review of the nurse's note dated 7/9/2015 revealed that at 6:20 AM the resident was found on the floor beside his/her bed. Staff documented that the resident . always at the edge of bed . patient will be benefit from floor mat to prevent any injury during the time of fall this based on perpetual and constant fall of patient at this time . Review of the resident's plan of care revised on 7/10/2015 indicates the resident is at risk for falls secondary to history of fall, resident preference in position himself at edge of bed for snacking, deconditioning with an approach to have floor mats at bedside at all times. Surveyor observations on 7/14/2015 from 10:45 AM and 11:15 AM and from 1:15 PM to 3:15 PM revealed the resident lying in his/her bed without floor mats at the bedside. During an interview on 7/15/2015 at approximately 1:30 PM, the resident's primary nursing assistant (staff C) indicated she worked on the first shift on 7/14/2015 and that there were no floor mats while the resident was in bed. Staff C further indicated that she was unaware that the resident requires floor mats at bedside at all times while s/he is in bed. During an interview with the DNS on 7/15/2015 at approximately 2:00 PM, she stated the resident should have floor mats at all times while s/he is in bed as indicated on the resident's plan of care.

br>Based on staff interviews and surveyor observations, and review of the staffing schedules, it has been determined the facility failed to provide services by sufficient numbers of nursing personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans for care for residents. Findings are as follows: According to the staffing scheduler, who reviewed the schedules with the surveyors, the staffing for the 3 West Dementia Unit should have a Nurse and two NA's on the first and second shifts and a nurse and one NA on the third shift. A review of the facilities nursing staffing schedules for all three shifts, on the 14 bed Dementia Unit, for 13 days, from August 16, 2015 - August 28, 2015 revealed the following: August 16, 2015: the RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit, On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, leaving only one nursing assistant on the Dementia Unit August 17, 2015: The RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit, On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, leaving only one nursing assistant on the Dementia Unit August 18, 2015: The RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit, leaving only one nursing assistant on the Dementia Unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and one nursing assistant left at 10:30 PM. August 19,2015: the RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit, leaving only one nursing assistant on the Dementia Unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and one nursing assistant on the Dementia Unit. On the third shift the RN also was assigned to cover both the Dementia Unit and the SubAcute Unit leaving only one nursing assistant on the Dementia Unit. August 20, 2015: the RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and one nursing assistant left at 8:00 PM,leaving only on NA on the Dementia Unit. On the third shift the RN also was assigned to cover both the Dementia Unit and The SubAcute Unit leaving only one nursing assistant on the Dementia Unit. August 21,2015: The RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit, and one nursing assistant was floated to another unit at 1:00 PM , leaving only one NA on the Dementia Unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and only one nursing assistant on the Dementia Unit. On the third shift the RN also was assigned to cover both the Dementia Unit and The SubAcute Unit leaving only one nursing assistant on the Dementia Unit. August 22, 2015: One nursing assistant left at 1:30 PM. On the Second shift a nurse worked from 3:00 PM - 7:00 PM covering both the Dementia Unit and the SubAcute Unit, and another nurse worked 7:00 PM - 11:00 PM covering both Units. Additionally only one nursing assistant was assigned to the Dementia unit. This shift was covered by two NA's on who worked 3:00 PM - 7:00 PM, and another NA worked 7:00 PM- 11:00 PM on the Dementia Unit. On the third shift the RN also was assigned to cover both the Dementia Unit and The SubAcute Unit leaving only one nursing assistant on the Dementia Unit. August 23,2015: the RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit. Additionally only one NA was assigned to the unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and one nursing assistant worked from 3;00 PM -10:00 Pm and one worked from 7:00 PM -11:00 PM. On the third shift the RN also was assigned to cover both the Dementia Unit and The SubAcute Unit leaving only one nursing assistant on the Dementia Unit. August 24, 2015: The RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit, leaving only one nursing assistant on the Dementia Unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and only one nursing assistant on the Dementia Unit. On the third shift the RN also was assigned to cover both the Dementia Unit and The SubAcute Unit leaving only one nursing assistant on the Dementia Unit. August 25,2015: the RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and only one nursing assistant, scheduled till 10:30 PM on the Dementia Unit. On the third shift the RN also was assigned to cover both the Dementia Unit and The SubAcute Unit leaving only one nursing assistant on the Dementia Unit. August 26, 2015: the RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and one nursing assistant left at 10:30 PM, leaving only one NA on the Dementia Unit. On the third shift the RN also was assigned to cover both the Dementia Unit and The SubAcute Unit leaving only one nursing assistant on the Dementia Unit. August 27, 2015: the RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and only one nursing assistant on the Dementia Unit. On the third shift the RN also was assigned to cover both the Dementia Unit and The SubAcute Unit leaving only one nursing assistant on the Dementia Unit. August 28, 2015: the RN on the day shift was also assigned to cover both the Dementia Unit and the Subacute Unit. One NA left at 1:00 PM, leaving only one NA on the Dementia Unit. On the Second shift the RN was again assigned to cover both the Dementia and the Subacute unit, and one nursing assistant was scheduled to leave at 9:00 PM on the Dementia Unit. On the third shift the RN also was assigned to cover both the Dementia Unit and The SubAcute Unit leaving only one nursing assistant on the Dementia Unit. Surveyor observations on 8/28/2015 at approximately 1:45 PM of resident's ID #3 and 16, they were observed ambulating unsupervised without the use of their walkers in the narrow corridor in front of the nurse's station. Resident ID #16 was also observed at this time without his/her eyeglasses. Then resident ID #20 was observed to step in between these residents. At this same time, further observation revealed these three residents where in close proximity to each other and began to argue with one another. There were no staff present to supervise, at the time of this observation. The surveyor located the only staff member nursing assistant (staff A) on the unit in another resident ' s room at the end of the unit that was separated by the common area. Staff A was unaware of this situation. ( refer to F 323) The surveyor located a nursing assistant (staff A) at approximately 2:00 PM, who was assisting another resident to the bathroom. When questioned regarding the staffing, she informed the surveyor that she was alone on the unit as the other nursing assistant had left at 1 PM, and the nurse was covering on the sub acute unit. The surveyor interviewed the (DNS) Director of Nurses, and the Administrator and the Nurse who was covering the subacute and the Dementia Unit at approximately 2: 20 PM, and they stated that they were not aware that one nursing assistant had left at 1:00 PM, leaving only one nursing assistant on the Dementia Unit with 13 residents. The nurse who was scheduled to cover both the Dementia Unit and the SubAcute Unit, was on the SubAcute unit at this time not aware that one nursing assistant was left alone on the Dementia Unit. On 8/28/2015 at approximately 4:00 PM, the Administrator stated that the West 3 Dementia Unit will not be left with only a nursing assistant but that it will be covered by a nurse and two nursing assistants on all shifts going forward. Surveyor also reviewed the staffing patterns for the rest of the facility for August 16- 28th which reveled the following: There were 93 open shifts that were not covered, that included nurses, nursing assistants and medication technicians. The breakdown is as follows. 1st Floor Unit The 35 bed long term care had 6 shifts not covered 2nd Floor 14 Bed Transitional Care Unit had 36 shifts not covered Harbor Unit 20 Bed Long term Care Unit had 4 shifts not covered 2 West Unit 30 Bed Long Term Care Unit had 2 shifts not covered 3 West 14 Bed Secured Dementia Unit had 12 Shifts not covered SubAcute 31 Bed Unit had 33 Shifts not covered Additionally during this 13 day time frame there were 91 incomplete shifts, that were covered by nurses, nursing assistants and medication technicians that, worked only a partial shift, not working a full 8 hour shift. Some staff starting late in the shift and others leaving before the next shift was scheduled to come on duty. According to the schedules reviewed of these 93 shifts some staff worked only 4 hours of the 8 hour shift, creating additional shortages on the units. 1st Floor Unit The 35 bed long term care had 31 times where staff did not work the full shift 2nd Floor 14 Bed Transitional Care Unit had 1 time where staff did not work the full shift Harbor Unit 20 Bed Long term Care Unit had 15 times where staff did not work the full shift 2 West Unit 30 Bed Long Term Care Unit had 17 times where staff did not work the full shift 3 West 14 Bed Secured Dementia Unit had 12 times where staff did not work the full shift SubAcute a 31 Bed SubAcute Unit had 15 times where staff did not work the full shift Record review for resident ID # 3, during the investigation of an allegation of resident to resident abuse on July 17, 2015, the surveyor reviewed the staffing and found that the Dementia Unit was again only staffed with one nursing assistant and the nurse was assigned to cover both the SubAcute Unit and the Dementia Unit. At the time of this incident, which was unwitnessed, resident ID #3, sustained a fall with head injury that required stitches and was sent to the hospital for treatment. The surveyor interviewed via telephone the nursing assistant (Staff ID # B) on 8/31/2015 at 9:45 AM, regarding the allegation of resident ID # 2 pushing ID # 3 on 7/17/2015. She informed the surveyor that she was the only staff on the 3 West Dementia unit at the time of the fall. On 8/28/2015 at approximately 2:30 PM the two surveyors interviewed the staffing scheduler who provided copies of the schedules to the surveyors which verified that staff were scheduled to leave at 1:00 PM on multiple days. When questioned the scheduler stated that she is instructed to staff based on the resident census and that she has to schedule staff for less that eight hour shifts, and they are sent home early, leaving only one nursing assistant on the Dementia Unit. The surveyor also investigated a complaint dated 8/24/2015 from a resident who resides on the Subacute Unit who stated that the facility is grossly understaffed causing poor quality of care. Review of the staffing schedules for the SubAcute Unit, provided to the surveyor by the facility reveals that for 8/24/2015 the first shift was short by an RN and a Nursing Assistant, the second shift was short a nursing assistant, and the third shift had on nursing assistant who worked a partial shift. On 8/25/2015 the schedule also reveals that the first shift was short by an RN and one Nursing Assistant, and the second shift was again short a nursing assistant. Additionally there is no evidence that the nursing staff covering the special care dementia unit has had In-Service training in caring for residents with Dementia. Refer to tags F 323 J,

br>Based on record review and staff interview, it was determined the facility is not administered in a manner that enables it to use its resources effectively and maintain the highest practicable physical and mental well-being of each resident. The failure of the facility resulted in immediate jeopardy. Findings are as follow: 1. As evidenced by the facility's failure to provide services by sufficient numbers of nursing personnel as referenced in F 353 , with scope and severity (S/S) at leve J. 2. As evidenced by the facility's failure to maintain the resident environment free of accident hazards relative to supervison of residents, assistance with assistive devisces, and obstructed pathways on the Dementia Unit, as referenced in F 323 S/S at level J. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions.