Every finding on record at AdviniaCare Summit Commons, LLC

Based on clinical record review and staff and resident interviews, it has been determined that the facility failed to protect a resident's right to be free from resident to resident abuse for 2 of 4 residents reviewed, Resident ID#s 1 and 3. Findings are as follows:Record review the facility policy titled Clinical Operations states in part, The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of residents/patients property by anyone including staff, family, friends, etc .1. Record review of facility reported incident submitted to the Rhode Island Department of Health on 7/10/2026 revealed that Resident ID #1 and Resident ID #2 were witnessed by staff having a verbal argument. Resident ID #2 was overheard by several staff members telling Resident ID #1 I will make sure you die overnight.Record review revealed that Resident ID #1, the alleged victim, was originally admitted to the facility in May of 2025 and readmitted in December of 2025 with diagnoses including, but not limited to, major depressive disorder, cognitive communication deficit and opioid dependence. Review of a Minimum Data Set (MDS) assessment conducted on 6/18/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating intact cognition. Record review of Resident ID #2, the alleged perpetrator, revealed s/he was originally admitted to the facility in October of 2025 and readmitted in July of 2026 with diagnoses including, but not limited to, bipolar II disorder, hemiplegia (weakness of one side of the body) and hemiparesis (paralysis of one side of the body) following a stroke and migraines. Review of a MDS assessment conducted on 6/8/2026 revealed a BIMS score of 15 of 15, indicating intact cognition. Record review of documentation from the facility's internal investigation revealed several written statements from staff that were present at the time of the verbal altercation. These statements indicated that Resident ID #2 had made threatening comments to Resident ID #1. Additionally, Resident ID #2 had also become aggressive with staff while trying to get physically closer to Resident ID #1.During a surveyor interview with Resident ID #1 on 7/15/2026 at approximately 11:25 AM, s/he revealed that Resident ID #2 attempted to physically attack him/her after verbally threatening to kill him/her. During a surveyor interview with the Administrator and the Director of Nursing Services (DNS) on 7/16/2026 at approximately 9:30 AM, they revealed that they were present at the time of the incident. Additionally, they confirmed that they overheard Resident ID #2 say I will make sure you die overnight to Resident ID #1. 2. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/17/2026 revealed that Resident ID #4 was observed in the room of Resident ID #3 with his/her hand under the bed sheet. Record review revealed that Resident ID #3, the alleged victim, was originally admitted to the facility in May of 2026 with diagnoses including, but not limited to, acquired absence of the eye, purulent endophthalmitis (an infection of the eye), schizoaffective disorder, muscle weakness, and opioid use. Review of a MDS assessment conducted on 6/2/2026 revealed a BIMS score of 14 of 15, indicating intact cognition. Record review revealed that Resident ID #4, the alleged perpetrator, was originally admitted to the facility in October of 2025 and readmitted in July of 2026 with diagnoses including, but not limited to, the acquired absence of the right and left legs below the knees and anxiety. Review of a MDS assessment conducted on 6/18/2026 revealed a BIMS score of 14 of 15, indicating intact cognition. Record review of a written statement authored by Nursing Assistant (NA), Staff A, revealed that she observed the alleged perpetrator, Resident ID #4, pass by Resident ID #3's room several times during the shift the incident occurred on. Staff A further stated that whenever Resident ID #4 noticed her watching him/her, s/he would try to make small talk but would immediately cut short and move along. Further the written statement revealed that when Staff A was assisting another resident in their room at approximately 4:00 AM, she saw Resident ID #4's reflection in a window and noticed him/her passing by in the hall. Staff A indicated she quickly finished up with the resident she was assisting and went to Resident ID #3's room and observed Resident ID #4 with his/her hand underneath Resident ID #3's bed sheets touching him/her inappropriately. Lastly the statement revealed that Resident ID #3 was wearing a hospital gown without any underwear or brief on when Resident ID #4 had his/her hand under the bed sheets of Resident ID #3. During a surveyor interview with the Administrator on 7/17/2026 at approximately 1:10 PM, she acknowledged that Staff A had observed Resident ID #4 pass by the room of Resident ID #3 repeatedly just before 4:00 AM on 7/17/2026. She then revealed that Staff A observed Resident ID #3 to be sleeping in bed and Resident ID #4 was observed with his/her hand underneath Resident ID #3's bed sheets. Lastly, she revealed that Resident ID #3 customarily sleeps with a light top on and no bottoms.

Based on clinical record review and resident and staff interviews, the facility failed to ensure that adequate supervision and assistive devices were provided to prevent an avoidable accident for 1 of 1 resident reviewed for accidents, Resident #77. Specifically, the facility failed to implement the resident's care-planned intervention requiring a two-person assist for bed mobility and turning/repositioning. As a result, a Nursing Assistant (NA) provided care to the resident without another staff member, resulting in the resident rolling from the bed onto the floor and sustaining an avoidable right tibia/fibula fracture that required emergency department evaluation, treatment, and pain management. Findings are as follows:Record review revealed the resident was admitted to the facility in August of 2022 with a diagnosis including, but not limited to, cerebral infarction (stroke).Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 of 15, indicating intact cognition. During a surveyor interview with the resident on 6/29/2026 at 9:40 AM, s/he revealed that s/he had fallen from bed recently and broke his/her leg. Additionally, s/he revealed one Nursing Assistant (NA) was providing care to him/her when the NA rolled him/her out of bed onto the floor.Review of the care plan revealed a focus area that the resident has an activity of daily living deficit from reduced endurance, obesity, and musculoskeletal weakness following a prior stroke. The care plan further revealed that the resident is unwilling to help with personal care, with an intervention that states, .2 persons assist for bed mobility and transfer utilizing Hoyer . Review of the progress notes revealed the following:6/3/2026 at 4:25 PM .the resident was on the floor. Staff notified writer they were in the room when it happened and was able to write a statement. Resident stated they fell of the bed during morning care.6/5/2026 at 6:30 PM .Resident noted to have undergone X-Ray of the right knee status post fall. Results revealed a positive tibia/fibula fracture (a breaks in both lower leg bones). Provider made aware of findings and gave order for resident to be sent to the emergency department (ED) for further evaluation and treatment.6/6/2026 at 6:26 AM .nurse reports had a fall in facility with pain reported in [right] leg. X ray performed resulted tibia/fibula [fracture]. Patient was sent out to ED for evaluation and was sent back same day.6/8/2026 at 1:57 PM revealed that the resident complained of pain following the fall, the Nurse Practitioner was notified, and an order was obtained for Oxycodone (pain medication) 5 milligrams every 6 hours as needed for 14 days.Review of the hospital emergency room paperwork dated 6/6/2026 states in part, .presented to our hospital for evaluation of witnessed fall 2 days ago while at a SNF (Skilled Nursing Facility) with subsequent imaging showing a right tibia/fib fracture. Patient requires full assist at baseline.Roughly 2 days ago, s/he was being moved by [his/her] CNA (Certified Nursing Assistant) and was getting turned on [his/her] bed when [s/he] was accidentally pushed off the bed, causing [him/her] to land over [his/her] hands and knees. The patient reports that [s/he] immediately started to experience right foot pain.right shin as well as right thigh pain.During a surveyor interview on 7/1/2026 at 8:24 AM with Licensed Practical Nurse, Staff C, she revealed that there was only one NA, Staff D, in the room at the time of the fall. Additionally, she acknowledged that the resident's care plan revealed that the resident was a two person assist with turning and repositioning at the time of the fall, and only one staff member was present.During a surveyor interview on 7/1/2026 at 1:35 PM with Staff D, she revealed that she believed the resident was a one person assist with care prior to his/her fall on 6/3/2026. She acknowledged that she independently provided care to this resident on 6/3/2026. She indicated that she positioned the resident on his/her side and when she turned her back to retrieve a facecloth that is when the resident fell off of the bed. During a surveyor interview with the Director of Nursing Services on 7/1/2026 at 9:05 AM, she acknowledged the resident's care plan was updated on 4/8/2026 to indicate that the resident requires two staff members for turning and repositioning. Additionally, she acknowledged the resident had only one staff member providing care when s/he fell from the bed and sustained a tibia/fibula fracture.The facility's failure to implement the required care plan intervention of a two-person assist for bed mobility resulted in actual harm for Resident ID #77. Due to a single staff member providing care to a resident with known one-sided weakness and obesity, the resident rolled out of bed and fell onto the floor. This failure resulted in severe physical injury, specifically a right tibia/fibula fracture requiring emergency department evaluation and treatment, as well as preventable pain and suffering.

Based on clinical record review, surveyor observation, and resident and staff interviews, the facility failed to follow the weekly menu relative to providing soup daily as stated on the menu for 4 of 4 units. Additionally, the facility failed to ensure that the residents' meal tickets matched the meal served to each resident, affecting Resident ID #s 12, 20, 45, 56, 58, 76, 93, and 115. Findings are as follows:Record review revealed that Resident ID #93 was admitted to the facility on [DATE] with diagnoses including, but not limited to, type 2 diabetes mellitus and heart failure.Record review of the Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 of 15, indicating intact cognition.During a surveyor interview during the initial tour on 6/29/2026 at 11:49 AM, Resident ID #93 stated that his/her meal ticket does not always match what is served. S/he stated, we do not have soup even though the slips indicate that we receive soup every day. 1. During surveyor observations of the lunch meal service on 6/30/2026, the facility failed to serve the specific food items listed on the meal tickets for the following residents: a. Resident ID #12's meal ticket indicated that s/he is supposed to receive a bowl of soup and chocolate pudding.Surveyor observation revealed the resident failed to receive a bowl of soup and was served Jello, instead of chocolate pudding.During a surveyor interview with Resident ID #12 following the above observation, s/he revealed that s/he wishes to have soup as listed on the meal ticket.b. Resident ID #45's meal ticket indicated that s/he is supposed to receive a side salad.Surveyor observation revealed the resident failed to receive a side salad.During a surveyor interview following the above observation, s/he revealed that s/he has not been served the salad.c. Resident ID #s 12, 20, 56, and 76's meal tickets indicated that they are supposed to have pineapple with their meals.Surveyor observation revealed the above residents failed to receive pineapple with their meals.2. During the breakfast service on 7/1/2026, surveyor observations confirmed the facility failed to serve English muffins to Resident ID #s 12, 20, 56, and 76, as indicated by their individual meal tickets. During a surveyor interview on 7/1/2026 at 1:41 PM, the Food Service Director revealed that the facility does not offer soup during the summer months, per the company's policy. He further stated that the facility's Dietitian, Staff F, should have updated the residents' meal tickets for accuracy.During a surveyor interview on 7/1/2026 at 1:52 PM, Staff F acknowledged that the residents' meal tickets and the food served on the nursing units failed to match.During a surveyor interview on 7/1/2026 at 2:51 PM, the Director of Nursing Services stated that she expects residents to receive the items listed on the menu. She acknowledged that discrepancies between menu listings and meal tickets have been an ongoing concern.

Based on record review, surveyor observations, and staff interviews, the facility failed to ensure that bed side rails were safely installed, assessed, and managed in accordance with manufacturer recommendations, the CMS Resident Assessment Instrument (RAI) Manual, and the facility's own policy. Specifically, the facility failed to: ensure bed side rails were compatible with the bed frame and installed according to manufacturer specifications for four of four units, affecting one of one resident reviewed for bed system compatibility, Resident ID #6. Additionally, the facility failed to complete required quarterly bed side rail assessments for five of five residents reviewed for quarterly reassessments, Resident ID #'s 6, 16, 77, 99, and 11 and the facility failed to develop and maintain individualized care plans addressing the use of bed side rails for four of five residents reviewed for care planning, Resident ID #s 10, 16, 77, and 99. These deficient practices had the potential to affect all residents utilizing bed side rails within the facility and placed residents at risk for foreseeable harm, including entrapment, falls, injury, and the continued use of restrictive devices without ongoing evaluation of their medical necessity, safety, or effectiveness. Findings are as follows:Record review of the Centers for Medicare & Medicaid Services' Resident Assessment Instrument (RAI) 3.0 Manual, dated October 2025, revealed that the use of bed siderails must be assessed prior to implementation and reassessed at least quarterly (every three months), and with any significant change in condition, to determine whether the continued use of the device remains appropriate and safe for the resident.Review of a facility policy titled, Side Rails/Bed Rails dated 10/24/2022 states in part, Purpose: To ensure the appropriate, safe and correct installation, use, and maintenance of bedrails.The facility shall ensure that prior to the installation of bed rails, the facility has attempted to use alternatives.The facility shall ensure the bed is appropriate for the resident and that bed rails are properly installed and maintained.After alternatives have been attempted and prior to installation, the facility shall obtain informed consent from the resident or if applicable, the resident representative for the use of bed rails.The care plan shall be developed on an individual basis, and may include but is not limited to the following related to use of bed rails: which medical need would be met through the use of bed rails.What the resident's functional ability is, such as bed mobility and ability to transfer between positions, to and from bed or chair, and to stand and toilet and staff required for each function that requires assistance.Before bed rails are installed, the facility should: Check with the manufacturer (s) to make sure the bed rails, mattress, and bed frame are compatible, since most bed rails and mattresses are purchased separately from the bed frame.Review of a facility provided, QI Project/Plan: Side Rails dated 2/26/2026 states in part, .Action Steps.ensure physician orders are obtained, ensure care plans are updated, ensure consents are obtained.A. During a surveyor observation conducted on 7/2/2026 at 8:56 AM, Resident ID #6's bed was observed to have two different bed side rails of dissimilar design attached to the bed.During a surveyor interview on 7/2/2026 at 9:13 AM with the Maintenance Director, he acknowledged that the bed side rails attached to Resident ID #6's bed did not match. When asked how the facility determines whether a bed rail is appropriate and compatible with a particular bed frame, he stated, As long as the holes line up.The Maintenance Director further revealed that the facility maintains an inventory of beds and bed side rails obtained from multiple sister facilities and various manufacturers. He acknowledged that the facility does not verify manufacturer compatibility before installing bed side rails and was unable to provide manufacturer specifications, compatibility guidance, or installation instructions demonstrating that the bed side rails attached to Resident ID #6's bed were approved for use with that bed frame. As a result, the facility could not demonstrate that the bed and bed side rail system had been assembled in accordance with manufacturer recommendations or that it was safe for resident use.This practice was not limited to Resident ID #6 and had the potential to affect any resident using a bed with side rails assembled under the same process, placing residents at risk for hazards associated with incompatible bed systems, including entrapment, falls, or equipment failure.B1. Record review revealed that Resident ID #6 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, abnormalities of gait and mobility.During surveyor observations on 6/29, 6/30, 7/1, and 7/2/2026 revealed the resident has bilateral bed side rails.Record review revealed that the last bed side rail assessment was completed on 2/20/2026.Record review failed to reveal evidence that a bed side rail assessment was completed quarterly as required per the RAI manual.B2. Record review revealed that Resident ID #10 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, brain damage and muscle weakness.During surveyor observations on 6/30, 7/1 and 7/2/2026 revealed the resident has bilateral bed side rails.Review of a Quarterly Evaluation dated 5/3/2026 revealed that the resident requires bed side rails. Record review failed to reveal evidence of a care plan for the use of bed side rails as required per the facility's policy.During a surveyor interview on 7/2/2026 at 9:35 AM with Licensed Practical Nurse (LPN), Staff E, she acknowledged that Resident ID #10 does not have a care plan in place for bed side rails.B3. Record review revealed that Resident ID #16 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, stroke and altered mental status.During surveyor observations on 6/29, 6/30, 7/1, and 7/2/2026 revealed the resident has bilateral bed side rails.Record review revealed that the last bed side rail assessment was completed on 2/12/2026.Record review failed to reveal evidence that a bed side rail assessment was completed quarterly as required per the RAI manual.Record review failed to reveal evidence of a care plan for the use of bed side rails as required per the facility's policy.B4. Record review revealed that Resident ID #77 was admitted to the facility in August of 2022 with diagnoses including, but not limited to, stroke and dementia.During surveyor observations on 6/29, 6/30, 7/1, and 7/2/2026 revealed the resident has bilateral bed side rails.Record review revealed that the last bed side rail assessment was completed on 2/18/2026.Record review failed to reveal evidence that a side rail assessment was completed quarterly as required per the RAI manual.Record review failed to reveal evidence of a care plan for the use of bed side rails as required per the facility's policy.B5. Record review revealed Resident ID #99 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, Alzheimer's disease and dementia.During surveyor observations on 6/29, 6/30, 7/1, and 7/2/2026 revealed the resident has bilateral bed side rails.Record review revealed that the last bed side rail assessment was completed on 2/26/2026.Record review failed to reveal evidence that a bed side rail assessment was completed quarterly as required per the RAI manual.Record review failed to reveal evidence of a care plan for the use of bed side rails as required per the facility's policy.B6. Record review revealed that Resident ID #111 was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease.During surveyor observations on 6/29, 6/30, 7/1, and 7/2/2026 revealed the resident has bilateral bed side rails.Record review revealed that the last bed side rail assessment was completed on 2/26/2026.Record review failed to reveal evidence that a bed side rail assessment was completed quarterly as required per the RAI manual.During a surveyor interview on 7/2/2026 at 10:28 AM, the Director of Nursing Services (DNS) revealed that all residents with bed side rails should have care plans in place as required in the facility policy. Additionally, she acknowledged that bed side rail assessments should be completed quarterly.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that a resident was treated with dignity and in a manner that maintained his/her quality of life for 1 of 3 residents reviewed related to gastrostomy tube (G-tube - a medical device inserted directly through the abdomen into the stomach prescribed to provide nutrition), Resident ID #16.Findings are as follows:Record review revealed the resident was admitted to the facility in May of 2026 with diagnoses including, but not limited to, cerebral infarction (stroke) and dysphagia (difficulty swallowing).Record review revealed a physician's order dated 4/13/2026 to administer Jevity 1.5 calorie nutrition (a balanced nutrition administered through a feeding tube) at 65 milliliters per hour via G-tube.Record review revealed a care plan intervention dated 4/8/2026 to provide privacy and promote dignity during care.During a surveyor observation on 6/30/2026 at 11:33 AM, the resident was seated in the common dining room with other residents when Registered Nurse, Staff A, removed the resident's abdominal binder, exposed his/her abdomen, placed a towel under the G-tube, attached the nutrition formula, and started the infusion. Additionally, Staff A failed to request permission from the resident or ensure privacy before exposing and accessing the G-tube site in a public area with other residents present.During a surveyor interview on 6/30/2026 at 1:39 PM, Staff A acknowledged reconnecting the resident's Jevity nutrition to his/her G-tube in the common area without providing privacy before exposing the resident's abdomen.During a surveyor interview on 6/30/2026 at 2:04 PM with the Director of Nursing Services, she revealed that she would expect staff to ask for permission prior to accessing the resident's G-tube site when in a common area. Additionally, she was unable to provide evidence that staff ensured the resident was provided with privacy and was treated with dignity.

Based on clinical record review and staff, resident and resident representative interviews, the facility failed to provide reasonable accommodations for resident needs and preferences by not individualizing the physical environment. Specifically, affecting 1 of 1 resident who requested a bariatric bed Resident ID #45 and for 1 of 1 resident who required the correct placement of a Foot Buddy positioning device, Resident ID #101. Findings are as follows:Review of a facility document titled ADL - SUPPORT last revised 5/2026 states in part, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).a. Record review revealed Resident ID #45 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, morbid obesity (a chronic disease with a body mass index of 40 or higher).Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating intact cognition.Further record review revealed that the resident's last recorded weight was 318 pounds on 6/2/2026.During a surveyor observation on 6/29/2026 at 11:49 AM, Resident ID #45 was sitting on the edge of a standard bed, which appeared to be too small to accommodate him/her comfortably.During a surveyor interview on 6/29/2026, following the above observation, Resident ID #45 stated, .as you can see, I need a bigger bed because this bed is so uncomfortable. The resident reported previously notifying maintenance staff, who instructed the resident to inform nursing. The resident stated s/he made this request to a nurse approximately one month prior but received no follow-up.During a surveyor interview on 6/30/2026 at 12:59 PM with Registered Nurse, Staff G, she revealed that she was made aware that the resident requested a larger bed approximately 2 weeks ago. She further revealed that the Maintenance staff were notified of the request. Additionally, Staff G revealed that the Maintenance staff indicated that they were looking into getting the resident a larger bed.During a surveyor interview on 6/30/2026 at 1:13 PM, Maintenance Assistant, Staff H, acknowledged being aware of the resident's request for a larger bed. However; she revealed that there were no functional bariatric beds available in the building at that time.During a surveyor interview on 6/30/2026 at 1:22 PM with the Director of Nursing Services (DNS), she revealed that she was not made aware of the resident's request for a bariatric bed. During a surveyor observation and subsequent interview on 7/1/2026 at 9:44 AM, the resident was noted to be in a new bed that was appropriate for his/her size. Additionally, Resident ID #45 expressed satisfaction, stating that s/he was happy and had slept well the previous night.b. Record review revealed Resident ID #101 was admitted to the facility in January of 2026 with diagnoses including, but not limited to, dementia and stiffness of joints.Review of the Quarterly MDS assessment dated [DATE] revealed that Resident ID #101 is noninterviewable. Additional review of the MDS revealed the resident depends on staff for all activities of daily living.Review of the care plan last revised on 5/19/2026 states the resident is at risk for falls, decrease in mobility and poor safety awareness related to cognitive impairment with an intervention to apply appropriate footwear when ambulating or when in the wheelchair. Additional review of the care plan dated 6/24/2026 states the resident is dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits and physical limitations. Further review of the care plan failed to identify the need for a foot buddy to be applied to the resident's wheelchair.During a surveyor observation on 6/29/2026 at 12:04 PM, Resident ID #101 was observed moaning in the main dining room. The resident's legs were improperly positioned behind the wheelchair leg rests, and the foot buddy support was only covering the lower footing of the rest. The facility staff were immediately notified of the incorrect positioning and adjusted the resident, at which point the moaning ceased.During a surveyor interview immediately following the observation with the resident's family member, s/he expressed concern regarding the resident experiencing pain due to the improper application of the foot buddy, noting that the resident's feet frequently fall through the wheelchair. The family member added that the resident stops moaning once properly repositioned.During a surveyor observation on 6/30/2026 at 12:01 PM, Resident ID #101's foot buddy device was noted to be incorrectly applied. Additionally, the resident was observed moaning and exhibiting increased vocalizations.Immediately following the observation, Nursing Assistant, Staff I, was notified by the surveyor of the incorrect application of the foot buddy. Staff I attempted to correct the device's positioning but was unable to secure it, as it repeatedly slid down during the application.During a surveyor interview on 6/30/2026 at 12:09 PM, with the Director of Rehabilitation, he reviewed the positioning and acknowledged that the foot buddy was applied upside down and required complete removal and reapplication. He further revealed that once applied correctly the foot buddy should not slide down. Furthermore, the Director of Rehabilitation stated he was uncertain if the facility staff had received education regarding the proper application of the device.During a surveyor interview with the DNS on 6/30/2026 at 2:01 PM, she revealed that she would expect the foot buddy to be applied correctly. She revealed that the rehabilitation department is currently on the units providing education to the staff about the application of the foot buddy. Furthermore, she acknowledged that the plan of care and orders failed to reveal evidence of the need for the foot buddy and that it should be in the resident's care plan.

Based on clinical record review and resident and staff interviews, the facility failed to ensure services provided meet professional standards of practice for 1 of 1 resident reviewed for wound care, Resident ID #111. Specifically, nursing staff improperly applied an Unna boot (a specialized compression dressing) to Resident ID #111's right lower extremity (RLE), omitting the foot and ankle. Findings are as follows:Review of the manufacturer's instruction for the Unna boot application revealed the following: 1. Position the foot at a right angle, so the foot is perpendicular to the leg. Begin wrapping without pressure just above the toes and continue upwards using a spiral technique with a 50% overlap.2. Mold wrap to the contours of the leg. Finish wrapping 1-2 [inches] below the knee. Smooth out wrinkles as needed.3. Secure by covering with a secondary dressing such as a self- adherent wrap, elastic bandage, or gauze roll.Record review revealed that Resident ID #111 was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, fluid overload.Record review revealed a physician order with a start date 5/6/2026 to cleanse the right lower extremity with normal saline, pat the extremity dry, and apply an Unna boot every Tuesday and Friday.During a surveyor interview with Resident ID #111 on 6/29/2026 at 9:27 AM, the resident revealed that a nurse applied the Unna boot wrapping his/her leg incorrectly. The resident revealed that s/he had increased pain from the application.Review of a skin/wound note dated 6/12/2026 revealed a skin assessment was completed, and the resident's leg was not weeping.Review of a progress note authored by Nurse Practitioner, Staff J, dated 6/21/2026, revealed a video consultation was conducted with Resident ID #111 and the facility nurse, regarding Resident ID #111 as s/he was experiencing acute pain. The resident was complaining of right ankle pain and the nurse reports ankle edema (swelling caused by excess fluid in tissues, often due to inflammation, injury, or underlying conditions), with serous drainage (clear to pale yellow, thin, watery fluid that leaks from an area affected by edema). On the video the resident was observed to have an Unna boot covered with an ACE bandage to the lower leg; however, the dressing was applied in a fashion that stopped abruptly above the ankle. During the consultation, Resident ID #111 stated that the dressing had been applied correctly by staff in the past but not this time.During a surveyor interview on 6/30/2026 at 11:32 AM with Registered Nurse (RN), Staff A, she revealed that the nurse wrapped the resident's leg inappropriately. She revealed that the Unna boot wrapping should have been applied from the base of the toes to below the knee.During a surveyor interviews on 6/30/2026 at 2:07 PM and 7/1/2026 at 10:07 AM, with the Director of Nursing Services, she acknowledged that the nurse didn't apply the Unna boot correctly.

Based on clinical record review and resident, resident representative, and staff interviews, the facility failed to provide written notification, including the reason for the room change, before the resident's room or roommate in the facility is changed, for 6 of 6 residents reviewed, Resident ID #s, 45, 66, 93, 99, 101, and 147.Findings are as follows:Record review of a facility policy titled Room Change last revised in October of 2022, states in part, .The resident has the right to refuse transfer to another room in the facility if the purpose of the transfer is.Solely for the convenience of staff.When a resident room change is occurring, the resident being moved.will be informed of the room change. The resident receiving a new roommate will also be notified.The notice of a change in room or roommate assignment will be both verbal and in writing including the reason(s) for the change. Staff should complete a room change notice and provide to the resident.placed in the resident's medical record.1. Record review revealed Resident ID #45 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, type two diabetes.Record review of a Brief Interview for Mental Status (BIMS) score dated 5/8/2026, revealed a score of 15 of 15, indicating intact cognition.Record review of the facility census revealed that the resident was moved from his/her room on 4/1/2026.Review failed to reveal evidence that Resident ID #45 received written notification of the room change, including the reason for the change, per the facility policy.2. Record review revealed Resident ID #147 was admitted to the facility in May of 2026 with a diagnosis including, but not limited to, pneumonia.Record review of a BIMS score dated 5/29/2026, revealed a score of 8 of 15, indicating a moderate cognitive impairment.Record review of the facility census revealed that the resident was moved from his/her room on 6/9/2026.Record review failed to reveal evidence that Resident ID# 147 received written notification of the room change, including the reason for the change, per the facility policy.During a surveyor interview on 6/30/2026 at approximately 3:00 PM with Resident ID #147, s/he revealed that s/he was not initially happy with the transfer to another floor because s/he made friends on the second floor.3. Record review revealed Resident ID #66 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, anxiety and depression.Record review of a BIMS score dated 5/28/2026, revealed a score of 15 of 15, indicating intact cognition. During a surveyor interview on 6/30/2026 at approximately 1:20 PM the resident revealed that one morning s/he was awoken by staff telling him/her that his/her room will be changed. The resident further revealed that s/he didn't not have a choice and did not want to move as s/he had been in that room for several years. The resident denied receiving written notification of the room change.Record review of the facility census revealed that the resident was moved from his/her room on 5/27/2026.Record review failed to reveal evidence that Resident ID #66 received written notification of the room change, including the reason for the change, per the facility policy.4. Record review revealed Resident ID #93 was admitted to the facility in October of 2021 with a diagnosis including, but not limited to, heart failure.Record review of a BIMS score dated 4/10/2026, revealed a score of 15 of 15, indicating intact cognition. During a surveyor interview on 7/1/2026 at 12:57 PM with Resident ID #93, s/he revealed that s/he was not notified about receiving a roommate prior to the transfer. Record review failed to reveal evidence of written notification to the resident that s/he was to receive a roommate.5. Record review revealed Resident ID #99 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia and obsessive-compulsive disorder. Record review of a BIMS score dated 6/25/2026, revealed a score of 0 of 15, indicating severe cognitive impairment.Record review of the facility census revealed that the resident was moved from his/her room three times from December 2024 to June of 2026.During a surveyor interview on 6/30/2026 at 1:06 PM with Resident ID #99's representative, s/he revealed that there were no written notifications provided for room changes within the facility. Record review failed to reveal evidence that Resident ID #99's resident representative received written notification of the room change, including the reason for the change, per the facility policy.6. Record review revealed Resident ID #101 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, dementia.Record review of a BIMS score dated 5/7/2026, revealed a score of 0 of 15, indicating severe cognitive impairment.Record review of the facility census revealed that the resident was moved from his/her room three times from January 2026 to June of 2026.During a surveyor interview on 6/30/2026 at 1:06 PM with Resident ID #101's representative, s/he revealed that there were no written notifications provided for room changes within the facility. Record review failed to reveal evidence that Resident ID #101's representative received written notification of the room change, including the reason for the change, per the facility policy.During a surveyor interview on 7/2/2026 at 11:17 AM, with the Social Worker, she revealed that when a room change or roommate change occurs the facility will complete an assessment in the record but does not give any written notification to the resident and/or resident representative.During a surveyor interview on 7/1/2026 at 10:36 AM and 7/2/2026 at 2:17 PM, with the Director of Nursing Services, she acknowledged that the facility failed to provide written notification, including the reason for the room change, before the resident's room or roommate in the facility is changed, for Resident ID #s, 45, 66, 93, 99, and 101, and 147.

Based on clinical record review and staff interview, the facility failed to ensure adequate supervision and failed to maintain an effective elopement prevention system for 1 of 1 resident reviewed for elopement risk, Resident #1. The resident was assessed as a high elopement risk, had a documented history of exit-seeking behaviors, requiring a wander guard device (a safety mechanism intended to monitor and prevent at-risk residents from exiting unsupervised) and resides on a secured unit intended to prevent unauthorized egress. Despite the utilization of the wander guard device, the facility's failure allowed the resident to elope undetected from the secured unit and travel approximately two miles away from the facility, including navigating and crossing four lanes of a heavily trafficked roadway before being located. This failure represents a significant breakdown in supervision and safety systems and placed the resident at risk for serious injury or death. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Heath on 3/16/2026 revealed that Resident ID #1, who resides on the secured unit, eloped from the facility on foot, was subsequently located by staff, and was returned. Record review revealed Resident ID #1 was admitted to the facility in February of 2026 with diagnoses including, but not limited to, Alzheimer's Disease, dementia, and s/he has a documented history of exit-seeking behaviors.Record review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 00, indicating the resident has severe cognitive impairment. Additionally, the MDS indicates that s/he has a behavior of wandering the unit.Record review of the care plan dated 3/9/2026, revealed the resident is at a high risk for elopement and that prior to his/her admission to this facility s/he has a history of eloping, recent attempts to leave the premises/unit, and s/he has verbalized statements relative to leaving. Additionally, the care plan also indicates that the resident exhibits a wandering behavior pattern, and s/he wears a wander guard.Record review of an undated written statement, authored by Licensed Practical Nurse, Staff C, indicated that at approximately 9:30 AM on 3/16/2026 the resident was observed attempting to open the unit exit door. The resident was redirected and escorted back to the dining room by the facility staff. Record review of a nursing progress note, dated 3/16/2026 at 1:13 PM, revealed that the resident had eloped from the unit via the stairway through an undisclosed exit after last being seen in his/her room at approximately 10:00 AM that morning. The note further revealed that at approximately 11:20 AM a Code Orange was called and the elopement protocol was initiated. The resident was located on a main road by staff members who then transported the resident back to the facility safely without injury. During a surveyor interview on 3/23/2026 at 9:06 AM, with the Director of Nursing Services (DNS) and the Administrator, they indicated that the resident is an elopement risk, wanders the unit, and wears a wander guard, but that the wander guard is not detected at the exit doors of the unit. They further revealed that the wander sensors are located only at the elevators. They revealed that on 3/16/2026, the resident left the secured unit by a stairwell door that alarms when opened, walked down several flights of stairs to the basement level, and then exited the facility through the basement exterior door. Additionally, they indicated that they believed Resident ID #1 eloped from a door that initially alarmed but then stopped when the door closed. Lastly, they revealed that the door stops alarming after a period of time. During a surveyor interview on 3/24/2026 at 10:27 AM, with Physical Therapist, Staff A, he stated that on 3/16/2026 at approximately 11:20 AM, he observed the resident walking along the main road and crossing a four-lane street. Staff A noted that at the time of the observation, he did not recognize the individual as a resident of the facility. Upon arriving to the facility, Staff A learned that a resident was missing. He then informed the facility of his observation. Staff A and two other staff members drove to the location where he saw the resident, they located him/her and drove him/her back to the facility.The facility failed to provide adequate supervision and elopement protection for Resident ID #1, who was a known high elopement risk. This failure enabled the resident to exit a secured unit undetected and travel approximately two miles off premises, for an approximate time frame of last being seen at 10:00 AM until his/her return at 11:45 AM. This resident was able to traverse a heavily trafficked roadway and cross four lanes of active traffic unattended. This lapse of supervision placed Resident ID #1 at risk for more than minimal harm, serious injury, or death.

Based on clinical record review, and staff and resident interviews, the facility failed to ensure that residents are provided or arranged services in accordance with professional standards of practice, relative to 1 of 1 resident who was admitted from the hospital with a diagnosis of spinal stenosis (the narrowing of one or more spaces within the spinal canal that can put pressure on the spinal cord and nerves, which can cause pain), with a referral to see a neurosurgeon (a medical doctor who diagnoses and treats conditions that affect the nervous system, including your brain, spinal cord and nerves) for spinal injections, which was not arranged, Resident ID #2. Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 3/13/2026 alleged, in part, that the facility failed to schedule a necessary surgical follow-up appointment for Resident ID #2, with the resident reportedly waiting approximately five months without resolution.Record review revealed the resident was admitted to the facility in October 2025 with diagnoses including but not limited to, hemiplegia (paralysis affecting one side of the body) and hemiparesis (muscle weakness, numbness or reduced motor control on one side of the body) following a stroke affecting the left non-dominant side, as well as spinal stenosis. Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, confirming the resident is cognitively intact and fully capable of expressing needs and concerns.During a surveyor interview on 3/23/2026 at 12:50 PM with the resident, s/he revealed that s/he had made multiple unsuccessful attempts to contact the facility's appointment scheduler to obtain a neurosurgical consultation for spinal injections, yet no appointment had been arranged.Record review of the Continuity of Care - Post-Acute Facility document dated 10/24/2025 confirmed that, upon discharge, a referral to the spine center was placed to evaluate the need for spinal steroid injections.Further review of the record revealed a provider progress note dated 11/17/2025 which indicated the resident's ongoing chronic lower extremity weakness related to lumbar disc protrusions and reiterated the need for outpatient neurosurgical follow-up. An additional referral was placed at that time.Despite these clear and repeated physician ordered referrals, record review failed to produce any evidence the facility scheduled or facilitated the required follow-up appointment.During a surveyor interview on 3/24/2026 at 10:36 AM with the Unit Secretary, Staff B, in the presence of the Director of Nursing Services (DNS), she acknowledged responsibility for scheduling resident appointments but stated she was unaware of the resident's referrals to the spine center. Both Staff B and the DNS were unable to provide evidence that the facility made efforts to arrange the neurosurgical consultation.

Based on clinical record review and resident and staff interviews, the facility failed to ensure residents were free from physical abuse for 2 of 4 residents reviewed, Resident ID #s 3 and 4, as evidenced by not implementing effective, enhanced interventions despite documented intrusive wandering by Resident #3 on 12/26/2025, 12/27/2025, 1/10/2026, and 1/12/2026. This failure led to a resident to resident physical altercation on 1/13/2026, in which Resident #4 forcefully pushed Resident #3, resulting in a fall and a left femoral neck fracture that required surgical repair. Additionally, the facility failed to ensure a resident was free from sexual abuse for 1 of 4 residents reviewed, Resident ID #5. On 1/27/2026 when Resident #6, who has severe cognitive impairment and a history of sexually inappropriate behavior, was found attempting to engage in sexual intercourse with Resident #5, who has a severe cognitive impairment and lacks the capacity to consent. Upon staff intervention Resident #6 became aggressive, brandishing scissors and threatening staff.Findings are as follows:Record review of a facility policy titled Abuse Prohibition Policy dated September 2020 states in part, . facility has the responsibility to ensure each resident has the right to be free from Abuse.Abuse means the willful infliction of injury.resulting in physical harm, pain or mental anguish.Adverse event is an undesirable and usually unanticipated event that caused.serious injury, or risk thereof.sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. 1. Review of a facility-reported incident submitted to the Rhode Island Department of Health (RIDOH) on 1/14/2026 revealed that Resident ID #3, who has a diagnosis of severe dementia with psychosis, wandered into the room of Resident ID #4, these residents reside on a secured unit. Despite being instructed to leave, Resident ID #3 remained in Resident ID #4's room. Resident ID #4 then grabbed Resident ID #3 by both of his/her wrists and forcefully shoved them, which caused Resident ID #3 to lose his/her balance, strike the wall, and fall to the floor. Resident ID #3 yelled out, alerting staff. Both residents were subsequently transported to the hospital.Record review revealed that Resident ID #4, was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, dementia.Record review of an admission Minimum Data Set (MDS) Assessment for Resident ID #4 dated 12/29/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident has intact cognition.Record review of a progress note dated 1/13/2026 at 9:36 PM revealed that Resident ID #4 reported Resident ID #3 entered his/her room and refused to leave, resulting in an altercation. Resident ID #4 was noted to have skin tears on both of his/her wrists and admitted to pushing Resident ID #3 to the floor.Record review revealed Resident ID #3, was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, severe dementia with behavioral disturbance.Record review of an admission MDS Assessment for Resident ID #3 dated 1/1/2026 revealed a BIMS score of 0 out of 15, indicating the resident has severely impaired cognition. Additional review revealed the resident required supervision or touch assistance for ambulation. Further, review of section E -behavior revealed that s/he experienced wandering for up to six days during the review period and the wandering significantly intruded on the privacy or activities of others.The facility was aware of Resident ID #3's ongoing, intrusive wandering behaviors, as evidenced by multiple documented progress notes, including but not limited to: - 12/26/2025: Resident wandered throughout the unit and entered other residents' rooms; requiring frequent redirection. - 12/27/2025: Resident repeatedly entered other residents' rooms despite redirection; requiring continuous staff monitoring. - 1/10/2026: Resident wandered into other residents' rooms; redirection had little effect. - 1/12/2026: Resident observed wandering and entering other residents' rooms.- 1/13/2026 at 6:11 PM: authored by the covering Nurse Practitioner, Staff A, revealed a telehealth visit was completed with the resident which indicated that the nurse called to report an altercation between two residents. Resident ID #3 wandered into Resident ID #4's room. Resident ID #3 was told to leave, and s/he did not. Resident ID #4 grabbed both of Resident ID #3's wrists and shoved him/her down to the floor. Resident ID #4 was in fear for his/her life. Resident ID #4 has skin tears to the backs of both hands. Resident ID #3 has red marks on both wrists that look like fingertip bruises starting to appear. Additional review revealed a psychiatry consultation was ordered for worsening condition and dangerous behaviors. - 1/13/2026 at 9:28 PM, authored by Licensed Practical Nurse, Staff B, revealed Resident ID #3 entered Resident ID #4's room and altercation occurred. During the altercation Resident ID #3 was pushed and fell to the ground. Resident ID #3 noted to have visible hand/finger marks on his/her wrists. Resident ID #3 could not walk after falling and complained of pain. The resident was sent to the hospital.Despite repeated documented incidents demonstrating escalation and ineffective redirection, record review failed to reveal evidence that the facility implemented new or enhanced interventions to mitigate the known risk of resident-to-resident altercations.Record review of a hospital continuity of care form revealed Resident ID #3 was admitted to the hospital on [DATE] secondary to a left femoral neck fracture which required a left hip hemiarthroplasty (joint replacement surgery where only one half of the joint is replaced). Additional review revealed a Physical Therapy evaluation was completed with the resident with the recommendations to utilize a Hoyer lift (a mechanical device utilized by staff to aid in transferring) for transfers upon discharge from the hospital.During a surveyor interview and observation on 1/29/2026 at approximately 3:10 PM, Resident ID #4 revealed that Resident ID #3 wandered into his/her room, s/he told Resident ID #3 to get out, and Resident ID #4 grabbed his/her bilateral hands and would not let go. Resident ID #4 indicated his/her right hand started to bleed. S/he indicated that s/he stood up from his/her wheelchair and pushed Resident ID #3 to the floor. The resident was observed with a scabbed area to his/her left hand and a resolved skin tear area on the right hand.During a surveyor interview on 1/29/2026 at 4:40 PM with the Director of Nursing Services (DNS), she acknowledged that Resident ID #3 wanders related to his/her cognition. She was unable to provide evidence that new interventions were put into place following Resident ID #3's wandering into other resident's rooms noted on 1/10/2026 and 1/12/2026. Additionally, she acknowledged that Resident ID #3 grabbed both of Resident ID #4's hands that resulted in skin tears, which led to Resident ID #4 pushing Resident ID #3 to the floor which also resulted in Resident ID #3 sustaining a left-femur fracture that required surgical repair.The facility's failure to implement appropriate interventions following witnessed incidents on 1/10/2026 and 1/12/2026, during which Resident ID #3 entered other residents' rooms and caused distress, placed Resident ID #3 at risk for resident-to-resident physical abuse. This failure resulted in a physical altercation in which Resident ID #3 was pushed by Resident ID #4, causing a fall and resulting in a left femur fracture. Additionally, Resident ID #4 sustained skin tears to the backs of his/her hands.2. Review of a facility reported incident submitted to the RIDOH on 1/27/2026 revealed at approximately 10:45 PM, Resident ID #s 5 and 6 were observed undressed from the waist down attempting to engage in sexual intercourse with one another. Staff intervened and Resident ID #6 became very aggressive and combative, waving a pair of scissors, threatening staff while swinging the scissors. Record review for Resident ID #6 revealed s/he was admitted to the facility in November of 2025 with diagnoses including, but not limited to, Alzheimer's Disease and vascular dementia.Record review of an MDS Assessment for Resident ID #6 dated 11/19/2025 revealed a Brief Interview for Mental Status Assessment (BIMS) score of 5 out of 15, indicating the resident has severe cognitive impairment. Further review revealed s/he can ambulate with supervision and/or touch assistance.Record review of a care plan dated 11/29/2025 revealed Resident ID #6 exhibits sexually inappropriate behavior towards other residents including hugging and kissingRecord review revealed the following nursing progress notes: - 11/28/2025 at 4:46 PM Resident ID #6 was observed yelling and aggressively moving towards the Nursing Assistant (NA) appearing as if s/he was going to hit her. The NA reported that Resident ID #6 had touched Resident ID #5 on the chest/breast area and tried to kiss the resident after s/he tried to move his/her head. - 1/28/2026 at 12:43 AM - Resident ID #6 was found engaging in inappropriate behavior with Resident ID #5. The resident was observed engaging in sexual intercourse with Resident ID #5. The resident had his/her pants and underpants lowered, attempting to engage in sexual activity with Resident ID #5.Record review revealed Resident ID #5 was readmitted to the facility in July of 2025 with diagnoses including, but not limited to, senile degeneration of the brain.Record review of a quarterly MDS assessment dated [DATE], revealed Resident ID #5 has a BIMS Score of 0 out of 15, indicating severe cognitive impairment. Additional review revealed s/he wanders daily and can ambulate with supervision and/or touch assistance.Record review of Resident ID #5's care plan dated 5/21/2019 revealed a behavioral problem exhibited by wandering the unit, with interventions including, but not limited to, provide for the immediate safety of the resident or other residents.Record review of a progress note dated 1/28/2026 at 12:57 AM for Resident ID #5 revealed s/he was found lying in bed with Resident ID #6 with his/her pants and brief lowered. Resident ID #6 was attempting to engage in sexual intercourse. A skin assessment was completed for Resident ID #5 and his/her perineal area observed with redness. During a surveyor interview on 1/28/2026 at 1:40 PM with the Director of Nursing Services (DNS), Staff L, she revealed that on 1/27/2026 at approximately 11:00 PM, the Nursing Assistant, found Resident ID #5 in Resident ID #6's bed. Resident ID #6 was lying on top of Resident ID #5 with his/her pants down attempting to engage in sexual intercourse. Resident ID #6 was observed with his/her pants and underwear down. The DNS further revealed that when the staff attempted to separate the two residents, Resident ID #6 became aggressive and combative. Both residents were sent to the hospital.During a surveyor interview on 1/29/2026 at 1:46 PM with Resident ID #5's responsible party, s/he indicated that s/he was made aware of a previous interaction between Resident ID #5 and Resident ID #6 that took place in November of 2025, but was assured by facility staff that the residents would be kept separated. Additionally, she revealed that Resident ID #5 does not understand or could not consent to a sexual relationship due to his/her cognitive impairment, therefore, would not want him/her to engage in a sexual relationship with another resident.During a surveyor interview on 1/29/2025 at 4:40 PM with the DNS, Staff L, she was unable to provide evidence that Resident ID #5 was kept free from resident-to-resident sexual abuse.

Based on record review and staff interview the facility failed to develop, implement, and maintain an effective training program, for existing staff, consistent with their expected roles, relative to education pertaining to emergency preparedness, as required per the facility assessment, for 4 of 5 staff reviewed, Staff H, I, J, and K. This failure has the potential to impact 163 of 163 residents and an indeterminable number of staff and visitors.Findings are as follows:According to the Facility Assessment, last revised 2/5/2026, the facility assessment indicates staffing is adjusted based on staff education to ensure the residents' health and safety are maintained.Record review failed to reveal evidence that the following staff completed emergency preparedness training: - Staff H, hired on 3/19/2015. - Staff I, hired on 10/11/2022. - Staff J, hired on 5/4/2021. - Staff K, hired on 11/7/2024.During a surveyor interview on 2/11/2026 at approximately 2:00 PM, with the Director of Nursing Services, Staff M, she was unable provide evidence of emergency preparedness training for Staff H, I, J and K. Additionally, she revealed it would be her expectation that training relative to emergency preparedness was completed for the above-mentioned staff.

Based on clinical record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 2 of 2 resident reviewed, who has an actual pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), Resident ID #'s 2 and 3.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/21/2026 alleges that Resident ID #2 had developed a pressure area on his/her buttocks while residing in the facility.Review of an undated facility policy titled, Prevention & Management of Pressure Injuries, states in part, .Resident with pressure injuries and those at risk for skin breakdown are identified, assessed and provided appropriate treatment to encourage healing and/or maintenance of skin integrity.Resident will have a weekly body audit completed by the licensed staff.Pressure injuries are assessed and documented on at least weekly.Pressure injury assessment includes:LocationMeasurement in centimeters-length, width and depth.Stage.Drainage AmountDrainage ColorOdor if present after cleaningAppearance of wound bedAppearance of wound edgesAppearance of the peri wound.1a. Record review revealed that Resident ID #3 was admitted to the facility in December of 2025 with diagnoses including, but not limited to, dementia and muscle weakness.Record review of an admission Minimum Data Set (MDS) Assessment Section M Skin Condition, dated 12/29/2025, revealed the resident was admitted with a Stage 3 pressure ulcer (full-thickness skin loss where subcutaneous fat is visible). Record review revealed a physician's order dated 12/27/2025 requiring weekly skin assessments to be completed every Wednesday during the 3:00 PM-11:00 PM shift.Review of the December 2025 and January 2026 Treatment Administration Records indicated that skin checks were documented as completed on the following dates: - 12/31/2025 - 1/7/2026 - 1/21/2026 - 1/28/2026However, review of the weekly body audits for Resident ID #3 failed to demonstrate that the Stage 3 pressure injury was assessed to include the wound location, measurements, drainage, odor, or description of the wound bed, wound edges, or peri-wound area on the following dates: - 12/31/2025 - 1/7/2026 - 1/14/2026 - 1/21/2026 - 1/28/2026Record review of the December of 2025 and January 2026 Treatment Administration Records revealed the skin checks were signed off as completed on the following dates: - 12/31/2025 - 1/7/2026 - 1/21/2026 - 1/28/20261b. Review of the contracted Wound Physician's progress note for Resident ID #3 dated 12/29/2025 revealed a recommendation for daily treatment of the resident's left lateral heel Stage 3 pressure ulcer, including cleansing with normal saline, application of SSD (Silvadene), and coverage with a silicone dressing daily.Review of the record revealed a physician's order dated 12/30/2025 to cleanse the resident's left heel with normal saline, apply Silvadene, and cover with a silicone dressing daily.Review of a follow-up progress note dated 1/5/2026 and signed on 1/7/2026 by the facility's contracted Wound Physician revealed a revised recommendation for daily treatment of the resident's left lateral heel Stage 3 pressure ulcer, including cleansing with normal saline, application of A & D ointment, and leaving the wound open to air.Review of the clinical record revealed a physician's order dated 1/12/2026 to cleanse the resident's left lateral heel with normal saline, apply A & D ointment, and leave the wound open to air.Review of the clinical record failed to reveal evidence that the order for Silvadene to the resident's left heel had been discontinued.Review of the January 2026 Treatment Administration Records revealed that Resident ID #3 received the Silvadene treatment and the A & D treatment from 1/13/2026 through 1/28/2026, for a total of 16 days.During a surveyor interview with the Nurse Practitioner, she stated that it would have been her expectation that the contracted Wound Physician's recommendation for A & D ointment be implemented and the Silvadene to be discontinued immediately.2.Record review revealed that Resident ID #2 was readmitted to the facility in November of 2025 with diagnoses including, but not limited to, dementia, hemiplegia and hemiparesis (weakness and/or paralysis) following a cerebral infarction (stroke) affecting the left non-dominant side.Record review of a Quarterly Minimum Data Set (MDS) Assessment Section M Skin Condition, dated 12/10/2025, revealed the resident is at risk for developing pressure ulcers/injuries.Record review of the weekly body audits revealed a skin check was completed on 12/19/2025, indicating no skin impairment. Further review of the weekly skin checks failed to reveal evidence that a weekly skin check was completed after 12/19/2025 through 1/11/2026. Record review revealed a Pressure Injury Evaluation form was completed on 1/12/2026 which indicated Resident ID #2 had a newly identified stage 2 pressure area (a partial-thickness skin loss with dermis exposure and the wound bed presenting as viable, red, or moist) to his/her coccyx ( a small triangular bone at the base of the spinal column).Record review of the weekly body audits completed on 1/20/2026 and 1/24/2026 for Resident ID #2 failed to reveal evidence that the Stage 2 pressure injury was assessed to include the location, measurements, drainage, odor or the appearance of the wound bed, including the edges or the peri wound. Record review of a weekly body audit completed on 1/24/2026 failed to reveal evidence that any skin impairment was identified for the resident. During a surveyor interview on 1/28/2026 at 2:29 PM and 4:02 PM with the Director of Nursing Services, Staff L, she indicated it would be her expectation for weekly skin checks to be completed and any pressure area to assessed with documentation including the location, measurements, drainage, odor or the appearance of the wound bed, including the edges or the peri wound.

Based on clinical record review and staff interview, the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 1 of 2 resident reviewed for skin tears and bruising, Resident ID #5.Findings are as follows:Review of a facility policy titled, Abuse prohibition policy states in part, .Identification .incidents.require an incident report, supervisory follow-up and a comprehensive internal facility investigation which shall be performed with subsequent timely notification to the appropriate agencies, as warranted.Record review revealed that Resident ID #5 was readmitted to the facility in July of 2025 with a diagnosis including, but not limited to, dementia.Record review revealed the following progress notes:-11/6/2025 at 5:22 PM -the resident presented with a bruise to his/her right forearm and elbow-11/17/2025 at 3:34 PM -left forearm discoloration and skin tear. S/he was unable to verbalize how skin tear occurred-12/2/2025 at 1:07 PM- a bruise on the right arm and redness on the right elbow were identified. S/he was unable to recall or report how the injury occurred.-12/27/2025 at 1:13 PM- the Nursing Assistant noticed a bruise on the left upper armFurther record review failed to reveal evidence that an investigation had been conducted to determine the origin of the above-mentioned bruises and skin tears.During a surveyor interview on 1/29/2026 at 2:29 PM with the Director of Nursing Services, Staff L, she was unable to provide evidence that an investigation was initiated for the above-mentioned bruises and skin tears.

Based on clinical record review and staff interview, the facility failed to complete an annual performance review for every Nursing Assistant (NA), at least once every 12 months, for 4 of 4 NA personnel records reviewed, Staff H, I, J, and K.Findings are as follows:Record review of the personnel records failed to reveal evidence that an annual performance evaluation was completed for the following NA's:-Staff H, hired on 3/19/2015.-Staff I, hired on 10/11/2022.-Staff J, hired on 5/4/2021.-Staff K, hired on 11/7/2024.During a surveyor interview with the Director of Nursing Services, Staff M, on 2/11/2025 at approximately 2:00 PM, she was unable to provide evidence that performance evaluations were completed for Staff H, I, J, and K within the last 12 months.

Based on surveyor observation, clinical record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to 1 of 2 residents reviewed who require one to one staff assistance with meals and supplements, Resident ID #2.Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 1/21/2026, alleges the resident has had weight loss and requires supervision with his/her meal and staff just leave his/her food in front of him/her. Additionally, the complaint alleges s/he does not receive his/her supplement. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. Record review revealed that Resident ID #2 was readmitted to the facility in November of 2025 with diagnoses including, but not limited to, dementia, hemiplegia and hemiparesis (weakness and/or paralysis) following cerebral infarction (stroke) affecting the left non-dominant side and repeat falls.Review of the Minimum Data Set (MDS) Assessment, dated 12/10/2025, revealed a Brief Interview for Mental Status (BIMS) score of 3 of 15, which indicates severe cognitive impairment. Additionally, the resident requires supervision or touching assistance with meals.Record review of a Nutritional Assessment progress note dated 1/10/2026 at 1:46 PM revealed the resident has experienced a gradual weight loss in the past 6 months with varied intakes attributed to the weight loss. Recommendations to continue Glucerna Supplement 237 cc (cubic centimeters) by mouth three times a day.Record review of a care plan last revised on 1/13/2026 revealed the resident requires assistance with activities of daily living related to left side weakness due to a stroke with interventions including, but not limited to, one to one feeding assistance with all meals.Record review reveals the following physician's orders:-1/7/2026 - Glucerna Supplement 237 cc by mouth three times a day-1/10/2026 - 1:1 assist with meals (one staff to one resident assisting with meals)-1/13/2026 -one to one feedingDuring a surveyor observation on 1/28/2026 at 12:22 PM the resident was observed sitting in his/her wheelchair with his/her lunch meal in front of him/her attempting to feed himself/herself. Additionally, the resident was attempting to utilize his/her right arm. His/her right arm was observed to be attached to the support on the right side of his/her wheelchair with a black strap. Additionally, during this continuous observation of the lunch meal the resident's tablemate was overheard stating the following:-12:22 PM [S/he] can't feed [Him/herself]; I want to feed you.-12:35 PM [S/he] can't feed [Him/herself]During this continuous observation Nursing Assistant, NA, Staff D, was overheard telling the resident table mate, [S/he] is gonna feed him/herself.During a surveyor interview on 1/28/2025 at 12:44 PM with Staff D, when asked if staff assist the resident with meals, she revealed that when the resident is seated in the dining room staff set up the resident for the meal. Additionally, she acknowledged that the resident was not being assisted one to one until it was brought to her attention by the surveyor.During a surveyor interview with the charge nurse Registered Nurse, Staff G, he indicated he was assigned to the resident that shift but was unaware that the resident required one to one assistance with his/her meals. Additionally, he acknowledged that the resident has a physician order for one-to-one feed.During a subsequent surveyor observation on 1/28/2026 at 1:10 PM the resident was observed sitting in his/her wheelchair with a brown liquid observed in front of him/her in a 4-ounce plastic cup. The surveyor asked the resident if s/he was going to drink the liquid. S/he was observed to attempt to lift the plastic cup but was unable to.During a surveyor interview immediately following the above observation with Medication Technician, Staff H, she acknowledged that the liquid was his/her ordered Glucerna supplement. Staff H was then observed to assist the resident with drinking his/her supplement after it was brought to her attention by the surveyor.During a surveyor interview on 1/28/2026 at 1:47 PM with the DNS, Staff L, she revealed it would be her expectation that staff would assist the resident with his/her lunch meal one to one, as ordered. Additionally, she revealed it would be her expectation that the resident would have been assisted with the administration of his/her supplement prior to it being brought to the staff's attention by the surveyor.

Based on clinical record review and staff interview, the facility failed to ensure that residents are free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident reviewed for an actual restraint, as the resident was observed in his/her wheelchair with a black Velcro strap across his/her right arm, Resident ID #2.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/24/2025 alleges in part, .initially admitted for short term rehab [s/he] was unable to recover from [his/her] stroke.has significant right-side weakness and cannot put a fork to [his/her] mouth .Review of a facility policy titled, Restraint Management states in part, .Physical Restraints: Is any manual, mechanical or physical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints include, but are not limited to.Arm restraints .Also included as restraints are facility practices to meet the definition of a restraint, such as: Using devices in conjunction with a chair .that the resident cannot remove easily, that prevents the resident from rising out of the chair. all restraints will have a specific physician order to include: type of device, how often device is to be used and duration of use, frequency of checking and removing (minimum of every two (2 ) hours).Record review revealed that Resident ID #2 was readmitted to the facility in November of 2025 with diagnoses including, but not limited to, dementia, hemiplegia and hemiparesis (weakness and/or paralysis) following a cerebral infarction (stroke) affecting the left non-dominant side and repeat falls.Review of the Minimum Data Set (MDS) Assessment, dated 12/10/2025, revealed a Brief Interview for Mental Status (BIMS) score of 3 of 15, which indicates severe cognitive impairment. Additionally, the assessment failed to reveal evidence that a restraint was in use. Further, the resident requires supervision or touching assistance with meals.Record review of a care plan last revised on 12/22/2025 revealed the resident is at risk for falls related to cognitive impairment and previous history of falls. Additionally, the resident requires the assistance of two staff members for transfers and ensure proper use of any appliance/device to aid with balance and/or transfers.During a surveyor observation on 1/28/2026 at 12:22 PM the resident was observed sitting in his/her wheelchair with an elevated- arm lateral body support (a device used to improve sitting posture); his/her right arm was connected to the device with a black looped arm strap. Additionally, the resident was observed attempting to feed him/herself with his/her right arm to which movement was restricted. This arm strap remained in place for the duration of his/her meal.During a surveyor interview on 1/28/2026 at 12:46 PM with Nursing Assistants (NA), Staff C, she revealed she was assigned to the resident for the 7:00 AM to 3:00 PM shift on 1/28/2026 and is the primary caregiver for the resident most dayshifts. Additionally, she acknowledged that the black arm strap was attached and holding the resident's right arm to the chair. When asked if the strap should be in place for the resident she stated, the black strap is there every day it's part of the chair.During a surveyor interview on 1/28/2026 at 1:47 PM with the Director of Nursing Services (DNS, Staff L, she indicated she was not aware that there was an arm strap in place for the resident.During a surveyor interview and subsequent observation on 1/28/2026 at 1:55 PM with the Director of Rehabilitation, Staff E, and in the presence of the Director of Nursing Services, Staff L, the Director of Rehabilitation indicated that the resident was currently receiving Physical Therapy services for wheelchair positioning. Additionally, the resident was observed sitting in his/her wheelchair with his/her right arm connected to the lateral support with a black strap. Staff E acknowledged the black strap was in place and he was unaware if it should be. Additionally, he stated, I never saw one like this relative to the device. Staff E asked the resident if s/he could remove the arm strap. Further, the Director of Nursing was observed to remove the arm strap prior to the resident attempting to remove it.Record review failed to reveal evidence of a physician's order for a restraint, an assessment for the use of a restraint, any medical symptoms being treated, or interventions attempted prior to the use of a restraint.During a surveyor interview on 1/28/2025 at 2:50 PM with the Nurse Practitioner, Staff F, she indicated that the resident should not have a strap on his/her right arm as that would be considered a restraint.During a surveyor interview on 1/29/2026 at 2:29 PM with the Director of Nursing Services, Staff L, she could not provide evidence that the facility assessed the need for a physical restraint, assessed for the least restrictive alternative, the amount of time the restraint is needed or the re-evaluation of the need for restraints per regulation.

Based on clinical record review and staff interviews, the facility failed to revise each resident's care plan, by the interdisciplinary team, for 1 of 2 resident's reviewed relative to gastrostomy tubes (g-tube-a tube inserted through the abdominal wall directly into the stomach used to provide nutrition, hydration and medications for residents that are unable to take food or fluids by mouth), Resident ID #1, and for 2 of 3 residents reviewed relative to falls, Resident IDs #1 and 2.Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/13/2026 alleges in part, that there were concerns that Resident ID #1 frequently damaged or pulled out his/her g- tube. It further alleges that the facility did not put proper precautions in place to prevent the resident from pulling out the g-tube including an abdominal binder (a wide compression wrap that encircles the abdomen used to secure the g-tube in place to help prevent dislodgement.) 1. Record review revealed Resident ID #1 was admitted to the facility in September of 2024, with diagnoses including, but not limited to, gastrostomy tube and muscle weakness.Review of the resident's physician's orders revealed the following: -9/4/2025-encourage the use of the abdominal binder at all times on every shift.-1/7/2026-resident to wear the abdominal binder, may remove during activity of daily living care or showering.Record review of the resident's care plan revealed the focus area initiated on 6/24/2025 for a behavior problem of tactile impulses related to a cerebrovascular accident (stroke), which manifests as rubbing eyes, pulling g-tube, pulling clothes, sheets etc. Record review revealed the last revision on this care plan was made on 8/26/2025 and the care plan did not include the use of the abdominal binder.During a surveyor interview with the Director of Nursing Services (DNS), she acknowledged that the care plan failed to be revised to include an intervention for an abdominal binder. Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/2/2026 alleges in part, that Resident ID #2's family member was concerned that the resident had 8 falls since his/her admission to the facility.2 a. Record review for Resident ID #1 revealed s/he had falls on the following dates:-12/8/2025 at 10:30 AM-12/9/2025 at 12:00 AM-12/21/2025 at 10:27 PM-12/23/2025 at 4:30 PM and at 7:15 PM-12/26/2025 at 11:10 PM-1/6/2026 at 5:45 PM-1/13/2026 at 3:39 PMRecord review of the resident's care plan revealed a focus area initiated on 2/3/2025 for frequent falls secondary to generalized weakness, decreased neuromuscular coordination and cognitive impairment. Record review revealed the last revision on this care plan was made on 12/2/2025 and did not include added interventions relative to the falls on 12/8, 12/9, 12/21, 12/23, 12/26/2025, 1/6 and 1/13/2026.During a surveyor interview on 1/15/2026 at 1:12 PM with the DNS, she was unable to provide evidence that the resident's care plan was updated following the above-mentioned falls. 2b. Record review revealed Resident ID #2 was admitted to the facility in December of 2025 with diagnoses including, but not limited to, dementia and unsteadiness on feet.Further record review revealed the resident had falls on the following dates:-12/11/2025 at 2:29 PM-12/12/2025 at 6:34 PM-12/14/2025 at 1:36 PM-12/21/2025 at 2:46 PM-12/22/2025 at 1:20 PM-12/23/2025 at 11:51 AM-12/24/2025 at 12:38 PM-12/25/2025 at 4:30 PMRecord review of the resident's care plan failed to reveal evidence that it was revised to include a focus area for falls.During a surveyor interview on 1/15/2026 at approximately 1:12 PM with the DNS, she was unable to provide evidence that the resident's care plan was revised to include falls.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to physician's orders for 1 of 2 residents with gastrostomy tubes (G-tube-a tube inserted through the abdominal wall directly into the stomach used to provide nutrition, hydration and medications for residents that are unable to take food or fluids by mouth), Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/13/2026 alleges in part, that there were concerns that the resident frequently damaged or pulled out his/her g- tube. It further alleges that the facility did not put proper precautions in place to prevent the resident from pulling out the g-tube including an abdominal binder (a wide compression wrap that encircles the abdomen used to secure the g-tube in place to help prevent dislodgement.)According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.Record review revealed the resident was admitted to the facility in September of 2024, with a diagnosis including, but not limited to, gastrostomy tube.Review of the resident's Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 0 out of 15, indicating the resident has severe cognitive impairment. It further revealed that the resident is dependent on staff for dressing.Review of the resident's physician's orders revealed the following: -9/4/2025-encourage the use of the abdominal binder at all times on every shift-1/7/2026-resident to wear the abdominal binder may remove during activity of daily living care or showeringDuring a surveyor observation on 1/15/2026 at approximately 10:55 AM the resident was observed in bed and did not appear to be wearing his/her abdominal binder under his/her shirt.During a subsequent surveyor observation on 1/15/2026 at 11:00 AM in the presence of Licensed Practical Nurse, Staff A, she acknowledged the resident was not wearing the abdominal binder. Of note, the abdominal binder was on a shelf across the room from the resident's bed.During a surveyor interview on 1/15/2026 at the time of the above observation with Staff A, she acknowledged that the resident was not wearing the abdominal binder and she had failed to assist the resident to put it on that morning.During a surveyor interview on 1/15/2026 at 11:30 AM with the Director of Nursing Services, she indicated that she would expect the abdominal binder to be in place on the resident.

Based on clinical record review, and staff and resident interview, the facility failed to provide a qualified dietitian for 4 of 4 residents reviewed who did not receive dietary consultations to evaluate individual nutritional needs, Resident ID #s 1, 2, 3, and 4.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/30/2025, alleged concerns with the quality of care provided.A. Record review revealed Resident ID #1 was admitted to the facility in July of 2025 with a diagnosis of progressive Multiple Sclerosis (MS, a disease of the central nervous system).Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.Record review of a care plan initiated on 7/21/2025 revealed that the resident has a potential for impaired nutritional status due to a diagnosis of MS. Record review revealed a physician's order dated 11/11/2025 for a dietary consult related to his/her MS diagnosis and to discuss his/her nutritional needsRecord review of progress notes for Resident ID #1 revealed the following entries: - 7/10/2025 at 5:51 PM authored by Nurse Practitioner/ Wound Care Certified, revealed a recommendation for a Registered Dietician consultation to optimize nutrition - 9/21/2025 at 9:37 PM authored by Advanced Registered Nurse Practitioner, following a wound evaluation, a recommendation to encourage appropriate dietary supplementation to promote wound healing and skin integrity - 10/16/2025 at 10:50 PM revealed the resident returned from a neurologist appointment with a recommendation for a dietary consult for protein supplementation - 11/11/2025 authored by Physician Assistant at 2:30 PM, revealed that the resident requested a dietary referral, stating that one had not yet been completed since admission. S/he reported difficulty maintaining muscle mass and strength due to MS. An order for dietitian referral had been placed for assessment and recommendationsRecord review failed to reveal evidence that a dietary consult was obtained to evaluate the individual nutritional needs of the resident since admission, as ordered, and after multiple providers recommended dietary consult. During a surveyor interview on 12/11/2025 at 1:15 PM, with the resident, s/he revealed that s/he had not yet received a consultation by a dietitian or nutritionist as s/he had requested to address concerns.B. Record review revealed Resident ID #2 was admitted to the facility in October of 2025 with diagnosis including, but not limited to, myxedema coma (a serious complication of a severely underactive thyroid) and dysphasia (difficulty swallowing).Record review of a care plan initiated on 11/6/2025 revealed that the resident is at risk for aspiration (when food, liquid, or other material enters a person's airway and lungs).Record review failed to reveal evidence that a dietary consult was obtained to evaluate the individual nutritional needs of the resident since his/her admission. C. Record review revealed Resident ID #3 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, type two diabetes and Alzheimer's disease.Record review of a care plan initiated on 7/21/2025 revealed that the resident had a potential for impaired nutrition status due to diagnosis of Alzheimer's disease, type two diabetes mellitus and s/he receives a therapeutic diet.Record review revealed that the resident was discharged from the facility in September of 2025. Further record review failed to reveal evidence that a dietary consult was obtained to evaluate the individual nutritional needs of the resident during their admission to the facility.D. Record review revealed Resident ID #4 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, dysphasia.Record review revealed the resident was discharged from the facility in October of 2025. Further record review failed to reveal evidence that a dietary consult was obtained to evaluate the individual nutritional needs of the resident during their admission to the facility.During a surveyor interview on 12/11/2025 at 2:21 PM, with the Director of Nursing Services (DNS), she indicated that it was her expectation that residents would be seen by a dietitian on admission, quarterly, and as indicated. She further revealed that the facility had not had a dietitian on staff for several months and was unable to recall the date when the dietitian was last at the facility to clinically assess the residents' individual nutritional needs.During a surveyor interview on 12/12/2025 at 9:21 AM, with the Nurse Practitioner, she revealed she was unaware that the above-mentioned residents had not received dietary consultations as indicated.During a surveyor interview on 12/12/2025 at 2:24 PM, with the DNS, in the presence of the Administrator, she acknowledged that the facility failed to provide the services of a dietitian, as needed, to evaluate the induvial nutritional needs of the residents.

Based on 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 as the facility failed to implement a water management program (WPM) based upon industry standards and/or the Centers for Disease Control and Prevention (CDC), and to perform and document specified testing for the prevention of Legionella disease (a very serious type of lung infection caused by the bacteria called Legionella which can be found in water) resulting in infections for 1 of 1 resident reviewed who tested positive for Legionella pneumonia, Resident ID #1.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on 10/15/2025 alleges that Resident ID #1 tested positive for Legionella pneumonia.Record review of the CDC document titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated June 2021, version 1.1 states in part, .The key to preventing Legionnaires' disease is maintenance of the water systems in which Legionella may grow .Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant. Common issues that contribute to water stagnation include .reduced building occupancy .Stagnation can also occur when fixtures go unused, like a rarely used shower .Further review of the CDC's Legionella Control Toolkit revealed, detection of the following results indicates that Legionella growth appears poorly controlled: 1.0-9.9 Colony Forming Units per Milliliter (CFU/mL) in potable water.1a. Review of a facility policy titled Legionella Policy last revised on 10/24/2022 states in part, It is the policy of this facility to have a water management program to reduce legionella bacteria growth and spread in the facility.Facility will conduct an annual water program assessment with a qualified contractor.Review of a facility document titled, Facility Compliance Services-Legionella . last revised on 5/1/2018 states in part, .The purpose of the assessment is to discover any vulnerabilities that would allow for amplification of Legionella.and to structure a response in advance of any environmental sampling for Legionella.Potential Risks and Facility Mitigation Steps: After Facility Review, the facility poses a High Risk to promote the growth of Legionella.showers/Tubs/Faucet Taps: Hot and cold-water taps, shower heads, and tubs should be periodically flushed to help mitigate the potential for stagnation. Showers, sprayers, Tubs, and Faucet taps should be disinfected with an EPA [Environmental Protection Agency] registered disinfectant on a scheduled cleaning program; to reduce buildup of bacteria.Uncommonly used tubs, Showers/faucets should be flushed for 3-5 minutes and disinfected monthly. This process should be documented and kept in the service records section of this program. It is recommended that cold water and hot water be flushed.Plumbed Eyewash stations should also be flushed monthly. Flushing of the station should be done for 3 minutes. These stations should also be disinfected regularly to reduce bacterial growth. This process should be documented and kept in the service records section of this program.HVAC Systems [heating, ventilation, and air conditioning]: Facility should maintain a strong maintenance program for filters, belts, and cleaning coils. This will help eliminate the growth of bacteria that may be able to form on the units. Preventative maintenance should be scheduled, and documentation of service should be recorded in the service section of this plan.Record review of the facility water sample results dated 8/26/2024 revealed the following 5 positive results out of 21 samples:-room [ROOM NUMBER] shower hot (Water Sample) collected 8/14/2024 Positive: Legionella at a concentration of 3.5 CFU/ml-room [ROOM NUMBER] sink hot (water sample) collected 8/14/2024 Positive: Legionella at a concentration of 0.3 CFU/ml-room [ROOM NUMBER] sink hot (water sample) collected 8/14/2024 Positive: Legionella at a concentration of 1.8 CFU/ml-room [ROOM NUMBER] sink hot (water sample) collected 8/14/2024 Positive: Legionella at a concentration of 5.3 CFU/ml-Communal Shower room [ROOM NUMBER]th floor, sink hot (water sample) collected 8/14/12024 Positive: Legionella at a concentration of 4.8 CFU/mlRecord review of a document from the facility's contracted Water Safety Company titled, Remediation/ Sanitization Report for [Facility Name and location] dated 8/22/2024, revealed that the facility conducted a remediation (sanitization) of the potable water system. The sanitization was performed as an acute remedial treatment.Conclusions/Recommendations Following Remediation Sanitization.Quarterly sampling is recommended following sanitization in the absence of a reportable case of Legionnaire's Disease.Regular flushing of vacant units and other areas where there are infrequently used sinks should be flushed on a weekly basis for at least 5 minutes.Record review revealed that the last time the water was tested for Legionella was on 10/21/2024. Additionally, the record review failed to reveal evidence of quarterly testing during the following months: January 2025, April 2025, and July 2025.Record review of facility documents titled Flush shower and sinks for 5 minutes revealed that the facility had completed its last flushing of showers/tubs/faucet taps to help mitigate the potential for stagnation on 3/6/2025.Further record review failed to reveal any further evidence of the above noted mitigation steps taken by the facility, including flushing of taps, shower head, tubs, eye wash station including an ongoing disinfection schedule. Further, the facility could not provide any documentation for HVAC preventative maintenance and/or cleaning schedules, although the facility determined it was at a high risk for legionella growth per the Facility Compliance Services-Legionella documentation.Further record review failed to reveal evidence that the facility conducted an annual water program assessment with a qualified contractor as indicated in their facility policy for 2019, 2020, 2021, 2022, 2023, and 2024.During a surveyor interview on 10/16/2025 at approximately 11:35 AM with the Maintenance Director, he acknowledged that the water management plan has not been followed. Additionally, he revealed that flushing of the tubs, shower heads, and taps, including uncommonly used ones had not been conducted since March of 2025 and should have been completed weekly.During a surveyor interview on 10/16/2025 at approximately 11:40 AM with the Administrator, she was unable to provide evidence that the facility followed their water management plan as outlined above.1b. Record review revealed that Resident ID #1 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, dementia and adjustment disorder.Record review of nursing progress note dated 10/12/2025 revealed that the resident had an unwitnessed fall, an elevated temperature of 102.9 degrees Fahrenheit, and was being sent to the hospital on [DATE].Record review of hospital documentation titled Discharge summary dated [DATE] states in part, .presented with fall and fevers .found to have LLL [left lower lobe] pneumonia on imaging. admitted to the medicine wards for sepsis [a life-threatening medical emergency caused by the body's overwhelming response to an infection], pneumonia. Patient was started on antibiotics .Urine Legionella test was positive, and the patient's course of Azithromycin [antibiotic] was extended to a total of 10 days.Failure to implement a mitigation plan to control legionella growth had the potential to cause serious injury, serious harm, serious impairment, or death, as one resident is currently hospitalized with a legionella infection. Additionally, the failure puts all residents at risk for serious adverse outcomes or death due to the potential of exposure to Legionella bacteria.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident reviewed for an actual restraint, as the resident was observed in bed with a bed sheet tied across his/her abdomen, Resident ID #1. Findings are as follows: Review of a facility policy titled, Restraint Management states in part, .Physical Restraints: Is any manual, mechanical or physical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints include, but are not limited to: Leg restraints, Arm restraints, Hand mitts, Waist ties .Also included as restraints are facility practices to meet the definition of a restraint, such as: Tucking in, or using Velcro to hold a sheet, fabric or clothing tightly so that the resident's movement is restricted . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 6/24/2025 states in part, The resident was observed with a blanket secured around [his/her] waist. At this time, it is unclear whether this positioning may have restricted [his/her] movement or function as a form of restraint . Record review revealed that Resident ID #1 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, cerebral infarction (stroke) and anxiety. Review of the Minimum Data Set (MDS) Assessment, dated 5/12/2025, revealed a Brief Interview for Mental Status (BIMS) score of 00 of 15, which indicates severe cognitive impairment. Additionally, the MDS revealed that the resident can reposition in bed independently and is dependent on staff for personal hygiene. Record review of a care plan last updated on 5/22/2025 revealed the resident is at risk for falls related to generalized weakness, diagnosis of a stroke, and cognitive impairment. Additionally, the resident requires the assistance of two staff members for transfers and rubber mats on the left side of the bed for safety. Further record review revealed that the resident had the following unwitnessed falls from his/her bed on the following dates: 6/4/2025 6/5/2025 6/7/2025 6/10/2025 6/16/2025 6/21/2025 During a surveyor interview on 6/25/2025 at 8:15 AM with the Speech Language Pathologist, Staff A, she indicated that she went into the resident's room on 6/23/2025 at approximately 11:00 AM, the resident's upper body was turned, and s/he appeared uncomfortable and restless. She asked the resident if s/he was uncomfortable, and the resident nodded his/her head yes. When she removed the top sheet, she noticed a sheet tied to the bottom straps of the perimeter mattress loops going from one side to the other, across his/her abdomen. During a surveyor interview on 6/25/2025 at 8:26 AM with Nursing Assistants (NA), Staff B, and C, they revealed that they provided morning care on 6/23/2025 at approximately 9:30-10:00 AM and noticed that a sheet was tied to the mattress across the resident's waist. Additionally, Staff B revealed she removed it to provide care and then placed it back on the resident once care was completed. During a surveyor interview on 6/25/2025 at 11:52 AM with NA, Staff D, he revealed that he was the resident's NA on 6/22/2025 during the 11:00 PM-7:00 AM shift. Additionally, he revealed that he did observe the sheet tied to the resident's mattress on both sides going across the resident's abdomen, removed it to provide care, and then put it back in place. He was unaware why it was being used and stated, I've never seen that done before, I do not know why I didn't take it off. I just assumed they wanted it on. Record review failed to reveal evidence of a physician's order for a restraint, an assessment for the use of a restraint, medical symptoms being treated, or interventions attempted prior to the use of a restraint. During a surveyor interview on 6/25/2025 at 11:10 AM with the Director of Nursing Services, she acknowledged that Resident ID #1 was physically restrained. She indicated the facility was actively investigating and could not identify the staff member responsible for tying the sheet to the resident's mattress. Additionally, she acknowledged the overnight staff on 6/22/2025 and the first shift staff 6/23/2025 provided written statements that they removed the bed sheet and then reapplied the bed sheet after providing care to the resident. This failure had the potential to cause more than minimal harm, placing the resident at risk for entrapment, suffocation, strangulation, serious injury, or death. Although Resident ID #1 was cognitively impaired, s/he retained the ability to move independently in bed, which further increased the risk of such adverse outcomes.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for 1 of 1 resident reviewed, who sustained a fall with injury from a shower chair that broke when staff attempted to pull the shower chair into the shower stall, resulting in fractured ribs and an admission to the Trauma Intensive Care Unit (TICU), Resident ID #4. Findings are as follows: Review of a facilty reported incident submitted to the Rhode Island Department of Health on 5/8/2025 revealed the resident had a fall and was sent to the Emergency Department (ED) for an evaluation and was admitted to the hospital with fractured ribs. Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/13/2025 alleged a Nursing Assistant (NA) was attempting to shower Resident ID #4 when the shower chair broke and the resident fell to the floor. Record review revealed Resident ID #4 was admitted to the facility in July of 2021 with a diagnosis including, but not limited to, a history of falls with fractures. Record review of an Annual Minimum Data Set assessment dated [DATE], revealed the resident is dependent on staff for showers, personal hygiene, and bed mobility. Record review of a care plan last updated on 3/22/2024 revealed the resident is at risk for falls related to decreased endurance and strength, impaired sense of balance and unsteady gait. Additionally, the resident requires the assistance of two staff members for transfers. Review of a progress note dated 5/8/2025 at 10:00 AM, revealed the resident had a fall and was sent to the ED for an evaluation and was admitted to the hospital with rib fractures. Record review of a hospital document titled, ED To Hospital admitted d 5/7/2025 at 2:49 PM, indicated that a NA was attempting to help the resident shower when the chair gave way, and the resident fell to the ground. The report also revealed the resident denied hitting his/her head, but complained of right-sided chest wall tenderness. Further review of the ED documentation revealed a physician's note dated 5/7/2025 at 8:11 PM stating Panscan [a term used to describe full-body imaging] notable for rib fractures .We've consulted trauma and spine team. Anticipate TICU admit. Review of the facility's investigation revealed statements from staff indicating that the front wheels of the shower chair lifted off the ground when NA, Staff A, attempted to pull the resident into the shower stall backwards. The chair tipped backwards, and Staff A was unable to lift the resident back up, so she lowered the resident to the ground and simultaneously, the back of the chair snapped in half. Additionally, statements indicated that no visible injuries were observed but that the resident complained of pain afterwards. During a surveyor observation of the 5th floor shower room in the presence of the Director of Nursing Services (DNS), on 5/14/2025 at approximately 10:30 AM, revealed the entrance into the shower stall had a pronounced incline/ramp with an approximate four inch rise over a short distance angled at approximately 45 degrees leading into the shower stall. Review of the manufactures manual for the shower chair last revised in January 2008 revealed the following: -Never allow the user to lean outside the frame of the equipment -Never allow the user to suddenly shift weight in any way creating a tipping hazard for the user and the equipment -Do not use this equipment on an incline, always make sure all casters are in constant contact with the flooring surface -The improper use of this equipment or failure to comply with all directions and warnings may result in death or injury During a surveyor interview on 5/14/2025 at 10:46 AM with Staff A, she indicated that on 5/7/2025 at approximately 10:00 AM, she, and NA, Staff B, assisted the resident from the hoyer lift (a mechanical device designed to assist caregivers in safely transferring residents or individuals with limited mobility) to the shower chair and then Staff B left with the hoyer. Staff A indicated that she could not pull the shower chair over the pronounced incline into the shower stall and so she attempted to pull the resident into the shower stall backwards in the chair, and that's when the chair started to tip. Staff A indicated that she was unable to lift the resident back up because of his/her weight, so she lowered the resident to the ground backwards and the back of the chair snapped in half on the way down and the resident fell to the floor. During a surveyor interview on 5/14/2025 at approximately 12:20 PM with the DNS, she acknowledged that the resident experienced an accident that resulted in physical injury from the result of Staff A's attempt to pull the resident in a shower chair up an incline into the shower shall.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 5 residents observed who receive insulin, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/26/2024, alleged that numerous medication errors involving several residents were being made, including insulin. Review of the facility policy titled, MEDICATION ADMINISTRATION BY ROUTE OR DOSAGE, revised in 3/2017, revealed that licensed nurses should verify medication orders on the Medication Administration Record (MAR) and check against the physician's order. Record review of Drugs.com revealed that Insulin Lispro is the not the same as Novolog, as these insulin's have different chemical structures. Record review revealed that Resident ID #1 was admitted to the facility with a diagnosis including, but not limited to, diabetes. Further record review revealed the resident requires the administration of insulin to manage this diagnosis. During a surveyor observation on 12/30/2024 at 11:46 AM, Licensed Practical Nurse (LPN), Staff A, administered 8 units of Insulin Lispro (a fast-acting insulin that starts to work in approximately 15 minutes after injection, it peaks in approximately 1 hour, and continues to work for 2 to 4 hours), subcutaneously (under skin, tissue layer between skin and muscle) to the resident. The surveyor completed the medication reconciliation after the above observation and the record failed to reveal evidence that the resident had an active order for Insulin Lispro. Further record review revealed this resident has had orders in the past for Insulin Lispro but these orders were discontinued, most recently on 12/21/2024. During a surveyor interview on 12/30/2024 at 12:10 PM with Staff A, she acknowledged that she administered Insulin Lispro without a physician's order. Staff A further explained that she administered the Insulin Lispro because she thought it was the same insulin as Novolog. She indicated that the resident has an order for Novolog which is to be given in the afternoon. During a surveyor interview on 12/30/2024 at 12:40 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the resident had an order for Insulin Lispro to be given on 12/30/2024. During a surveyor interview on 12/31/2024 at 10:45 AM with the resident's physician, he revealed that Insulin Lispro and Novolog are fast acting insulin's but these insulin's have different chemical structures. The resident's physician further revealed that he would expect that the ordered insulin would be the insulin that is administered. During a surveyor interview on 1/8/2025 at 1:25 PM with the DNS, she revealed that the resident was previously on Insulin Lispro and when Staff A went to administer the insulin on 12/30/2024 she did not see the prescribed insulin in the medication cart, so she went to the medication refrigerator and took out a discontinued bottle of Insulin Lispro and administered it to the resident. The failure of the facility to administer the correct insulin to the resident had the potential to place the resident at risk for serious injury, impairment, harm or death.

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 accidents for 1 of 4 residents reviewed for elopement, Resident ID #1. Findings are as follows: Review of an anonymous community reported complaint submitted to the Rhode Island Department of Health on 10/8/2024 alleges that Resident ID #1 eloped from the facility on 10/7/2024 during the early afternoon. The complaint indicates that management does not disclose when these things happen, and management wanted him/her to wait before filing a complaint. Review of the facility policy titled Leave of Absence (LOA) states in part, Nursing staff will obtain an order for LOA with Responsible Party for a resident/patient on admission .If a resident is their own responsible party they may go on LOA unattended .When the resident is leaving the facility, an attempt will be made to complete the LOA log acknowledging that the resident or person taking the resident on LOA accepts responsibility for his/her well-being . Review of the facility policy titled ELOPEMENT states in part, .The licensed Nurse will conduct an Elopement Risk Assessment on admission, readmission, annually, quarterly, and upon change of condition .When it is determined that a resident may be missing .The senior nursing person on duty at the time will direct a systematic search procedure .The police should be notified as soon as the resident is not located within the facility or on the immediate grounds .Document relevant information in the Resident's medical record, Incident report, and DPH [Department of Public Health] report, as warranted . Review of the elopement binder reveals that the facility is equipped with a wander guard system (a system with three components: bracelets that residents wear, sensors that monitor doors, and a technology platform that sends safety alerts in real time when a resident wearing a sensor approaches an exit door) on the fourth floor. Record review revealed the resident was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, mild neurocognitive disorder due to known physiological condition, malignant neoplasm of the stomach (stomach cancer), nicotine dependence, chronic pain syndrome, abnormalities of gait and mobility, adult failure to thrive, opioid use disorder, epilepsy (a brain disorder that causes recurring, unprovoked seizures), viral hepatitis C, and acute embolism and thrombosis (blood clot) of the left lower extremity. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) a score of 9 out of 15 indicating the resident has moderate cognitive impairment. Record review of a care plan dated 10/19/2023 revealed the resident has impaired cognition related to short term memory loss. Additional review of a care plan with a revision date of 5/3/2024 revealed the resident is at risk for falls related to decrease endurance/strength, generalized weakness, and poor safety awareness due periods of forgetfulness. Record review of a nursing progress note dated 10/7/2024, written at 11:20 PM revealed that when staff went to administer the resident his/her evening medications on 10/7/2024, the resident was not in his/her room and the nursing supervisor was immediately notified. Record review of a progress note dated 10/8/2024 at 12:30 AM states in part, This writer was informed at 2045 [8:45 PM] that this resident was unable to be located since 3:00 PM at the beginning of the shift .Every inch of the facility, including the outer parameters were searched and the resident was still not located .ADNS [Assistant Director of Nursing Services] called police department at 23:05 [11:05 PM] . Record review of a progress note dated 10/8/2024 at 5:48 AM revealed the facility received a phone call from Landmark Hospital (Landmark Hospital is approximately 13.4 miles from the facility) indicating that Resident #1 received an evaluation at 4:10 AM in the emergency room and the physician was requesting the facility to fax Resident ID #1's demographics and medication list. The progress notes also indicates that the family was informed of the resident's location. Record review of a progress note dated 10/8/2024 at 11:50 AM revealed the resident returned from the hospital after having been medically cleared after leaving the facility against medical advice. Record review of an Emergency Department (ED) note dated 10/8/2024 at 4:25 AM revealed the resident arrived at the hospital at 4:22 AM by the Woonsocket police. The resident was noted to be confused and admitted to smoking marijuana that night. The ED spoke to the resident's family member and the family member indicated that the resident has poor memory at his/her baseline. Additional review of an ED note dated 10/8/2024 at 5:18 AM from Landmark Hospital revealed that the resident was brought to the ED by the police after s/he reported that s/he was lost. Additionally, this progress note revealed the resident was found by the Woonsocket police at a coffee shop on [NAME] Avenue in Woonsocket. This location is approximately 13.2 miles from the facility. The resident was discharged back to the facility without being treated for any acute medical issues. Surveyor review of the facility's video surveillance footage on 10/10/2024 at 1:59 PM revealed the resident exited the facility with his/her walker on 10/7/2024 at 2:41 PM. Record review failed to reveal evidence that the facility implemented safety measures to ensure the resident's well-being upon his/her return to the facility after his/her successful elopement on 10/8/2024 until it was brought to the facility's attention by the surveyor on 10/9/2024. Additionally, the facility failed to conduct an elopement assessment upon the resident's return following a change in condition as indicated in the facility's policy. During a surveyor interview with the Administrator and the Regional Director of Nursing on 10/9/2024 at 10:30 AM, they both indicated that this was not an elopement, that the resident was his/her own responsible party/decision maker and that s/he was out on an LOA. The Administrator revealed that the resident walks down the street daily for a coffee or cigarettes and that s/he has always returned. When questioned by the surveyor as to why the facility initiated their elopement policy/procedure on 10/7/2024, including calling the police department, if they felt this was an LOA, they were unable to answer. Record review failed to reveal evidence that an order was obtained for Resident ID #1's LOA that the facility indicated that s/he took on 10/7/2024. Additional record review of the LOA log for 10/7/2024 failed to reveal evidence that this resident had left the facility. During a surveyor interview with Licensed Practical Nurse, Staff A (who was on duty from 3:00 PM to 11:00 PM on 10/7/2024 when the resident was identified as missing), on 10/8/2024 at 3:00 PM she revealed that she had seen the resident at the beginning of the shift and that it was a very busy night. Staff A indicated that she was not aware the resident was missing until 8:45 PM when the Medication Technician went to administer the resident's medications and s/he was not in the room. Staff A indicated that she notified the nursing supervisor immediately and that the supervisor initiated their elopement policy/procedure. The Providence Police were notified of the missing resident on 10/7/2024 at 11:05 PM by the ADNS. During a surveyor interview with the ADNS on 10/9/2024 at approximately 9:30 AM, she revealed that she was notified at 9:00 PM on 10/7/2024 that Resident ID #1 was missing. She notified the Administrator, and she then went to the facility to assist. The ADNS indicated that the resident was unable to be located and therefore she called the Providence Police Department at 11:05 PM. During a surveyor interview with the resident's family member on 10/10/2024 at 10:06 AM, s/he revealed that the facility contacted him/her on 10/7/2024 at approximately 9:00 PM to let him/her know that the resident was missing. S/he also revealed that the Woonsocket police called him/her notifying him/her that the resident was found in Woonsocket at coffee shop and flagged down the police because the s/he was lost. During a surveyor interview with the resident on 10/10/2024 at 9:40 AM s/he indicated that s/he had gone for a long walk to downtown Providence and got lost, so s/he flagged down the police who took him/her to the hospital. S/he had no idea that s/he was found in Woonsocket and had no recollection of how s/he had gone from Providence to Woonsocket. This resident left the faciity on [DATE] at 2:41 PM with his/her walker. The facility did not know the resident was missing until approximately 8:45 PM on 10/7/2024, which was 6 hours after s/he had left the facility. The facility initiated their elopement policy/procedure at approximately 8:45 PM but the police were not called until 11:05 PM. The whereabouts of the resident was unknown from 2:41 PM until the resident flagged down a Woonsocket police offer at a coffee shop as s/he indicated s/he was lost (time unknown). The facility was unaware of how the resident traveled approximately 13.2 miles from his/her facility in Providence to Woonsocket during the evening, night, and early morning hours of 10/7/2024 into 10/8/2024. The resident was treated at Landmark Hospital at approximately 4:10 AM and was discharged back to the facility without being treated for any acute medical issues. When the resident returned on 10/8/2024 to the facility approximately 14 hours after s/he went missing the facility failed to implement any safety measures to ensure his/her well-being in the facility including safety checks, providing a wander guard, or putting him/her on the secured unit. Additionally, the facility did not follow their elopement policy/procedure relative to conducting an elopement assessment after the resident had successfully eloped. The facility's failure to recognize this incident as an elopement placed him/her at risk for more than minimal harm, impairment, or death as they did not implement any interventions to keep him/her safe. Due to the facility's failure to investigate this incident, they had no pertinent information available to share with the surveyors during the investigation of this complaint. The information found in this statement of deficiencies was gathered by the surveyors. 41729

Based on record review and staff interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 2 residents reviewed, who received insulin, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/8/2024 at 5:02 PM, alleges the resident was admitted to the hospital following an unresponsive episode at the nursing facility. There was a question if the unresponsive episode and subsequent emergency room visit, and hospital admission were the results of a medication error. Record review of a facility reported incident submitted the Rhode Island Department of Health on 3/8/2024 at 5:15 PM, revealed that the resident was found with an alteration in mental status at approximately 5:30 PM. A code blue (an emergency response) was called as the resident's blood sugar was 31 (normal blood sugar range is between 70-125 milligrams/deciliter (mg/dl). Glucagon (a medication used to treat a low blood sugar) was administered and 911 was called. The blood sugar was retaken, and the result was 38. A second dose of Glucagon was administered and 911 arrived and transported the resident to the emergency room for evaluation. The resident was later admitted with a diagnosis of altered mental status. Record review of the facility policy titled Hypoglycemia-clinical management of revealed in part, hypoglycemia is defined as fingerstick of serum glucose (blood glucose) less than 60 mg /dl .If the resident is unresponsive, administer Intramuscular (injection in the muscle) or Subcutaneous (injection under the skin) Glucagon as ordered by the physician. Review of the facility policy titled Medication Administration and Documentation-General revealed that licensed nurses should review physician orders and compare the order against the Medication Administration Record (MAR). 1a. Record review revealed Resident ID #1 was admitted to the facility in March of 2024 for short-term rehab. Further record review reveals that s/he is a diabetic and requires the administration of insulin to manage this diagnosis. Record review revealed the following physician's orders: Insulin Aspart injection solution (a fast-acting insulin that starts to work about 15 minutes after, injection peaks in about one hour, and keeps working for 2 to 4 hours) 100 unit/ml (milliliter) inject 40 Units subcutaneously once a day, at 11:00 AM. Hold for a blood sugar less than 200. Insulin Aspart Prot & Aspart subcutaneous Suspension Pen-Injector (70-30) (a mix of fast acting and intermediate-acting insulin that works up to 24 hours) 100 unit/ml inject 36 units subcutaneous, at bedtime. Hold for a blood sugar less than 200. Review of the March 2024 MAR revealed that the resident's blood sugar was less than 200 on the following dates and s/he received the Aspart 70-30: - 3/3/2024- Blood Sugar 198- Administered Aspart 70-30 by Registered Nurse (RN), Staff A - 3/4/2024- Blood Sugar 157- Administered Aspart 70-30 by RN, Staff D - 3/6/2024- Blood Sugar 183- Administered Aspart 70-30 by Staff D Additional record review revealed that on 3/7/2024 at 11:00 AM the resident's blood sugar was 138. Staff A proceeded to administer the resident 40 Units of Aspart, despite his/her order to hold the Aspart for a blood sugar of then less 200. Record review of the resident's progress notes revealed the following entries: - 3/7/2024 at 6:39 AM: Received resident in bed resting with eyes closed. Equal and unlabored respirations. Resident alert and oriented. Able to make needs known . - 3/7/2024 documented as late entry at 6:07 PM: Authored by RN, Staff C- This nurse responded to a code blue for Resident ID #1. She indicated that resident was diaphoretic (clammy/sweaty skin) and unresponsive to verbal and tactile stimuli. His/her oxygen saturation level was 88% (Normal range 95-100%) on 2 liters of oxygen. The resident was placed on a non-rebreather at 15 Liters. The residents blood sugar was checked with a result of 31. Glucagon was administered at 5:40 PM. The resident's blood sugar rechecked at 5:48 with result of 34. A second dose of Glucagon was administered to the resident and his/her blood sugar continued to rise slowly with result of 38. During the code blue emergency services arrived on scene. An Intravenous (IV) was placed in his/her left hand by Emergency Medical Services (EMS), with Dextrose 10 (a medication used to increase blood sugar) administered. The resident's blood sugar was rechecked and at this time his/her blood sugar 168. -3/7/2024 at 9:41 PM: Authored by RN, Staff E, - Resident found unresponsive laying down in bed at 5:30 PM. His/her oxygen saturation was 90% on 2 liters via nasal cannula (a thin tube that goes inside the nose and delivers oxygen). His/her blood sugar was 31. The resident was placed on a non-rebreather at 15 liters, oxygen improved to 96%. 1 MG (milligram) of Glucagon was administered at 5:40 PM. The blood sugar was rechecked which resulted in the blood sugar of 34. A second dose of Glucagon 1 MG was administered at 5:48 PM. The blood sugar was rechecked and resulted in a blood sugar of 38. A code blue was called during the event and rescue was also called. The resident was picked up via 911 at 5:55 PM and sent to the hospital. -3/7/2024 11:21 PM: The resident was admitted to the hospital for altered mental status. Record review of the EMS run report revealed that the primary complaint was hypoglycemia (low blood sugar level). EMS arrived and the resident was found to be unstable. His/her blood glucose was checked resulting in a value of 38 mg/dl. Intravenous access was established, and the resident was administered D 10 intravenously and his/her blood sugar was rechecked with a value of 78. Additionally, the resident required supplemental oxygen and became more responsive and alert. Review of the hospital admission record from 3/7/2024, revealed the following physician progress note, .presenting with unresponsive episode at rehab facility .Patient's blood sugar was checked, blood glucose was 30's. EMS arrived and administered IV dextrose. On arrival to ED [emergency department] patient's glucose improved to the 190's. However [s/he] is confused .thinks [s/he] is in the car . During a surveyor interview with Staff A, on 3/11/2024 at 12:02 PM, she revealed that on 3/7/2024 she obtained the resident's blood sugar of 138 and acknowledged she administered the 40 units of Aspart insulin to the resident on 3/7/2024 and 36 units of 70/30 on 3/3/2024. Additionally, she indicated that she was unable to see that the resident had parameters for administration of his/her ordered insulin, because the entire order is not visible on the screen. She further revealed that she would have to hover her mouse over the order to be able to see that there were parameters in place for the administration of this medication. During a surveyor interview with Staff B, on 3/11/2024 at 3:10 PM she revealed that she was unaware that the resident had parameters to hold his/her insulin for a blood sugar less than 200. Additionally, she revealed that she was not aware that she should hover the mouse over the order to see the order in its entirety. Further she acknowledged she administered the resident insulin outside of ordered parameters on 3/4/2024 and 3/6/2024. During a surveyor interview on 3/11/2024 at 12:53 PM with the Director of Nursing Services in the presence of the Regional Nurse, she acknowledged that the resident received his/her 70/30 insulin on 3/3/2024, 3/4/2024 and 3/6/2024 and should not have. Additionally, she acknowledged that the resident received 40 units of Aspart insulin on 3/7/2024 which required him/her to receive glucagon administration to increase his/her low blood sugar. Lastly, she was unable to provide evidence that Resident ID #1 was kept free from significant medication errors. 1b. Record review revealed a physician's order dated 3/7/2024 for Glucagon Emergency Kit - 1 mg- Inject one syringe intramuscularly as needed for hypoglycemic reaction for blood sugar under 60. Recheck blood sugar every 15 minutes until the resident's blood sugar is greater than 70. Notify the MD for blood sugar less than 60. Record review revealed a progress note dated 3/7/2024 at 6:07 PM that the resident was found to be unresponsive with a blood sugar of 31 on 3/7/2024 and a code blue was called. S/he required the administration of Glucagon to raise his/her blood sugar level, which was administered by Registered Nurse, Staff B at 5:40 PM. Further record review revealed the resident's blood sugar was taken again and the results were 34 at 5:48 PM, and a second dose of Glucagon was administered to the resident by Registered Nurse Staff, C. During a surveyor interview with Staff C, on 3/12/2024 at 1:06 PM she revealed that on 3/7/2024 she responded to the code blue for Resident ID #1. She indicated that she noticed that the Glucagon bottle that Staff B had pulled to administer to the resident still had the Glucagon powder in the vial. She indicated that the resident's blood sugar was not responding to the first dose of Glucagon because s/he did not receive it, as the medication was not reconstituted, and the resident only received the sterile water. Once she realized that the Glucagon was not administered, she decided to get another vial of Glucagon and administer another dose to the resident. During a surveyor interview with Staff B, on 3/12/2024 at 1:50 PM she revealed that she was unaware that she needed to reconstitute the Glucagon prior to administering it. She acknowledged that she had only administered an injection of sterile water and she did not reconstitute the medication. Additionally, she revealed that she had not received any training or competencies for the use of Glucagon. During a surveyor interview on 3/12/2024 at 1:40 PM with the Director of Nursing Services, she indicated that she would have expected Staff B, to give the correct dose of Glucagon by reconstituting the medication as required. Additionally, she was unable to provide evidence of training and/or competency for Staff B related to the reconstitution and administration of the Glucagon medication. Due to the facility's failure Resident ID #1 received insulin when s/he should not have resulting in the resident experiencing a critical low blood sugar, diaphoresis, and unresponsiveness. Further the failure required the resident to receive Glucagon intramuscularly, required 15 liters of oxygen via nonrebreather, due to hypoxia, Intravenous D 10 and subsequent hospital transfer and admission. Cross Reference F 726

Based on record review and staff interview, it has been determined that the facility failed to ensure licensed nurses had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 1 resident reviewed relative to the need for a Glucagon injection (a medication used to treat low blood sugar) secondary to a critically low blood sugar level, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/8/2024 at 5:02 PM, alleges the resident was admitted to the hospital following an unresponsive episode at the nursing facility. There was a question if the unresponsive episode and subsequent emergency room visit, and hospital admission were the results of a medication error. The skilled nursing facility denies the error. Record review of a facility reported incident submitted the Rhode Island Department of Health on 3/8/2024 at 5:15 PM, revealed that the resident was found with an alteration in mental status at approximately 5:30 PM. A code blue (an emergency response) was called as the resident's blood sugar was 31 (normal blood sugar range is between 70-125 milligrams/deciliter (mg/dl). Glucagon was administered and 911 was called. The blood sugar was retaken, and the result was 38 mg/dl. A second dose of Glucagon was administered and 911 arrived and transported the resident to the emergency room for evaluation. The resident was later admitted with a diagnosis of altered mental status. Record review of the Facility Assessment revealed that the facility has identified that they are able to provide care and nursing services for residents in the category of Metabolic disorders including but not limited to Diabetes. Record review of the facility policy titled Hypoglycemia-clinical management of revealed in part, hypoglycemia is defined as fingerstick of serum glucose (blood glucose) less than 60 mg /dl .If the resident is unresponsive, administer Intramuscular (injection in the muscle) or Subcutaneous (injection under the skin) Glucagon as ordered by the physician. Record review revealed that Resident ID #1 was admitted to the facility in March of 2024 for short-term rehab. Further record review revealed that s/he is a diabetic and requires the administration of insulin to manage this diagnosis. Record review revealed a physician's order dated 3/7/2024 for Glucagon Emergency Kit - 1 mg- Inject one syringe intramuscularly as needed for hypoglycemic reaction for blood sugar under 60. Recheck blood sugar every 15 minutes until the resident's blood sugar is greater than 70. Notify the MD for blood sugar less than 60. Record review revealed a progress note dated 3/7/2024 at 6:07 PM that the resident was found to be unresponsive with a blood sugar of 31 on 3/7/2024 and a code blue was called. S/he required the administration of Glucagon to raise his/her blood sugar level, which was administered by Registered Nurse, Staff B at 5:40 PM. Further review revealed the resident's blood sugar was taken again and the results were 34 at 5:48 PM, and a second dose of Glucagon was administered to the resident by Registered Nurse Staff, C. During a surveyor interview with Staff C, on 3/12/2024 at 1:06 PM she revealed that on 3/7/2024 she responded to the code blue for Resident ID #1. She indicated that she noticed that the Glucagon bottle that Staff B had pulled to administer to the resident still had the Glucagon powder in the vial. She indicated that the resident's blood sugar was not responding to the first dose of Glucagon because s/he did not receive it, as the medication was not reconstituted, and the resident only received the sterile water. Once she realized that the Glucagon was not administered, she decided to get another vial of Glucagon and administer another dose to the resident. During a surveyor interview with Staff B, on 3/12/2024 at 1:50 PM she revealed that she was unaware that she needed to reconstitute the Glucagon prior to administering it. She acknowledged that she had only administered an injection of the sterile water as she did not reconstitute the medication. Additionally, she revealed that she had not received any trainings or competencies for the use of Glucagon. Record review of Registered Nurse, Staff B's personnel record failed to reveal evidence of a competency related to the reconstitution and administration of Glucagon. Additional record review of the expanded sample revealed that personnel files for Registered Nurses, Staff A, Staff D, Staff E and Licensed Practical Nurse Staff F failed to reveal evidence of competencies related to the reconstitution and administration of Glucagon. During a surveyor interview on 3/12/2024 at 1:40 PM with the Director of Nursing Services, she indicated that she would have expected Staff B, to give the correct dose of Glucagon by reconstituting the medication as required. Additionally, she was unable to provide evidence that Staff A, B, D, E and F received any training and/or competencies related to the reconstitution and administration of Glucagon. Cross Reference F 760

Based on record review, resident representative interview, and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 3 discharged residents reviewed, Resident ID #1. The facility also failed to complete a discharge summary that includes, but is not limited to, a recapitulation of the resident's stay, a final summary of the residents status at discharge and a reconciliation of the residents medications for 1 of 3 residents reviewed Resident ID #1. Findings are as follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised on 2/3/2023, states in part, .A discharge summary must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another. The discharge summary may help reduce or eliminate confusion among the various facilities, agencies, practitioners, and caregivers involved with the resident's care .The discharge summary contains necessary medical information that the facility must furnish at the time the resident leaves the facility, to the receiving provider assuming responsibility for the resident's care after discharge .Discharge instructions and accompanying prescriptions provided to the resident and if applicable, the resident representative must accurately reflect the reconciled medication list in the discharge summary .For residents discharged to their home, the medical record should contain documentation that written discharge instructions were given to the resident and if applicable, the resident representative. These instructions must be discussed with the resident and resident representative and conveyed in a language and manner they will understand . Record review of the facility's discharge policy titled Discharge Planning states in part, This facility maintains a centralized, coordinated, organized discharge planning program to ensure that each resident has a planned program of continuing care which meets the resident's post-discharge needs . Record review of a community complaint reported to the Rhode Island Department of Health on 3/6/2024, alleges Resident ID #1 was discharged home with another resident's (Resident ID #2's) medications. Additionally, the complaint alleges that Resident ID #1 was not told how to take his/her medications and took the medications that were not his/hers for 1 week. Record review of Resident ID #1 revealed s/he was admitted to the facility in December of 2023 with diagnoses including, but not limited to, type 2 diabetes mellitus and rhabdomyolysis (a condition where the breakdown products of muscle tissue are released in the blood. These are harmful to the kidney). During an interview with Resident ID #1's primary care physician on 3/7/2024 at 10:11 AM, he revealed that the resident presented to his/her appointment with another patient's medications. During a surveyor interview with Resident ID #1's daughter on 3/7/2024 at approximately 10:15 AM she revealed that she did not receive education pertaining to the resident's medications. She indicated that during the discharge on 2/29/2024 she was just handed a bag full of medications. She revealed that when she got home, she administered the medications to Resident ID #1 for 5 days. She revealed that since being home the resident has been confused and has fallen twice and now has pain to his/her shoulder and back. Additionally, she revealed that his/her finger is swollen and bruised and is now using medication for pain relief. She revealed that the name on the medication card was Resident ID #2. Although, Resident ID #2's name was on the medication cards, she thought it was the physician's name. It was not until she attended the primary care visit with Resident ID #1 on 3/5/2024 and the physician reviewed the medications that they realized his/her family member had been taking someone else's medications. She further revealed the following medications were sent home on 2/29/2024 at discharge: Lasix (a medication used to treat excess fluid in the body) 20 milligrams (MG), Gabapentin (a medication used to treat seizures and/or pain) 300 MG, Levofloxacin (an antibiotic) 750 MG, levothyroxine (a medication used to treat an under active thyroid) 25 Micrograms and metformin (a medication used to treat high blood sugar) 500 MG. Record review reveals Resident ID #2 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, diabetes, morbid obesity and right foot wound. Record review reveals that Resident ID # was prescribed the following medications at the time of Resident ID #1's discharge: - Lasix 20 MG - Gabapentin 300 MG - Levofloxacin 750 MG - Levothyroxine 25 MCG - Metformin 500 MG Record review revealed Resident ID #1 was not prescribed the above-mentioned medications at the time of discharge. Review of a facility document titled Continuity of Care Discharge/Transfer of Patient Form indicated that the resident's medication list was attached to this document. Further review of this document failed to reveal a discharge summary that was signed as completed by the discharging nurse or that it was signed off as reviewed by the resident or responsible party. During a surveyor interview with Registered Nurse, Staff A, on 3/7/2024 at approximately 1:21 PM, she acknowledged that she handed Resident ID #1's family a bag of medications and paperwork for discharge. She further acknowledged she did not review the medication cards with the resident or family and did not check them prior to the resident leaving the facility to ensure that they were the correct medications prescribed for this resident. Additionally, she acknowledged that she did not complete the discharge paperwork for this resident on discharge. During a surveyor interview with the Director of Nursing Services (DNS) on 3/7/2024 at approximately 11:34 AM, she acknowledged that Resident ID #1 was discharged with Resident ID #2's medications as listed above and that the Continuity of Care Discharge/Transfer of Patient Form was not completed in its entirety. Additionally, she was unable to provide evidence that all pre-discharge medications were reconciled with the resident's post-discharge medications prior to Resident ID #1 being discharged home from the facility.

Based on record review, staff and resident interview, it has been determined that the facility failed to transcribe and/or implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings are as follows: 1. Review of a community reported complaint received by the Rhode Island Department of Health (RIDOH), alleges that Resident ID #1 presented to the emergency room of an acute care hospital on 8/18/2022 with for left femur fracture (sustained in June) and returned for re-evaluation of this fracture, blister and skin breakdown. Record review revealed Resident ID #1 was admitted to the facility in June of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the hospital Continuity of Care form (COC) dated 6/16/2022, provided to the facility upon the resident's admission, states in part, Orthopaedic [a doctor that diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .follow up with the office .in 10-14 days . Additional record review revealed a care plan initiated 6/19/2022 which states in part, .Resident has a fractured left Femur .Interventions .Ortho [Orthopaedic] follow up as ordered . Review of a facility COC form dated 7/7/2022 revealed the resident was scheduled for an orthopaedic appointment on 7/7/2022. The form indicates that the facility did not have the staff to accompany the resident to this appointment. Review of a nursing progress note dated 8/2/2022 at 9:17 PM. authored by Registered Nurse (RN), Staff F, states in part, .writer observed resident cast leaking from the 'window created in the cast' .Window opened, area cleaned, xeroform and gauze put in place .Resident appears to be in pain during wound care . During a surveyor interview Staff F, on 8/23/2022 at 3:26 PM, revealed she has been providing care to the resident since his/her admission. She further revealed that the resident had a cast to his/her left lower leg from mid-thigh to toes on admission without a window. Staff F indicated that on 8/2/2022 while caring for the resident she observed the resident with a cast that now had a window and noted drainage seeping from this window. She further indicated that she observed the resident's skin where the drainage was coming from and revealed noted an open pink blister with no dressing in place. She then revealed that she was aware the resident had gone to an orthopaedic appointment at some point, but realized there was no evidence in the record that indicated the resident had a window to his/her cast, any new orders or a treatment in place for the blister after she recognized the leakage. She indicated that she went to look for a COC form to determine if there were any new orders etc. She then indicated she found a COC form from the orthopaedic doctor dated 7/26/2022 under papers on the desk with recommendations for xeroform and gauze. Record review revealed that the resident did attend an orthopaedic appointment on 7/26/2022, which was 19 days after the original appointment. The consultation notes from the 7/26/2022 appointment indicated the original cast was removed and a new cast with a window was placed, as there was blistering noted to lateral thigh. There was also a new order for .daily skin checks at window of the cast .[daily] xeroform + gauze . Record review of the July 2022 Treatment Administration Record (TAR) failed to reveal evidence that the recommended daily skin checks and xeroform treatment were implemented. Record review of the August 2022 TAR revealed the daily skin checks and xeroform treatment were not implemented until 8/2/2022. As a result, the resident missed 7 opportunities for daily skin checks and wound care. Record review revealed that the resident was seen by the facility's consulting wound physician on 8/10/2022. The document states in part; .Wound care is consulted to evaluate and provide treatment recommendations for a trauma wound to the L [left] thigh .thigh above cast and in cast window swollen edematous .small opening that per staff was once a blister caused by a previous cast, skin surrounding opening forms a small dome around .Treatment Recommendations .[MEDICATION(S)], gauze .BID [twice a day] + prn [as needed] . Record review failed to reveal evidence that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor interview with the consulting wound physician on 8/24/2022 at 9:32 AM, she revealed that she assessed the resident initially on 8/10/2022 at the request of a nursing assistant. She further revealed that the resident's skin in the window was moist, and she recommended treating the area with [MEDICATION(S)] and a gauze dressing twice daily. She further revealed that the protocol is for treatment recommendations to be given to a licensed nurse or the Director of Nursing Services (DNS) but at the time she could not locate a nurse on the unit and the facility did not have a DNS. She further revealed that her expectation for physician treatment recommendations are to be implemented in no less than 24 hours. Record review of a nurse's progress note dated 8/15/2022 at 1:06 PM states in part, .Patient .leg looked increasingly more red .it was found to be swollen, warm to touch .showed signs of increased pain .Call .made to MD [medical doctor], and Ortho MD which both agreed to send to [hospital] . Review of the resident's hospital clinical notes dated 8/15/2022 states in part, .Due to concern for [CONDITION(S)] (a serious bacterial infection of the skin)/myositis (inflammation of the muscles) per CT (computed tomography, a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) findings, started on abx (antibiotic medication) and ordered MRI (magnetic resonance imaging, a test that uses magnets and radio waves to make detailed pictures of the body's organs, muscles, soft tissues, and structures) for better eval per radiology recommendations .Started on vanco and [MEDICATION(S)] (medications used to treat serious bacterial infections). Continue abx pending MRI results/[CONDITION(S)] ([CONDITION(S)]-resistant Staphylococcus aureus, a staph infection) and further clinical evaluation after which could be deescalated .Per ortho, knee immobilizer and dressing can be taken down for wound care and then re-applied .Wound consult placed .Pt was visibly uncomfortable, flapping arms and trying to remove mitts . During a surveyor interview with the DNS and the Regional RN on 8/22/2022 at 3:56 PM, they were unable to provide evidence the resident attended the orthopaedic appointment prior to 7/26/2022 and acknowledged the appointment was missed due to staffing. Additionally, they were unable to provide evidence that recommendations from the orthopaedic doctor on 7/26/2022 were implemented prior to 8/2/2022 and the wound doctor's recommendations were not implemented until 8/13/2022. Due to multiple facility failures including the resident not being seen by the Orthopaedic in the recommended time frame, Orthopaedic orders being implemented late, consulting wound physician treatment recommendations initiated late this resident required hospitalization and evaluation for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of a community reported complaint received by RIDOH on 8/29/2022 alleges that Resident ID #2's medications are being administered late. Record review for Resident ID #2 reveals s/he was readmitted to the facility in August of 2022 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's current care plan revealed Resident has a PCN tube [percutaneous nephrostomy catheter, a small flexible, rubber tube that is placed through your skin into the kidney to drain your urine] secondary to Hydronephrosis [Hydronephrosis is swelling of one or both kidneys. Kidney swelling happens when urine can't drain from a kidney and builds up in the kidney as a result. This can occur from a blockage in the tubes that drain urine from the kidneys (ureters) or from an anatomical defect that doesn't allow urine to drain properly]. Review of the resident's August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the progress notes revealed a note dated 8/24/2022 indicating a urine sample was obtained. Additional review of the progress notes revealed a note authored by Licensed Practical Nurse, (LPN), Staff D, dated 8/26/2022 and time stamped at 4:45 PM that indicated the resident's urologist was called and a new order for an antibiotic, [MEDICATION(S)] 500 milligrams was ordered to be administered twice a day for 7 days. Additional review of the resident's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's progress notes indicated s/he was transferred and admitted to the hospital on 8/27/2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor observation of the facility's Pyxis machine (automated medication dispensing system supporting decentralized medication management), in the presence of the DNS on 8/29/2022 at approximately 3:45 PM, she acknowledged that [MEDICATION(S)] was readily available to be administered to Resident ID #2, as there were 10 capsules of the antibiotic in the machine. During an interview with LPN Staff D on 8/30/2022 at 11:10 AM, she was unable to explain why she entered the order for the antibiotic to start at 7:00 PM on 8/27/2022 rather than the evening of 8/26/2022 when the order was received. Additionally, she acknowledged the resident missed 2 of 2 opportunities to receive this medication prior to being hospitalized on [DATE] for a [CONDITION(S)]. During a surveyor interview with the Nurse Practitioner, Staff E, on 8/30/2022 at 9:39 AM, she indicated that it was her expectation that nursing staff enter and initiate orders at the time they are given by the provider. During a surveyor interview with the DNS on 8/29/2022 at approximately 3:30 PM, she acknowledged Resident ID #2 did not receive his/her prescribed antibiotic for 2 of 2 opportunities. Additionally, she was unable to explain why Staff D had entered the order for the antibiotic to start on 8/27/2022 at 7:00 PM, when the resident's urologist had ordered it on 8/26/2022.

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 6 sample residents reviewed, Resident ID #1. Findings are as follows: According to, Nursing 2012 Drug Handbook, Lippincott Williams & Wilkins, it states in part .Rights of Medication Administration: 1. Right patient Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. When available, use technology . Record review of a facility and community reported incident sent to the Rhode Island Department of health on 4/10/2022 indicates that a resident was administered [MEDICATION(S)] (a synthetic analgesic drug that is similar to [MEDICATION(S)] in its effects but longer acting, used as a substitute drug in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review for the resident revealed s/he was admitted to the facility in March of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Progress Note dated 4/9/2022 at 11:30 PM stated in part, A wrong patient medication administration error occurred with this resident, this shift. This writer entered resident's room at approximately 8:15 PM mistakenly thinking that [s/he] was another resident .I opened the bottle of [MEDICATION(S)] .I handed the bottle to [him/her]. [S/he] took it and drank approximately 1/3 of the medication and then stopped and yelled out 'This tastes awful!' . I immediately took the bottle away from [him/her] . Further record review revealed that this resident was sent and admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the hospital paperwork states in part .At some point in the PM of 4/9/22, reportedly at about 8:00 PM, the patient was mistakenly administered a dose of [MEDICATION(S)] which was intended for another patient. Apparently, the dose was 60 mg, but the patient only consumes part of the dose, and it is estimated by the facility that the consumed dose was approximately 25 mg. The patient was sent to the ED subsequently after this inadvertently ingestion. It is reported that poison control was contacted and recommended a 24-hour observation .and thus the patient was admitted to medicine for observation. Further record review revealed that the resident remained in the hospital at that the time of survey. During an interview with the Administrator and Director of Nursing on 4/12/2022 at approximately 3:40 PM, they indicated that the nurse did not follow the six rights of medication administration. They acknowledged that this resident received [MEDICATION(S)] in error.

Based on record review and staff interview, it was determined that the facility failed to provide adequate supervision for resident at risk for elopement, for 1 of 1 sample resident (ID# 2). Findings are as follows: Resident ID# 2 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. A care plan was developed on 11/21/2014 and updated on 9/2015. One of the elopement interventions is to conduct 15 minutes checks on the resident. Review of nurse's note dated 11/3/2015 documented that at 10:25 PM the facility received a phone call from the hospital, stating the resident had been found in Pawtucket by the police and had been brought to emergency room . S/he had been in the emergency room for the past two and a half hours. Review of the 11/4/2015 nurse's note documented that at 12:00 AM the resident returned to the facility from the hospital. S/he was noted with a hematoma on her/his right eye, scratches on the nose and both hands as well as discoloration on both of her/his forearms. S/he also had abrasion's on her/his left inner knee and jaw pain. A review of the CT brain results dated 11/3/2015 revealed a hematoma overlying the right frontal bone (bruise to the forehead), non displaced fracture of the bone around teeth/jaw. Further record review revealed no evidence that the 15 minutes checks were done between 3:00 PM to 11:00 PM for this resident on 11/3/2015. A review of staff written statements dated 11/3/2015 revealed the resident was last seen at approximately 7:15 PM. Interview on 1/27/2016 at 12:15 PM, the Director of Nursing Services (DNS) was unable to produce evidence that the resident received adequate supervision to prevent elopement. Upon further interview with the DNS, she indicated that the following interventions were put into place after the accident: a) The nursing assistant (NA) who cared for the resident prior to the elopement was suspended pending outcome of the facilities investigation and she was later terminated. b) A door and wander guard inspection to the main elevator was conducted on 11/3/2015. c) The wander guard system was installed on the services elevator at this time. d.) The resident's care plan has been updated and NA's care card has been reviewed and revised. e) Nursing staff have been re-educated on the elopement policy. 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.

Based on surveyor observation, record review and resident and staff interview, it has been determined that the facility failed to ensure that resident's receive the proper treatment and care relative to foot care for 2 of 5 sample resident's (ID #s 2 and 4). Findings are as follows: 1. Review of resident ID # 4's record reveals that s/he was admitted to the facility on [DATE]. There is no evidence in the record that s/he had ever been seen by a podiatrist. Observation of resident ID #4 on 5/12/2015 at 11:10 AM, in the presence of the primary Nursing Assistant (NA) (D) assigned to the resident, revealed the resident with elongated toe nails with reddened cuticles along the great toe and second toe of the right foot with brown crusted matter covering the crevices between the nail bed and cuticle. During an interview with the resident s/he stated that his/her toes are sore but she does not recall when s/he was last seen by the foot doctor. Additionally, the resident's finger nails were observed to be elongated with broken serrated edges. When interviewing the NA (D) immediately following this observation, she stated that she reported the resident's long nails to the nurse on 5/7/2015. The NA further states that the resident does complain about sore toes so they put lambs wool in between the toes. Review of a Weekly Skin Assessment completed on 5/7/2015 by the 11:00 PM - 7:00 AM staff nurse (A) does not reveal that there were any concerns with the resident feet. When interviewing the 2nd floor Charge Nurse, immediately following this observations, she stated she was unaware of the condition of the resident's feet and proceeded to contact the podiatrist. . Review of the resident's podiatry note dated on this same date (5/12/2015), reveals, Inflamed toe nails on both feet and Infection of the skin of the toe nail folds requiring topical antibiotic treatments to be performed as ordered. 2. A family member of ID # 2, who was readmitted to the 4th floor dementia unit on 9/4/2014, complained that when she accompanied the resident to the emergency room for an non-related medical issue, she noticed that the resident's nails were grossly overgrown. The complainant further reported that when they returned back to the facility she showed the resident's nails to the Director of Nursing Services (DNS). When interviewing the DNS on 5/12/2015 at 12:00 PM relative to the resident's family member's complaint, she stated I was embarrassed and mortified when I saw them and immediately scheduled a visit from the podiatrist. During an interview with the resident's primary NA (E) she stated, I never really noticed that his/her nails were long because the foot doctor sees the resident every three months but I would have reported to the nurse if they were really long. During an interview with the 4th floor Unit Manager, at 12:15 PM, she was unable to provide evidence that the resident had previously been seen by a podiatrist. 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.