Every finding on record at Bayview Rehabilitation and Healthcare Center

Based on clinical record review and staff interviews, the facility failed to ensure that 1 of 1 residents reviewed was free from significant medication errors. Specifically, on 3/12/2026 at approximately 8:45 PM, a Certified Medication Technician administered clozapine 150 mg and melatonin 3 mg prescribed for another resident to Resident #1 without verifying identity, in violation of facility policy. As a direct result, the resident required emergency transfer and hospitalization due to altered responsiveness, hypothermia, aspiration pneumonia, and tachycardia, subsequently transitioned to comfort care, and expired on 3/18/2026. This system failure created immediate jeopardy, resulting in actual harm, including death.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 3/16/2026, revealed that at approximately 8:45 PM on 3/12/2026, Certified Medication Technician (CMT), Staff A, administered another resident's medications to Resident ID #1. Resident ID #1 was transferred to the hospital on 3/13/2026 and admitted with pneumonia after s/he was noted with decreased responsiveness and abnormal lung sounds. Record review of the facility's investigation report revealed a written statement dated 3/13/2026, authored by Licensed Practical Nurse (LPN), Staff B, which revealed that on 3/12/2026 the CMT administered medications intended for Resident ID #2, clozapine (an antipsychotic medication prescribed to treat, schizophrenia, a severe mental illness, after other treatments have failed. Clozapine works by altering the chemicals in the brain) 150 milligrams (mg) and melatonin 3 mg (a medication prescribed for sleep) to Resident ID #1. Review of an undated facility policy titled, Administering Medications states in part, .Medications are administered in a safe and timely manner, and as prescribed.The individual administering medications verifies the resident's identity before giving the resident his/her medication. Methods of identifying the resident include:a. checking identification band;b. checking photograph attached to medical record; andc. if necessary, verify resident identification with other facility personnel.Record review of the Food and Drug Administration's prescribing information for clozapine states in part, .WARNING.Clozapine tablets can cause severe neutropenia [low neutrophils, a type of white blood cell that helps the body fight infections] which can lead to serious and fatal infections.Orthostatic Hypotension [a sudden drop in blood pressure when a person stands or changes position].Syncope [fainting]: Risk is dose - related. Starting dose is 12.5 mg.Increased Mortality in Elderly Patients with Dementia-Related Psychosis.The most commonly reported signs and symptoms associated with clozapine overdose are: sedation.coma, tachycardia [fast heartrate], hypotension [low blood pressure], respiratory depression or failure; and hypersalivation [excessive saliva]. There are reports of aspiration pneumonia, cardiac arrhythmias [irregular heartbeat], and seizure.Record review revealed Resident ID #1 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, congestive heart failure (a condition when the heart is weakened or stiff and can't pump enough blood to meet the body's needs for oxygen and nutrients) and atrial fibrillation (afib, is a common heart condition causing an irregular, often fast, heart rate. It occurs when the heart's upper chambers receive chaotic electrical signals, causing them to quiver instead of beating effectively). Additionally, the record revealed the resident was greater than [AGE] years of age. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 10 out of 15, indicating moderately impaired cognition. Record review revealed the following progress note entries:-3/12/2026 at 11:58 PM, authored by LPN, Staff B- that during the evening medication administration pass, the resident was administered medications intended for another resident. Additionally, the note indicates that Resident ID #1 did not receive his/her regularly scheduled medications which included, warfarin (an important medication prescribed to treat afib. Warfarin helps with blood flow to treat and prevent blood clots) 0.5 mg and metoprolol (a medication prescribed to treat high blood pressure and afib) 12.5 mg.-3/13/2026 at 12:11 AM, authored by a provider which states in part, .A nurse called to report that a medication technician administered the wrong medications to patient. The medication technician entered the wrong room and administered medications intended for the next-door neighbor, without verifying the resident's identity. All patient identifiers were missed. The medications administered in error included clozapine 150 mg, melatonin 3mg.[S/he] weighs 79.2 pounds, and the dose of clozapine administered is a significant concern given [his/her] small body habitus.-3/13/2026 at 9:00 AM, authored by an LPN, revealed that at 8:10 AM, staff found the resident to be unresponsive with abnormal breathing, pale skin color, and a heart rate of 136 beats per minute (a normal heart rate is 60 - 00 beats per minute) and blood oxygen level of 90% (normal range is greater than 92%). The note further revealed that the resident was transferred to the hospital via rescue.Additional record review for Resident ID #1 failed to reveal evidence of a physician's order for clozapine 150 mg or melatonin 3 mg. Record review of the Emergency Medical Services (EMS) Patient Care Report document dated 3/13/2026 at 9:34 AM, revealed that upon EMS arrival to the nursing home, staff were attempting to obtain the resident's vital signs but were unsuccessful. The resident was found lying in bed unresponsive .after receiving improper medication from nursing staff last night. with audible gurgling and excessive secretions in his/her mouth which required suctioning (a medical procedure that requires the use of a machine to create a vacuum that pulls out secretions or saliva. This is done by inserting a tube with a suction device into the patient's mouth or nose and then applying suction) to clear his/her airway. The note further indicated that the resident presented with a fast and irregular heart rate (HR) between 150 -190 beats per minute (bpm). S/he required high flow oxygen delivery through a bagged valve system (use of a handheld medical device to assist a patient who is not breathing or has inadequate spontaneous breathing) for a respiratory rate (RR) of 4 breaths per minute (normal range is 12 -20 breaths per minute) and administered intravenous emergency heart medication. Lastly, the document revealed the following vital signs in part, were obtained during his/her transport to the hospital:3/13/2026 8:45 AM, blood pressure (BP) 141/104 (normal is 120/80)3/13/2026 8:46 AM, HR 172 bpm3/13/2026 8:50 AM, BP 154/112, HR 150 bpm, RR 4 breaths per minute 3/13/2026 8:55 AM, BP 177/108, HR 156 bpm, RR 8 breaths per minuteRecord review of the hospital document dated 3/13/2026 at 6:01 PM, titled MEDICAL admission H&P [history and physical] revealed the resident presented to the hospital with an elevated heart rate, shortness of breath, and altered mental status after s/he was administered medications intended for another resident at his/her nursing home on the night of 3/12/2026. Additionally, the hospital document revealed that while in the Emergency Department s/he .was found to be with profound hypothermia [low body temperature] to the low 90s [normal range is 97 - 99 degrees Fahrenheit]. Further, the document indicated that a chest x-ray revealed a small left pleural effusion (a condition where an accumulation of fluid builds around the lungs) and aspiration pneumonia (a type of lung infection which is caused from material from the mouth or stomach entering the lungs). S/he was admitted to the hospital, transitioned to end-of-life care at the decision of his/her family member as they did not want him her/her to be subjected to invasive testing and treatments. The resident subsequently expired on 3/18/2026 at 5:09 AM at the hospital. During a surveyor interview with the Director of Nursing Services on 3/18/2026 at 11:08 AM, she was unable to provide evidence that Resident ID #1 was kept free from significant medication errors when Staff A administered medications to Resident ID #1, that included an antipsychotic, that were intended for Resident ID #2. During a surveyor interview on 3/19/2026 at 10:48 AM, with the Medical Director, she stated that she would have expected the correct medications to be administered to the right resident. As a result of this survey, it was determined that the facility's failure to adhere to fundamental medication administration practices specifically, the failure to verify resident identity and ensure medications were administered as prescribed constituted a systemic breakdown in care. This deficient practice directly resulted in Resident ID #1 being administered a high-risk antipsychotic medication intended for another resident, leading to significant adverse effects, rapid clinical decline, emergency medical intervention, and ultimately death. The facility's actions placed Resident ID #1 in immediate jeopardy, resulting in actual harm at the highest level, including a fatal outcome. An immediate plan of correction was initiated upon the identification of the failure on 3/12/2026, to ensure the safety of all residents in the facility. The plan included, medication administration education, observation of medication passes and a competency exam was completed with all licensed nurses and medication technicians. The exam included, but was not limited to, following acceptable standards of practice for medication administration, the five rights of medication administration, acceptable measures to verify a resident's identity, and careful review of the label on the medication to confirm the resident name. Additionally, the plan included auditing of three medication pass observations weekly for four weeks. Therefore, this citation will be cited as F 760 as a singular event IJ past non-compliance.Cross reference F-726

Based on clinical record review and staff interview, the facility failed to have sufficient nursing staff with the necessary competencies and skills to provide the required nursing and related services. Specifically, the facility failed to assure that all persons administering medications conducted and documented 4 out of 4 quarterly evaluations per state requirements for 1 of 1 Certified Medication Technician (CMT) reviewed, Staff A, who administered medications erroneously to Resident ID #1. The resident was transferred to the hospital due to the medication errors and later expired. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE], revealed that at approximately 8:45 PM on [DATE], Certified Medication Technician (CMT), Staff A, administered another resident's medication to Resident ID #1. Resident ID #1 was transferred to the hospital on [DATE] and was admitted with pneumonia after s/he was noted with decreased responsiveness and abnormal lung sounds. According to Rhode Island regulations section 1.16.10 Administration of Drugs by Medication Technicians, .Medication aides or technicians who have satisfactorily completed a State-approved course in drug administration and have demonstrated competency in accordance with State-approved protocol in drug administration may administer oral or topical drugs .The director of nursing or his or her registered nurse designee shall conduct and document quarterly evaluations of the medication technicians who are administering drugs. Copies of said evaluations shall be placed in the medication technicians' personnel records.Record review of the Facility assessment dated [DATE], states in part, .Education is a key component to ensuring our residents receive quality care.Department specific training and competencies are completed with staff throughout employment to ensure that they can safely and competently provide the levels and types of care required by our resident population.Record review of Staff A's personnel record revealed she was hired as a CMT/Nursing Assistant on [DATE]. Additionally, the record revealed a document titled Medication Administration Competency dated [DATE]. Review of the document section titled Medication Administration failed to reveal evidence that competency was demonstrated by Staff A relative to identifying a patient [resident] prior to the administration of medications.Further record review failed to reveal evidence that quarterly medication aide evaluations were completed for Staff A as required in accordance with state regulations for four of four quarters reviewed. Record review revealed Resident ID #1 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, congestive heart failure (a condition when the heart is weakened or stiff and can't pump enough blood to meet the body's needs for oxygen and nutrients) and atrial fibrillation (afib, is a common heart condition causing an irregular, often fast, heart rate. It occurs when the heart's upper chambers receive chaotic electrical signals, causing them to quiver instead of beating effectively). Additionally, the record revealed this resident was greater than [AGE] years of age.Record review of the facility's investigation report revealed a written statement dated [DATE], authored by Licensed Practical Nurse, Staff B, which revealed that during the evening on [DATE], Resident ID #1 was administered medications intended for Resident ID #2. The medications included, but are not limited to, clozapine (Clozaril, is an antipsychotic medication prescribed to treat a severe mental illness that is resistive to other treatment. It works by altering the chemicals in the brain) 150 milligrams (mg) and 3 mg melatonin (a medication prescribed for sleep).Record review of a progress note dated [DATE] at 12:11 AM, authored by a provider states in part, .A nurse called to report that a medication technician administered the wrong medications to patient. The medication technician entered the wrong room and administered medications intended for the next-door neighbor, without verifying the resident's identity. All patient identifiers were missed. The medications administered in error included clozapine 150 mg, melatonin 3mg.[S/he] weighs 79.2 pounds, and the dose of clozapine administered is a significant concern given [his/her] small body habitus. Record review of a hospital document dated [DATE] at 6:01 PM, titled MEDICAL admission H&P [history and physical] revealed the resident presented to the hospital on [DATE] with an elevated heart rate, shortness of breath, and altered mental status after s/he was administered medications intended for another resident at his/her nursing facility on the night of [DATE]. Additionally, the hospital document revealed that while in the Emergency Department s/he .was found to be with profound hypothermia [low body temperature] to the low 90s ranging from 93 to 95 [degrees Fahrenheit]. Further, the document indicated that a chest x-ray revealed a small left pleural effusion (a collection of an accumulation of fluid around the lungs) and aspiration pneumonia (a type of lung infection that is caused by material from the mouth or stomach entering the lungs). S/he was admitted to the hospital for inpatient comfort measures only at the decision of his/her family member and passed away on [DATE] at 5:09 AM.During a surveyor interview on [DATE] at 12:51 PM with CMT, Staff A, she revealed that she had been employed at the facility since February 2025 and indicated that she was scheduled to administer medications periodically. She further indicated that during the evening of [DATE] she administered medication erroneously to Resident ID #1. Additionally, she revealed that she failed to properly identify Resident ID #1 prior to administering him/her the medications that were intended for Resident ID #2. Lastly, Staff A stated that she has had only one administration evaluation since being hired. During a surveyor interview on [DATE] at 11:08 AM with the Director of Nursing Services, she acknowledged that medication aide evaluations are to be completed no less than quarterly. Additionally, she was unable to provide evidence that Staff A demonstrated competency in administering medications in accordance with state requirements.The facility's failure to ensure its nursing staff are competent in medication administration resulted in Resident ID #1 receiving medications intended for Resident ID #2. This resulted in Resident ID #1 being transported to the hospital emergently via rescue where s/he was treated for the adverse effects of the medications and diagnosed with pneumonia. S/he was admitted and transitioned to end-of-life care and expired on [DATE]. Cross reference F-760

Based on record review and staff interview, the facility failed to ensure that services provided meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed with an order for Midodrine (a medication prescribed to increase a person's blood pressure) and an order for a wound treatment, Resident ID #1.Findings are as follows:Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients.Record review revealed the resident was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, hypotension (low blood pressure). 1. Record review of the provider's progress note dated 11/18/2025 at 11:53 PM, states in part, .Orders: midodrine 5mg [milligrams] PO [by mouth] TID [three times daily] prn [as needed] for systolic [the top number of a blood pressure reading] < 100 or diastolic [the bottom number of a blood pressure reading] < 60 x [times] 7 days.Record review revealed a physician's order dated 11/19/2025 for Midodrine 5 mg three times daily as needed for a systolic blood pressure less than 100, a diastolic blood pressure less than 60 (the normal blood pressure reading is 120/80). Record review revealed an additional physician's order dated 11/18/2025 for vital signs every shift for 7 days. Record review of the documented blood pressures revealed the following:-11/19/2025 at 2:08 AM, 84/60 -11/19/2025 at 6:19 AM, 76/59-11/19/2025 at 10:12 AM, 82/58-11/19/2025 at 10:34 PM, 99/62-11/20/2025 at 8:30 AM, 80/54-11/20/2025 at 10:30 AM, 79/51-11/20/2025 at 8:12 PM, 80/49-11/21/2025 at 5:40 AM, 96/68Record review of the November 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received the Midodrine as ordered, for the above-mentioned blood pressure readings.During a surveyor interview on 12/1/2025 at 3:04 PM with Registered Nurse, Staff A, she acknowledged that she did not administer the Midodrine when indicated, on 11/19/2025 for a blood pressure reading of 82/58 and on 11/20/2025 for a blood pressure reading of 79/51. During a surveyor interview on 12/1/2025 at 3:45 PM with the Director of Nursing Services (DNS), she acknowledged the Midodrine was not administered as ordered, for the above-mentioned blood pressure readings.2. Record review revealed a physician's order dated 11/19/2025 to cleanse the left posterior (back) calf with normal saline, pat dry, apply calcium alginate (a type of wound treatment), and cover with a bordered gauze, every evening shift.Record review of the November 2025 Treatment Administration Record revealed on the evening shift of 11/20/205, the wound treatment was not completed, and the nurse had documented that the resident was sleeping. During a surveyor interview on 12/1/2025 at 3:45 PM with the DNS, she could not provide evidence that the resident's left posterior calf wound treatment was completed on 11/20/2025, as ordered.

Based on record review and staff interview, the facility failed to ensure the resident's drug regimen was free from unnecessary medications for 1 of 1 resident reviewed receiving Metoprolol Tartrate (a medication prescribed to treat cardiac conditions and assists in lowering the blood pressure and heart rate), Resident ID #1.Findings are as follows:Record review revealed the resident was admitted to the facility in November of 2025 with diagnoses including, but not limited to, atrial fibrillation (an irregular and often rapid heart rhythm) and hypotension (low blood pressure).Record review of a nursing admission progress note dated 11/18/2025 revealed the resident's vital signs were obtained upon admission, and the highest blood pressure (BP) reading was 78/48 (normal blood pressure 120/80). The on-call provider was notified of his/her low blood pressure and parameters were ordered for the medication Metoprolol.Record review revealed a physician's order dated 11/18/2025 for Metoprolol Tartrate, give 12.5 milligrams (mg) by mouth twice daily, with parameters to hold the medication for a systolic blood pressure (the top number of a blood pressure reading) of less than 100. Additional review of the medication orders indicated that on 11/19/2025 the Metoprolol administration times were revised within the order by Registered Nurse, Staff C, and the ordered parameters to hold the medication for the systolic blood pressure readings that were initially entered, were no longer visible within the order.Record review revealed an additional physician's order dated 11/18/2025 for vital signs every shift for 7 days.Record review of the November 2025 Medication Administration Record (MAR) revealed the following BP readings:-11/18/2025, evening shift BP 84/60 -11/19/2025, day shift BP 82/58-11/19/2025, evening shift BP 82/58-11/20/2025, day shift BP 79/51-11/20/2025, evening shift BP 80/49 Record review of the November 2025 MAR revealed the Metoprolol was signed off as administered, on the following dates and shifts:-11/19/2025, evening shift-11/20/2025, day shift-11/20/2025, evening shiftDuring a surveyor interview on 12/1/2025 at 3:28 PM with the Certified Medication Technician, Staff B, she acknowledged that the MAR indicated she signed off that she had administered the Metoprolol on the evening of 11/19/2025 with a blood pressure of 82/58.During a surveyor interview on 12/1/2025 at 3:37 PM with the Director of Nursing, she acknowledged that the resident received the Metoprolol on 11/19/2025 and 11/20/2025 with the above-mentioned blood pressure readings. During a surveyor interview on 12/1/2025 at approximately 3:50 PM with the Registered Nurse, Staff C, she acknowledged that she revised the order on 11/19/2025 to reflect the appropriate medication administration times, but she was unaware that the medication parameters were subsequently removed from the order.

Based on record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed receiving Warfarin/Coumadin (an anticoagulant medication prescribed to treat and prevent harmful blood clots from forming or growing larger), Resident ID #3. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, deep vein thrombosis (a blood clot that forms in the deep veins of the leg).Record review revealed a physician's order dated 11/7/2025 for Warfarin 3 milligrams (mg) by mouth, every evening, for treating/preventing blood clots until 11/13/2025.Record review revealed a physician's order dated 11/14/2025 for a PT/INR (a blood test that determines the continued dosing for Warfarin), one time on 11/14/2025.Record review revealed the PT/INR was obtained, as ordered, and resulted on 11/14/2025. Record review for 11/14/2025 failed to reveal evidence that the PT/INR results were reviewed or that the provider was notified of the results. Additional record review failed to reveal evidence that a new order for Warfarin was obtained for the resident's continued dosing for Warfarin therapy. Record review of the November 2025 Medication Administration Record (MAR) revealed, the resident received Warfarin daily for the month of November, since his/her admission, except on 11/14/2025 and 11/15/2025. Further review of the MAR revealed a physician's order was subsequently transcribed on 11/17/2025 for a Coumadin Alert, indicating that the resident receives Coumadin therapy and to ensure that there is a current Coumadin order in place every evening shift. Additionally, the Coumadin Alert order was signed off each shift by staff, with the resident's INR results documented and the current Coumadin dose. During a surveyor interview on 12/1/2025 at 3:13 PM with Registered Nurse, Staff A, she revealed that she was the resident's nurse during the day shift on 11/14/2025 and the PT/INR may not have resulted before the end of her shift. Additionally, she was unable to provide evidence of a progress note addressing the resident's PT/INR results on 11/14/2025 or that a Warfarin order was obtained on 11/14/2025 or 11/15/2025. During a surveyor interview on 12/1/2025 at 3:36 PM with the Director of Nursing, she revealed that the Coumadin Alert order is usually transcribed to ensure staff administering medications are aware when a resident is on Coumadin therapy and she acknowledged that the order was not transcribed until 11/17/2025. Additionally, the DNS acknowledged that the resident did not receive his/her Coumadin doses on 11/14/2025 or 11/15/2025.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 2 of 2 residents with medications and treatments that were not signed off as administered, Resident ID #s 1 and 6, for 1 of 3 residents observed with a non-pressure related wound, Resident ID #6, and for 1 of 3 residents reviewed with an order for a nutritional supplement, Resident ID #90.Findings are as follows:According to Mosby's 3rd Edition, Basic Nursing, states in part, .after administering a drug, the nurse records it immediately on the appropriate record form .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 #1 was readmitted to the facility in October of 2024 with diagnoses including, but not limited to, diabetes with foot ulcers, and obstructive and reflux uropathy (a condition in which the kidneys are damaged by the backward flow of urine into the kidneys). Record review revealed the following physician's orders dated 4/30/2025: - diabetic foot care: wash and dry feet, inspect for any changes, and rub lotion to feet at bedtime- measure urinary output every shift- urinary catheter care and maintain catheter for urinary retention and change as needed for obstruction every shift- urinary catheter careFurther record review revealed the following physician's orders:- 5/1/2025, apply skin prep (a skin protectant) to the left heel every day and evening- 5/15/2025, skin check after removing the left Ankle-Foot Orthosis (AFO, a brace designed to support the ankle and foot) every day and evening- 7/26/2025, enhanced barrier precautions (EBP, an infection control intervention used to prevent the spread of infection) three times a day- 8/19/2025, offload left lower extremity three times a day- 8/21/2025, monitor dressing to the left foot three times a dayRecord review of the September 2025 Treatment Administration Record (TAR) failed to reveal evidence that the resident received the following treatments and care on the evening shift of 9/6/2025 as ordered:- diabetic foot care: wash and dry feet, inspect for any changes, and rub lotion to feet at bedtime- urinary catheter care- apply skin prep to the left heel- maintained EBP- skin check after removing left AFO- offload left lower extremity- monitor dressing to the left footRecord review of the September 2025 TAR failed to reveal evidence that the resident's urinary output was documented on the evening shifts of 9/2/2025 and 9/6/2025, and on the day shift of 9/5/2025, as ordered.Additional review of the September 2025 TAR failed to reveal evidence that the resident's dressing to the resident's left foot was monitored during the day shift on 9/5/2025, as ordered.2. Record review revealed Resident ID #6 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, diabetes, back and lower extremity pain, and anxiety disorder.a. Record review revealed the following physician's orders dated 5/8/2025: - behaviors/interventions: monitor for anxiousness every shift- monitor for side effects of anti-anxiety medications every shift- monitor for signs and symptoms of bleeding and bruising every shift- non weight bearing to the right lower extremity every shift- frequent skin checks to the left wrist splint site every shiftRecord review of the September 2025 TAR failed to reveal evidence that the resident received the above-mentioned treatments and care on the evening shift of 9/6/2025, as ordered.Record review revealed a physician's order dated 5/12/2025 for Diclofenac Sodium External Gel 1% (a topical medication prescribed to treat pain) apply to the left shoulder four times a day.Record review of the September 2025 TAR failed to reveal evidence that the resident received the above-mentioned medication on the day shift of 9/5/2025 and the evening shift of 9/6/2025, as ordered.Record review revealed a physician's order dated 8/26/2025 for Triamcinolone Acetonide Cream 0.1% (a topical steroid medication prescribed to treat inflammation) to apply to a rash below the knee amputation site twice a day.Record review of the September 2025 TAR failed to reveal evidence that the resident received the above-mentioned medication on the day shift of 9/5/2025 and the evening shift of 9/6/2025, as ordered.b. During a surveyor observations on 9/9/2025 at 9:20 AM and on 9/11/2025 at 9:10 AM, Resident ID #6 was observed with a white bandage to his/her right forearm dated 9/8/2025 with a moderate amount of old dried bloody drainage. Record review failed to reveal evidence of a physician's order for a treatment to the resident's right forearm. During a surveyor observation on 9/11/2025 at 9:57 AM in the presence of the Unit Manager, Staff A, she acknowledged the dressing to the resident's right forearm and that the dressing was dated 9/8. She indicated that she was unaware of any injury or dressing to the resident's right forearm. Furthermore, Staff A was unable to provide evidence of a treatment order for the dressing observed on the resident's right forearm. During a surveyor interview on 9/11/2025 at 1:38 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that Resident ID #s 1 and 6 received all medications and treatments as ordered on 9/2/2025, 9/5/2025, and 9/6/2025. Additionally, the DNS indicated that she would have expected the nurse to have notified the physician when Resident ID #6's wound was identified, and that the nurse should have obtained a treatment order for the right forearm wound.3. Record review revealed Resident ID #90 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, Parkinson's disease (a chronic progressive neurological disorder that affects movement) and gastroesophageal reflux disease (a chronic digestive condition where stomach acid flows back up into the esophagus causing irritation and inflammation). Record review of a care plan dated 8/23/2025 revealed the resident has a nutritional problem with interventions including, but not limited to, providing and serving a nutritional supplement, as ordered. Record review revealed a physician order dated 9/5/2025 for Ensure Plus (a nutritional supplement designed for individuals who need additional calories, protein, and nutrients) 120 milliliter (ml) three times a day. Record review of the September 2025 Medication Administration Record (MAR) failed to reveal evidence the resident is receiving the Ensure Plus 120 ml three times a day as ordered since 9/5/2025.During a surveyor interview on 9/10/2025 at 1:26 PM with Registered Nurse, Staff B, she acknowledged that the resident's order for Ensure Plus was changed on 9/5/2025 from twice a day to three times a day. Additionally, Staff B acknowledged that the resident was not receiving the Ensure Plus three times a day as ordered since 9/5/2025. During a surveyor interview on 9/11/2025 at 9:22 AM with the DNS, she was unable to provide evidence that Resident ID #90 was receiving the ensure plus, as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice relative to 2 of 4 residents reviewed for oxygen use, Resident ID #s 11 and 46.Findings are as follows: According to Lippincott Nursing Procedure Ninth Edition 2023, page 621, states in part, .Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed . 1. Record review revealed Resident ID #11 was admitted to the facility in November of 2024 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (a lung condition caused by damage to the airways that limits airflow). Record review revealed a physician's order dated 11/22/2024 for oxygen to be administered at 2 liters per minute (LPM), via nasal cannula (a flexible tubing used to deliver supplemental oxygen directly into the nostrils), every shift. Surveyor observations revealed the resident was receiving the incorrect LPM of oxygen on the following dates and times: - 9/8/2025 at 9:53 AM, the resident was receiving 2.5 LPM - 9/10/2025 at 11:34 AM and at 2:42 PM, the resident was receiving 3 LPM During a surveyor interview immediately following the above observation at 2:42 PM with Registered Nurse, Staff B, she acknowledged that the resident was not receiving the 2 liters of oxygen, as ordered. During a surveyor interview on 9/11/2025 at 10:11 AM with the Director of Nursing Services (DNS) in the presence of the Regional Director of Clinical Services (RDCS), she could not provide evidence that resident ID #11 was receiving oxygen at 2 liters, as ordered. 2. Review of a facility policy titled, Oxygen Administration, dated October 2010, states in part, .Documentation .the following should be recorded in the resident's medical record: .3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. [as needed] administration . Record review revealed Resident ID #46 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, pneumonia. Record review revealed the resident was diagnosed with pneumonia on 9/7/2025. Record review revealed a physician's order dated 9/7/2025 for supplemental oxygen at 1 to 2 liters (L) via nasal cannula to maintain oxygen above 90% as needed for wheezing, coughing and shortness of breath. Additional record review failed to reveal evidence that the resident's oxygen saturation level was obtained each shift as ordered. During surveyor observations on 9/8/2025 at 2:27 PM and on 9/9/2025 at 9:13 AM, the resident was observed to be receiving oxygen via nasal cannula at 2 L. Surveyor observations on 9/11/2025 at 9:32 AM, 9:41 AM, 9:48 AM and at 9:53 AM revealed the resident was receiving oxygen at 5 L. Record review of the September 2025 Treatment Administration Record failed to reveal documentation that the resident was receiving oxygen on the above-mentioned dates. During a surveyor interview immediately following the above observation at 9:53 PM with Registered Nurse, Staff B, she acknowledged that the resident was receiving 5 liters of oxygen and should have been receiving 1-2 liters. She also acknowledged that the order for oxygen was not signed off as given in the TAR for the above-mentioned dates and times. During a surveyor interview with the DNS and RDCS on 9/11/2025 at 10:13 AM, they indicated that staff should be documenting oxygen saturation each shift to ensure that the resident's saturation level is maintained per the order. Additionally, the DNS could not provide evidence that the resident was receiving oxygen at 1-2 liters, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 3 of 4 residents reviewed for insulin administration, Resident ID #s 1, 2, and 6. Findings are as follows:1a. Record review revealed Resident ID #1 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review revealed the following physician's orders: -8/7/2025, Insulin Glargine (a long-acting insulin) 100 units per milliliter (ml) pen injector, inject 18 units subcutaneously daily at bedtime (HS). -8/20/2025, Insulin Aspart (a rapid acting insulin) 100 units per ml, inject per the sliding scale (insulin that is administered according to parameters for a blood sugar reading) subcutaneously before meals and at HS.Record review of the September 2025 Medication Administration Record (MAR) revealed that the Insulin Glargine was not signed off as administered on 9/6/2025 at HS. Further review of the MAR failed to reveal evidence that the resident's blood sugars were obtained or that Insulin Aspart was signed off as administered on 9/5 at 11:00 AM, 9/6 at 4:00 PM and 9/6 at 9:00 PM.1b. Record review revealed a progress note dated 9/4/2025 indicating that the resident's blood sugar was 412 and the provider was notified. Further review revealed an order was given for Lispro insulin (a rapid acting insulin) 12 units to be administered once. Record review of the September 2025 MAR failed to reveal evidence that the order was transcribed or that the Lispro 12 units was administered as ordered. During a surveyor interview on 9/11/2025 at 2:27 PM with the Regional Director of Clinical Services, she acknowledged that the above order had not been transcribed to the MAR and had not been documented as administered. 2. Record review revealed Resident ID #2 was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus.Record review revealed a physician's order dated 9/1/2025 for Insulin Lispro 100 unit/ml inject per sliding scale if the blood sugar is;150-200, administer 2 units201-250, administer 4 units251- 300, administer 6 units301-350, administer 8 units351-400, administer 10 unitsIf blood sugar is less than 70 or greater than 400 notify the physicianRecord review of the September 2025 MAR revealed that on 9/9/2025 at 5:00 PM the resident's blood sugar was 431.Record review of a progress note dated 9/9/2025 at 5:53 PM states in part, .NP [Nurse Practitioner] notified of resident's elevated FBS [fasting blood sugar] new orders to administer 14 units of Lispro.Record review of the physician's orders failed to reveal evidence of a one-time order to administer the insulin Lispro 14 units on 9/9/2025.Record review of the MAR failed to reveal evidence that the resident received the one-time order for 14 units of the insulin Lispro on 9/9/2025.During a surveyor interview on 9/11/2025 at 11:37 AM with the Unit Manager, Registered Nurse, Staff A, she was unable to provide evidence that the resident was administered the 14 units of insulin Lispro on 9/9/2025.3. Record review revealed Resident ID #6 was readmitted to the facility in May of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus.Record review revealed the following physician's orders:-5/8/2025, Insulin Lispro 100 units/ml, inject insulin per the sliding scale, subcutaneously four times a day.-7/15/2025, Insulin Lispro 100 units/ml, inject 3 units subcutaneously with meals, hold for a blood sugar less than 100.-7/21/2025, Insulin Glargine 100 units/ml pen injector, inject 30 units subcutaneously daily at bedtime.a. Record review of the September 2025 MAR failed to reveal evidence that the resident's blood sugars were obtained on 9/6/2025 prior to his/her dinner meal and at HS for administration of his/her sliding scale insulin Lispro. Additionally, the insulin Lispro was not signed off as administered for those above-mentioned times.Additional review of the MAR revealed that the Insulin Glargine was not signed off as administered on 9/6/2025 at HS and the Insulin Lispro was not signed off as administered on 9/6/2025 at 5 PM.During a surveyor interview on 9/11/2025 at 11:53 with Unit Manager, Licensed Practical Nurse, Staff D, she revealed that if a medication is administered it should be signed off in the record as administered and if a medication is not signed off as administered, that indicates that the medication was not given. During a surveyor interview on 9/11/2025 at 12:42 AM with Licensed Practical Nurse, Staff E, she indicated that if the medications were not signed off as administered, then they were not completed by her on the above dates and times. b. Record review of the MAR revealed that on 9/8/2025 at 8:00 AM the resident's blood sugar was documented as 94 and the nurse documented on the MAR that she administered 3 units of the insulin Lispro to the resident's right upper arm.During a surveyor interview on 9/11/2025 at 11:26 AM with Registered Nurse, Staff C, she acknowledged that she signed off administration of the Lispro on 9/8/2025 for the 8:00 AM shift. Furthermore, she could not provide evidence that the Lispro was held for a blood sugar less than 100 on 9/8/2025, as ordered.During a surveyor interview with the DNS on 9/11/2025 at 1:38, she was unable to provide evidence that the above-mentioned residents received their insulin as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infection, relative to 1 of 2 residents observed during a wound dressing change, Resident ID #2.Findings are as follows:Review of a facility policy titled Wound Care states in part, .Steps in the procedure.pour liquid solutions directly on gauze sponges.Wash tissue around the wound that is usually covered by the dressing.remove dry gauze. Apply treatment as indicated .Record review revealed Resident ID #2 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, cellulitis (a bacterial infection involving the skin) of left lower limb, and infection and inflammation to internal left knee prosthesis (an artificial device that replaces a missing body part).Record review of the wound care progress note dated 9/10/2025 revealed the following:-Deep tissue injury (DTI- pressure-induced damage to the underlying tissues occurring beneath the skin's surface) to the 5th right toe with a scab -Right midfoot lateral (away from the middle of the body) pressure wound stage 4 (full-thickness tissue loss that extends through the skin and underlying soft tissue, exposing muscle, tendon, ligament, cartilage, or bone) containing 100% Eschar (dead tissue that can develop in wounds)-Right lateral ankle vascular wound (a type of wound that develops due to problems with blood circulation) containing 100% EscharRecord review revealed the following physician orders for the wounds on the resident' right foot:-9/11/2025, Right lateral 5th toe paint with betadine and cover with kerlix (a type of bandage) daily-9/11/2025, Right lateral ankle paint with betadine and wrap with kerlix daily-9/11/2025, Right lateral midfoot paint ulcer with betadine and wrap with kerlix dailyDuring a surveyor observation on 9/11/2025 at 9:39 AM of the wound dressing changes to the above-mentioned wounds, in the presence of the Assistant Director of Nursing Services (ADNS) and Licensed Practical Nurse, Staff G, Staff G removed the soiled dressings, sanitized her hands, and donned new gloves. She then sprayed wound cleanser onto a gauze and proceeded to wash the wound on the midfoot, the wound on the lateral ankle and then the wound on the lateral toe using the same gauze. Staff G then sanitized her hands, applied new gloves, and applied betadine to some gauze, and proceeded to paint the wound on the midfoot, the wound on the lateral ankle and then the wound on the lateral toe with the betadine using the same gauze for all three wounds.During a surveyor interview on 9/11/2025 at 10:23 AM with Staff G, she acknowledged that she had used the same gauze to wash all three of the above-mentioned wounds. She further acknowledged that she used the same gauze to apply betadine to all three of the wounds.During a surveyor interview on 9/11/2025 at 10:29 AM with the ADNS, she acknowledged the above observation. She further indicated her expectation would be for staff to clean each wound with a separate piece of gauze, and to apply the betadine to each wound with a separate piece of gauze to help prevent the transmission of infection.

Based on record review and staff interview, it has been determined the facility failed to maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices, for 2 of 6 residents reviewed for pressure injuries (a localized area of the skin and/or underlying soft tissue damage caused by prolonged pressure), Resident ID #s 53 and 114. Findings are as follows: 1. Record review revealed Resident ID #53 was admitted to the facility with diagnoses including, but not limited to, mild protein-calorie malnutrition and dementia. Record review revealed a physician's order dated 10/21/2024 for weekly skin checks every Friday. Record review revealed the resident had a pressure injury to his/her left ischium (the lower back part of the hip bone) that was documented as healed by the Wound Physician on 8/6/2025. Record review revealed the following skin assessments indicated the resident had a pressure ulcer, after the documentation indicated that the resident's pressure ulcer had healed: -8/15/2025 -8/29/2025 During a surveyor interview on 9/11/2025 at 1:33 PM with the Director of Nursing Services (DNS), she revealed that she would expect nurses to document accurately, and that if a resident's pressure ulcer had healed, the weekly skin assessments should indicate that there are no active skin impairments. 2. Record review revealed Resident ID #114 was admitted to the facility in June of 2025 with diagnoses including, but not limited to, cerebral infarction (stroke), dementia, and an intact blister to his/her right heel. Record review revealed a physician's order dated 6/24/2025 for weekly skin checks Additional record review revealed that the blister to his/her right heel had opened and was identified as a deep tissue injury (DTI, pressure-induced damage to the underlying tissues occurring beneath the skin's surface) on 7/22/2025. Record review revealed the following skin assessments indicated the resident had no skin impairments, although additional documentation in the resident's record indicated that the resident had a blister to the right heel which was later identified as a DTI on 7/22: -7/1/2025 -7/8/2025 -7/21/2025 -7/28/2025 Further record review failed to reveal evidence that a skin check was completed weekly on 7/14/2025, as ordered. During a surveyor interview with the Unit Manager and Wound Nurse, Staff D, on 9/11/2025 at 12:17 PM, she was unable to provide evidence that the resident's blister on his/her right heel was included in the above-mentioned weekly skin checks. Additionally, she was unable to provide evidence that a weekly skin check was completed the week of 7/14/2025. During a surveyor interview on 9/11/2025 at 1:07 PM with the DNS, she acknowledged that the documentation for Resident ID #114's weekly skin checks was inaccurate and incomplete.

Based on record review and staff interview it has been determined that the facility failed to provide a resident the right to participate in the development and implementation of his or her person-centered plan of care and facilitate the inclusion of the resident and/or resident representative for 1 of 3 residents reviewed for care planning meetings, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/17/2024 alleges in part, I have several concerns on the care [Resident ID #1] is receiving . During a surveyor interview on 10/22/2024 at 1:32 PM with the complainant, a family member of the resident, s/he revealed that s/he is very concerned that the facility has not had a care plan meeting for the resident since admission. Additionally, s/he indicated that the concerns in the complaint could have been discussed if the resident and family members were provided the opportunity to have a care plan meeting. Record review of the facility's policy titled, Care Planning-Interdisciplinary Team revised in March of 2022, states in part, Comprehensive, person- centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT) .The IDT includes but is not limited to . The resident's attending physician .a registered nurse .nursing assistant .a member of food and nutrition services .to the extent practicable, the resident and/or the resident's representative .other staff as appropriate or necessary to meet the needs of the resident .The resident, the resident's family and/or the resident's legal representative .are encouraged to participate in the development of and revisions to the resident's care plan .Care plan meetings are scheduled at the best time of the day for the resident and family when possible . Record review revealed the resident was admitted to the facility in May of 2024 with diagnoses including, but not limited to, Parkinson's Disease (a disorder that affects the nervous system), muscle wasting and atrophy (the loss of muscle mass). Record review of a facility document titled Care Plan Meeting Review revealed in part, .To be completed on Admission .Quarterly, Annually and with Significant change in Condition . It further revealed that one care planning meeting was completed on 5/31/2024. Further record review failed to reveal evidence that a quarterly care plan meeting took place. During a surveyor interview on 10/22/2024 at approximately 3:00 PM with Social Worker, Staff A, she acknowledged that a quarterly care planning meeting was not conducted for the resident. During a surveyor interview on 10/22/2024 at approximately 3:30 PM with the Director of Nursing Services, she revealed that she would expect care plan meetings to be conducted quarterly.

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 3 residents reviewed for constipation, Resident ID #2. Findings are as follows: Review of a community reported complaint received by the Rhode Island Department of Health on 8/30/2024 alleged that a resident had recently been admitted to the hospital from the facility with a diagnosis of, but not limited to, fecal impaction (a large, hard mass of stool that is stuck in the rectum that can cause serious illness or death). Record review revealed Resident ID #2 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, dehydration, urinary tract infection, and Parkinson's disease. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 out of 15, indicating severely impaired cognition. Further review revealed the resident was incontinent of bowel and was dependent on staff for toileting. Review of a care plan dated 7/29/2024 revealed the resident has constipation related to decreased mobility, diminished appetite, and medication side effects with a goal to have a normal bowel movement at least every 3 days. Further review revealed the resident has Parkinson's Disease with interventions to monitor for constipation, implement the bowel regimen, monitor, and document effectiveness and to report ineffectiveness to a physician or designee. Record review of the bowel movement (BM) report revealed documentation that the resident did not have a bowel movement from 8/15/2024 until 8/22/2024, indicating that the resident did not have a bowel movement for 7 days. Record review revealed the following physician's orders for constipation dated 7/26/2024: - Milk of Magnesia (MOM) Suspension 400 milligrams(mg)/5 milliliters- administer 30 ml by mouth as needed - Dulcolax Suppository 10 mg- administer 1 suppository rectally as needed - Fleet Enema 7-19 gm/118 ml- insert 1 application rectally as needed Record review of the August 2024 Medication Administration Record revealed MOM was administered on 8/19/2024, on the 5th day without a bowel movement, and on 8/20/2024, which were both documented as being ineffective. Further review revealed a Dulcolax Suppository was administered on 8/19/2024 and on 8/21/2024, which both were documented as being ineffective. Additional review revealed a Fleet Enema was administered on 8/22/2024, which was documented as ineffective. Record review of a progress note, dated 8/20/2024, authored by Advanced Practice Registered Nurse (APRN), Staff A, revealed .Nursing states patient having difficult BMs. [S/he] is on standing senna [a medication for occasional constipation], will add daily miralax . During a surveyor interview on 9/3/2024 at approximately 10:50 AM with Registered Nurse, Staff B, she indicated that the nurse on 2nd shift generates a BM report and creates a bowel list of residents who have not had a BM in 72 hours. She further indicated that the bowel protocol is to start with administering MOM, then a suppository if no BM and finally, an enema if still no BM. Additionally, she indicated that the physician should be notified if the resident has not had results from the bowel protocol and has not had a bowel movement for 3 days. Record review failed to reveal evidence that a provider was notified that the resident had not had a bowel movement for 7 days. During a surveyor interview on 9/3/2024 at 11:33 AM with Licensed Practical Nurse, Staff C, she indicated that a resident would be on a bowel list after 3 days without a bowel movement and the bowel protocol would be initiated. She further indicated that the physician should be notified if the resident has not had a bowel movement following the bowel protocol. Additionally, she acknowledged that the resident had not had a bowel movement for 7 days, from 8/15/2024 until 8/22/2024. The surveyor requested a copy of the facility's Bowel Protocol that Staff B and C were referring to during their interviews from the Director of Nursing Services (DNS) on 9/3/2024 at approximately 12:00 PM, and she indicated that the facility does not have a bowel protocol. During a surveyor interview on 9/3/2024 at 1:41 PM with Staff A, she indicated that she had assessed the resident on 8/20/2024 and was informed by the nursing staff that the resident was having difficulty with bowel movements, which she assumed meant that the resident was having small or hard BMs. She further indicated that she had not been made aware that the resident had not had any bowel movements for 6 days. She further stated that if she had been made aware that the resident had not had a bowel movement for 6 days, she would not have ordered Miralax daily but would have provided a different treatment or medication. During a surveyor interview on 9/3/2024 at 12:52 PM and again at 2:04 PM with the DNS, she indicated that she would expect as needed medications for constipation to be administered to the resident if they has not had a bowel movement in 3 days. She further indicated that she would expect the physician to be notified if the resident has not had a bowel movement in 4 to 5 days. Additionally, she could not provide evidence that a provider was notified that the resident did not have a bowel movement for 7 days.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to Covid-19, for 1 of 2 units observed, the Country Unit, affecting Resident ID #s 2, 6, 11, 14, 15, 19, 26, 28, 30, 38, 42, 44, 46, 47, 49, 54, 55, 58, 64, 65, 67, 80, 82, 84, 87, 88, 92, 97, 104, and 109, as the facility failed to have cleaning and disinfecting wipes effective at killing Covid-19 readily accessible to staff and was using Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol, which are ineffective at killing Covid-19, to clean and disinfect multi-use resident equipment. Further, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to Enhanced Barrier Precautions (EBP), for failing to place a resident on enhanced barrier precautions (EBP) and staff who failed to don the required Personal Protective Equipment (PPE) prior to entering resident rooms that required such, for 1 of 3 residents reviewed, Resident ID #102, and 1 of 1 resident on contact precautions observed during the medication administration task in which staff failed to don the required PPE prior to entering his/her room, Resident ID #22. Findings are as follows: 1. Record review of a facility policy titled, Isolation-Categories of Transmission-Based Precautions states in part, When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer [blood pressure cuff], or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible .If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with other residents . During a surveyor observation on 8/19/2024 at approximately at 8:00 AM, upon entering the building, signage was posted notifying staff and visitors of the required use of N95 masks due to a Covid-19 outbreak. Record review revealed that the facility's Covid-19 outbreak started on 7/30/2024 for staff and 8/2/2024 for residents. During surveyor observations on 8/19/2024 of the Country unit revealed that Resident ID #s 2, 11, 14, 15, 19, 26, 30, 38, 42, 44, 46, 47, 49, 54, 55, 58, 64, 65, 67, 80, 82, 84, 87, 88, 92, 97, 104, and 109 were on isolation precautions relative to Covid-19 with isolation bins and signage posted outside the rooms. Further observation of the Country Unit and the above resident's isolation bins failed to reveal evidence of dedicated care equipment or disinfecting wipes available for use. During a surveyor observation on 8/20/2024 at 9:09 AM revealed one container of Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol, located on one isolation cart on the Country Unit. Further observation of the Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol revealed the wipes kill 13 different infectious micro-organisms, but it failed to list Covid-19 as an infectious micro-organism that it kills. During a surveyor observation on 8/20/2024 at 9:15 AM, revealed Nursing Assistant, Staff M, entering a Covid-19 positive room, Resident IDs #46 and 64, to obtain the resident's blood pressure. Medication Technician, Staff N, entered the room and exited the room at 9:25 AM with a blood pressure cuff and stethoscope. Staff N then placed the blood pressure cuff and stethoscope on top of two open glove containers. Staff N then proceeded to pick up the equipment and clean the blood pressure cuff and the stethoscope with the Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol, and placed them back on the medication cart for reuse. Review of the List N tool: Covid -19 Disinfectants List, last updated on July 1, 2024, failed to identify Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol as a product that meets EPA's [Environmental Protection Agency] criteria for use against Covid-19. During a surveyor interview on 8/20/2024 at 9:27 AM with Medication Technician, Staff N, she acknowledged that the facility uses multiuse equipment and that Resident ID #s 46 and 64 were on precautions for Covid-19. Additionally, she acknowledged the multiuse equipment was cleaned with the Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol. During a surveyor interview on 8/20/2024 at 10:31 AM with the Infection Preventionist, she revealed that staff should use the bleach wipes for Covid-19 and not the Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol. Further record review revealed an additional 2 residents had tested positive for Covid-19 on 8/20/2024, Resident ID #s 6 and 28. 2. Review of signage posted for Resident ID #s 14, 19, 26, 38, 46, 65, and 97 revealed Isolation Droplet/Contact .clean hands .gowns .N95 Respirator .Eye protection (goggles or face shield) .Gloves . According to the Center for Disease Control and Prevention (CDC) titled, Infection Control Guidance: SARS-CoV-2 last revised on 6/24/2024, states in part, .use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Record review revealed a facility provided document titled, Summer '24 COVID Outbreak a line list for residents with a start date of the initial outbreak for residents of 8/2/2024. During surveyor observations on 8/19/2024 revealed Nursing Assistant, Staff O, entering the following Covid-19 positive rooms without donning eye protection and wearing a KN95 mask (not an N95): - 11:00 AM Resident ID #38's room - 12:07 PM Resident ID #s 19 and 97 room - 12:09 PM Resident ID #s 19 and 97 room Further observation revealed the room had an isolation cart outside of the room and droplet/contact precaution signage posted. During a surveyor observation on 8/19/2024 at 12:24 PM revealed the Social Worker entered Resident ID #65's room, a Covid-19 positive room, wearing a KN95 mask, gown, gloves, and eye protection. She failed to don an N95 mask. Further observation revealed the room had an isolation cart outside of the room and droplet/contact precaution signage posted. During a surveyor observation on 8/20/2024 at 8:44 AM, Medication Technician, Staff N, entered Resident ID#s 14 and 26's room, a Covid-19 positive room, wearing a KN95 mask, gown, and gloves. She failed to don an N95 mask or eye protection. Further observation revealed the room had an isolation cart outside of the room and a droplet/contact precaution signage posted. During a surveyor interview on 8/20/2024 at 8:47 AM with Staff N, she acknowledged that the resident was positive for Covid-19 and acknowledged the signage indicating the use of an N95 mask and eye protection and that she failed to don both an N95 mask and eye protection. During a surveyor observation on 8/20/2024 at 9:15 AM, Nursing Assistant, Staff M, entered a Covid-19 positive room, Resident ID #s 46 and 64, wearing a KN95 mask, gown, gloves, and eye protection. She failed to don an N95 mask. Further observation revealed the room had an isolation cart outside of the room and droplet/contact precaution signage posted. During a surveyor interview on 8/20/2024 at 10:31 AM with the Infection Preventionist, she revealed that staff should be wearing an N95 mask, not a KN95 mask, and indicated that they should wear eye protection in Covid-19 positive rooms. 3. Review of a facility policy titled, Enhanced Barrier Precautions states in part, Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDRO) to residents .EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices [indwelling foley catheter, a flexible tube inserted into the bladder to drain urine] regardless of MDRO colonization .signs are posted indicating the type of precautions and PPE [personal protective equipment] required .PPE is readily available . Record review revealed that Resident ID #102 was admitted to the facility in July of 2024 with diagnoses including but not limited to, urinary tract infection and cerebral infarction (stroke). Record review revealed that the resident has an indwelling foley catheter. Record review revealed an order for EBP for an indwelling foley catheter dated 8/1/2024. During surveyor observations from 8/19/2024 through 8/22/2024 failed to reveal evidence of an isolation cart or signage posted indicating that the resident was on EBP indicating the type of PPE that is required for this resident. During a surveyor observation and subsequent interview on 8/22/2024 at 11:39 AM with the Unit Manager, Registered Nurse (RN), Staff P, she acknowledged that the resident was not on EBP and indicated that she should have been. Further, she acknowledged that the resident did not have signage posted indicating that s/he was on EBP or that an isolation cart was outside of the resident's room. She further revealed that the resident was in a different room and was transferred to a new room on 8/13/2024 and that the precautions signage and isolation cart did not follow the resident to his/her new room. 4. Record review of a facility provided policy titled, Isolation-Categories of Transmission-Based Precautions revealed for contact precautions, staff and visitors are to wear gloves when entering the room. Additionally, staff and visitors are to wear a disposable gown upon entering the room and remove before leaving the room and to avoid touching potentially contaminated surfaces with clothing after the gown has been removed. Record review revealed that Resident ID #22 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, Methicillin Resistant Staphylococcus Aureus Infection (MRSA; a multi-drug resistant organism or MDRO) and Chronic Obstructive Pulmonary Disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review revealed a physician's order dated 7/18/2024 for Contact Precaution for MRSA of nares, blood and right shoulder. Review of a care plan initiated on 7/2/2024 revealed that Resident ID #22 has an active/colonized MDRO, MRSA with interventions which include, but are not limited to, isolation precautions per policy, and recommendation from the CDC and local Department of Health. During a surveyor observation on 8/21/2024 at 8:36 AM during the medication administration task with RN, Staff K, Resident ID #22's room revealed signage posted on the doorway indicating contact precautions were required. The signage revealed that providers and staff must also don gloves and gown before entering the resident's room. Further observation revealed Staff K entered Resident ID #22's room wearing gloves. She failed to don a gown as listed in the policy and the signage. Staff K then administered the resident's intravenous antibiotic via a peripherally inserted central catheter (PICC; a long, thin tube that's inserted through a vein in your arm and is used to deliver medications and other treatments directly to the large central veins near your heart). She then touched the resident's pillows, arrange his/her bed linens, and touched the bedside table without wearing a gown. During a surveyor interview immediately following the above-mentioned observation, she acknowledged that she did not wear a gown prior to entering the resident's room. She further acknowledged that she accessed the resident's PICC line and touched multiple potentially contaminated surfaces without wearing a gown per the facility policy and posted signage. During a surveyor interview on 8/21/2024 at 1:22 PM with the DNS, she was unable to provide evidence that the staff followed the resident's isolation precautions as ordered. During a surveyor interview on 8/22/2024 at approximately 2:00 PM with the DNS, she was unable to provide evidence the facility provided effective infection control practices to prevent the spread of Covid-19 and MDRO infections. These failures could have the potential to increase the transmission of Covid-19 and MDROs to multiple residents within the facility. 46539 48928

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being, for 1 of 3 residents reviewed for behaviors, Resident ID #66. Findings are as follows: Record review revealed the resident was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, bipolar disorder and schizophrenia. Review of the resident's care plan revealed a focus area initiated on 2/24/2024, for the use of anti-psychotic medications related to his/her diagnosis of schizophrenia. Interventions include, but are not limited to, administer anti-psychotic medication as ordered. Record review revealed a physicians order dated 7/11/2024 for Risperdal (Risperidone, an antipsychotic medication), 50 milligrams (mg), with instructions to inject intramuscularly (IM), one time a day, every 14 days. Review of the August 2024 Medication Administration Record (MAR) revealed the resident's IM Risperdal was documented with a 22, which indicates Drug / Treatment Not Administered, on 8/8/2024. Additionally, the order was discontinued on 8/8/2024. Review of a progress note dated 8/8/2024 which states in part, [Pharmacy] notified of Risperdal .expected late this evening .RNP [Registered Nurse Practitioner] notified, order to change date to 8/9/24 as resident received medication every 2 weeks. Further review of the August 2024 MAR failed to reveal evidence that a new IM Risperdal order was transcribed or administered to the resident on 8/9/2024, as ordered by the Nurse Practitioner (NP). Review of a document titled, PSYCHIATRIC EVALUATION & CONSULTATION dated 8/12/2024 states in part, Chief Complaint: Pt [patient] reports + HI [homicidal ideation] and + AH [auditory hallucinations] .Pt reports 'I want to stab people' and complains [his/her] HI has returned and that [s/he] is hearing voices. Pt reports that there is no specific person [s/he] wants to hurt, 'just anyone' Pt reports [his/her] mood is worsening in response to [his/her/ psychosis .After investigation and discussion with nursing staff, pt missed [his/her] scheduled injection last week .Advised that pt be restarted on Risperidone injection ASAP [As soon as possible] along with some additional oral coverage . Further review revealed the resident was considered to be a danger to him/herself or others. Review of a progress note dated 8/12/2024, authored by the NP, Staff B states in part, .[S/he] is seen in [follow up], has been having homicidal ideations. Per nursing, pt [patient] missed her last IM Risperidone dose. PT with plan to stab people, does not have means to do so. Able to contract for safety. Seen by psych . Further review of the progress note dated 8/12/2024 revealed the following recommendations were made: - Restart Risperidone Consta 50mg/2ml (milliliter) IM, every 2 weeks - Start Risperidone 2 mg at hour of sleep, for 7 days - 15 minute safety checks until further notice - Plastic utensils with meals Further review of the August 2024 MAR revealed the resident received his/her dose of IM Risperdal on 8/13/2024 and received his/her dose of 2 mg Risperdal, one time a day, from 8/12 to 8/18/2024. Further review revealed the resident was on 15-minute safety checks from 8/12 to 8/20. During a surveyor interview on 8/22/2024 at 12:49 PM, with Psychiatric Nurse Practitioner, Staff G, she revealed that had the resident not missed his/her IM dose of Risperdal, she would not have ordered the resident to receive 2 mg of Risperdal, every evening, from 8/12 to 8/18/2024. During a surveyor interview on 8/22/2024 at 1:18 PM, with the Director of Nursing Services, she revealed that she would have expected the nurses to transcribe the resident's IM Risperdal order on 8/9/2024 and administer it, as ordered. Although this concern was corrected by the facility on 8/12/2024 by reinstating the resident's IM dose of Risperdal, implementing Risperdal 2 mg every evening from 8/12 to 8/19/2024, and maintaining 15-minute safety checks, the missed dose of IM Risperdal on 8/9/2024, caused the resident to experience a relapse in psychosis and was considered to be a danger to his/herself and others. During this period of psychosis, the resident was experiencing homicidal ideations and auditory hallucinations. This the facility was unable to provide any formal in-service training that was completed in regards to this incident. Cross Reference F 658

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to protect the residents' right to be free from abuse for 1 of 1 resident reviewed for abuse, Resident ID #46. Findings are as follows: Review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated October of 2022 states in part, .Residents have the right to be free from abuse .This includes but is not limited to .physical abuse .Protect residents from abuse .by anyone including .other residents . Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/8/2024 alleges that Resident ID #42 approached Resident ID #46, began yelling at him/her and hit his/her left arm several times which resulted in a skin tear. Record review revealed that the victim, Resident ID #46, was admitted to the facility in November of 2023 with a diagnoses including, but not limited to, dementia. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Record review revealed that the perpetrator, Resident ID #42, was admitted to the facility in June of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke), dysarthria (difficulty speaking,) and cognitive social or emotional deficits following a stroke. Record review of a progress note dated 5/8/2024 at 10:38 PM, revealed that Resident ID #46 hit Resident ID #42. The note further indicates that Resident ID #46 was sitting quietly in his/her wheelchair when Resident ID #42 suddenly began to yell at Resident ID #46 and proceeded to hit him/her, striking Resident ID #46 on his/her left arm. Resident ID #46 sustained 2 skin tears which measured 1.0 centimeter (cm) by 0.5 cm and 0.5 cm by 0.5 cm. Review of the facility's 5-Day investigation report titled, Conclusion dated 5/14/2024, revealed that Resident ID #42 had a BIMS score of 15 out of 15, indicating intact cognition. Additionally, it indicated that Resident ID #42 has impulse control issues following his/her stroke and became frustrated when Resident ID #46 did not move his/her feet. During a surveyor interview on 8/21/2024 at 10:22 AM with Nursing Assistant, Staff L, she revealed that she witnessed the incident between Resident ID #s 42 and 46. She indicated that Resident ID #42 is alert and oriented and can be verbally aggressive towards others. She further indicated that Resident ID #46 was sitting in front of the Nurse's station when Resident ID #42 began yelling at Resident ID #46 and then struck Resident ID #46 approximately 3 times in his/her arm, resulting in skin tears. Lastly, she indicated that the incident was unprovoked. During a surveyor interview on 8/21/2024 at 1:36 PM with the Director of Nursing Services, she revealed that Resident ID #42 can be verbally aggressive at times due to his/her speech impairment. Additionally, she acknowledged that Resident ID #46 was not kept free from physical abuse.

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 complete and accurately documented, relative to hearing aids for 1 of 1 resident reviewed for hearing impairment, Resident ID #46. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2023 with a diagnosis including, but not limited to, dementia. Review of the resident's care plan revealed a focus area initiated on 11/14/2023 which revealed the resident is hard of hearing and wears hearing aids. Interventions include, but are not limited to, provide the resident with appropriate hearing aids, as required. Review of a Sensory and Communication Status note dated 8/14/2024 revealed the resident has bilateral hearing limitations that affects his/her ability to function. Record review revealed a physician's order dated 2/3/2024 to insert bilateral hearing aids every morning and remove at bedtime. Review of the Medication Administration Records (MAR) for July and August 2024 revealed the above-mentioned order was documented as completed from July 1st through July 31st and August 1st through August 21st. During a surveyor observation on 8/21/2024 at approximately 10:08 AM, the resident was observed without his/her hearing aids in place. During a surveyor interview immediately following the above observation with Certified Medication Technician, Staff I, she acknowledged that the resident's hearing aids were not in place. Additionally, she revealed that the resident's right hearing aid had been broken for a few weeks. Further, she acknowledged that the order was inaccurately documented as being completed. During a surveyor interview on 8/21/2024 at 11:34 AM with the Unit Manager, Licensed Practical Nurse, Staff C, she revealed that the resident's hearing aid has been broken for approximately 6 weeks. During a surveyor interview on 8/21/2024 at 1:39 PM with the Director of Nursing Services, she indicated that she would expect the staff to accurately document when the resident is wearing his/her hearing aids, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every Nursing Assistant (NA), at least once every 12 months, for 3 of 3 NA personnel records reviewed, Staff D, E, and F. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NA's: -Staff D, hired in February of 2023 -Staff E, hired in July of 2022 -Staff F, hired in July of 2023 During a surveyor interview with the Administrator on 8/21/2024 at 2:20 PM, he acknowledged that the above-mentioned NA's have not had a yearly performance evaluation and indicated it will be added to Quality Assurance and Performance Improvement (QAPI) as of 8/29/2024. Further, he was unable to provide evidence that performance evaluations were completed within the last 12 months for the above-mentioned NA's.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for skin abrasions, Resident ID #83. Findings are as follows: Review of a facility policy titled Wound Care last revised October 2010 states in part, .The following information should be recorded in the resident's medical record .All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound . According to Wound Care Education Institute, 2020, Wound care documentation should be carried out weekly including type of wound, measurements, type of tissue, symptoms of infection, presence of drainage, wound edges, pain, and current treatment. Record review revealed the resident was initially admitted to the facility in February of 2022 with a diagnosis including, but not limited to, dementia. Review of the resident's care plan revealed a focus area initiated on 8/15/2024, which indicated the resident has impaired skin integrity related to an abrasion. Interventions include, but are not limited to, evaluate and document healing process, report significant changes and declines to the provider, and monitor for new or worsening signs or symptoms of complications and infection, such as necrosis (dead tissue), erythema (abnormal redness), warmth, edema (swelling), exudate (drainage), foul odor, maceration (the softening or breaking down of skin due to moisture), pain/tenderness, fever/chills, etc. Review of a progress note dated 4/7/2024 revealed the resident returned to the facility following a hospitalization , and was noted to have a new open area to his/her mid/upper back, measuring 0.3 centimeters (cm) by 0.4 cm. It further revealed there was no drainage or foul odor noted, wound bed was pink and the area surrounding the wound was blanchable (skin that remains white or pale for longer than normal when pressed). Record review revealed a physicians order dated 4/7/2024 for a wound care consult. Record review failed to reveal evidence that a wound care consult was obtained until 8/15/2024, approximately four months after it was initially ordered. Record review revealed the following physician wound treatment orders relative to the above-mentioned wound: - 4/7/2024 - 5/17/2024 Cleanse open area to mid upper back with wound cleanser, apply bacitracin (wound ointment) to wound bed and cover with bordered gauze once daily. - 5/17/2024 - 5/20/2024 Cleanse open area to mid upper back with wound cleanser, apply xeroform (wound dressing) to wound bed and cover with bordered gauze once daily. - 5/21/2024 - 7/30/2024 Cleanse open area to mid upper back with wound cleanser, apply xeroform to wound bed and cover with bordered gauze once daily. - 7/31/2024 - 8/14/2024 Cleanse open area to mid upper back with wound cleanser, apply xeroform to wound bed and cover with bordered gauze once every other day. - 8/15/2024 (current treatment) Cleanse open area to mid upper back with wound cleanser, apply alginate (wound dressing) to wound bed and cover with bordered gauze once every other day. Record review revealed the following dates a full body skin assessment was completed, following his/her readmission to the facility in April of 2024: - 4/8/2024: revealed an open lesion other than an ulcer located on his/her upper back with a treatment in place. - 4/11/2024: revealed an open lesion other than an ulcer located on his/her mid back with a treatment in place and was documented as healing. - 4/18/2024: revealed an open lesion other than an ulcer located on his/her mid back with a treatment in place and was documented as healing. - 4/25/2024: revealed an open lesion other than an ulcer located on his/her mid back with a treatment in place. - 5/2/2024: revealed an open lesion other than an ulcer located on his/her mid back with a treatment in place. - 5/9/2024: revealed an open lesion other than an ulcer located on his/her upper-mid back with a treatment in place. - 5/16/2024: revealed an abrasion located on his/her upper-mid back with a treatment in place. - 5/23/2024: revealed an open lesion other than an ulcer located on his/her upper-mid back with a treatment in place, which recently changed, and was documented as healing. - 5/30/2024: revealed an open lesion other than an ulcer located on his/her upper back with a treatment in place and was documented as improving. - 6/6/2024: revealed an excoriation to his/her upper back, with a treatment in place. - 6/13/2024: revealed an excoriation to his/her upper back, with a treatment in place. - 6/20/2024: revealed no skin impairments were noted. - 6/27/2024: revealed a new skin tear to his/her left elbow, sustained from a fall, with a treatment in place. It further revealed an open lesion other than an ulcer located on his/her upper back with a treatment in place and tolerated by the resident. - 7/4/2024: revealed an open lesion other than an ulcer located on his/her upper back with a treatment in place. - 7/18/2024: revealed an open lesion other than an ulcer located on his/her mid back. - 7/25/2024: revealed an open lesion other than an ulcer located on his/her upper-mid back, open quarter size lesion, with a treatment in place. - 8/2/2024: revealed no skin impairments. - 8/8/2024: revealed a skin impairment was noted. - 8/15/2024: revealed a skin impairment was noted. Further review of the above-mentioned skin assessments failed to reveal documentation of the resident's wound including, but not limited to, wound bed color, size, and drainage, as per facility policy. Review of a document titled Skin & Wound Evaluation dated 8/15/2024, revealed the resident has a facility acquired abrasion to his/her right scapula (shoulder blade), measuring 2.0 cm by 2.3 cm by 0.1 cm. It further revealed the wound had moderate bloody/sanguineous (discharge that is made up of both blood and serum) discharge. During a surveyor interview on 8/21/2024 at 11:01 AM with the Wound Physician, she revealed that she comes to the facility every Wednesday and acknowledged that the resident had his/her initial wound consult for the above-mentioned wound on 8/14/2024. She further revealed that she would expect the facility to be measuring the resident's wound weekly in her absence. During a surveyor interview on 8/21/2024 at 11:26 AM with the Unit Manager, Licensed Practical Nurse, Staff C, she revealed that she was unaware of the order for a wound consult back in April. Additionally, she revealed that she obtained a wound consult for the resident's wound because the nursing staff indicated to her that the wound was worsening. Furthermore, she revealed that she does not obtain wound measurements for abrasions unless it is non-healing or worsening. During a surveyor interview on 8/21/2024 at 1:27 PM with the Director of Nursing Services, she revealed that she would expect wound measurements and wound descriptions to be documented upon conducting weekly skin assessments. Further, she revealed that she would have expected a wound consult to have been obtained when it was initially recommended in April of 2024. 46241

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 2 residents reviewed relative to Post-traumatic stress disorder (PTSD, occurs in some individuals who have encountered a shocking, scary, or dangerous situation) Resident ID #49 and 1 of 1 resident reviewed for wandering, Resident ID #65. Findings are as follows: 1. Review of a facility provided policy titled, Wandering and Elopements states in part, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for resident .If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . Record review revealed that Resident ID #65 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, adjustment disorder and psychosis. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was documented as wandering 1 to 3 days during the 7 day look back period. Record review revealed the resident resides on a secured unit. Record review revealed the following progress notes regarding the resident wandering behavoirs from the facility: - [DATE] which states in part, .Nursing reports patient has had a technical elopement. Patient went outside with activities and did not come back in with staff and was missing. Patient has come back in and in no acute distress . - [DATE] which states in part, Resident self propelled outside of east doors, resident self propelled outside [approximately] 50 feet [away] from building. Resident easily redirected back into building without difficulty. No injuries noted, resident pleasant and cooperative time of redirection. - [DATE] Resident again exited building from the east day room, but was successfully redirected back inside Record review failed to reveal evidence of a care plan that includes strategies and interventions to maintain the resident's safety and prevent future wandering behaviors. During a surveyor interview with Licensed Practical Nurse, Staff A, on [DATE] at 2:02 PM and [DATE] at 8:09 AM, she revealed that the resident does wander and needs frequent redirection. During a surveyor interview on [DATE] at 1:12 PM with the Director of Nursing Services (DNS) and the Regional Registered Nurse, they acknowledged that there was not a care plan in place related to the residents wandering behaviors and indicated that there should be one in place. 2. Record review revealed that Resident ID #49 was readmitted to the facility in March of 2022 with a diagnosis including, but is not limited to, PTSD. Review of a Comprehensive MDS assessment dated [DATE] revealed the resident is coded as having a diagnosis of PTSD, anxiety, and depression. Record review revealed the resident was seen by psychiatric services with the following concerns: - [DATE] The resident goes on to repeat the sad story of losing so many of [his/her] children in life and dealing with a 'vicious' aunt. The resident endorses that [s/he] has trouble falling asleep at night sometimes related to having intrusive memories. [The resident] denies formal depression or anxiety and explains that is normal for [him/her] to feel this way because of [his/her] past traumas, and thus continues to appear mildly sad and anxious . - [DATE] The resident .reports similarly to last month and denies any major problems or concerns and again repeats [his/her] story of the loss of [his/her] children. [The resident] denies major depression or anxiety, or significant appetite or sleep concerns. [The resident] is pleasant, cooperative, mood and affect appear brighter today . - [DATE] Provided brief supportive therapy to [the resident]. [The resident] is alert, easy to engage. Purpose of session is to evaluate mood and accompanied symptoms. Speech tends to be hyperverbal. I do not belong here but I am. Perseverates on [his/her] eight children, most of whom are now deceased . Two are currently living. Tends to focus on the same issues, being 96 now, staying in a nursing home. Prefers to stay alone vs engage with others. Responsive to support and encouragement offered; [The resident] should continue to be followed regularly to provide support . - [DATE] revealed psychiatric services met with the resident for behavioral health services. The resident .Endorsed anxiety, depression and lack of appetite. States does not attend activities and mostly stays in room. Provided emotional support and coping skills training - effects of depression on physical and mental health. Identified activities to elevate mood and encouraged [the resident] to engage [with] others/activities. Introduced mindfulness to self soothe and increase calm/peace . - [DATE] Current Assessment/Plan [the resident] is sitting up in [his/her] room, sleepy this morning but rousable, alert, confused/forgetful, pleasant. [The resident] presents with stable mood and affect, good eye contact Will continue to monitor .PTSD . Record review revealed the physician saw the resident on [DATE] at 1:01 PM and noted the resident's diagnosis of PTSD, with psychiatric services involved. Record review failed to reveal evidence of a trauma informed care plan that identifies trauma triggers and interventions to implement related to the diagnosis of PTSD. During a surveyor interview on [DATE] at 9:18 AM with the Social Worker, she revealed that when she meets with the resident s/he talks to her about his/her children passing away. She further revealed that she was unaware that the resident had a diagnosis of PTSD. Additionally, she acknowledged that the resident did not have a care plan related to PTSD and indicated that there should be one. During a surveyor interview on [DATE] at approximately 3:00 PM, with the DNS, she was unable to provide evidence that a comprehensive person-centered care plan was developed and implemented to address the resident's PTSD. 47279

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food service safety, relative to the main kitchen and 2 of 2 kitchenettes. Findings are as follows: Record review of Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and help in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . 1. During the initial tour of the main kitchen in the presence of the Food Service Director (FSD), on 8/19/2024 at 8:10 AM, the following was observed in the walk-in refrigerator: - A half size hotel pan approximately 1/2 full of uncooked chicken with a use by date of 8/17/2024. - A quarter size hotel pan approximately 3/4 full and labeled puree chicken with a use by date of 8/18/2024. - A package of 20 frozen prepared egg rolls, unlabeled and undated. During a surveyor interview with the FSD immediately following the above observations, she acknowledged the above items should have been labeled, dated, and discarded according to the dates. During a surveyor observation of the Ocean Unit Kitchenette on 8/21/2024 at 10:35 AM, revealed the following: - A blue soup bowl, covered, containing cooked oatmeal without a label or use by date. - A 1-quart container of vanilla ice cream with a manufacturer's use by date of 8/14/2024. During a surveyor observation of the Country Unit Kitchenette on 8/21/2024 at 10:50 AM, revealed an undated individual packaged dessert with a manufacturer's label of strawberry cream pie without a use by date. During a surveyor interview with the FSD immediately following the above observations, she revealed the above items should have been labeled, dated, and discarded according to the dates. 2. During a surveyor observation of lunch service in the main kitchen, in the presence of the FSD on 8/21/2024 at 11:35 AM, revealed a large hotel sheet pan placed on a preparation area beside the gas stove located behind the hot food service line. The tray contained several plated alternative meal options, which included cold salad plates and sandwiches. The following observations were made: - A salad plate containing two scoops of chicken salad on top of a tossed salad with a holding temperature of 51 degrees Fahrenheit (F). - A plate containing a chicken salad sandwich on wheat bread with a holding temperature of 48 degrees F. - A plate containing a tossed salad with cut up fresh fruit and a large scoop of cottage cheese with a holding temperature of 51 degrees F. During a surveyor interview with the FSD immediately following the above-mentioned observations, she acknowledged the holding temperatures of the food items were not safe to serve. Additionally, she acknowledged that cold food temperatures should not have been greater than 41 degrees F and should have been refrigerated.