Every finding on record at AdviniaCare Waterview Villas, LLC

Based on clinical record review and staff interview, the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a foley catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #1, and for 1 of 1 resident with a suprapubic catheter (SP tube, a medical device that drains urine from the bladder through a small incision in the abdomen), Resident ID #2.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/11/2026 alleges that Resident ID #1 has a foley catheter and had recently been hospitalized related to poor foley catheter care by the nursing facility. The report further alleges that the resident was injured when the foley was replaced by the facility nurse pushing on his/her stomach while trying to insert the foley catheter and asked to be sent to the hospital. The resident was sent to the hospital on 6/9/2026 and admitted with diagnoses of a urinary tract infection (UTI) and sepsis (a life-threatening organ dysfunction caused by an infection).1. Record review revealed that Resident ID #1 was readmitted to the facility in June of 2026 with diagnoses including, but not limited to, urinary retention, UTI due to a foley catheter, and sepsis.Review of a care plan created on 4/20/2026 revealed that Resident ID #1 requires a foley catheter related to a diagnosis of urinary retention. Interventions include, but are not limited to, changing the foley catheter per the physician's orders.Record review revealed the following physician's orders:4/28/2026: Urology consultation ordered related to new medications and use of a foley catheter for urinary retention.5/14/2026: Indwelling catheter 16 French, change as needed.Record review revealed the following nursing progress notes:4/19/2026: Foley catheter initiated related to urinary retention.4/20/2026: New order for Flomax (a medication prescribed to relax the muscles in the prostate and bladder so that urine can flow easily) 0.4 milligrams daily.4/28/2026: New order for a urology appointment due to recent foley catheter and medication.Record review of progress note authored by the Physician's Assistant (PA) dated 4/29/2026 states in part, .requires urology consult, consider void trial of the foley catheter.Record review failed to reveal evidence that a urology appointment had been scheduled for Resident ID #1. Record review revealed that the resident was admitted to the hospital from [DATE]- 5/14/2026 with diagnoses of sepsis secondary to catheter associated UTI.Record review of a hospital document titled, Discharge Summary dated 5/14/2026 states in part, .presented for evaluation of fever and shivering .there was concern over the patient's foley not being exchanged frequently enough.Foley catheter was exchanged on 5/6 and should be replaced every 8 weeks.Record review of progress note authored by the PA dated 5/15/2026 revealed that the resident requires a urology referral related to difficulty voiding and his/her recent hospital admission for a UTI and sepsis.Record review of the nursing progress notes revealed the following:5/16/2026: The resident tested positive for a UTI and required an antibiotic.6/7/2026: The resident complained of abdominal pain, his/her abdomen was noted to be distended, and the tip of his/her genital was noted to be split with white drainage. Hematuria (blood in urine) was also noted in the foley bag.6/9/2026: Gross hematuria and mucus in urine, new order was given to hold his/her blood thinner medication and obtain labs.6/10/2026: Resident noted with abdominal distention, leukocytosis (high white blood cells which could indicate significant bacterial infection) and gross hematuria. A new order was given to send the resident to the hospital.Record review revealed that the resident was readmitted to the hospital from [DATE] to 6/12/2026 with a diagnosis of a UTI due to a foley catheter and sepsis.Record review of a hospital document titled, Discharge Summary dated 6/12/2026 states in part, .Outpatient follow up with urology for foley exchanges every (6- 8 weeks). Foley exchanges should not be done at the SNF [Skilled Nursing Facility].Consider suprapubic tube.if patient is retaining urine DO NOT exchange foley at SNF, and DO NOT overload [his/her] bladder with flushes. Also DO NOT use external abdominal pressure, this will NOT help with bladder decompression and increases risk for injury. Please reach out to urology or bring patient back to the hospital.Record review failed to reveal evidence that Resident ID #1 was scheduled for a Urology appointment as ordered from 4/28/2026 through 6/18/2026. During a surveyor interview on 6/18/2026 at 11:56 AM and 12:44 PM with the facility Scheduler, she revealed that Resident ID #1 had not been scheduled for a urologist appointment. Additionally, she revealed that she was able to make the resident's appointment today for 7/21/2026 after it was brought to the facility's attention by the surveyor.During a surveyor interview on 6/18/2026 at 12:00 PM with the Urology receptionist, she revealed that the facility had not contacted the urology office until today and the only referrals they had received for Resident ID #1 was from the hospital on 5/14/2026 and 6/12/2026.During a surveyor interview on 6/18/2026 at 1:26 PM with the PA, he revealed it would be his expectation that the facility would have scheduled a urology consult, per the physician's order on 4/28/2026 for an appointment, and was unaware that Resident ID #1 had not been seen by a urologist.The facility had multiple opportunities to ensure appropriate urologic follow-up, including after the physician's order dated 4/28/2026, following the resident's hospitalization for catheter-associated sepsis on 5/14/2026, after the PA documented the need for urology referral on 5/15/2026, and after the resident developed recurrent urinary symptoms including hematuria, abdominal distention, and a positive urinary tract infection. Despite these repeated indicators of worsening clinical condition, the facility failed to arrange the ordered consultation.2. Record review revealed that Resident ID #2 was originally admitted to the facility in January of 2026 with a diagnosis including, but not limited to, flaccid neuropathic bladder (the inability of the bladder muscles to contract effectively leading to urinary retention).Review of a care plan dated 1/28/2026 revealed that Resident ID #2 requires an SP catheter related to neurogenic bladder. Interventions include but are not limited to changing the SP catheter per the physician's order.Record review revealed that the resident was admitted to the hospital from [DATE] to 5/14/2026 with a diagnosis of a complicated UTI and an obstructed SP catheter.Record review of a progress note authored by the PA dated 5/19/2026 states in part, .Patient had diminished output in [his/her] suprapubic catheter and then staff eventually unable to flush, sent to ED on 5/8/2026. Had replacement of his suprapubic catheter and continued to have some leakage around catheter site. Followed carefully by urology and recommended outpatient follow-up.Record review revealed a physician's order dated 6/8/2026 for his/her SP tube to be changed every 4 weeks.Record review of the 2026 June Treatment Administration Record revealed the above order was signed off as completed on 6/8/2026.During a surveyor interview on 6/18/2026 at 11:26 AM with the Assistant Director of Nursing Services, she revealed that the nurses do not change SP tubes in the facility. Additionally, she revealed that residents who require an SP tube exchange would go out to their urologist.During a surveyor interview on 6/18/2026 at 2:44 PM with Licensed Practical Nurse, Staff A, she revealed that she did not exchange Resident ID #2's SP tube. She further revealed that she signed off the above order in error and acknowledged that the resident needs to go to his/her urologist for a SP catheter exchange. During a surveyor interview on 6/18/2026 at 12:18 PM with Urology receptionist, she revealed that the last appointment Resident ID #2 had at their office for an SP catheter exchange was in July of 2025. She further revealed that s/he did not have an appointment scheduled at this time.During a surveyor interview on 6/18/2026 at 11:56 AM and 12:44 PM with the facility Scheduler, she failed to reveal evidence that Resident ID #2 had a urology appointment until after it was brought to their attention by the surveyor. Additionally, she revealed that she was able to make the resident's appointment today for 7/10/2026.During a surveyor interview on 6/18/2026 at 1:26 PM with the PA, he revealed it would be his expectation that the facility would have scheduled a follow up appointment with urology for a SP tube exchange for Resident ID #2 every 4 weeks if it could not be completed in the facility.Record review failed to reveal evidence that Resident ID #2 has had a urology appointment or SP catheter exchange from his/her admission to the facility in January of 2026 until s/he was hospitalized in May of 2026 with a UTI and an obstructed SP catheter. Further record review failed to reveal evidence that the facility made a urology appointment from 5/8/2026 to 6/18/2026 until it was brought to the facility's attention by the surveyor.

Based on record review, surveyor observation, and staff interview, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 3 of 6 medication carts observed during the medication storage task.Findings are as follows:Record review of a facility policy titled, Medication Storage states in part, .medications will be stored in the original, labeled containers received from the pharmacy.Expired, discontinued and or/contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy.1a. During a surveyor observation on [DATE] at 9:15 AM of the second-floor medication cart side A in the presence of Registered Nurse (RN), Staff B, revealed the following:One 20 milliliter (mL) bottle of Lidocaine injection (a medication prescribed to prevent pain during a procedure), opened and undated.One tube of Erythromycin 0.5% (a medication prescribed to treat infection), opened and dated [DATE] with an expiration date of [DATE].One 1.5 fluid ounce bottle of nasal moisturizing spray opened and dated [DATE] with no resident name identifier.During a surveyor interview immediately following the above observation, Staff B, acknowledged that the lidocaine was opened, undated and in use, the nasal spray should have a resident name identifier, and the Erythromycin should have been discarded.1b. During a surveyor observation on [DATE] at 9:18 AM of the second floor nurse side A cart in the presence of Staff B, revealed the following: One 1-gram (gm) vial of Ceftriaxone (an antibiotic medication), with the prescription label partially torn off.Four 1-gram bottles of Ertapenem (an antibiotic medication) for two discharged residents. During a surveyor interview immediately following the above observation with Staff B, she acknowledged that the Ceftriaxone label did not contain the name of the resident for who it was prescribed and should have been discarded. Additionally, she acknowledged that the vials of Ertapenem were for residents who have been discharged and should have been discarded.2. During a surveyor observation on [DATE] at 12:52 PM of the Third- floor medication cart Side A in the presence of, Licensed Practical Nurse, Staff C, revealed the following:One 1 gm vial of Ertapenem for a resident that was discharged .During a surveyor interview immediately following the above observation with Staff C, she acknowledged that the medication was prescribed for a resident who had been discharged and the medication should have been discarded.During a surveyor interview on [DATE] at 12:55 PM with the Director of Nursing Services, she revealed that it would be her expectation that nursing staff would remove expired or discontinued medications from the medication carts and dispose of them per the facility policy.

Based on clinical record review and staff interview, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented and readily accessible for 2 of 2 residents reviewed for physician referral outpatient appointments, Resident ID #s 10 and 104.Findings are as follows:1. Record review revealed that Resident ID #10 was admitted to the facility in February of 2026 with diagnoses including, but not limited to, heart failure and a fall.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition.Record review of the hospital Discharge summary dated [DATE] revealed that the resident was admitted after s/he had a witnessed fall with a head injury. Further review revealed that s/he was scheduled to have a follow-up appointment within 2 weeks to discuss a hernia repair.Record review of nursing progress note dated 3/5/2026 states, .Returned from general surgery with the following note, Dr. had to cancel clinic due to an emergency that came in.Appointment rescheduled [Communication] tab updated .Record review of the Communications Tab dated 3/5/2026 at 3:38 PM states, need transport: appointment rescheduled to 3/9/2026 at 1:45 PM.General Surgery.Record review failed to reveal evidence of a Continuity of Care (COC) report from the 3/5/2026 appointment. Further record review failed to reveal evidence that the resident went to a follow up appointment on 3/9/2026.During a surveyor interview with the general surgery office on 3/25/2026 at 1:30 PM, they revealed that the resident had an appointment on 3/16/2026 that s/he was a NO SHOW for. Additionally, the receptionist revealed that the resident was rescheduled again for April.During a surveyor interview with the Facility Scheduler, Staff D, on 3/25/2026 at 1:40 PM, she revealed that the nurses review the COC and add the follow-up appointments in the Communication Tab of the medical record. She further revealed she was not aware of the residents' follow-up appointment on 3/9 or 3/16/2026, indicating that transportation was not scheduled for this resident's appointment.During a surveyor interview on 3/25/2026 at 1:46 PM, with the Director of Nursing Services (DNS), she was unable to provide the COC document for Resident ID #10's appointment on 3/5/2026. She revealed that the scanning process for medical records is delayed and the COC could be in an office but could not locate the document.2. Record review Resident ID #104 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, a left artificial hip joint.Record review of the MDS assessment dated [DATE], revealed a BIMs score of 15 out of 15, indicating the resident is cognitively intact.Record review of a nursing progress note dated 3/19/2026, revealed the resident had returned to the facility after an orthopedic appointment related to a failed total arthroplasty (joint replacement surgery). Additional review of the nursing progress note revealed that the resident needs dental clearance before the hip replacement surgery could be scheduled.Record review failed to reveal evidence of a COC report from the 3/19/2026 Orthopedic appointment.During a surveyor interview on 3/26/2026 at 1:13 PM, with the Orthopedics Administrator, she revealed that the resident was evaluated on 3/19/2026 related to a left hip replacement. The Physician documented several pre-operational instructions before the surgery would be scheduled. Additionally, she faxed the COC from the 3/19/2026 appointment to the surveyor.Record review of the COC, dated 3/19/2026 states in part, .Clinical findings include severe pain and inability to ambulate.Imaging confirms upward migration of the acetabular component (movement of the hip replacement).which will continue to worsen without intervention.Patient instructions:Left hip replacement has failed and needs to be fixed with another surgeryMust see a dentist for a check-up and cleaning to make sure there are no infectionsWill be referred to a bone health specialist and will need a bone density scanCardiac clearance required prior to surgery .Record review failed to reveal evidence that the above Orthopedic instructions provided on 3/19/2026 were implemented or reviewed with the provider. During a surveyor interview on 3/26/2026 at approximately 1:43 PM with the DNS, she could not provide the COC document for Resident ID # 104's orthopedic appointment on 3/19/2026. She revealed that the scanning process for medical records is delayed and the COC could be in an office but could not locate the document.

Based on clinical record review and staff interview, the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight relative to 1 of 1 resident reviewed for severe weight loss who was not reweighed for verification, Resident ID #8.Findings are as follows:Review of a facility policy titled, Weight Assessment and Interventions, dated 5/2019, states in part, .Weights will be recorded in the medical record (electronic health record where available) for each resident . Any weight change of 5lb [pounds] in a month and 3lbs in a week since their last weight assessment should be retaken within 72hrs for confirmation and verified by Nursing .Re weigh should be reviewed by the Licensed Nurse .Licensed Nurse should notify Dietician of identified weight change once reviewed .Dietician notification should be documented within Resident's medical record .Dietician.should respond within 72 hours of receipt of notification.Review of the resident's record revealed s/he was readmitted to the facility in November of 2025 with diagnoses including, but not limited to, fractured left hip and dysphagia (difficulty swallowing).Record review revealed the following weight documentation:1/5/2026 102.4 lbs.2/5/2026 84 lbs.2/17/2026 87 lbs.2/23/2026 86.4 lbs.3/2/2026 93.4 lbs.3/9/2026 85.6 lbs.3/16/2026 90.8 lbs.Additional record review revealed the resident experienced a severe weight loss of 18.4 lbs. in one month from 1/5/2026 to 2/5/2026. Record review failed to reveal evidence that the resident was re-weighed within 72 hours of 2/5/2026 to confirm and verify the current weight per the facility's policy. Additionally, record review failed to reveal evidence that the Registered Dietitian (RD) was notified of the severe weight loss until 2/17/2026, 12 days after his/her severe weight loss.Further record review failed to reveal evidence that the resident was reweighed per the facility policy after s/he experienced a weight gain of 7 lbs. from 2/23/2026 to 3/2/2026 and a weight loss of 7.8 lbs. from 3/2/2026 to 3/9/2026. During a surveyor interview with the RD on 3/25/2026 at 3:46 PM, she revealed that she is notified of residents' significant weight changes by the nursing staff and by running a report each month. She indicated that if there are weight discrepancies of 3 lbs. or more in a week or 5 lbs. or more in a month, then the resident is reweighed, usually on the same day. Additionally, she was unable to recall when she was notified of the resident's weight loss on 2/5/2026 and would have expected nursing staff to reweigh the resident per facility policy. Further, she indicated a reweight should have been obtained following the changes in the resident's weight on 3/2/2026 and 3/9/2026.During a surveyor interview with the Director of Nursing Services on 3/26/2026 at 1:34 PM, she indicated that if there is a significant change in a resident's weight, a reweigh should be completed within 24 hours by nursing staff. She indicated that if the change in weight is verified, she would expect nursing to notify the RD so she can assess the resident and implement interventions. Additionally, she acknowledged that reweighs were not obtained following the resident's severe weight loss on 2/5/2026 and his/her significant weight changes on 3/2/2026 and 3/9/2026, per the facility policy.

Based on record review and staff interview, it has been determined that the facility assessment failed to include active involvement/input received from resident representatives, and family members.Findings are as follows:Record review of a facility provided document titled, Requirements of Participation: Facility Assessment, reviewed and approved on 1/21/2026, failed to reveal evidence that the facility developed and maintained a plan that included involvement by the residents' families and/or representatives.During a surveyor interview with the Director of Nursing Services on 3/26/2026 at 2:48 PM, she acknowledged that the facility assessment did not include input from resident representatives/families.

Based on clinical record review, resident, and staff interview the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident related to pramipexole (a medication prescribed to treat restless leg syndrome (RLS;) RLS is a neurological condition characterized by uncomfortable sensations described as crawling, tingling, or aching.) for 1 of 1 resident reviewed, Resident ID #1.Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 2/12/2026 alleges that Resident ID #1 was not administered his/her prescribed pramipexole because the medication was unavailable due to an issue with the pharmacy.Record review revealed that the resident was admitted to the facility in January of 2026 with diagnoses including, but not limited to, RLS and seizures.Review of an admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.Record review revealed the following physician's order:-1/23/2026, pramipexole dihydrochloride oral tablet 0.5 milligrams, give two tablets by mouth, two times a day related to RLS.Record review of the February 2026 Medication Administration Record revealed that the pramipexole was documented as not administered per the order on the following dates and times:-2/8/2026 afternoon-2/9/2026 morning-2/9/2026 afternoon-2/10/2026 morning-2/10/2026 afternoon-2/11/2026 morning-2/11/2026 afternoon-2/12/2025 morning -2/12/2026 afternoon This indicates that the resident was not administered his/her prescribed pramipexole for a total of nine doses from 2/8/2026 through 2/12/2026. Additionally, the record revealed that because of this the resident requested to be transferred to the Emergency Department (ED) so s/he could receive the medication, as it was unavailable at the facility. Record review of a progress note dated 2/11/2026 at 8:21 PM, authored by a provider revealed that the pharmacy failed to deliver the resident's ordered pramipexole for RLS. The note further indicates that the resident requested to be transferred to the ED to have access to his/her medication. During a surveyor interview on 2/27/2026 at 11:31 AM, with the resident, s/he stated that s/he went about three days without receiving his/her pramipexole as ordered for RLS because it was not available. S/he further indicated that s/he requested to be transferred to the ED because his/her legs were uncomfortable, with pain that radiated to his/her back. Additionally, s/he stated that s/he paced around the unit because sitting still was uncomfortable. During a surveyor interview with the Director of Nursing Services on 2/27/2026 at 2:55 PM, she acknowledged that the medication was not administered as ordered because it was unavailable from the pharmacy on 2/8, 2/9, 2/10, 2/11, and 2/12/2026.During a surveyor interview on 2/27/2026 at 3:25 PM with the Pharmacy Account Manager, he stated that the request for a refill of the pramipexole was not submitted by the facility until 2/12/2026.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure ordered diagnostic testing was obtained and failed to ensure significant laboratory results were reviewed and reported to the practitioner for 1 of 1 resident reviewed (Resident ID #1) who was treated for a herpes simplex outbreak (viral infection that can cause painful blisters or ulcers and is spread through skin to skin contact). The facility's failures in following practitioner orders, reviewing and reporting abnormal laboratory results, and ensuring timely communication with the resident's responsible party led to a delay in treatment and resulted in the need for a more invasive course of treatment. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/1/2025 alleged that Resident ID #1's genital area was observed to be .severely swollen, red, and extremely painful. The complaint further alleged that after this observation of the resident's genital area, the family was notified that the resident had been treated for a herpes outbreak approximately a month prior and that the family had not been made aware of this new diagnosis. Additionally, the complaint alleged potential neglect and misconduct and questioned how this virus was contracted at the facility. Record review revealed Resident ID #1 was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, dementia and malignant neoplasm of the colon (colon cancer).Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 out of 15, indicating a moderate cognitive impairment. Further review revealed the resident is dependent of staff for activities of daily living, including incontinence care. Record review of a care plan revised 6/13/2022 revealed the resident is at risk for skin breakdown related to limited mobility and incontinence with an intervention to inspect the skin for redness, irritation and breakdown during care. Record review revealed the following progress notes:-8/26/2025- [genitals] discharge and swollen [genitals] noted, reported to Nurse Practitioner (NP) with a new order for warm compresses four times a day for three days. -8/28/2025- Evaluated by NP, new order given for antifungal and barrier cream to be mixed and applied during incontinence care to peri area.-9/10/2025- Nursing reports redness and open areas to [genitals], assessed by NP, swelling, redness and lesions noted to [genitals]. New orders given to obtain a urinalysis with culture and sensitivity (UA C&S), obtain a [genitals] swab, and apply Clotrimazole cream (antifungal cream) twice a day for seven days for suspected fungal infection. -9/10/2025- [genitals] swab and UA obtained, put into fridge on 4th floor, lab notified.-9/17/2025- Positive urinary tract infection (UTI), results reported to NP. New order given for Ertapenem (antibiotic) 1 gram intramuscularly for seven days. -11/2/2025- [genitals] red, irritated, blotches on both [genitals], some [genital] discharge, picture sent to NP. New order for Valacyclovir 1,000 milligrams by mouth every 12 hours for 10 days to start as soon as possible. -11/3/2025, authored by the NP, Staff A, .being seen for edema [swelling] and lesions to [genitals] bilaterally.evaluated and presents with Herpes simplex outbreak.to start treatment.[genitals] is edematous and has multiple lesions bilaterally.please [continue] to keep [relative] informed of any changes in POC [plan of care] .-11/29/2025- [Relative] reports that s/he changed the resident's brief and noticed redness on his/her buttocks. S/he stated that s/he applied cream after washing the resident. -12/1/2025- Spoke with the resident's [relative] about the blister on the resident's [genitals], educated that the resident was treated a month ago and now the area looks like it's back. NP, Staff A, made aware and will evaluate again this evening. -12/1/2025- Resident's [relative] had the resident sent out to the emergency room via 911 related to lesions on [genitals].Record review failed to reveal evidence that the [genitals] swab was completed, as ordered. Further review failed to reveal evidence of any laboratory results pertaining to a [genital] swab. Record review of the UA revealed a positive UTI on 9/13/2025. This result was not reviewed or reported to a provider until 9/17/2025, four days after the results and seven days after the UA C&S was obtained.Record review failed to reveal evidence that the resident's relative, listed as the responsible party, was notified of the resident's change in condition in September or November of 2025 pertaining to the UTI or the new diagnosis and medication prescribed related to Herpes simplex. During a surveyor interview on 12/2/2025 at 12:16 PM with the NP, Staff A, she indicated that she was not aware of the genital issues identified in August and September of 2025 and that she had only been made aware of the lesions on the genitals in November of 2025. She further indicated that she evaluated the resident on 11/3/2025 and visually diagnosed the genital lesions as a Herpes simplex outbreak. She indicated that she was not contacted after the treatment was ordered until the resident's relative voiced concerns about the resident's condition on 12/1/2025. Additionally, she indicated that she would've expected the genital swab to have been completed, as ordered, and that the positive UA reported and treated immediately. Furthermore, she indicated that she would've expected that the resident's relative would've been notified of the changes in conditions. During a surveyor interview on 12/2/2025 at 12:59 PM with Licensed Practical Nurse, Staff B, he acknowledged that the genital swab was documented as obtained however, results were never received from the lab. He further acknowledged that the UA results weren't reported to a provider for four days after the positive UA resulted. Additionally, he indicated that the resident's family or responsible party should be notified if a resident has a change in condition or when a new medication is prescribed. Furthermore, he could not provide evidence that Resident ID #1's responsible party had been notified of the change in condition. During a surveyor interview on 12/2/2025 at 3:15 PM with the Director of Nursing Services, she acknowledged the genital swab was ordered and documented as obtained however could not explain why the genital swab had not resulted, or why it had not been followed up on. She further indicated that she would have expected the positive UA results to have been reported to a provider as soon as they were made available. Additionally, she acknowledged that the resident's family had not been notified of the change in condition in November. As the facility failed to complete and follow up on ordered diagnostic testing, delays in reporting significant laboratory results, inadequate assessment and monitoring of worsening genital lesions, and the lack of timely notification to the resident's responsible party, collectively resulted in delays in treatment as well as more invasive treatment.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that staff updated and implemented proper safety measures, including the use of bed rails, which resulted in the resident sustaining a significant fracture that required surgery and a significant decline from his/her prior level of function due to a preventable fall for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Record review revealed the resident was initially admitted to the facility in January of 2018 and readmitted in November of 2025 with diagnoses including, but not limited to, dementia, left hip fracture and history of falls.Record review of a facility policy titled falls management, last revised in April 2024, revealed in part, .A fall is defined as any incident in which a resident has a change in elevation.anytime a resident is found on the floor, a fall is considered to have occurred.Record review of a facility policy titled side rails, last revised in August 2018, revealed in part, .procedure.evaluation is completed to identify potential benefits from utilizing side rails and minimize risk.consent will be obtained prior to initiation of side rails .a. Record review revealed that the resident sustained a fall while ambulating on 10/2/2025 and had pain to his/her left hip and leg.Record review of the physical therapy evaluation and plan of care dated 10/7/2025 revealed that Resident ID #1 experienced a decline in functional ability for mobility and transfers following the fall that occurred on 10/2/2025. During the evaluation the resident required moderate assistance for bed mobility using side rails, moderate assistance for functional mobility with a rolling walker, and moderate assistance for functional transfers. The resident demonstrated an unsteady gait related to decreased balance, left hip pain, and reduced activity tolerance. The therapy goals included enabling the resident to safely perform bed mobility tasks using side rails to facilitate getting in and out of bed. The physical therapy evaluation and plan of care was signed by the physician on 10/8/2025.Record review of a care plan, last revised on 10/28/2025, failed to reveal evidence that the resident required side rails for mobility and transfers after his/her fall on 10/2/2025.During an interview with the Director of Nursing Services (DNS) on 11/10/2025 at 2:30 PM she indicated that the side rails were installed on Resident ID #1's bed on 10/27/2025. This was approximately 20 days from the date the side rails were recommended by physical therapy, and the recommendation was signed by the physician. b. Record review of a facility reported incident sent to the Rhode Island Department of Health on 11/5/2025 revealed that the resident had a fall out of bed on 10/27/2025.Record review revealed the following progress notes:- 10/27/2025- the resident was found at approximately 6:45 AM lying on the floor on his/her side, a Nursing Assistant (NA) assisted the resident back to bed and reported that the resident complained of back and leg pain.- 11/1/2025, the resident continues to complain of pain. It further revealed that the pain regimen was not effective, as the resident continued to complain of pain while being transferred into bed. It further revealed that an X-ray of the hip and pelvis were ordered.- 11/4/2025, the X-ray results were reviewed by the physician, and the resident was sent to the emergency department due to the risk for bone necrosis (death of tissue due to restricted blood supply) related to the type of fractures s/he sustained.Record review of a hospital Discharge summary dated [DATE] revealed the resident would be returning to the nursing home on that day and revealed that the resident presented to the emergency department after s/he was found to have a left femoral neck fracture and pelvic fracture after a fall. Additionally, it revealed that the resident was ambulatory with a walker prior to the fall and now requires a wheelchair. Further review of the hospital document revealed that the resident was in pain with the movement of the leg and could not provide further history due to dementia. Furthermore, imaging was ordered and revealed an acute comminuted fracture of the left femur (a type of bone fracture where the bone breaks into multiple pieces that occurs suddenly and is typically caused by a traumatic event, such as a fall) and the resident was then admitted for surgery. During a surveyor observation on 11/10/2025 at approximately 11:30 AM, the resident was noted to be seated in a wheelchair. S/he was unable to stand effectively, complained of pain, and was being assisted by two staff members utilizing a gait belt.During a surveyor interview on 11/10/2025 at 11:50 AM with Licensed Practical Nurse, Staff B, she revealed that after the resident's fall on 10/27/2025, s/he was complaining of increased pain with care and was no longer using his/her walker. She further revealed that she requested an order for an X-ray from the physician on 11/1/2025 due to concerns of the resident's increased pain and a significant decrease in ADLs. Staff B further revealed that the X-ray was not completed until 11/3/2025.During a surveyor interview on 11/10/2025 at 3:51 PM with the DNS, she could provide evidence the resident received the X-ray prior to 11/3/2025.During a surveyor interview on 11/17/2025 at approximately 5:00 PM with the DNS, she revealed that the resident had rolled out of bed on 10/27/2025. Additionally, she acknowledged at the time of the fall the bed rails were not put in place. During a surveyor interview on 11/17/2025 at approximately 3:20 PM with Nursing Assistant (NA), Staff C, he revealed that he was the resident's NA that night. He indicated that the resident fell out of bed because s/he did not have any side rails on his/her bed. During a surveyor interview on 11/18/2025 at 12:23 PM with Licensed Practical Nurse, Staff D, she revealed that Staff C reported to her that the resident had fallen out of bed. Additionally, she revealed that when she went into the room, she found the resident on the floor in between the two beds. She further revealed that the resident was unable to walk and that she and Staff C pivoted the resident and assisted him/her back to the bed. The facility's failure to ensure that staff update and implement proper safety measures, including the use of bed rails, resulted in the resident sustaining a significant fracture that required surgery and a significant decline from his/her prior level of function due to a preventable fall.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that garbage is properly disposed of in accordance with professional standards for food safety, relative to refuse being left outside the dumpster, potentially harboring and feeding pests. Findings are as follows:Review of the 2022 Food and Drug Administration (FDA) Food Code, Section 5-501.112 Outside Storage Prohibitions states in part, (A) Except as specified in (B) of this section, REFUSE receptacles not meeting the requirements specified under 5-501.13(A) such as receptacles that are not rodent-resistant, unprotected plastic bags and paper bags, or baled units that contain materials with FOOD residue may not be stored outside .Review of the 2022 FDA Food Code, Section 5-502.11 Frequency states in part, REFUSE, recyclables, and returnable shall be removed from the PREMISES at a frequency that will minimize the development of objectionable odors and other conditions that attract or harbor insects and rodents .Record review of a community report complaint submitted to the Rhode Island Department of Health on 10/10/2025 alleges that overflowing garbage at the facility was attracting pests and was creating a risk of disease for both residents and staff.Record review of an undated photograph provided by the complainant revealed multiple garbage bags accumulated next to the dumpsters. Record review of an email authored by the facility Administrator revealed that he had contacted his supervisors on 10/6/2025 and 10/7/2025 to inform them that the waste management company had placed a hold on the account due to nonpayment. It further revealed that trash bags were accumulating in the parking lot and that the company was requesting proof of payment to remove the hold.During a surveyor interview on 11/17/2025 at 11:08 PM with the Administrator he acknowledged that there were issues with the trash removal company at the beginning of October 2025 as they have stopped trash pickup without notice due to nonpayment. Additionally, he acknowledged that the garbage was accumulating in the parking lot.

Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that each resident receives adequate care to prevent an accident for 1 of 1 resident reviewed. The resident required two staff members to assist during care, one staff member was providing care, resulting in the resident falling out of bed, injuring multiple areas, including a facial injury requiring immediate transfer to the hospital and hospitalization, Resident ID #1. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/18/2025 revealed Resident ID #1 rolled out of bed after morning care, and s/he was sent to Rhode Island Hospital via 911 for evaluation. Record review revealed the resident was originally admitted to the facility in November of 2023 with diagnoses including, but not limited to, anoxic brain damage (brain does not receive enough oxygen), seizures, and diabetes.Record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident is dependent on staff for bed mobility and that two staff members are required to assist during this task.Record review of the MDS assessment dated [DATE] revealed the resident is dependent on staff during a shower or bath. Additionally, the MDS revealed that two staff members are required to assist during this task.Record review of the resident's care card (a documentation system that enables staff to reference key resident information that shapes their nursing care plan) revealed the resident is dependent for the following care areas: - Personal Hygiene with assist of 2 staff members - Shower or Bathe self with assist of 2 staff members - Roll left or right with assist of 2 staff members Record review of a nursing progress note dated 7/16/2025 revealed the resident fell out of bed, with some bleeding noted from the head and face. Additionally, the resident was sent out to the hospital for evaluation.Record review of the hospital documentation dated 7/16/2025 revealed the resident was evaluated for a 0.5-centimeter (cm) laceration near the right eyebrow, and an abrasion to the left elbow and right knee. During a surveyor interview on 7/21/2025 at 10:30 AM with Nursing Assistant, Staff A, she indicated that on 7/16/2025, she was providing care by herself and completed a full bed bath on the resident and then untucked the bed sheet in an attempt to change him/her. Staff A revealed she tried to pull the sheet off of the bed and the resident fell off the bed onto his/her bottom and then she witnessed the resident hit his/her head on the floor. Additionally, Staff A revealed that she normally works alone while providing care for the resident. She stated that she could not recall the information documented on the care card or MDS regarding the number of staff required to provide care for this resident.During a surveyor interview on 7/21/2025 at 1:55 PM with Licensed Practical Nurse (LPN), Staff B, he indicated that on 7/16/2025, Staff A requested help after the resident fell onto the floor. He entered room and described the resident as alert, and s/he had some blood on his/her face. Staff B called the rescue for the resident to be transported to Rhode Island Hospital for an evaluation. During a surveyor interview conducted on 7/21/2025 at approximately 2:30 PM with the Director of Nursing Services (DNS), she stated that staff may request assistance with care if they feel it is necessary. The DNS noted that the resident typically holds onto the bed rail to assist with turning during care. However, the DNS did not acknowledge that two staff members are required when providing hygiene or bed bath care, despite documentation in the MDS and care card indicating this requirement.Record review revealed that at the time of this survey, the resident remained in the hospital. Due to the facility's failure to follow the MDS Assessment and care card directives, Staff A provided care alone without the required assistance of a second staff member. As a result, Resident ID #1 fell from the bed to the floor, sustaining multiple injuries, including trauma to the face.

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 2 of 2 residents reviewed with contractures (the shortening of muscles, tendons, skin, and nearby soft tissues that cause the joints to become very stiff, which prevents normal movement), Resident ID #s 67 and 79. Additionally, the facility failed to ensure a resident with limited mobility received appropriate services and equipment for 1 of 1 resident reviewed who was admitted to the facility for respite care, Resident ID #272. Findings are as follows: Review of a facility policy titled Admission of A Resident states in part, .obtain sufficient, accurate information that will be required to properly care for the resident .Perform Admission Evaluation/Screen .Review with the Interdisciplinary Team: diet orders, rehabilitation orders, and social services concerns . Review of a facility policy titled Screens, last revised January 2012, states in part, .All patients/residents will be screened annually .the purpose of the screen is to determine if the patient/resident would benefit from a therapy evaluation . 1. Record review revealed Resident ID #67 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, anoxic brain damage (caused by a lack of oxygen to the brain) and muscle wasting. Record review of a Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Further review revealed the resident had impaired range of motion of one side of his/her upper extremities. Additional review revealed the resident is dependent on staff for activities of daily living (ADLs). Record review of a Rehab Screen dated 5/17/2024 failed to reveal documentation of any contractures. During surveyor observations on the following dates and times, the resident was noted to have a contracted left hand, without any intervention in place: - 1/27/2025 at 11:45 AM - 1/28/2025 at 9:52 AM -1/30/2025 at approximately 1:15 PM - 1/31/2025 at 9:41 AM Review of a care plan dated 11/28/2023 revealed the resident has pain related to impaired mobility with interventions including, but not limited to, offer non-pharmacological interventions to reduce pain. Further review revealed the resident is at risk for skin breakdown. Additional review of the care plan failed to reveal evidence the resident had a left-hand contracture, limited range of motion, or that there were interventions implemented to prevent a further decrease in his/her range of motion. Record review of the physician's orders failed to reveal evidence of any orders to prevent a further decrease in range of motion for the resident. During a surveyor interview on 1/30/2025 at 1:20 PM with Licensed Practical Nurse, Staff M, he acknowledged that the resident's left hand was contracted and indicated that the resident is not currently working with physical (PT) or occupational therapy (OT). Additionally, he acknowledged that there were no interventions in place to prevent a further decrease in the resident's range of motion. During a surveyor interview on 1/31/2025 at 9:08 AM with Physical Therapist, Staff N, she acknowledged that when the resident was screened by rehab on 5/17/2024, it was not documented that s/he had a left hand contracture. Additionally, she could not provide evidence that any interventions have been put in place to prevent a further decrease in the resident's range of motion. During a surveyor interview on 1/31/2025 at 9:41 AM with Resident ID #67, s/he indicated that his/her left hand was painful and that s/he could not move it. The resident further indicated that s/he does not work with therapy but would wear a splint if it would help with the pain his/her hand. During a surveyor interview on 1/31/2025 at 9:44 AM with Registered Nurse (RN), Staff F, she indicated that the resident does complain of pain to his/her left hand when staff are providing care. During a surveyor interview on 1/31/2025 at 9:49 AM with the Director of Nursing Service (DNS), she indicated that the resident has impaired cognition however, s/he knows information about him/herself. She further indicated that she was aware that the resident had a left hand contracture and would expect the contracture and limited range of motion to be addressed in the care plan and to have interventions should be in place to prevent a further decrease in the resident's range of motion. 2. Record review revealed Resident ID #79 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, spinal stenosis (spinal narrowing which compresses the spinal cord) and peripheral autonomic neuropathy (nerve damage). Review of a MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed the resident was documented as not having any range of motion impairments to his/her upper extremities. Record review of a Rehab Screen dated 11/11/2024 failed to reveal documentation of any contractures. During a surveyor interview and observation on 1/27/2025 at 11:44 AM, with Resident ID #79, s/he indicated that s/he is not receiving therapy services. The resident was observed to have limited range of motion and bilateral hand contractures. Review of the care plan dated 9/18/2024 revealed the resident has an ADL deficit related to weakness. Further review failed to reveal evidence that the resident has bilateral hand contractures, limited range of motion, or that there were interventions in place to prevent further decrease in the resident's range of motion. Record review revealed the following physician's orders: -OT evaluation and treatment as indicated dated 11/30/2024 -PT evaluation and treatment as indicated dated 12/30/2024 During a surveyor interview on 1/29/2025 at approximately 10:00 AM with the Interim Director of Rehab, Staff O, she indicated that rehab screens are completed quarterly and that due to the resident being bed bound (if someone is bedbound, it means they are not able to move around safely or comfortably. They may need to help to get to and from the toilet, to sit up in bed or to move from the bed to a chair, and help to change their position in bed), s/he does not require therapy services. Additionally, she was unable to provide evidence of a therapy screen upon Resident ID #79's admission in September 2024. During a surveyor interview and observation on 1/31/2025 at 8:58 AM with RN, Staff B, she acknowledged that both of the resident's hands were contracted. During a surveyor interview on 1/31/2025 at 11:14 AM with Staff O, she indicated that she was unaware that the resident had any limited range of motion or contractures to his/her bilateral hands. Additionally, she could not provide evidence that a PT or OT evaluation had been completed as ordered, or that interventions were put into place to prevent a further decrease in the resident's range of motion. During a surveyor interview on 1/31/2025 at 11:16 AM, with the DNS, she was unaware that the resident's bilateral hands were contracted or that s/he had limited range of motion in his/her upper extremities. She further indicated that she would have expected the contractures and limited range of motion to have been identified by therapy and that a care plan would be implemented to prevent a further decrease in the resident's range of motion. 3. Record review revealed Resident ID #272 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, reduced mobility and a history of poliomyelitis (a viral infection that causes nerve injury which leads to partial or full paralysis.) Record review revealed a BIMS dated 1/17/2025 with a score of 14 out of 15, indicating the resident's cognition was intact. During a surveyor interview on 1/27/2025 at approximately 10:00 AM with the resident, s/he indicated that s/he had not been out of bed since his/her admission. Additionally, the resident revealed that s/he enjoyed sitting in his/her recliner at home. Furthermore s/he indicated that s/he had an uncomfortable area on his/her buttocks. Review of a hospital continuity of care form dated 1/16/2025 revealed activity instructions including, but not limited to, Bed and wheel chair bound. Review of the .Admission Screening Tool dated 1/16/2025 revealed the resident was admitted to the facility for a 2-3 month respite stay, due to his/her caregiver having surgery. Further review revealed the resident requires the assistance of two people for transfers. Review of a care plan dated 1/27/2025 revealed the resident has a self-care deficit related to impaired mobility with interventions including, but not limited to, encourage the resident to get out of bed with all meals. Record review failed to reveal evidence that the resident had been screened by Physical or Occupational therapy since his/her admission to the facility. During multiple surveyor observations on 1/27, 1/28, 1/29, and 1/30/2025, all the days of the survey, the resident was lying in bed, flat on his/her back. Further observations failed to reveal that the resident had a wheelchair in his/her room. During a surveyor interview on 1/30/2025 at 9:28 AM with Nursing Assistant (NA), Staff J, she indicated that she had been assisting the resident with care this past week and had not transferred the resident out of bed. She further indicated that she thought that the resident preferred to stay in bed. During a surveyor interview on 1/30/2025 at 9:31 AM with the resident in the presence of Staff J, the resident stated that s/he would love to get out of bed. S/he then stated that the staff have never offered to transfer him/her out of bed. During an interview on 1/30/2025 at 11:04 AM with Registered Nurse (RN), Staff B, she indicated that she was unaware if the resident had been transferred out of bed since his/her admission. She further indicated that the resident did not have a wheelchair and would need to be screened by therapy to receive a wheelchair from the facility. During a surveyor interview on 1/30/2025 at 11:07 AM with the Regional Therapy Director, she indicated that she would expect a therapist to screen each resident within 24 to 48 hours of admission to establish a baseline and to provide the resident with any adaptive equipment needed, including a wheelchair. Additionally, she could not provide evidence that a therapy screen had been completed for the resident since his/her admission. During a surveyor interview on 1/30/2025 at 11:31 AM with the DNS, she indicated that she would expect a therapy screen to be completed to establish safe transfer status for the resident, and to identify if a resident needs a wheelchair. During a surveyor interview on 1/31/2025 at 1:09 PM with Physician, Staff L, he indicated that he would expect an elderly resident who is admitted to the facility for more than a few days, to be screened by therapy for safety. Record review revealed a Rehab Screen was conducted for this resident on 1/30/2025, after the above concerns were brought to the facility's attention by the surveyor, 15 days after the resident's admission. Additional review of the Rehab Screen revealed that the resident required the assistance of one staff for transfers to a wheelchair. Further review revealed that the resident was provided with a wheelchair. Cross reference F-686 47939

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing for 1 of 1 resident reviewed, who was admitted to the facility for respite care, Resident ID #272. Findings are as follows: According to an article published in the National Library of Medicine titled, Pressure ulcers: Learn More - Preventing pressure ulcers, last updated on August 19, 2022, states in part, .Regularly changing a person's lying or sitting position is the best way to prevent pressure ulcers. Special mattresses and other aids can help to relieve pressure on at-risk areas of skin .Most pressure ulcers (bedsores) arise from sitting or lying in the same position for a long time without moving. Most people keep changing their position when they sit for a long time or are asleep, consciously or subconsciously. But people who are very weak, ill, paralyzed or unconscious move much less or not at all. This means that the parts of their body that they are sitting or lying on are constantly under more pressure .People who are confined to a wheelchair or have to stay in bed for a long time are at greater risk. Then it's critical to relieve pressure on the skin by regularly changing the position they sit or lie in. People who develop pressure ulcers often say that they can feel parts of their body becoming sore .It is also important to move if possible - even if you have to lie in bed or sit in a wheelchair. If you are able to sit up, leave the bed, or even walk a few steps with a bit of help, it ' s a good idea to do that as often as possible . Review of the facility policy titled Admission of A Resident states in part, .obtain sufficient, accurate information that will be required to properly care for the resident . Record review revealed Resident ID #272 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, reduced mobility and a history of poliomyelitis (a viral infection that causes nerve injury which leads to partial or full paralysis). Record review revealed a Brief Interview for Mental Status assessment dated [DATE] with a score of 14 out of 15, indicating the resident's cognition was intact. During a surveyor interview on 1/27/2025 at approximately 10:00 AM with the resident, s/he indicated that s/he had not been out of bed since his/her admission. Additionally, the resident revealed that s/he enjoyed sitting in his/her recliner at home. Furthermore the resident indicated that s/he had an uncomfortable area on his/her buttocks. Review of a hospital continuity of care form dated 1/16/2025 revealed activity instructions including, but not limited to, Bed and wheel chair bound, (if someone is bedbound, it means they are not able to move around safely or comfortably. They may need to help to get to and from the toilet, to sit up in bed or to move from the bed to a chair, and help to change their position in bed to prevent bed sores). Review of the .Admission Screening Tool dated 1/16/2025 revealed the resident was admitted to the facility for a 2-3 month respite stay, due to his/her caregiver having surgery. Further review revealed the resident requires the assistance of two people for transfers. Additional review failed to reveal evidence that the resident had a wound upon admission. Review of the resident's care card, a document used by direct care staff for pertinent care information, revealed the resident was dependent on the assistance of two staff members for bed mobility and transfers. Review of a Norton Assessment (a tool used to determine a person's risk of developing a pressure ulcer) dated 1/23/2025 revealed the resident was chair bound with very limited mobility. Further review revealed the resident was at a moderate risk of developing a pressure ulcer. Review of a care plan dated 1/27/2025 revealed the resident was at risk for skin breakdown related to impaired mobility. Record review of an admission skin assessment dated [DATE] failed to reveal evidence of any open areas to the resident's buttocks. Record review of a skin assessment dated [DATE], 6 days after his/her admission, revealed the resident was found to have a facility acquired wound to his/her right buttocks, that measured 3.5 centimeters(cm) by 3.5 cm by 0.1 cm. Record review revealed a physician's order dated 1/23/2025 to cleanse a right buttocks wound with wound cleanser followed by honeygel (a wound gel) and cover the wound with a bordered foam dressing daily. Review of a wound physician's progress note dated 1/28/2025 revealed the resident had a moisture associated wound which measured 2 cm by 3 cm by 0.2 cm. Further review revealed the surrounding area of the wound was normal. During multiple surveyor observations on 1/27, 1/28, 1/29, and 1/30/2025, all days of the survey, the resident was noted to be lying in bed, flat on his/her back. During a surveyor interview on 1/30/2025 at 9:28 AM with Nursing Assistant (NA), Staff J, she indicated that she had been assisting the resident this past week and had not transferred the resident out of bed. She further indicated that she thought that the resident preferred to stay in bed. During a surveyor interview on 1/30/2025 at 9:31 AM with the resident in the presence of Staff J, the resident stated that s/he would love to get out of bed. S/he then stated that the staff have never offered to transfer him/her out of bed. During an interview on 1/30/2025 at 11:04 AM with Registered Nurse (RN), Staff B, she indicated that she was unaware if the resident had been transferred out of bed since admission. During a surveyor observation of the resident's buttocks wound on 1/30/2025 at 9:43 AM, in the presence of Staff B, she removed the soiled dressing from the resident, this dressing was dated 1/28/2025 indicating that it was not changed on 1/29/2025, as ordered. Observation of the wound revealed two dark colored areas around the wound with non-blanchable redness (when you push the skin, and the area stays red, indicating there is little or no blood flow going to that area) to the proximal peri wound (around the wound). Staff B acknowledged these observations. During a surveyor interview on 1/30/2025 at 10:31 AM with the Wound Nurse, Staff K, she indicated that a moisture associated wound is typically blanchable (when the skin loses its color when pressure is applied and quickly returns) where a pressure ulcer (injury to the skin caused by prolonged pressure) is characterized by a non-blanchable area. During a surveyor interview and observation of the resident's buttocks wound on 1/30/2025 at 10:40 AM with Staff K, she indicated that the darkened areas and the non blanchable redness on the resident's buttocks were not present on 1/28/2025, and that these pressure areas were new. She further indicated that the approximate measurements of the two darkened areas were each 0.5 cm by 0.5 cm and that the non-blanchable area was approximately 3 cm by 5 cm. During a surveyor interview on 1/30/2025 at 11:31 AM with the Director of Nursing Services, she indicted that she would expect staff to offer a resident to get out of bed. The facility's failure to transfer the resident out of bed for 15 consecutive days resulted in the resident developing a pressure ulcer, as evidenced by the resident not having a wound to his/her buttocks upon admission. Cross reference F-688

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen and the main dining room. 1. The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .Nonfood contact surfaces shall be kept free of an accumulation of dirt, dust, food residue, and other debris . Surveyor observations of the main kitchen on 1/27/2025 at approximately 8:45 AM and on 1/28/2025 and 1/29/2025 at 9:40 AM revealed the following: - Grease accumulation along the sides and the corners of the steamer - Grease accumulation along the corners and sides of the food warmer - Grease accumulation along the sides and the corners of the stove - Utility cart that stored containers of spices with crumbs and debris in the corners - 4 food meal delivery carts with grease and grime accumulation along the lower edges Surveyor observations on 1/29/2024 at 12:15 PM and on 1/30/2025 at 9:15 AM, of the main dining room, revealed the steam table with grease accumulation on the knobs and food spills on the front of the unit. 2. The Rhode Island Food Code 2018 Edition 3-201.11 states in part, .Food shall be obtained from sources that comply with Law . During a surveyor observation on 1/29/2025 at 9:40 AM the main kitchen reach in refrigerator unit revealed a dozen of eggs stored in a gray egg container, with a use by date of 12/14/2024. Immediately following the above-observation, dietary cook, Staff R, revealed the eggs were for a staff member and that they were fresh farm eggs from his farm raised chickens. During a surveyor observation and interview on 1/30/2025 at 9:15 AM with the Administrator, he acknowledged that the above-mentioned food service equipment was in need of cleaning and that the eggs that were brought in from home were improperly stored.

46338 47939 Based on surveyor observations, record review and staff interviews, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed with refusals of medications, Resident ID #3, 1 of 1 resident reviewed with an order to not have straws with liquids, Resident ID #52, and 1 of 5 residents reviewed with an order for insulin parameters, Resident ID #93. Additionally, the facility failed to meet professional standards of quality relative to 1 of 2 wound dressings observed, Resident ID #272. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . 1. Record review revealed Resident ID #3 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, Parkinson's disease (a chronic and progressive movement disorder) and hypertension (high blood pressure). Record review revealed the following physician's orders dated 11/27/2024: - Amlodipine (a medication prescribed to treat high blood pressure) 10 MG (milligrams), give 1 tablet daily. - Lisinopril (a medication prescribed to treat high blood pressure) 40 MG, give 1 tablet daily. - Metoprolol Succinate (a medication prescribed to treat high blood pressure) 50 MG, give 1 tablet daily. - Multivitamin, give 1 tablet daily. Record review of the resident's January 2025 Medication Administration Record (MAR) revealed that s/he had not received his/her Amlodipine, Lisinopril, Metoprolol and multivitamin as ordered by the physician, secondary to refusals on the following dates: - 1/1/2025 - 1/2/2025 - 1/4/2025 - 1/6/2025 - 1/7/2025 - 1/10/2025 - 1/13/2025 - 1/14/2025 - 1/16/2025 - 1/17/2025 - 1/18/2025 - 1/19/2025 - 1/21/2025 - 1/24/2025 Further record review revealed a physician's order dated 11/26/2024 for Carbidopa-Levodopa (a medication prescribed to treat Parkinson's disease) 25-100 MG, give 2 tablets orally, three times a day. Record review of the resident's January 2025 Medication Administration Record revealed that s/he had not received his/her Carbidopa-Levodopa as ordered by the physician, secondary to refusals on the following dates and times: - 1/1/2025 at 8:00 AM - 1/2/2025 at 8:00 AM - 1/4/2025 at 8:00 AM - 1/5/2025 at 2:00 PM - 1/6/2025 at 8:00 AM - 1/7/2025 at 8:00 AM - 1/10/2025 at 8:00 AM and 2:00 PM - 1/13/2025 at 8:00 AM - 1/14/2025 at 8:00 AM and 2:00 PM - 1/16/2025 at 8:00 AM - 1/17/2025 at 8:00 AM - 1/18/2025 at 8:00 AM - 1/19/2025 at 8:00 AM and 2:00 PM - 1/21/2025 at 8:00 AM - 1/24/2025 at 8:00 AM and 2:00 PM - 1/25/2025 at 2:00 PM and 8:00 PM - 1/27/2025 at 2:00 PM Record review failed to reveal evidence that the provider was notified that the resident did not receive Amlodipine, Lisinopril, Metoprolol, Multivitamin and Carbidopa-Levodopa on the above mentioned dates and times. During a surveyor interview on 1/31/2025 at 9:50 AM with the Director of Nursing Services (DNS), she acknowledged the above-mentioned medications were refused. Additionally, she indicated it would be her expectation that the provider would be notified of the medication refusals. During a surveyor interview on 1/31/2025 at 10:45 AM with the Nurse Practitioner, she indicated that she was not made aware of the above-mentioned medication refusals. 2. Record review revealed Resident ID #52 was readmitted to the facility in December of 2024, with diagnoses including, but not limited to, dysphagia (difficulty swallowing) and dementia. Record review revealed a dietary order dated 12/17/2024, indicating no straws with liquids. Surveyor observations revelaed the following: -1/27/2025 at 12:02 PM, a styrofoam cup with a straw on the bedside table -1/28/2025 at 12:05 PM, an Ensure chocolate supplement with a straw on the bedside table -1/28/2025 at 12:22 PM, an Ensure chocolate supplement with a straw on the resident's meal tray -1/29/2025 at 11:52 AM, a styrofoam cup with a straw on the bedside table During a subsequent surveyor observation on 1/28/2025 at 12:50 PM, Registered Nurse (RN), Staff B, was observed administering the resident his/her medication with a chocolate Ensure supplement and a straw. During a surveyor interview on 1/29/2025 at 11:52 AM with Nursing Assistant, Staff C, she acknowledged the straw in the styrofoam cup. Additionally, she revealed she was assigned to the resident that shift and she was unaware the resident had an order to not have straws with liquids. During a surveyor interview on 1/29/2025 at 11:58 AM with RN, Staff D, and Licensed Practical Nurse (LPN), Staff E, both nurses acknowledged the order for no straws. Additionally, they acknowledged they were not aware of the physician order until it was brought to their attention by the surveyor. During a surveyor interview on 1/29/2025 at 12:32 PM with the DNS, she acknowledged the resident's order for no straws. Additionally, she revealed it would be her expectation that straws would not be provided to the resident. 3. Record review revealed Resident ID #93 was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to, Diabetes Mellitus Type 2. Record review revealed a physician's order dated 9/6/2024 for Admelog solostar (insulin) 100 unit/milliliter (U/ML) solution, inject per sliding scale, and notify the provider if the blood sugar reading is greater than 400, three times per day. Record review of the resident's January 2025 MAR revealed that s/he had blood sugar readings greater than 400 on the following dates and times: - 1/2/2025 407 at 11:30 AM - 1/8/2025 477 at 11:30 AM - 1/11/2025 443 at 11:30 AM - 1/14/2025 401 at 11:30 AM - 1/20/2025 444 at 11:30 AM - 1/22/2025 464 at 7:30 AM - 1/23/2025 404 at 11:30 AM - 1/24/2025 426 at 7:30 AM - 1/27/2025 406 at 11:30 AM - 1/28/2025 531 at 11:30 AM Record review failed to reveal evidence that the provider was notified of the above-mentioned blood sugar readings. During a surveyor interview on 1/30/2025 at 10:42 AM with the DNS, she acknowledged the above-mentioned blood sugar readings. Additionally, she was unable to provide evidence that the provider was notified of the above-mentioned blood sugar readings above 400, as ordered. 4. Record review revealed Resident ID #272 was admitted to the facility in January of 2025, with a diagnosis including, but not limited to, poliomyelitis (a viral infection causing nerve injury which leads to partial or full paralysis). Record review revealed a physician's order dated, 1/23/2025 to cleanse the right buttocks wound with wound cleanser, apply honey gel (a wound gel), and cover with a bordered foam daily. During a surveyor observation and simultaneous interview on 1/30/2025 at 9:34 AM with RN, Staff B, was observed removing a soiled dressing from the resident's wound dated 1/28/2025. Staff B, acknowledged that the dressing was dated 1/28/2025 and that it should have been changed on 1/29/2025. During a surveyor interview on 1/31/2025 at 11:31 AM with the DNS, she indicated it would be her expectation for the treatment to have been completed as ordered. 46118

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident who is diagnosed with a mental disorder or has a history of trauma, receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being relative to 1 of 1 resident reviewed for suicidal ideations, Resident ID #113. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, suicidal ideations, bipolar disorder, and Post Traumatic Stress Disorder. Review of a Brief Interview for Mental Status assessment dated [DATE] revealed a score of 13 out of 15, indicating the resident is cognitively intact. Review of a mood interview dated 1/11/2025 revealed a score of 15 out of 27, indicating the resident has moderately severe depression. Record review of a document titled, Nursing Home Consult Service, dated 1/6/2025 states in part, .long history of psych illness .history of multiple suicide attempts .12/10 in patient psych for ingestion of 2 handfuls of gabapentin [a medication used to treat nerve pain] and lisinopril [a medication used to treat high blood pressure] with the intent to end [his/her] life .denies suicide ideation [SI] at skilled nursing center .admits to chronic suicide ideation which is exacerbated in the setting of social stressors .no acute psych concerns but at chronic risk .Recommendation .monitor for SI, if any active urges would send out to ED [Emergency Department] .discussed behavioral plan with staff . Record review of the care plan dated 1/8/2025 revealed a focus area related to signs and a history of major depression, bipolar disorder and recent suicidal ideation. Further review failed to reveal interventions including to monitor for suicidal ideation. Additional review failed to reveal evidence of a behavioral plan related to suicidal ideation. Record review of the January 2025 Treatment Administration Record failed to reveal any evidence of behavioral monitoring related to suicidal ideation. Record review of the nursing progress notes failed to reveal reveal any evidence of behavioral monitoring related to suicidal ideation. During a surveyor interview on 1/30/2025 at 8:55 AM with Registered Nurse, Staff B, she was unable to provide evidence of the facility was monitoring the resident's behavior related to suicidal ideation for Resident ID #113. During a surveyor interview on 1/30/2025 at 11:23 AM with the Director of Nursing Services, she indicated that she would expect the staff to be monitoring the resident's behavior relative to suicidal ideation and contacting the physician as needed. Additionally, she was unable to provide evidence the facility was monitoring the resident's behavior related to suicidal ideation. 45263 46118

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases, relative to the disinfection of a glucometer that is used to obtain blood glucose readings for multiple residents, for 1 of 2 observations of blood sugar monitoring. Findings are as follows: Record review of a facility policy titled, Glucose Monitoring Equipment revised in October 2018, revealed in part, .Blood glucose monitoring equipment will be cleaned with bleach wipe before and after use and/or as per manufacturer guidelines .Glucometers will be cleaned/disinfected with bleach wipes per manufacturer guidelines . Record review of the Embrace Pro manufacturer instruction manual revealed that the glucometer is to be cleaned by .using a moist (not wet) cloth or tissue with isopropyl alcohol or mild detergent with water . Record review revealed Resident ID #2 was readmitted to the facility in July of 2023 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review revealed a physician's order dated 9/20/2024 for Humalog insulin 100 Unit/milliliter (ML), twice daily, to be administered according to a sliding scale based on his/her blood sugar. During a surveyor observation on 1/29/2025 at 11:30 AM with Registered Nurse, Staff F, she obtained Resident ID #2's blood sugar. Additionally the observation failed to reveal Staff F wiped down the glucometer before and after obtaining the resident's blood sugar. Furthermore, Staff F failed to disinfect the glucometer prior to placing it back in to the medication cart. During a surveyor interview on 1/29/2025 at 11:34 PM with Staff F, she acknowledged that she failed to clean the glucometer before and after using it to obtain the resident's blood sugar. During a surveyor interview on 1/29/2025 at 12:48 PM with the Director of Nursing Services, she revealed that she would expect Staff F to clean the glucometer with a bleach wipe prior to and after obtaining the resident's blood sugar.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide an ongoing activity program to support a resident in his/her choice of activities based on the comprehensive assessment, care plan, and preferences for 1 of 1 resident reviewed, Resident ID #90. Findings are as follows: Record review revealed the resident was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, mild communication deficit and major depressive disorder. Review of an Admission Minimum Data Set (MDS) Assessment, Section F, titled, Preferences for Customary Routine and Activities, dated 11/21/2024, revealed that it is very important for the resident to have books, to read the newspaper and magazines, to listen to music that s/he likes, and to do activities s/he likes with groups of people. Review of the resident's care plan dated 8/16/2024 and revised on 11/22/2024 revealed that the resident has impaired cognition due to dementia with the intervention to encourage socialization and recreation activity. Surveyor observations of the resident on the following dates and times failed to reveal evidence that the resident was offered or participated in any activities while in his/her room alone. -1/27/2025 - 10:12 AM, resident was in bed with his/her eyes opened, without his/her television or music on. -1/27/2025- 1:32 PM, s/he was in bed staring at the ceiling, without his/her television or music on. -1/27/2025 - 3:00 PM s/he was laying in bed, without his/her television or music on. -1/28/2025 - 11:30 AM, the resident was observed sitting on the bed, without his/her television or music on. -1/29/2025 - 10:45 AM, the resident was observed lying in bed with her eyes opened, without his/her television or music on. - 1/29/2025 - 2:53 PM, the resident was observed sitting up on the bed, without his/her television or music on. Review of the resident's daily activity report sheet failed to reveal any documented activity on 1/27/2025, 1/28/2025 and 1/29/2025. Review of the January 2025 Activity staff schedule revealed a daily assigned staff member was on the third floor (dementia unit), from 9:30 AM to 4:30 PM. During a surveyor interview on 1/30/2025 at 9:11 AM with a Nursing Assistant, Staff H, she revealed that the resident does not like to come out of his/her room so whenever s/he stays in his/her room, someone from the activities department is supposed to go into the room for an activity session. Further, Staff H, revealed that the resident likes to read, listen to music, and watch television when s/he stays in their room. During a surveyor interview on 1/30/2025 at 10:52 AM with the assigned unit Activities Aide, Staff I, she acknowledged that she failed to visit the resident on the above-mentioned dates. During a surveyor interview on 1/30/2025 at 12:10 PM with the Director of Nursing Services, she indicated that she would expect the Nursing Assistants to put the resident's television or compact disc player on, as indicated by his/her plan of care.

47939 Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight for 2 of 4 resident reviewed for weight loss, Resident ID #s 52 and 272. Findings are as follows: Record review of a facility's policy titled, WEIGHTS states in part, .The following resident/patients are weighed weekly X4 [times 4 weeks] .Newly admitted residents/patients .Newly weight loss/gain of 5 pounds [Lb] or more on a resident weighing 100 pound or more requires a reweight for verification .Weight are documented in the resident's/patient's medical record and/or the weight book. If a significant weight loss/gain is identified (>5% in 30 days or >10% in 6 months), the IDT [interdisciplinary Team], dietician, physician and family are notified. All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly . Record review of a facility policy titled, Food & Dining Service' states in part, .The objective of food service is to supply the resident/patient a diet comparable with his needs .a record of food and fluid intake will be kept on the appropriate form .Each resident is seen by the dietician to review their diet on admission, quarterly and significant change . 1. Record review revealed Resident ID #52 was readmitted to the facility in December of 2024, with diagnoses including, but not limited to, dementia and dysphagia (difficulty swallowing). Review of a care plan dated 11/20/2023 revealed, the resident is at risk for malnutrition due to dementia and a history of dysphagia. Additionally, the care plan was revised on 12/14/2024 indicating mild protein calorie malnutrition (This occurs when you are not consuming enough protein and calories. This can lead to muscle loss and fat loss.) Further review revealed interventions including, but not limited to, staff are to obtain weekly weights per policy and consult the dietician as needed for changes in weight. Record review of a nutritional assessment completed by the Dietitian on 12/14/2024, revealed that the resident has been noted with a decline in intake since his/her admission and requires weekly weights. Record review revealed the following weights: -12/23/2024 167 lbs. -1/6/2025 159 lbs. Record review failed to reveal weights were obtained during the weeks of 12/29/2024 through 1/4/2025. Indicating the resident had a 8 lb. weight loss in 2 weeks. Record review revealed the following documentation of the resident's intakes for meals from 12/24/2024 through 1/6/2025 were as follows: -12/24/2024- Only 1 meal was documented with 26-50% consumed. -12/25/2024- Only 1 meal was documented with 26-50% consumed. -12/26/2024- 2 meals were documented with 76% to 100% consumed, 1 meal was documented with 26-50% consumed. -12/27/2024- 1 meal was documented as refused, 1 meal was documented with 0% to 25% consumed and 1 meal was documented with 51% to 75% consumed. -12/28/2024- 3 meals were documented with 0 to 25% consumed. -12/29/2024- 2 meals were documented with 0% to 25% consumed, and 1 meal was documented with 26% to 50% consumed. -12/30/2024- 1 meal was documented as refused and 2 meals were documented with 0% to 25% consumed. -12/31/2024- 2 meals were documented with 0% to 25% consumed, and 1 meal was documented with 26-50% consumed. -1/1/2025- 1 meal was documented with 0% to 25% consumed, 1 meal was documented with 26% to 50% consumed, and 1 was meal documented with 76% to 100% consumed. -1/2/2025- 2 meals were documented with 51% to 75% consumed and 1 meal was documented with 26% to 50% consumed. -1/3/2025- 1 meal was documented with 26% to 50% consumed, and 2 meals were documented with 76% to 100% consumed. -1/4/2025- 1 meal was documented with 26% to 50% consumed, and 2 meals were documented with 76% to 100% consumed. -1/5/2025- Only 1 meal was documented with 76-100% consumed. -1/6/2025- 2 meals were documented with 51% to 75% consumed, and 1 meal was documented with 76% to 100% consumed. Record review failed to reveal evidence that the resident was re-weighed on 1/6/2025 when s/he had a documented weight loss of 8 lbs. Additional record review failed to reveal evidence any additional interventions or weights implemented for the resident from 1/6/2025 through 1/30/2025, until it was brought to the facility's attention by the surveyor. During surveyor interviews on 1/30/2025 at 10:38 AM and 11:23 AM with the Dietitian, she acknowledged that the resident had a weight loss of 8 lbs. in 2 weeks. She revealed that it would be her expectation that the resident would have been re-weighed to ensure the accuracy of the weight. Further, she revealed that as part of her assessment process she does review the weights weekly but had not reviewed the resident's weight obtained on 1/6/2025. Additionally, she revealed that she had not been notified of the weight loss documented on 1/6/2025, and that she re-weighed the resident on 1/30/2025 and his/her weight was recorded as 158 lbs., confirming the previous weight loss and the loss of an additional pound. 2. Record review revealed Resident ID #272 was admitted to the facility on [DATE], with diagnoses including, but not limited to, poliomyelitis (a viral infection causing nerve injury which leads to partial or full paralysis) and depression. Record review revealed the following weights: -1/16/2025 86.3 lbs. -1/27/2025 85 lbs. Record review failed to reveal weights were obtained during the weeks of 1/19/2025 through 1/25/2025. Indicating the resident lost 1.3 lbs. in 10 days. Record review failed to reveal evidence of that any additional weights were obtained for the resident after 1/27/2025. Further record review failed to reveal evidence of an order to obtain Resident ID #272's weekly times four weeks upon his/her admission, per the facility's policy. Record review revealed documentation of the resident's intakes for meals and snacks from 1/16/2025 through 1/28/2025 as follows: -1/16/2025- Only 1 meal was documented with 76-100% consumed. -1/17/2025- Only 2 meals were documented with 76-100% consumed. -1/18/2025- Only 2 meals were documented,1 meal with 26% to 50% consumed and 1 meal with 76-100% consumed. -1/19/2025- 2 meals were documented with 76% and 100% consumed. -1/20/2025- 2 meals were documented with 51% to 75% consumed, and 1 meal was documented with 0% to 25% consumed. -1/22/2025- 1 meal was documented with 0% to 25% consumed, and 2 meals were documented with 26% to 50% consumed. -1/23/2025- 2 meals were documented with 26% to 50% consumed, and 1 meal was documented with 51% to 75% consumed. -1/24/2025- 1 meal was documented as refused,1 meal was documented with 51% to 75% consumed, and 1 meal was documented with 76% to 100% consumed. -1/25/2025- 3 meals were documented with 26% to 50% consumed. -1/26/2025- 3 meals were documented with 26% to 50% consumed. -1/27/2025- 3 meals were documented with 26% to 50% consumed. -1/28/2025- Only 1 meal was documented with 76% and 100% consumed. Record review failed to reveal evidence of a nutritional care plan for the resident. Further record review failed to reveal evidence that an admission nutritional assessment was completed by the Dietitian for Resident ID #272. During a surveyor interview on 1/30/2025 at 10:52 AM with the Dietitian, she acknowledged the resident experienced a weight loss. Additionally, she revealed that she assessed the resident on 1/20/2025, and recommended Ensure (a nutritional supplement) twice a day, however she was unable to provide evidence of an assessment or that the Ensure recommendation was communicated to the facility. During surveyor interviews on 1/30/2025 at 10:52 AM and 11:31 AM with the Director of Nursing Services (DNS) she revealed that she would have expected the staff to re-weigh Resident ID #52 after his/her weight was obtained on 1/6/2025. Additionally, the DNS could not provide evidence that the Dietitian, family, or provider were notified of the resident's weight loss, as indicated in the facility's policy. Furthermore, she could not provide evidence of an admission nutritional assessment completed for Resident ID #272 or that any intervention were implemented for him/her.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles relative to 1 of 1 secured unit observed. Findings are as follows: Record review of a facility policy titled, Medication storage room/Medication cart policy dated February 2018, revealed in part, .The facility provides pharmaceutical services that are conducted in accordance with accepted ethical and professional standards of practice and that meet applicable Federal, State and Local Laws, rules and regulations .Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel .Storage for other medications will be limited to a locked medication room . During a surveyor observation of the medication administration pass on 1/29/2025, with Certified Medication Technician (CMT), Staff P, the following was observed: - At approximately 9:35 AM Licensed Practical Nurse, Staff M, asked Staff P, for the medication technician key ring, because another staff member had to use the bathroom. - At approximately 9:40 AM, Staff M, walked back towards the medication cart where Staff P, was administering medications. Staff P, asked Staff M, if she could have the keys to her cart back. Staff M, indicated that a housekeeper had the medication cart keys because she needed to use the bathroom. - At approximately 9:45 AM the keys were returned to Staff P, by housekeeper, Staff Q. During a surveyor interview on 1/29/2025 at 10:04 AM with CMT, Staff P, she revealed that the medication technician key ring contains the only key to unlock the bathroom on the unit. Additionally she revealed that the keys for the two medication carts and the key for the medication storage room are on the same key ring. She acknowledged that staff members take the keys so they can use the locked bathroom, and that they need to find a better system. During a surveyor interview on 1/29/2025 at approximately 10:10 AM with Staff M, he acknowledged that when anyone must use the unit's bathroom, they must use the medication technician's key ring because it contains the only bathroom key. During a surveyor interview on 1/29/2025 at approximately 10:15 AM with housekeeper, Staff Q, she acknowledged that she must get the key ring from the medication technician when she needs to use the bathroom. During a surveyor interview on 1/29/2025 at 1:48 PM with the Director of Nursing Services, she acknowledged that the bathroom key should be separate from the medication storage keys. She could not provide evidence that the medication storage areas were only accessible to licensed nurses or medication technicians, as required.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 2 residents reviewed for heel boots, Resident ID #83, for 2 of 2 residents reviewed for off-loading heels, Resident ID #s 46 and 83 and for 1 of 2 residents observed for wound dressings, Resident ID #272 . Findings are as follows: 1. Record review revealed Resident ID #83 was readmitted to the facility in April of 2023 with diagnoses including, but not limited to, contracture of the right knee and vascular dementia. Review of the care plan dated 4/28/2023 revealed that s/he is at risk for skin breakdown related to limited mobility. Review of a Norton Assessment (a tool used to determine a person's risk of developing a pressure ulcer) dated 12/10/2024, revealed a score of 6 indicating that the resident is at high risk to develop a pressure ulcer. Record review revealed the following physician's orders dated 4/28/2023: - offload the resident's heels every shift as tolerated for skin integrity - wear heel protectors as tolerated while in bed every shift. Surveyor observations on the following dates and times revealed that the resident's heels were not offloaded or that the boots were applied, as ordered: - 1/27/2025 at 10:03 AM and 12:24 PM - 1/28/2025 at 9:25 AM and 12:28 PM Review of the January 2025 Treatment Administration Record (TAR) revealed that the above-mentioned orders were signed off as completed. During a surveyor interview on 1/28/2025 at 12:52 PM with Registered Nurse, Staff G, she acknowledged that the resident's heels were not offloaded, and his/her boots were not applied as ordered. Additionally, she acknowledged that the TAR was signed off inaccurately to indicate that the orders were completed. 2. Record review revealed Resident ID #46 was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, muscle weakness and major depressive disorder. Review of a physician's order dated 12/3/2024 revealed an order to offload the resident's heels every shift as tolerated for skin integrity. During surveyor observations on the following date and times revealed the resident's heels were not offloaded, as ordered. - 1/27/2025 at 9:40 AM - 1/28/2025 at 12:24 PM - 1/29/2025 at 2:21 PM During a surveyor interview on 1/29/2025 at 2:29 PM with Registered Nurse, Staff F, she acknowledged that the resident's heels were not offloaded as ordered. Further, she was provide evidence the TAR was documented accurately on 1/29/2025. 3. Record review revealed Resident ID #272 was readmitted to the facility in January of 2025 with diagnoses including, but not limited to Poliomyelitis (a viral infection causing nerve injury which leads to partial or full paralysis). Review of a physician's order dated 1/23/2025 indicated to cleanse the right buttock moisture-associated skin damage with wound cleanser, to apply honey gel then cover the wound with a bordered foam dressing every evening shift. During a surveyor observation on 1/30/2025 at 9:54 AM of the dressing change with Registered Nurse, Staff B, the soiled dressing was observed to have the date of 1/28/2025 which indicated that it was not changed on 1/29/2025, as ordered. Review of the January 2025 TAR revealed that the dressing change was signed off as completed on 1/29/2025. Additionally, Staff B, acknowledged the date of 1/28/2025 was on the dressing she removed and indicated that it was not changed on 1/29/2025, as ordered. During a surveyor interview on 1/30/2025 at approximately 12:00 PM with the Director of Nursing Services, she indicated that she would expect the staff to follow the physician's orders and document information accurately in the residents' medical records. 46118

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 1 of 6 residents reviewed who is at risk for developing pressure ulcers or who have actual pressure ulcers, Resident ID #56. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2017 and readmitted in September of 2022 with diagnoses which include, but are not limited to, vascular dementia and muscle weakness. Record review of a quarterly Minimum Data Set (MDS, used to assess a resident's cognitive and functional status) assessment dated [DATE] revealed the resident requires extensive assistance of two staff with bed mobility. Record review of a care plan initiated on 5/22/2019 and revised on 2/17/2022 states in part, .at risk for skin breakdown due to [his/her] advanced age, limited mobility, and incontinence .Interventions .Treatment as ordered . Record review of a pressure injury evaluation dated 11/10/2022 states in part, .current stage: Suspected deep tissue injury [localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure] .left great toe .type: pressure .length: 0.25 cm [centimeter] width:0.25 cm .comments: dark red/black discoloration noted to left great toe .Eschar [a collection of dry, dead tissue within a wound] 75% . Record review of a nursing progress note dated 11/10/2022 states in part, Resident noted with a dark reddish-black circular area to [his/her] left great toe. Area measures approximately 0.25 cm x [by] 0.25 cm .Facility DON [Director of Nursing] along with NP [Nurse Practitioner] is made aware, NO [new order]: 1. Apply skin prep to wound bed qshift [each shift] 2. Place a foot cradle [a device placed at the foot of the bed that is used to relieve the weight of the bedding from the feet] . Record review of the resident's physician's orders failed to reveal evidence of an order for a foot cradle from 11/10/2022 through 11/30/2022 when it was brought to the facility's attention by the surveyor. During surveyor observations on the following dates and times, the resident was observed lying in bed without the foot cradle in place: -11/27/2022 at 11:00 AM -11/28/2022 at 12:00 PM - 11/30/2022 at 8:09 AM and 9:45 AM. Additional record review of a physician's order with a revision date of 11/16/2022 states in part, Measure area to left great toe weekly and complete pressure evaluation everyday shift Tuesday . Record review of the resident's weekly skin evaluation failed to reveal evidence of a skin assessment of the left great toe on 11/17/2022 and 11/24/2022 as ordered. During an additional surveyor observation on 11/30/2022 at 10:15 AM in the presence of a License Practical Nurse, Staff C, reveal the resident lying in bed without a foot cradle. Additionally, the resident left great toe was measured by Staff C which revealed a measurement of 1.5 cm x 0.7 cm. During a surveyor interview immediately following this observation with Staff C, he acknowledged that the foot cradle was not in place as ordered. Additionally, Staff C acknowledged that the resident's area on his/her left great toe had increased in size from the initial measurement on 11/10/2022. During a surveyor interview on 11/30/2022 at 1:19 PM with the Director of Nursing Services, she could not provide evidence as to why the order for the foot cradle was not implemented when it was ordered on 11/10/2022. Additionally, she indicated that she would expect the staff to assess and document the resident's left great toe wound weekly as ordered. During a surveyor interview on 12/1/2022 at 12:01 PM with the Nurse Practitioner, Staff E, she indicated that she would expect the order for the foot cradle to have been implemented as ordered on 11/10/2022. Additionally, she indicated that she would expect the staff to do a weekly assessment of the resident's left great toe as ordered. 46118

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 2 of 9 sample residents reviewed, Resident ID #'s 1 and 9. Findings are as follows: 1) Review of the online 2000-2021 Davis-Drug-Guide states in part, [MEDICATION(S)] .High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error .Adverse Reactions/Side Effects .RESPIRATORY DEPRESSION [refers to a low shallow breathing rate] .* CAPITALS indicate life-threatening .Toxicity Overdose: If an opioid antagonist is required to reverse respiratory depression or coma, [MEDICATION(S)] [[MEDICATION(S)]] is the antidote . Record review of the facility reported incident received by the Rhode Island Department of Health (RIDOH) on 7/6/2021 states in part, At 6:00 am this morning [Registered Nurse, (RN), Staff A] administered [MEDICATION(S)] to [Resident ID #1] in error. [Resident's] MD was notified. [MD] stated to monitor and no new orders given. At 0820 [Resident ID #1] was noted unresponsive with eyes open. Two doses of [MEDICATION(S)] were administered and Resident became responsive. 911 was called and [ Resident ID #1] was transported to the hospital for further evaluation .At 4:30 pm we were informed [s/he] was being admitted for drug overdose . Review of the community reported incident received by the RIDOH on 7/6/2021 from a social worker at the hospital states in part, .Patient presented to .Hospital ED [emergency department] today for a reported overdose reporting that [s/he] was giving another resident's medication .Hospital Dr . contacted facility and was informed that the overnight nurse [RN, Staff A] gave patient the wrong medication and patient [Resident ID #1] was then found unresponsive by the morning nurse . During an interview with the Director of Nursing Services (DNS) on 7/8/2021 at approximately 8:45 AM, she indicated that RN, Staff A, was passing 6:00 AM medications, when she went to Resident ID #1's room and administered 90 milligrams (mg) of [MEDICATION(S)] to him/her that was prescribed for Resident ID #2, who resides two rooms over (approximately 24 feet) from Resident ID #1's room. Record review revealed Resident ID #1 was admitted to the facility from an acute inpatient hospitalization in June of 2021, with primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan dated 6/17/2021 revealed in part .has difficulty understanding R/T: [related to] impaired hearing. Interventions include speaking in a loud voice, using simple direct language or gestures as needed, observing resident for understanding, giving resident time to respond, and repeating as necessary. Review of the resident's progress notes revealed the following entries: -7/6/2021 9:13 AM authored by RN, Staff A - [Doctor] was called at 6 AM this morning to do with a med. error. N.N.O's [no new orders] were given. -7/6/2021 4:22 PM authored by RN, Staff C- This writer was called to resident's room in regards to resident becoming unresponsive at approx[imately] 0820. Resident's eyes open but unable to communicate, pupils noted to be small, skin pale in color, both arms and legs limp, noted to have tachycardia. SpO2 [is a measurement of the amount of oxygen-carrying hemoglobin in the blood] 62% [a normal level is 94-100 %] on 3L [liters] O2 via NC [nasal cannula; a device used to deliver supplemental oxygen] with shallow breathing noted, O2 increased to 4L SpO2 remained at 63%. Placed on nonrebreather [a mask that is a medical device that helps deliver oxygen in emergency situations] at 15 Liters, SpO2 increased to 97%. Resident given [MEDICATION(S)] at approx[imately] 0824, 3 minutes given, resident still unresponsive. Given 2nd dose of [MEDICATION(S)] when resident came to. Able to grasp this writers hand. Did have 1 episode of vomiting, 911 notified and able to transport resident to [hospital] for further evaluation. -7/6/2021 8:08 PM authored by RN, Staff B .This writer was called to resident's room at approximately 8:26 AM, Resident was unresponsive with eyes open but unable to communicate, pupils noted to be pin point, his skin was pale in color, both arms and legs noted to be limp, and noted to be in tachycardia. Stat code and 911 was called. Residents SpO2 was 62% on 3L O2 via NC with shallow breathing noted, O2 was increased to 4L Spo2 remained at 63%. Placed on nonrebreather at 15 Liters by the other nurse present, Resident given [MEDICATION(S)] was administered at approximately 0824, after 3 minutes resident still unresponsive. Given 2nd dose of [MEDICATION(S)] then resident became responsive .Resident was then able to grasp the other nurses hand. Resident was able to sit up in bed then had 1 episode of vomiting, as 911 arrived at facility,[s/he] was then transport by 911 rescue to [hospital] for further evaluation .informed that resident was going to be admitted . Review of the resident's Hospital records for his/her 7/6/2021 admission revealed the following: -7/6/2021- Pt [patient] is a resident [at facility], pt was given 90 mg of [MEDICATION(S)] by staff at facility, pt was found unresponsive by the day shift CNA [certified nursing assistant], pt given .[MEDICATION(S)], pt responded. -7/7/2021- .past medical history significant for [CONDITION(S)] on 2-3 L oxygen supplementation at baseline .recently discharged [DATE] from [hospital] for [CONDITION(S)] exacerbation. Was at SNF [skilled nursing facility] and per SNF documentation was administered [MEDICATION(S)] 90mg earlier today and became unresponsive, responsive to [MEDICATION(S)] administration .Got [MEDICATION(S)] 0.4 mg once 11 am then 1 mg an hour later then started on [MEDICATION(S)] drip on 12:51 pm. Trialed off the drip around 6:30 pm and then placed on it again Patient was then accepted to .[intensive care unit] for continued need of [MEDICATION(S)] drip .[MEDICATION(S)] gtt [drip] d/c'ed [discontinued] around 8AM, more somnolent [abnormally drowsy] 2h later, and placed back on [MEDICATION(S)] gtt 0.2mg/hr .The patient is critically ill because of resp[iratory] failure . During an interview with RN, Staff B on 7/8/2021 at approximately 12:00 PM, she indicated that on the morning of 7/6/2021 she arrived at the facility at approximately 7:15 AM and was told by RN, Staff A that she had administered Resident ID #2's 90 mg of [MEDICATION(S)] to Resident ID #1 in error. RN, Staff A indicated that she had called the doctor and reported the medication error to him, and he told her to monitor the resident. She stated she checked on the resident and checked his/her vital signs, which were stable, then made the CNAs aware of the medication error and asked them to check on him/her frequently as she had to finish getting report from RN, Staff A and then complete the morning blood sugars. She indicated that at around 8:20 AM she heard her name being called by CNA, Staff D and she responded to the resident's room where s/he was found to be pale, unresponsive, to have pinpoint pupils and limp limbs. She then exited the room and called a code. Another RN, Staff C, responded to the code. The resident was assessed at that time and was found to have an SPO2 level of 62% on 3L of oxygen, which increased to 63% when they increased the oxygen to 4L. She stated they then placed a non-rebreather mask on the resident and increased the oxygen level to 15 L. They administered two doses of [MEDICATION(S)]. The resident did not respond to the first dose administered. They waited three minutes and administered a second dose, to which the resident responded by squeezing RN, Staff C's hand, but was incoherent (speaking in an incomprehensible or confusing way; unclear). During an interview with CNA, Staff D on 7/8/2021 at approximately 12:25 PM, she indicated that her shift started at 6:00 AM on the morning on 7/6/2021. She stated that at approximately 6:45 AM she overheard RN, Staff A on the phone with the doctor reporting something about [MEDICATION(S)] to him. Additionally, she revealed that RN, Staff A never informed her to monitor Resident ID #1. However, RN, Staff B informed her at the start of Staff B's shift (7:15 AM) of the medication error and instructed her to check on the resident as often as possible. She then revealed that at approximately 8:20 AM, she went to the resident's room with his/her breakfast tray and found him/her to be unresponsive, at that time she alerted RN, Staff B of the resident's condition. Review of a handwritten statement dated 7/6/2021 and timed 8:50 AM, authored by RN, Staff A, reads as follows, I was passing meds, and went into [Resident ID #1's room] and asked the resident if [s/he] was [Resident ID #2]. The resident was sleeping. I woke [him/her] up. [S/he] sat up and I said [Resident ID #2's name] and [s/he] said yes. I gave [him/her] the bottle of [MEDICATION(S)]. The resident drank it and then said. What is this. I looked at [him/her] and said [Resident ID #2's name]? [S/he] said no. I said you said you were [Resident ID #2]. I got up and walked out of the room. I didn't say anything to the patient. I went right to the phone and called [his/her] Dr .[the doctor] asked what the dosage of the [MEDICATION(S)] was. I told him it was a large dose, 90 mg. He said, yes that's a large dose. He then said [MEDICATION(S)] wouldn't do anything and looked on his computer for the reaction to look for. I then passed it along to the oncoming nurse and went down stairs to wait for [the DNS]. During an interview with the resident's primary care physician on 7/8/2021 at approximately 2:30 PM, he indicated that he did not feel the resident required transfer to a hospital when the incident was first reported to him, as the resident was not in any distress at that time. He also revealed that he was aware that [MEDICATION(S)] peaks (reaches its highest level in the blood stream) 2-3 hours after it is taken. Additionally, he revealed that he was aware this resident had issues with his/her respiratory status. During an interview with RN, Staff A on 7/9/2021 at 9:38 AM, she revealed that at approximately 6:00 AM on the morning of 7/6/2021 she went into Resident ID #1's room and found him/her to be sleeping, she called him/her by Resident ID#2's name, and s/he did not wake up so she shook him/her and again called him/her by Resident ID #2's name, s/he opened their eyes and responded yes and sat up in bed. She then handed Resident ID #1 the 90 mg bottle of [MEDICATION(S)] and s/he drank it and then said, What is this? S/he then called Resident ID #1 by Resident ID #2's name to which Resident ID #1 responded no. RN, Staff A then indicated she turned around and left Resident ID #1's room without informing them of the medication error and called the resident's primary care physician and informed him of the medication error. The physician told her that 90 mg was a large dose of [MEDICATION(S)] in which she responded, I know. The physician instructed her not to give [MEDICATION(S)] to the resident as he didn't think it would do any good. He further indicated that he was looking up adverse reactions to [MEDICATION(S)] in his computer. She stated he told her to monitor the resident for constipation, drowsiness and [CONDITION(S)]. She stated she acknowledged what the physician told her and then proceeded to finish her morning medication pass and reported the medication error to RN, Staff B at the end of her shift. Additionally, she revealed she had no idea how she ended in the wrong resident's room with the medication and that although the physician instructed her to monitor the resident, she never went back to Resident ID #1's room. She indicated that she felt because it had just happened and she gave report to the oncoming nurse, she didn't need to. She also indicated that she did not inform the resident or the resident's responsible party of the medication error. Additional review of Resident ID #1's hospital record on 7/12/2021 revealed s/he was still hospitalized on that date, and according to a physician's note dated 7/11/2021, timestamped at 12:39 PM, .LS [lung sounds] dim[inished] throughout (poor air move[m]ent) very DOE [dyspneic; short of breath with exertion] with desats [desaturation; oxygen level dropping] to 85-88% on 4 L .cont[inue] to monitor resp[iratory] status .Remains HLOC [higher level of care] at present . 2) .Review of the article Arrhythmia & Electrophysiology Review dated September 2012, located in the online library of the US National Library of Medicine National Institutes of Health, states in part Patients with [CONDITION(S)] (AF) are at increased thromboembolic risk [stroke], and they suffer more severe strokes with worse outcomes .Most thromboembolic complications of AF are eminently preventable with oral anticoagulation .AF increases the risk of stroke fivefold .the benefit of [MEDICATION(S)] [[MEDICATION(S)]] is dependent on the amount of time that patients spend with their INRs in therapeutic range .The optimal INR .for protection against [CONDITION(S)] [stroke] has been established as 2.0-3.0, with increased risk of thromboembolic and bleeding complications outside of this range. Record review revealed Resident ID #9 was admitted to the facility in June of 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes revealed the following: -6/29/2021 22:43 Nursing Progress Note, Note Text: INR 1.9 reported to .NP [Nurse Practitioner] new order for [MEDICATION(S)] increase to 7.5mg daily recheck [INR] 7/7 Review of the resident's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet ([MEDICATION(S)] Sodium) Give 7.5 mg by mouth in the evening related to UNSPECIFIED [CONDITION(S)] (I48.91) until 07/06/2021 00:00 [12:00 AM] Draw next PT / INR on 07/7/21 Additional review of the resident's EMAR failed to reveal evidence that s/he received his/her dose of [MEDICATION(S)] as ordered on 7/6/2021. During an interview with Licensed Practical Nurse, Staff E, on 7/9/2021 at approximately 1:30 PM, she indicated that she was unaware that she had scheduled the time of Resident ID #9's [MEDICATION(S)] order to expire at 12:00 AM on 7/6/2021. Additionally, she acknowledged, this error caused the resident's [MEDICATION(S)] order to expire at midnight on 7/6/2021 and would not appear on his/her EMAR to be administered that evening as ordered. During an interview with the DNS on 7/9/2021 at approximately 1:25 PM she was unable to provide evidence that the resident received their ordered dose of [MEDICATION(S)] on 7/6/2021.