Every finding on record at Berkshire Place

Based on clinical record review and staff interview, the facility failed to ensure that a resident receives necessary treatment and services, consistent with professional standards of practice, for 1 of 1 resident reviewed related to follow-up appointments following a hospitalization, Resident ID #5.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on 8/13/2026 alleges that the facility failed to implement specialist referrals from the hospital including an endocrinology (a doctor that specializes in diabetes) appointment and a neuropsychiatry evaluation since March of 2026 for Resident ID #5.Record review revealed that Resident ID #5 was admitted to the facility in March of 2026 with diagnoses including, but not limited to, dementia and diabetes.Further record review revealed that the resident was transferred to another facility on 8/22/2026.Record review of a hospital document dated 3/17/2026 titled, Continuity of Care- Post Acute Facility revealed that the resident was admitted to the hospital related to progressing dementia and acute encephalopathy (a disturbance of brain function) related to diabetes.Further review revealed the following appointments to be scheduled after discharge from the hospital:-Endocrinology appointment -Neuropsychiatry evaluationRecord review of provider progress notes revealed the following:3/25/2026: .Previously, patient was hospitalized 3/14-3/17/26 for acute hypoglycemic [low blood sugar] encephalopathy, thyroid ultrasound 3/18/26 .endocrinology referral placed.neuropsychiatry evaluation pending.3/31/2026: .***Follow-up*** Endocrinology referral for thyroid nodule evaluation MRI brain with and without contrast pending at RIH Neuropsychiatry evaluation to be scheduled per hospital follow-up recommendations.4/14/2026: .Endocrinology referral pending for further evaluation and management. ***Follow-up*** Continue monitoring blood sugars as scheduled.Endocrinology referral pending.Neuropsychiatry evaluation to be scheduled per hospital follow-up recommendations.4/19/2026: .***Follow-up***- Continue monitoring blood sugars as scheduled - Endocrinology referral .evaluation (pending) .Neuropsychiatry evaluation (pending).6/4/2026: . Endocrinology referral .Neuropsychiatry evaluation pending.6/18/2026: . Endocrinology referral pending .Neuropsychiatry evaluation pending.7/27/2026: .***Follow-up***- Endocrinology appointment remains pending for diabetes management - Neurology referral pending for evaluation of rapid cognitive decline - Outpatient neurocognitive testing orders remain in place.7/30/2026: .endocrinology appointment remaining pending.Neurology referral pending for evaluation of rapid cognitive decline.8/13/2026: .***Follow-up***- Endocrinology appointment has been scheduled (date to be confirmed) for diabetes management- Neurology referral pending for evaluation of rapid cognitive decline- Outpatient neurocognitive testing orders remain in place.Record review of the Treatment Administration Record from March 2026 through August 2026 revealed a physician's order with a start date of 3/18/2026 to obtain neuropsychiatry evaluation appointment and discontinue when obtained. Further review revealed that the order was documented daily as Y, N or NA from 3/18/2026 through 8/22/2026.Record review revealed that a neuropsychiatry evaluation appointment was not scheduled until 8/21/2026, for 11/19/2026 approximately 5 months from the physician's order.Record review revealed that an endocrinology appointment was scheduled on 8/17/2026 for 11/13/2026 approximately 5 months after the physician's order.During a surveyor interview on 8/27/2026 at approximately 10:35 AM with Transport Aide, she revealed that she was having difficulty obtaining appointments related to the resident's health insurance. Additionally, she provided fax transcripts that the information was sent to an endocrinology office on 7/27/2026. She could not provide evidence that the facility contacted endocrinology prior to 7/27/2026. She further revealed that the resident had a neuropsychiatry appointment scheduled but was canceled related to his/her insurance. She could not provide evidence that another appointment was scheduled until 8/21/2026.During a surveyor interview with the Regional Director of Nursing Services on 8/27/2026 at approximately 12:00 PM, she was unable to provide evidence that Resident ID #5's appointments for endocrinology and neuropsychology were scheduled timely.

Based on clinical record review, and staff interview, the facility failed to ensure that resident records are complete and accurately documented related to behavior monitoring for 1 of 1 resident reviewed, Resident ID #1.Findings are as follows:According to Fundamentals of Nursing, Seventh Edition dated 2011, states in part, Documenting Nursing Care .Remembering the legal truth 'It wasn't done if it wasn't documented'.Documentation Guidelines.Aim: Complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.Record review revealed Resident ID #1 was admitted to the facility in July 2025 with diagnoses including, but not limited to, Huntington's disease (a hereditary neurodegenerative disorder that affects movement, cognition, and mental health, and cognitive communication deficit). Further record review revealed that the resident expired on 8/24/2026.Review of the care plan initiated on 6/23/2025 revealed that Resident ID #1 had an identified history of behaviors, including, but not limited to, rejecting care, physical aggression, combativeness with care, refusal of medications and treatments, paranoid statements, gripping objects, furniture, and staff and refusing to let go, and self-mutilating behaviors such as scratching his/her arms and legs and clenching or wringing his/her hands.Record review revealed a physician's order dated 5/12/2026 requiring staff to monitor the resident for changes in behavior and, each shift, to: (1) record the number of episodes; (2) record the intervention(s) provided; and (3) document the outcome of the intervention. The order identified multiple interventions, including redirection, one-to-one support, referral to nursing notes, diversional activity, toileting, offering food or fluids, psychiatry/psychology consultation, repositioning, and re-approaching the resident. The order further required staff to document the outcome of the intervention each shift as improved, unchanged, or worsened.Review of the July and August 2026 Treatment Administration Records (TAR) revealed that the above physician's order was documented as completed daily from 7/1/2026 through 8/24/2026. However, the required behavior-monitoring fields were repeatedly documented with 0 and NA. The TAR failed to accurately document or reference to the resident's record for changes in his/her behaviors relative to; the number of episodes, the intervention(s) provided, and the outcome of the provided interventions.The TAR documentation was inconsistent with other clinical information contained in the medical record. Record review of a provider note dated 8/7/2026 revealed that on 7/28/2026, the hospice agency recommended reinstating an order for olanzapine, an antipsychotic medication, to be administered as needed every 12 hours for aggression and/or agitation. The provider reviewed and approved the recommendation due to the resident's ongoing behaviors.During a surveyor interview on 8/26/2026 at 10:44 AM, Registered Nurse (RN), Staff A, revealed that Resident ID #1 experienced frequent behaviors, including yelling out and being combative with care, and was considered a high fall risk. Staff A further revealed that the resident frequently required close monitoring and was often placed in the dayroom or at the nurses' station so staff could monitor and assist the resident as needed due to his/her behaviors.During a surveyor interview on 8/26/2026 at approximately 12:00 PM, RN, Staff B, revealed that Resident ID #1 had behaviors requiring close monitoring and was placed in a recliner at the nurses' station for observation. Staff B further revealed that the resident required two staff members to provide care due to his/her behaviors.During a surveyor interview on 8/26/2026 at approximately 12:50 PM, the Regional Director of Nursing Services acknowledged that the behavior-monitoring documentation was inaccurate and stated that she would expect the resident's behaviors, interventions, and outcomes to be accurately documented at the end of each shift in accordance with the physician's order.

Based on clinical record review and staff interview, the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for 1 of 1 resident reviewed, Resident ID #2.Findings are as follows:Record review of a community reported complaint sent to the Rhode Island Department of Health on 7/21/2026 alleged in part, that the facility failed to inform the state Preadmission Screening and Resident Review (PASRR) office of a significant change in the mental or physical condition prior to and/or after the resident was sent to the hospital.Record review revealed Resident ID #2 was admitted to the facility in September of 2022 with diagnoses including, but not limited to, paranoid schizophrenia, major depression and anxiety.Further review revealed the resident was discharged to the hospital on 6/29/2026.Record review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed a Level II PASRR Condition of a serious mental illness.Record review of a facility document titled, Psychiatric Evaluation and Consultation dated 6/3/2026 states in part, .Patient seen and assessed today via urgent telehealth visit after staff was concerned over accusatory, paranoid, and auditory hallucinations. Chart reviewed for current psychiatric diagnoses and medication management. Discussed and collaborated with nursing on patient behaviors and concerns.Record review of the nursing notes revealed the following:6/16/2026: Due to the facility's inability to meet [Resident ID #2] safety and care needs, as well as to ensure the safety of others, [Resident ID #2] was presented with a 30-day notice of discharge by the Administrator in the presence of the Regional Director of Operations on 6/15/2026. Education and explanation of the discharge process were provided.expressed interest in relocating to a different home and stated that [s/he] does not wish to appeal the decision. The facility will continue to work on identifying and securing an appropriate placement for [Resident ID #2].6/16/2026: .called and spoke with resident's [family] on 6/15/2026 and today (6/16/2026) to review resident's 30-day notice to discharge from the facility. Resident received a 30-day notice due to ongoing behaviors and recent altercations with other residents. Resident's [family] mentioned that [s/he] is aware of [his/her] psychiatric history and diagnosis of schizophrenia. However, [s/he] has not been in contact with [him/her] for a while and did not realize [s/he] was experiencing these behaviors here at [the facility].6/22/2026: DSS [ Department of Social Services] contacted.Adult Behavioral Health Services to gather information regarding their impatient behavioral health services. DSS will relay this information to residents' family for further review. Social Services will also continue to provide supportive services as needed.6/24/2026: .was issued 30 day notice this quarter secondary to increasing behaviors (rR2R [Resident to Resident] where [s/he] was the aggressor).6/29/2026: Resident complained of chest pain this morning and was transferred to the emergency department for further evaluation.confirmed that the resident was admitted for further cardiac evaluation.6/30/2026: Call placed to [emergency department] to follow up on resident and was told [s/he] got admitted for pleural effusion.Record review failed to reveal evidence that the facility notified the state mental health authority promptly after a significant change in the mental or physical condition for Resident ID #2.During a surveyor interview on 8/27/2026 at 9:54 AM with the facility Social Worker, she revealed that she was not involved with this resident and was unaware if the facility contacted the state mental health authority related to Resident ID #2's increasing behaviors, 30-day discharge notice and hospital admission.During a surveyor interview with the Regional Director of Nursing Services on 8/27/2026 at approximately 12:50 PM, she was unable to provide evidence that the facility contacted the state mental health authority related to Resident ID #2's increasing behaviors, 30-day discharge notice and hospital admission as required by his/her Level II PASARR mental illness.

Based on clinical record review and staff interview, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 3 residents reviewed relative to medication administration, Resident ID #s 3 and 4. Findings are as follows:According to, Mosby's Drug Guide Tenth Edition 2013, section, SAFE MEDICATION ADMINISTRATION GUIDE states in part, The 5 rights of medication administration. Always adhere to the 5 rights of medication administration when transcribing, preparing, administering, and documenting medications . 5. Right time: All medications should be administered within 30 minutes of the scheduled time .Review of a facility policy titled, Medication Administration General Guidelines dated 1/2023 states in part, .Medications are administered 60 minutes of scheduled time, except before or after meal orders.Review of a community reported complaint received by the Rhode Island Department of Health on 8/25/2026 alleges that Resident ID #3 did not receive his/her morning medications until 1:00 PM.a. Record review revealed that Resident ID #3 was admitted to the facility in June of 2026 with diagnoses including, but not limited to, pneumonia and dementia.Record review revealed the following physician's orders:-Senna docusate sodium (laxative) 8.6-50 Milligrams (mg) daily at 8:00 AM-Thiamine HCL 100 mg daily at 8:00 AM-Trelegy Ellipta (inhaler) administer 1 puff daily at 8:00 AM-Cholecalciferol (vitamin D supplement) 2000 units daily at 8:00 AM-Ferrous Sulfate (iron supplement) 325 mg daily at 8:00 AM-Guaifenesin ER (cough medication) 600 mg daily at 8:00 AM-Isosorbide Mononitrate ER (prescribed for high blood pressure) 30 mg daily at 8:00 AM-Prednisone (steroid) 20 mg daily at 10:00 AM-Magnesium oxide (prescribed for indigestion) 400 mg daily at 10:00 AM-Losartan Potassium (prescribed for high blood pressure) 25 mg daily between 8:00-11:00 AM-Folic Acid 1 mg daily between 8:00-11:00 AM-Rexulti (antipsychotic) 0.5 mg daily between 8:00-11:00 AM-Seroquel (antipsychotic) 12.5 mg daily between 8:00- 11:00 AM-Sertraline (antidepressant) 50 mg daily between 8:00- 11:00 AM-Omeprazole (prescribed for indigestion) 40 mg daily between 8:00- 11:00 AMReview of the August 2026 Medication Administration Record (MAR) revealed that on 8/24/2026 the above medications were documented as administered at 12:55 PM, approximately 2-4.5 hours after the scheduled time.b. Record review revealed that Resident ID #4 was admitted to the facility in November of 2017 with diagnoses including, but not limited to, Alzheimer's disease, heart failure and diabetes.Record review revealed the following physician's orders:- Aspirin 81 mg daily between 7:00-11:00 AM- Empagliflozin (prescribed to lower blood sugar in type 2 diabetes) 5 mg daily between 8:00-11:00 AM-Losartan Potassium (prescribed for high blood pressure) 12.5 mg daily between 8:00-11:00 AM-Memantine (prescribed to treat symptoms of Alzheimer's disease) 10 mg daily between 8:00-11:00 AMReview of the August 2026 MAR revealed that on 8/24/2026 the above medications were documented as administered at 12:20 PM, 1 hour and 20 minutes after the scheduled time.During a surveyor interview with the Regional Director of Nursing Services on 8/27/2026 at approximately 12:00 PM, she revealed that she would expect the residents to receive their medications as ordered and within the scheduled timeframe. Additionally, she was unable to provide evidence that the facility notified the provider of the late administrations.

Based on clinical record review and staff interview, the facility failed to ensure Resident ID #1's right to be free from abuse by failing to assess, monitor, and implement effective interventions to address Resident ID #2's known and escalating history of physically aggressive behaviors including failure to update the care plan following documented resident-to-resident incidents and failure to fully implement psychiatric recommendations resulting in a resident-to-resident altercation on 4/27/2026 in which Resident ID #2 struck Resident ID #1 on the left eyebrow with a cane, causing a laceration requiring wound closure with steri-strips and ongoing wound treatment. Resident ID #1, who carries diagnoses of paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, was cognitively intact and was aware of and distressed by the assault, as evidenced by his/her request for police involvement and the decision to press criminal charges. These actions are consistent with a reasonable person experiencing fear, violation of personal safety, and psychological distress in what is his/her place of residence. This failure placed Resident ID #1 and other residents in the facility at risk of serious physical and psychosocial harm from a resident with a documented, unmitigated pattern of escalating aggression.Findings are as follows:Review of a facility policy titled, Abuse Prohibition last revised on 10/31/2022 states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse, mistreatment, neglect .Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish .Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/27/2026 revealed that on 4/27/2026 Resident ID #1 was struck by Resident ID #2 with his/her cane which resulted in Resident ID #1 sustaining a laceration to his/her left eyebrow. 1. Record review revealed that Resident ID #1 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, paranoia schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves), adjustment disorder (a disorder when an individual experiences difficult coping with a life change) with mixed anxiety and depressed mood.Review of Resident ID #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact condition.Record review of a progress note dated 4/27/2026 at 10:30 AM authored by the Registered Nurse Practitioner (RNP), Staff A, revealed Resident ID #1 was on the receiving end of a physical altercation with another resident. S/he was noted to have a deep bleeding abrasion to his/her left eyebrow. Further, a police report has been requested (by the victim), Resident ID #1.Further review of the progress notes dated 4/27/2026 at 11:44 AM authored by Licensed Practical Nurse, Staff B, revealed that Resident ID #1 was observed with a new laceration to his/her left eyebrow measuring 0.5 centimeters (cm) in length by 2.0 cm in width by 0.1 cm in depth related to a resident-to-resident incident. Wound closure strips were applied to the laceration. Further review revealed Resident ID #1 was educated on the need for sutures however, the resident refused to go to the hospital.Record review revealed a physician's order dated 4/27/2026 to monitor the wound closure strips to the laceration on Resident ID #1's left eyebrow with additional instructions to cleanse the wound with normal saline, pat dry and apply bacitracin and cover with a bandage every shift.Record review revealed Resident ID #2, was admitted to the facility in December of 2024 with diagnoses including, but not limited to, an impulse disorder (a psychiatric condition characterized by the inability to resist urges or impulses that may harm oneself or others), adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety.Review of Resident ID #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15, indicating intact condition. Additional review of the MDS revealed, S/he exhibited both physical and verbal behaviors for 1 to 3 days during the assessment look back period. Record review revealed the following progress notes for Resident ID #2:-9/13/2025 at 7:02 PM during a smoking session, the resident threatened to slit the throat of another resident if s/he touches his/her stuff again. Additionally, the note indicates upon interview by staff the resident stated in part, just because I said I'm going to Rip [his/her] heart out if [s/he] touches anything of mine again, so what? And next time it'll be you.-11/7/2025 at 1:43 PM Resident was involved in a verbal dispute with another resident. The resident engaged in raising his/her voice, name-calling, and verbal threats.-12/28/2025 1:04 PM progress note authored by the on-call provider revealed, Resident ID #2 was involved in an incident tonight in which another resident took off his/her helmet and struck Resident ID #2 on the leg there was no evidence of injury. Additionally, the progress note revealed that the nursing staff reports after the incident Resident ID #2 was overheard stating to the other resident the next time you put your hands on me I will kill you.-2/21/2026 at 1:40 PM authored by the on-call provider the resident is evaluated for new aggressive behavior attacked his/her roommate with a cane due to the T.V. volume. The resident will require emergency room transfer for psychiatry evaluation.-3/9/2026 at 3:46 PM authored by the charge nurse revealed that when Resident ID #2 did not win the Bingo s/he threw the poker chips on the floor. S/he was asked to leave the dining room twice. The second time s/he stood at the door swearing and yelling at the activity aide and other residents.-3/17/2026 at 5:52 AM authored by the charge nurse revealed Resident ID #2's roommate has been avoiding using the shared bathroom due to Resident ID #2 making inappropriate comments and displays frustration when the light is turned on during the night.-4/10/2026 at 1:03 PM authored by the charge nurse revealed Resident ID #2 threw his/her lunch plate across the nurses station at a Nursing Assistant because s/he was unhappy with the portion size.-4/14/2026 at 11:33 AM revealed the Interdisciplinary team met with the resident to discuss his/her recent behaviors and throwing of a plate. This writer explained that any violent behavior like throwing objects would not be tolerated as it puts residents and staff at risk. Resident expressed understanding but adamantly denied throwing anything despite multiple witnesses. This writer explained that any further unsafe acts would result in potentially receiving a 30-day notice of involuntary discharge due to safety concerns.-4/27/2026 at 12:32 PM authored by the Director of Nursing Services revealed, Resident ID #2 was noted to be ambulating down the hall heading towards his/her room. Another resident (Resident ID #1) was ambulating down the hall walking in the opposite direction. The residents began engaging in a verbal dispute. Before staff could intervene Resident ID #2 used his/her cane to make contact with Resident ID #1. The police were contacted and arrived to the facility, Resident ID #2 was subsequently discharged from the facility into police custody.Record review revealed a care plan dated 1/16/2025 indicating Resident ID #2 has a behavior problem of being verbally aggressive towards staff with resident-to-resident altercations occurring on 12/28/2025, 2/21/2026 and 4/27/2026.Additional record review failed to reveal interventions to mitigate the risk of his/her physical aggressive behaviors to other residents in the facility or interventions for staff to implement/utilize to ensure the safety of the other residents residing in the facility after his/her resident-to-resident incident on 2/21/2026 and documented throwing of objects on 3/9/2026 and 4/10/2026. 2. Record review of a psychiatric evaluation and consultation note dated 4/23/2026 revealed a recommendation to start Trazadone 25 milligrams (mg) twice daily as needed for agitation, anxiety and insomnia and to monitor his/her response and tolerability.Record review of a Physician's order dated 4/24/2026 for trazadone 25 mg twice daily as needed for insomnia.Record review failed to reveal evidence that the trazadone order was implemented to include agitation and anxiety, as indications for use.During a surveyor interview on 4/30/2026 with the RNP, Staff A, at 1:48 PM she revealed it would be her expectation that the order for trazadone would have included agitation and anxiety as indications for use. During a surveyor interview on 4/30/2026 at approximately 3:50 PM with the Director of Nursing Services, she revealed it would be her expectation that the order for Trazadone would have included the indication to be used for agitation or anxiety. Additionally, she was unable to provide evidence that the resident's care plan was updated to include interventions for staff to implement in order to mitigate the risk of his/her physically aggressive behaviors as documented on 2/21/2026, 3/9/2026, and 4/10/2026. Further, she acknowledged that Resident ID #2 was observed striking Resident ID #1 with his/her cane on 4/27/2026 causing a laceration to his/her left eyebrow which required steri strips and treatment. During a surveyor interview on 4/30/2026 at 4:08 PM with the Administrator, she acknowledged that Resident ID #2 was discharged into police custody on 4/27/2026 secondary to admitted ly striking Resident ID #1 with his/her cane that resulted in injury.Record review of a [police department] Incident Report dated 4/27/2026 revealed Resident ID #1 wanted to press charges after stating s/he was struck with a walking cane. Resident ID #2 admitted to striking Resident ID #1 with his/her cane. The report further revealed Resident ID #2 was subsequently arrested on one count of felony assault with a dangerous weapon.The facility's failure to assess, monitor, and implement effective interventions to address Resident ID #2's known history of escalating aggressive behaviors, including failure to update the care plan and fully implement psychiatric recommendations, resulted in a resident-to-resident altercation causing injury to Resident ID #1, and demonstrates the facility did not ensure a safe environment free from abuse.Cross reference F740

Based on clinical record review and staff interview, the facility failed to ensure that Resident ID #2 received adequate behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for 1 of 2 residents reviewed. Specifically, the facility failed to implement the full psychiatric recommendation for trazodone - including agitation and anxiety as indications for use - and failed to update the care plan with effective interventions to address Resident ID #2's known and escalating pattern of physically aggressive behaviors, contributing to a resident-to-resident altercation on 4/27/2026 in which Resident ID #2 struck Resident ID #1 with a cane, causing a laceration to the left eyebrow requiring wound closure with steri-strips and ongoing wound treatment.Findings are as follows:Review of the facility policy titled Abuse Prohibition, last revised on 10/31/2022, states in part: It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse, mistreatment, neglect .Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish .Record review revealed that Resident ID #2 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, an impulse disorder (a psychiatric condition characterized by the inability to resist urges or impulses that may harm oneself or others), adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety.Review of Resident ID #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Additional review of the MDS revealed that s/he exhibited both physical and verbal behaviors for 1 to 3 days during the assessment look-back period.Record review revealed the following documented behavioral incidents for Resident ID #2:9/13/2025 at 7:02 PM -During a smoking session, Resident ID #2 threatened to slit the throat of another resident. Upon interview by staff, the resident stated in part, just because I said I'm going to rip [his/her] heart out if [s/he] touches anything of mine again, so what? And next time it'll be you.11/7/2025 at 1:43 PM - Resident ID #2 was involved in a verbal dispute with another resident, engaging in raising his/her voice, name-calling, and verbal threats.12/28/2025 at 1:04 PM -A progress note authored by the on-call provider revealed Resident ID #2 was involved in an incident in which another resident struck Resident ID #2 on the leg with a helmet. Following the incident, Resident ID #2 was overheard stating to the other resident, the next time you put your hands on me I will kill you.2/21/2026 at 1:40 PM - A progress note authored by the on-call provider revealed Resident ID #2 attacked his/her roommate with a cane due to the television volume and required emergency room transfer for a psychiatric evaluation.3/9/2026 at 3:46 PM - A progress note authored by the charge nurse revealed that when Resident ID #2 did not win at Bingo, s/he threw poker chips on the floor, was asked to leave the dining room twice, and stood at the door swearing and yelling at the activity aide and other residents.3/17/2026 at 5:52 AM - A progress note authored by the charge nurse revealed Resident ID #2's roommate had been avoiding the shared bathroom due to Resident ID #2 making inappropriate comments and displaying frustration when the light was turned on during the night.4/10/2026 at 1:03 PM - A progress note authored by the charge nurse revealed Resident ID #2 threw his/her lunch plate across the nurses' station at a nursing assistant because s/he was unhappy with the portion size.4/14/2026 at 11:33 AM - A progress note revealed the Interdisciplinary Team (IDT) met with Resident ID #2 to discuss his/her recent behaviors, including the throwing of a plate. The resident was informed that any violent behavior would not be tolerated and that further unsafe acts could result in a 30-day notice of involuntary discharge. The resident expressed understanding but denied throwing anything despite multiple witnesses.Record review revealed a psychiatric evaluation and consultation note dated 4/23/2026 with a recommendation to start trazodone 25 milligrams (mg) twice daily as needed for agitation, anxiety, and insomnia, and to monitor his/her response and tolerability.Record review of a physician's order dated 4/24/2026 revealed trazodone 25 mg twice daily as needed was ordered for insomnia only.Record review failed to reveal evidence that the trazodone order was implemented to include agitation and anxiety as indications for use, as recommended by the consulting psychiatrist.Record review revealed a care plan initiated on 1/16/2025 indicating Resident ID #2 has a behavior problem of being verbally aggressive towards staff, with documented resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026.Additional record review failed to reveal interventions to mitigate the risk of Resident ID #2's physically aggressive behaviors toward other residents, or interventions for staff to implement to ensure the safety of other residents residing in the facility, following the resident-to-resident incident on 2/21/2026 and the documented throwing of objects on 3/9/2026 and 4/10/2026.During a surveyor interview on 4/30/2026 with the Registered Nurse Practitioner (RNP), Staff A, at 1:48 PM, she stated it would be her expectation that the order for trazodone would have included agitation and anxiety as indications for use.During a surveyor interview on 4/30/2026 at approximately 3:50 PM with the Director of Nursing Services (DNS), she stated it would be her expectation that the trazodone order would have included agitation and anxiety as indications for use. Additionally, she was unable to provide evidence that Resident ID #2's care plan was updated to include interventions to mitigate the risk of his/her physically aggressive behaviors, as documented on 2/21/2026, 3/9/2026, and 4/10/2026.The facility's failure to fully implement the psychiatric recommendation for trazodone and to update the care plan with effective behavioral interventions following Resident ID #2's known and escalating pattern of aggressive behaviors resulted in a resident-to-resident altercation on 4/27/2026 that caused physical injury to Resident ID #1 and demonstrated the facility's failure to provide adequate behavioral health services to support Resident ID #2's highest practicable mental and psychosocial well-being, while simultaneously placing other residents at risk of harm.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a foley catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #1, and for 2 of 2 residents with a suprapubic catheter (SP tube, a medical device that drains urine from the bladder through a small incision in the abdomen) Resident ID #s 2 and 3.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/1/2026 alleges that on 3/31/2026, Resident ID #1 arrived to the emergency room and was observed to have a foley catheter that was crusted and had evidence of erosion to the urinary meatus [the opening where urine exits during urination]. Additionally, the resident had significant urinary retention and the foley catheter needed to be replaced. The report further documented that his/her urine was foul smelling. 1. Record review revealed that Resident ID #1 was admitted to the facility in December of 2025 with diagnoses including, but not limited to, urinary retention and neurogenic bladder (a condition where nerve damage disrupts communication between the brain, spinal cord, and bladder, leading to loss of bladder control).Further record review revealed that the resident was admitted to the hospital on [DATE] with diagnoses of septic shock and acute respiratory failure.Review of a care plan last revised on 1/30/2026 revealed that Resident ID #1 requires a foley catheter related to a diagnosis of neurogenic bladder. Interventions include, but are not limited to, changing the foley catheter per the physician's orders.Record review revealed the following physician's orders:1/1/2026: Change the resident's foley catheter monthly and as needed.2/4/2026: Change the resident's foley catheter monthly and as needed.2/24/2026: Primary team to determine if foley catheter is to be exchanged out by urology for discoloration of urine.Record review of the January, February, and March 2026 Treatment Administration Records (TAR) revealed the following:1/4/2026: Change the resident's foley catheter monthly and as needed was documented as NA [not applicable].2/4/2026: Change the resident's foley catheter monthly and as needed was documented as refused change.2/24/2026: Primary team to determine if foley catheter is to be exchanged out by urology for discoloration of urine signed off as completed.3/4/2026: Change resident's foley catheter monthly and as needed was documented as n.Record review of progress note authored by the on-call provider dated 2/24/2026 states in part, .urine noted to be cloudy, and blood tinged .Determine if foley should be exchanged out if so, the patient prefers urology to exchange.Record review failed to reveal evidence that urology was contacted, or an appointment was scheduled for a foley catheter exchange. Further record review revealed the last time the foley catheter was exchanged was on 12/31/2025 at the hospital.During a surveyor interview on 4/2/2026 at 12:26 PM with the Nurse Practitioner, she revealed that it is her practice to have foley catheters exchanged monthly and as needed which could be completed at the facility or with a urologist. She further revealed that it would be her expectation that if the resident is refusing to have it exchanged in the facility that the nursing staff would call urology, per the physician's order on 2/24/2026 for an appointment.During a surveyor interview on 4/2/2026 at 2:18 PM with the Assistant Director of Nursing (ADNS), she was unable to provide evidence that the resident's foley catheter was exchanged as ordered by the physician or that urology was contacted for an appointment.2. Record review revealed that Resident ID #2 was readmitted to the facility in December of 2025 with diagnoses including, but not limited to, external genitalia, head, and neck malignancies (cancer).Review of a care plan dated 10/28/2025 revealed that Resident ID #2 requires an SP catheter related to a terminal condition. Interventions include but are not limited to, changing the SP catheter per the physician's order.Record review revealed a physician's order dated 10/14/2025 to call to set up the resident's appointment with urology for an SP catheter exchange.Record review of the January, February, and March 2026 TARs revealed the above order was signed off as completed daily.Record review of a continuity of care document, Consultation and Referral form dated 12/2/2025 revealed that the resident was seen by urology and had a SP catheter exchanged, further review revealed that s/he requires an SP exchange in 4 weeks at the facility.Record review failed to reveal evidence that the resident's SP catheter was exchanged since 12/2/2025.During a surveyor interview on 4/2/2026 at 12:26 PM with the resident's Nurse Practitioner, she revealed that it would be her expectation that the SP catheter would be exchanged in the facility if s/he was not going to urology.During a surveyor interview on 4/2/2026 at 2:18 PM with the ADNS, she revealed that the nursing staff at the facility all have competencies to exchange SP tubes in the facility. She further revealed that there may have been confusion if s/he was having it exchanged at the urologist office. She was unable to provide evidence that Resident ID #2's SP catheter had been exchanged since 12/2/2025. 3. Record review revealed that Resident ID #3 was admitted to the facility in June of 2025 with a diagnosis including, but not limited to, flaccid neuropathic bladder (the inability of the bladder muscles to contract effectively leading to urinary retention).Review of a care plan last revised on 6/13/2025 revealed that Resident ID #3 requires an SP catheter. Interventions include, but are not limited to, changing the SP catheter per the physician's order.Record review revealed a physician's order dated 6/11/2024 that the resident SP catheter exchange is completed at urology.Record review of a continuity of care document, Consultation and Referral form dated 11/6/2025 revealed that the resident was seen by urology and had his/her SP catheter exchanged. Further review revealed s/he had a follow-up appointment with urology for an annual check-up and SP catheter exchange scheduled for 12/15/2025.During a surveyor interview on 4/2/2026 at 12:56 PM with the above Urology receptionist, she revealed that the resident did not show up for his/her 12/15/2025 appointment and has not had an appointment since 11/6/2025.During a surveyor interview on 4/2/2026 at 2:18 PM with the ADNS, she was unable to provide evidence that Resident ID #3 has had a urology appointment since 11/6/2025 and that his/her SP tube has been exchanged per the physician's order.

Based on surveyor observation, record review, family member, and staff interview, it has been determined that the facility failed to ensure that a resident who was admitted to the facility without a limited range of motion does not experience a reduction in range of motion for 1 of 2 residents observed with contractures (the shortening of muscles, tendons, skin, and nearby soft tissues that cause the joints to become very stiff, which prevent normal movement), Resident ID #99. Findings are as follows:Record review revealed the resident was admitted to the facility in February of 2023 and readmitted in August of 2025 with diagnoses including, but not limited to, dementia, left sided hemiplegia (paralysis that affects only one side of the body), left sided hemiparesis (muscle weakness on one side of the body) and bilateral lower leg contractures.Record review revealed the resident's functional abilities from the following Minimum Data Set (MDS) Assessments: Quarterly MDS dated [DATE]:Sit-stand: and bed mobility: dependentChair/bed-to-chair transfer: supervision or touching assistance-helper provides verbal cues or touching/steadying assistance as resident completes activity.Walk 10 feet (ft)= independentWalk 50 ft: supervision or touching assistance-helper provides verbal cues or touching/steadying assistance as resident completes activity.Walk 150 ft: independent- Resident completes the activity by him/herself with no assistance from helper.Quarterly MDS dated [DATE]: Sit-stand: and bed mobility: dependentChair/bed-to-chair transfer: dependent-helper does all of the effort. Resident does none of the effort to complete activity.Walk 10 ft= supervision or touching assistanceWalk 50 ft: not attempted due to medical condition or safety concernsWalk 150 ft: not attempted due to medical condition or safety concerns Quarterly MDS dated [DATE]:Sit to stand/ Bed mobility/transfers: dependentChair/bed-to-chair transfer: dependent-helper does all of the effort. Resident does none of the effort to complete activity.Walk 10 ft: supervision or touching assistanceWalk 50 ft: independent-Resident completes the activity by him/herself with no assistance from helperWalk 150 ft: independent-Resident completes the activity by him/herself with no assistance from helper Annual MDS dated [DATE]:Bed mobility/transfers: DependentSit to stand/ Bed mobility/transfers: dependentChair/bed-to-chair transfer: dependent-helper does all of the effort. Resident does none of the effort to complete activity.Walk 10 ft: supervision or touching assistanceWalk 50 ft: supervision or touching assistance-Helper provides verbal cues touching/steadying assistance as resident completes activity.Walk 150 ft: not applicable Quarterly MDS dated [DATE]:Bed mobility/transfers: DependentSit to stand/ Bed mobility/transfers: dependentChair/bed-to-chair transfer: dependent-helper does all of the effort. Resident does none of the effort to complete activity.Walk 10 ft: not attempted due to medical condition or safety concernsThe above findings indicate that the resident has experienced a progressive decline in ambulatory status over time. In September of 2024, the resident was able to ambulate up to 150 feet. However, by December of 2024, the resident was no longer able to ambulate that distance. As of April 2025, the resident was unable to ambulate any distance.Record review of a Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 00 which indicates the resident is unable to complete the assessment and has severe cognitive impairment. Additional review of this assessment revealed the resident is non-ambulatory and s/he is dependent with bed mobility. Record review of the resident's care plan revised on 8/13/2025 revealed the resident has impaired mobility and that the resident is dependent with bed mobility, transfers, ambulating and all activities of daily living. Record review revealed a Physical Therapy (PT) Discharge summary dated [DATE] states in part:- .Functional Skills Assessment:- Transfers: sit to stand=supervision or touching assistance. Chair/bed-to-chair transfer=supervision or touching assistance- Ambulation: Walk 10 feet=supervision or touching assistance- Ambulation: Walk 50 feet with Two Turns=Supervision or touching assistance.Record review of a progress note authored by Registered Nurse Practitioner (RNP), Staff S, dated 10/2/2024 states in part, .Plan: Order Physical Therapy Evaluation and Treatment.Starting to have contractures.Record review failed to reveal evidence that the resident had a PT evaluation or treatment as ordered on 10/2/2024. PT did not complete an evaluation until 8/27/2025 which was after the surveyor brought this to the facility's attention, which is approximately 10 months after the evaluation was ordered.Review of a PT document titled Evaluation Only dated 8/27/2025 states in part, .Musculoskeletal Assessment.LE [lower extremity] ROM [range of motion]=Impaired: LLE [left lower extremity ROM: Impaired. RLE [right lower extremity] ROM: Right Hip= Impaired; Knee= Impaired; Ankle=Impaired, LLE ROM: left Hip=Impaired; Knee=Impaired; Ankle=Impaired .RLE. LLE: Strength=patient with poor tolerance to PROM [passive range of motion] with increase tone, resulting in increased discomfort as noted by verbalization.During surveyor observations on the following dates and times, the resident was observed in bed with bilateral lower extremities contractures:-8/25/2025 at 9:50 AM, 11:25 AM, and 1:20 PM-8/26/2025 at 2:00 PM and 2:10 PM-8/27/2025 at 12:24 PM During an additional surveyor observation on 8/26/2025, at 2:15 PM, in the presence of the Unit Manager, Staff A, the resident was observed lying in bed with bilateral lower extremity contractures. The contractures were so severe that the resident's right heel was pressed up against his/her buttock.During a surveyor interview immediately following the above-mentioned observation, Staff A acknowledged the resident has bilateral lower extremity contractures. Additionally, Staff A indicated that she was unaware of when the resident's lower extremities became contracted.During a surveyor interview with the resident's family member on 8/26/2025 at 11:07 AM, s/he revealed that the resident was ambulating when s/he was admitted and is now contracted. She indicated that the resident has not received therapy to address his/her contractures.During interviews with the Staff A on 8/27/2025 at 12:15 PM and on 8/28/2025 at 8:40 AM, she revealed that she had made the PT referral on 8/26/2025 after observing the resident's contractures with the surveyor. Additionally, she indicated that the resident did not receive interventions to prevent contractures or received PT to address his/her contractures.During a surveyor interview on 8/27/2025 at 9:44 AM with the Director of Rehabilitation, she indicated that the resident had been evaluated by Occupational Therapy (OT) quarterly, and the last OT evaluation was on 8/5/2025 after s/he was readmitted after a brief hospital stay. She indicated that the resident was only evaluated and not admitted to OT services.Although the resident was evaluated by OT services, OT services focuses on improving the ability to perform daily activities such as dressing, bathing or cooking and PT services focuses on improving physical mobility and range of motion.During a surveyor interview on 8/28/2025, at 9:19 AM, RNP, Staff D acknowledged that the resident had severe bilateral lower extremity contractures. She was unable to provide information on when the contractures developed. Staff D further stated that she would assess the resident and consult with Physical Therapy to ensure appropriate interventions are implemented to prevent further decline in the resident's functional status. During a surveyor interviews on 8/27/2025 at 12:46 PM and on 8/28/2025 at 8:33 AM with the Director of Nursing Services (DNS), she acknowledged the resident has bilateral lower extremity contractures and was unable to provide evidence of when the resident's lower extremities became contracted or when the resident was no longer able to ambulate. The DNS indicated that the resident was ambulatory when she had begun in her role as the DNS at the facility in 2023. The DNS further acknowledged that the resident had developed his/her contractures at the facility, and she was unable to provide evidence that the resident had received treatment to prevent or address his/her contractures. The facility failed to ensure timely and appropriate assessment, intervention, and follow-up regarding the resident's progressive decline in functional mobility and development of severe bilateral lower extremity contractures, despite a physician's order for a PT evaluation on 10/2/2024. The records failed to reveal evidence of a completed evaluation until 8/27/2025, approximately 10 months later and only after the concern was brought to the facility's attention by the surveyor.Further, the facility failed to monitor and address the resident's deteriorating ambulatory status over time. In September of 2024, the resident was able to ambulate up to 150 feet, by December of 2024 the resident could no longer ambulate that distance, and as of 4/2025 the resident was no longer ambulatory. These significant changes were not appropriately assessed or addressed through timely interventions.These failures demonstrate a lack of timely coordination, communication, and clinical oversight, which may have contributed to the resident's functional decline and risk for further deterioration. The facility failed to take necessary actions to maintain or improve the resident's highest practicable level of functioning, as required under federal regulations.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 9 residents reviewed for weight loss, Resident ID #4.Findings are as follows:Review of a facility policy titled, Weight Loss/Gain Protocol and Heights states in part, POLICY: All residents are to be weighed upon admission and at least monthly; so as to monitor for weight loss or gain, to assess for underlying causes for weight loss or gain, to intervene accordingly and timely to allow for an optimal level for well-being.PROCEDURE:.a significant weight discrepancy is defined as: 1. A weight change of 3 pounds or more in one week (if resident on weekly weights); 2. A loss/gain of 5% or greater within one month.When a significant weight loss/gain is noted.the following must occur.a. Reweigh all residents who are reported to have a significant weight discrepancy in order to assess the accuracy of the weight. The reweigh shall be done within 48 hours of the initial weight. b. If the re-weigh is accurate and there has been a significant weight loss/gain, nursing must notify the; Physician, Dietician, DNS [Director of Nursing Services], Resident Representative.c. Review the resident's current diet for appropriateness. d. Start weekly weights, if not already on.II. For any resident who tolerates less than 50% of any meal, the resident(s) will be offered a nutritional supplement (the house supplement).1a. Record review revealed Resident ID #4 was admitted to the facility in May of 2022 with diagnoses including, but not limited to, fracture of the neck, dementia with psychotic disturbance, and stage 4 pressure ulcer (full thickness tissue loss extending into muscle, tendon, or bone) of the right buttock.Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a Brief Interview for Mental Status score of 4, indicating s/he has severe cognitive impairment. Additionally, it revealed the resident experienced a weight loss of 5% or more in the last month without being on a physician-prescribed weight loss regimen.Record review revealed the resident weighed 164.8 pounds (lbs.) on 1/2/2025 and 161.9 lbs. on 3/2/2025.Record review revealed a physician's order dated 1/30/2024, for a house supplement, 4 ounces, two times per day.Additional record review revealed a nutrition note dated 4/11/2025 which states in part, Weight is stable at this time with overall good intake, recommend reducing supplementation at this time to QD [once daily], RD [Registered Dietitian] to follow up and provide additional recommendations as warranted.Additional record review revealed a physician's order dated 4/12/2025 to decrease the house supplement, of 4 ounces, from twice daily to once a day. Record review revealed s/he consumed 100% of the ordered supplement for 26 out of 28 opportunities in August of 2025.Record review revealed the following documented weights:4/1/2025- 160. 4 lbs.5/2/2025 - 158.2 lbs.6/2/2025 - 154.6 lbs.7/2/2025 - 142.1 lbs.7/8/2025 - 143.0 lbs.8/4/2025 - 142.3 lbs.This indicates that the resident lost 18.3 lbs. from 4/1/2025 to 7/2/2025, which is a severe weight loss of 11.4%.Record review failed to reveal evidence that a reweight was obtained following the weight loss on 7/2/2025, per the facility policy.Record review failed to reveal evidence that the RD, Staff F, assessed the resident for his/her weight loss on 7/2/2025 until 8/26/2025. Further review failed to reveal evidence that new interventions were implemented for Resident ID #4's severe weight loss.During a surveyor interview with the Nurse Practitioner (NP), Staff G, on 8/28/2025 at 9:43 AM, she revealed that she was aware of Resident ID #4's weight loss in July and thought that dietary was following [him/her]. Additionally, she acknowledged that there were no interventions in place to mitigate his/her weight loss, and she would have increased the house supplement back to twice per day and ordered Remeron (a medication to stimulate appetite) to improve his/her intake.During a surveyor interview with the RD on 8/28/2025 at 10:43 AM, she revealed she is made aware of any significant changes in weight through the weight exceptions report in the medical record. She indicated that she would expect a reweight to be obtained when there is a difference of 5 lbs. or more from the previous weight. She also indicated that she was aware of Resident ID #4's weight loss, however, she acknowledged that she did not recommend any additional interventions to address it.Record review failed to reveal evidence that a subsequent weight was obtained after the weight loss was brought to the facility's attention by the surveyor.1b. Record review of a wound progress note dated 6/26/2025, states in part, .wound consult requested for resident with wound to right inferior buttock.pressure ulcer of right buttock, unstageable [a full-thickness pressure injury where the base of the wound is obscured by dead or leathery tissue].ASSESSMENT/PLAN: All recommendations will remain in effect until discontinued, revised, or replaced.Optimize Nutrition - Registered Dietician consultation.Additional record review revealed the wound was diagnosed as a stage 4 pressure ulcer.Record review failed to reveal evidence that the RD assessed the resident for nutrition recommendations related to his/her pressure ulcer until 8/26/2025, 2 months after the wound was identified.Record review revealed the following physician orders were implemented for wound healing on 8/27/2025:- Ascorbic acid tablet 250 milligrams (mg), 1 tablet by mouth one time a day- Zinc oral tablet 50 mg, one tablet by mouth one time a day- Prostat Extra Protein, 30 milliliters, one time a dayDuring a surveyor interview with NP, Staff G, on 8/28/2025 at 9:43 AM, she revealed that the resident's pressure ulcer was originally identified on 6/26/2025. She indicated that she agrees with the treatment recommendations made by the wound provider. Additionally, she revealed she would have expected dietary to conduct a consult for the resident's wound when it was identified.During a surveyor interview with the RD, Staff F, in the presence of RD, Staff H, on 8/28/2025 at 10:43 AM, she revealed she was aware that the resident had a stage 4 pressure ulcer discussed at weekly interdisciplinary meetings, however, there is no specific process for wound recommendations relative to nutrition. She was unable to provide evidence that the resident was assessed for nutritional needs relative to his/her wound until 8/26/2025.During a surveyor interview with the Director of Nursing Services (DNS) on 8/28/2025 at 12:49 PM, she indicated she would have expected new interventions to be implemented to address Resident ID #4's severe weight loss. Additionally, she was unable to provide evidence that a dietary consult for his/her wound was completed until 8/26/2025.

Based on surveyor observation, record review, 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 4 of 4 kitchenettes observed.Findings are as follows:1. Record review of Rhode Island Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and 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 .During the initial tour of the kitchen in the presence of the Assistant Food Service Director (AFSD), on 8/25/2025 at 8:37 AM, the following was observed:In the walk-in refrigerator: - three containers of fresh strawberries, approximately 1 pound each, observed with white fuzzy matter, without a discard date - one container of fresh blueberries, approximately 1 pint, observed with white fuzzy matter, without a discard date In the walk-in freezer: - one bag of sausage patties, containing approximately 20 patties, open without a label or discard date. During a surveyor interview with the AFSD immediately following the above observations, he acknowledged the container of strawberries and blueberries should have been thrown away. Additionally, he acknowledged that the bag containing sausage patties should have been labeled and included a discard date.During a surveyor observation of the 1st floor kitchenette on 8/28/2025 at approximately 9:52 AM, revealed a large bag of a rice crispy type cereal, approximately 32 ounces, was observed to be 1/4 full, opened, without a label or discard date.During a surveyor interview immediately following the above observation with Nursing Assistant, Staff N, she acknowledged the cereal did not contain a label or discard date and should have.During a surveyor observation of the 2nd floor kitchenette on 8/28/2025 at approximately at 8:00 AM, a large bag of a rice crispy type cereal approximately 32 ounces, was observed to be 2/3 full, opened, without a label or discard date.During a surveyor interview immediately following the above observation with the Food Service Director, Staff O, she acknowledged the cereal did not contain a label or discard date and should it have.During a surveyor observation of the 3rd floor kitchenette on 8/27/2025 at 10:13 AM, revealed a large bag of a corn flake type cereal approximately 32 ounces, was observed to 1/2 full, opened, without a label or discard date.During a surveyor interview immediately following the above observation with Medication Technician, Staff P, acknowledged it did not contain a label or discard date and should have.During a surveyor observation of the 4th floor kitchenette on 8/28/2025 at 9:35 AM, revealed in an upper cabinet above the top shelf, a covered warmer plate containing 2 biscuits, an egg omelet and two fried eggs wrapped in a napkin, along with a cup 2/3 full of oatmeal.During a surveyor interview immediately following the above observation with Nursing Assistant, Staff Q, she acknowledged the plate of food and indicated that it should not have been placed there.2. Record review of the Rhode Island Food Code, 2022 Edition, Section 3-501.15 states in part, FOOD EMPLOYEES shall clean their hands in a HANDWASHING SINK OR APPROVED automatic handwashing facility and may not clean their hands in a sink used for FOOD preparation or WAREWASHING, or in a service sink.Record review of a facility policy titled Hand Washing, indicates that staff should wash their hands before handling food (even between tasks), before handling clean dishes and upon arrival and returning to the kitchen. During a surveyor observation of the main kitchen on 8/25/2025 at approximately 10:00 AM, Dietary Aide, Staff R, was observed scraping food off of a dirty dish into the trash barrel using her bare hands, she was observed with visible food debris on her hands as she walked over to the 3-bay sink that is used to wash pans. She then placed a metal bin in the wash sink and proceeded to rinse her hands off in the 3-bay sanitizer sink. She then touched the outside of a clean stack of bins and resumed scraping dirty dishes.During a surveyor interview with Staff R immediately following the above observations she acknowledged that she rinsed her hands in the sanitizing sink and indicated that she should have used the handwashing sink.

Based on record review and staff interview, it has been determined that the facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program relative to a performance improvement project (PIP) involving significant weight loss. Findings are as follows:Review of the QAPI binder for 2025 revealed that the facility had a PIP in place for significant weight loss. Further record review failed to reveal evidence of documentation demonstrating the plan implementation, and evaluation of corrective actions or performance improvement activities relative to the significant weight loss PIP.During a surveyor interview on 8/28/2025 at 1:00 PM with the Administrator and Director of Nursing, they were unable to provide evidence of documentation that includes the monitoring and auditing of data relative to their QAPI plan for significant weight loss.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 2 of 7 residents reviewed with pressure ulcers (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #s 4 and 99.Findings are as follows:1.Record review revealed Resident ID #4 was admitted to the facility in May of 2022 with diagnoses including, but not limited to, fracture of the neck, dementia with psychotic disturbance, and stage 4 pressure ulcer (full thickness tissue loss extending into muscle, tendon, or bone) of the right buttockRecord review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has one or more unhealed pressure ulcers or injuries.Record review of a progress note dated 6/21/2025 states in part, During care, CNA [certified nursing assistant] reported that resident had an open area. Upon assessment, the resident was noted to have redness and an open area in the right trochanter [upper buttocks/hip, where the femur meets the hip socket] area.NP [Nurse Practitioner] .was notified.who gave the order to clean the area with normal saline, cover with a dry dressing off-load pressure every 2 hours.Further record review revealed the wound was assessed by the Wound Nurse on 6/23/2025 and a new treatment implemented to cleanse the wound with wound cleanser, pat dry, apply calcium alginate to the base of the wound, and cover with a bordered foam dressing daily and as needed.Record review of the following wound provider progress notes revealed the following: -6/26/2025, states in part, .wound consult requested for resident with wound to right inferior buttock. Slough [dead yellow or white tissue that accumulates on the surface of the wound] noted to wound- unable to determine depth. Will treat with Santyl [a topical medication used to remove dead skin tissue from wounds].pressure ulcer of right buttock, unstageable [a full-thickness pressure injury where the base of the wound is obscured by dead or leathery tissue].ASSESSMENT/PLAN: All recommendations will remain in effect until discontinued, revised, or replaced.Optimize Nutrition - Registered Dietician [RD] consultation. -7/10/2025, states in part, .Right inferior buttock wound measurements increased. Slough and small amount of granulation tissue [a type of connective tissue that forms on the surface of the wound during the healing process] noted. Odor, erythema [redness], and purulent [pus] drainage noted.wound.right inferior, buttock.unstageable.Optimize Nutrition - Registered Dietician consultation.-7/17/2025, states in part, .wound.right, inferior, buttock.unstageable.ASSESSMENT/PLAN: Optimize Nutrition - Registered Dietician consultation.-7/31/2025, states in part, .wound.right, inferior, buttock.unstageable.ASSESSMENT/PLAN: Optimize Nutrition - Registered Dietician consultation.-8/7/2025, states in part, .wound.right, inferior, buttock.unstageable.ASSESSMENT/PLAN: Optimize Nutrition - Registered Dietician consultation.-8/14/2025, states in part, Right inferior buttock wound measurements and slough improving. Fascia [muscle tissue] noted .wound.right, inferior, buttock.stage 4.ASSESSMENT/PLAN: Optimize Nutrition - Registered Dietician consultation.-8/21/2025, states in part, wound.right, inferior, buttock.stage 4.ASSESSMENT/PLAN: Optimize Nutrition - Registered Dietician consultation.Record review failed to reveal evidence that the RD completed a nutritional consult after the Wound Provider made repeated recommendations for a dietary consult, until 8/26/2025 which was 2 months after the wound was identified.Record review revealed the following dietary recommendations were approved by the provider and orders were implemented for wound healing on 8/27/2025:- Ascorbic acid tablet 250 milligrams (mg), 1 tablet by mouth one time a day- Zinc oral tablet 50 mg, one tablet by mouth one time a day- Prostat Extra Protein, 30 milliliters, one time a day During a surveyor interview with RNP, Staff G, on 8/28/2025 at 9:43 AM, she revealed that the resident's pressure ulcer was originally identified on 6/26/2025 and treatment recommendations were made by the Wound Provider. Additionally, she revealed she would have expected the RD to complete a dietary consult for the resident's wound when the wound was identified.During a surveyor interview with the RD, Staff F, in the presence of RD, Staff H, on 8/28/2025 at 10:43 AM, she revealed she was aware that the resident had a stage 4 pressure ulcer as this was discussed at the weekly interdisciplinary meetings, however, she acknowledged that she failed to complete a nutritional assessment for the resident until 8/26/2025.During a surveyor interview with the Director of Nursing Services (DNS) on 8/28/2025 at 12:49 PM, she was unable to provide evidence that a dietary consult for Resident ID #4's pressure wound was completed until 8/26/2025.2. Record review revealed Resident ID #99 was admitted to the facility in February of 2023 and readmitted in August of 2025 with diagnoses including, but not limited to, dementia, left sided hemiplegia (paralysis that affects only one side of the body), left sided hemiparesis (muscle weakness on one side of the body) and bilateral lower leg contractures.The resident experienced a progressive decline in functional abilities over a period of time and developed contractures to his/her lower extremities. In September of 2024, the resident was able to ambulate up to 150 feet and by April of 2025, the resident was unable to ambulate any distance.Record review of a Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 00 which indicates the resident is unable to complete the assessment and has severe cognitive impairment. Additional review of this assessment revealed the resident is non-ambulatory and s/he is dependent with bed mobility. Record review of the resident's care plan revised on 6/19/2025 and on 7/14/2025 revealed the resident has potential for pressure injury development related to impaired mobility and impairment cognition, and the resident is dependent with bed mobility, transfers, ambulating and all activities of daily living. Staff interventions include but is not limited to offload the resident's bilateral heels with booties or pillow (s) as tolerated.Record review revealed the following progress notes:- 1/17/2025: .patient was noted to have a new DTI [deep tissue injury, a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on the side of right foot and boggy heels (tissue that feels unusually soft often a sign of a DTI indicating damage to the tissues beneath the intact skin) . - 3/11/2025: .resident has reddened area to right heel.which is new.Noticed darkened areas to right lateral foot.non-blanchable [a localized area of red, purple, or bluish skin that remains discolored when pressed, indicating impaired blood flow and underlying tissue damage]. - 4/3/2025: .unstageable pressure wound [a pressure sore where the depth of tissue damage cannot be determined due to presence of dead tissue] to L [left]medial heel.- 5/29/2025: .patient does have a wound on [his/her] right side of [his/her] foot.pressure ulcers on both heels.- 8/6/2025: right heel boggy.During surveyor observations on the following dates and times, the resident was lying in bed without wearing booties and s/he did not have a pillow(s) under his/her lower extremities as indicated in the care plan:-8/25/2025 at 9:50 AM, 11:25 AM, and 1:20 PM-8/26/2025 at 2:00 PM and 2:10 PM-8/27/2025 at 12:24 PM During a surveyor interview on 8/27/2025 at 12:25 PM with Nursing Assistant, Staff B, she revealed that she provided care to the resident on 8/25/2025 and 8/26/2025 and further revealed that she did not put booties on the resident after care was provided. She further indicated that the resident no longer uses booties.During an additional surveyor observation on 8/26/2025, at 2:15 PM, in the presence of the Unit Manager, Staff A, the resident was observed lying in bed with bilateral lower extremity contractures. The contractures were so severe that the resident's right heel was pressed up against his/her buttock. Further observation of the resident's bilateral heels revealed his/her skin was intact.During a surveyor interview immediately following the above-mentioned observation, Staff A acknowledged the resident was not wearing his/her booties and did not have a pillow (s) under his/her lower extremities. During subsequent interviews with Staff A on 8/27/2025 at 12:15 PM and 8/28/2025 at 8:40 AM, she acknowledged the resident's care plan indicated booties are to be worn and revealed the resident did not have booties in his/her room. Additionally, she indicated that the resident has had a history of pressure ulcers to his/her bilateral heels. Cross reference F 688

Based on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 4 residents reviewed, Resident ID #2.Findings are as follows:Record review revealed the resident was readmitted to the facility in April of 2025 with a diagnosis including, but is not limited to, sepsis (a life-threatening emergency caused by the body's response to an infection).Review of the resident's physician orders revealed an active order, with a start date of 4/11/2025, for a Complete Blood Count (CBC) and a Complete Metabolic Panel (CMP) every Thursday.Record review of the resident's lab work failed to reveal evidence that the CBC and CMP were obtained on the following dates: 7/3, 7/10, 7/17, 7/25, 7/31, 8/7 and 8/21/2025. This indicates that the resident did not receive his/her ordered lab work for 7 of 9 opportunities. During a surveyor interview on 8/27/2025 at 10:43 AM with Registered Nurse, Staff I, she revealed that the order was put into the electronic medical record incorrectly so that it didn't alert the nurse to fill out the lab slip. This caused the CBC and CMP not to be obtained as ordered.During a surveyor interview on 8/27/2025 at approximately 12:48 PM, with the Director of Nursing Services, she acknowledged that the lab work was not obtained as ordered on the above dates.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following the parameters for a physician's order for Metoprolol Succinate Extended Release (a medication prescribed to treat various heart conditions), for one of one resident reviewed, Resident ID #125. Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow 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 July of 2025 with diagnoses including, but not limited to, high blood pressure and heart failure (a condition where the heart is unable to pump blood effectively).Record review revealed a physician's order dated 7/3/2025 for Metoprolol Succinate Extended Release, give 50 milligrams (mg) by mouth daily. Further review of the order revealed parameters to hold the medication for a systolic blood pressure (the top number of a blood pressure reading) of less than 100 and/or a heart rate of less than 60. Record review of the July and August 2025 Medication Administration Records failed to reveal evidence that the resident's heart rate was obtained prior to the Metoprolol Succinate being administered.During a surveyor interview on 8/28/2025 at 9:47 AM with Registered Nurse, Staff E, she acknowledged that the Metoprolol order did not include documentation of the resident's heart rate. Additionally, she was unable to provide evidence that the resident's heart rate was obtained prior to the administrations of Metoprolol for July and August of 2025.During a surveyor interview on 8/28/2025 at 11:00 AM with the Director of Nursing, she revealed that she would expect that the Metoprolol order would be followed, and that the resident's heart rate would be obtained prior to the medication being administered.

Based on surveyor observation and staff interview, it has been determined that the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services relative to the testing of the water temperature of the main dishwashing machine to ensure proper sanitization. Findings are as follows:Record review of a facility policy titled, OnTray Dietary Policies and Procedures Mechanical Ware Washing (Dish Machine) reveals in part, . The proper cleaning and sanitizing of dishes in the dietary department is extremely important to the health and safety of residents. It is especially important to follow the guidelines noted below and the requirements of the dish machine.The dietary Manager should ensure that the staff know where the requirements are located on the machine, and where the temperature logs and test strips or thermometer, for high temp machines.are located. It is advisable to use a test strip or thermometer for high temp machines instead of relying on the outside thermometer.The internal temperature of the sanitizing cycle (if a high-temperature machine).should be tested and logged before washing dishes from each meal to ensure the dish machine is properly sanitizing dishes.Follow the manufacturer's directions for checking temperature and sanitizer.According to the dish machine manual titled American Dish Services Installation Instructions states in part, .TESTING FOR TEMPERATURE- for high temp sanitizing. The measurements taken at the manifold for a minimum of 180 Fahrenheit (F).if color changing tapes are used to verify temperature, then only 165 F labels should be used.this is according to the National Sanitation Foundation (NSF)/American National Standards Institute (ANSI) Standard 3 test health protocol [a standard of minimum public health and sanitation requirements for commercial dishwashing machines] .During a surveyor observation of a test dishwashing cycle on 8/25/2025 at 9:15 AM, the Assistant Food Service Director (AFSD) was observed placing a bowl on a dish rack through the dish machine. When the cycle was finished, the AFSD then took the temperature of the water collected in the bowl with a thermometer which read 164 F. On the machine's gauge, the wash cycle was observed to reach a temperature of 161 F and the final rinse cycle reached a temperature of 175 F. When prompted by the surveyor, he ran a second test cycle to which the gauge read a temperature of 182 F for the final rinse.During a surveyor interview at the time of the above observation with the AFSD, he revealed he obtains the water temperature by dipping a thermometer into a cup of water collected from the wash cycle. Additionally, he indicated that since he didn't see any chemicals, the dish machine was probably a high temperature machine. Further, he was unaware that he needed to use temperature test strips in the manifold to ensure the machine was sanitizing properly.During a surveyor interview on 8/25/2025 at 9:20 AM with the following staff revealed that they do not test the water temperatures of the dish machine, and they are unaware of how to perform the procedure:-Dietary Aide (DA), Staff J-DA, Staff K-DA, Staff LDuring a surveyor interview on 8/25/2025 at approximately 9:30 AM with Dietary Cook, Staff M, she revealed that the DA's are responsible to test the dish machine's water temperatures.Record review of the instructions for using the temperature test strips indicated that a single-use label should be applied directly to a dry dish or bin before it is loaded into the machine. The label has an adhesive backing to ensure it stays securely in place. These stickers utilize a thermochromatic color-change band that shifts from blue to orange when the appropriate temperature for sanitization is reached.During a surveyor observation and interview with the AFSD on 8/25/2025 at 9:52 AM, the AFSD was seen dipping a temperature test strip into a cup containing water collected from the dish machine cycle. He explained that this was the method he used when testing the dish machine's temperature. This indicated that the AFSD to was unaware of how to test the dish machine to ensure proper sanitization. Additionally, he revealed that the machine has an external gauge which he uses to record water temperatures.During a surveyor observation and simultaneous interview with the AFSD on 8/25/2025 at 9:56 AM, he was observed twice unsuccessfully attempting to place a test sticker to a wet plate. The surveyor then prompted the AFSD to place the self-adhesive test strip on a dry plate and run that through the dish machine cycle to accurately test the temperature at the manifold to ensure the minimum temperature of 180 F is reached at the final rinse. Additionally, the AFSD acknowledged that he did not know the proper procedure to test the water temperature.

Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or, no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the local state agency (Rhode Island Department of Health, RIDOH), in accordance with State law, for 1 of 2 residents reviewed for allegations of abuse, Resident ID #1. Findings are as follows: Review of a facility's policy titled Abuse prohibition dated 10/31/2022 states in part, .Any instance of actual or suspected abuse .must be reported immediately to the DNS [Director of Nursing] .an incident report is to be filled out. The Department of Health will be contacted of allegations of abuse . Review of a community reported complaint submitted to RIDOH dated 5/19/2025 alleged, Resident ID #1's continuity of care form that was sent with him/her to a facility from the hospital revealed that s/he had allegedly killed someone at Berkshire Place. Record review revealed the resident was readmitted to the facility in December of 2021 with diagnoses including, but not limited to, dementia and anxiety disorder. Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident's cognition is intact. Record review of a progress note dated 3/13/2025 at 12:30 PM revealed, Resident ID #1 walked up to another resident and threatened to physically harm that resident. Further record review of this progress note revealed that Resident ID #1 was sent to the emergency room for an evaluation and was admitted . During a surveyor interview on 5/19/2025 at 9:33 AM with the Director of Nursing services (DNS), she acknowledged that the resident threatened to physically harm another resident on 3/13/2025 and s/he was sent to the hospital for an evaluation. Additionally, the DNS acknowledged that she did not repot this incident to RIDOH, as required.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 2 of 4 medication carts observed. Findings are as follows: Review of a facility policy titled Medication Storage dated January 2023 states in part, Medications and biological's are stored properly, following manufacturers or provider pharmacy recommendations to maintain their integrity .Medications requiring refrigeration are kept in a refrigerator . Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/19/2025, alleged that medications are not stored and administered correctly to residents. 1. A surveyor observation on 5/20/2025 at 9:07 AM of the second floor [NAME] Medication Cart in the presence of Certified Medication Technician (CMT), Staff A, revealed two Trelegy Ellipta inhalers opened and not dated. Manufacturer's instructions indicate to discard the inhalers 6 weeks after opening. During a surveyor interview immediately following the above-mentioned observation with Staff A, she acknowledged the inhalers were opened and not dated. 2. A surveyor observation on 5/20/2025 at 9:17 AM of the second-floor nurse medication cart in the presence of Licensed Practical Nurse, Staff B, revealed the following: - Morphine Sulfate 100 milligram (mg)/5 millimeter (ml) opened and not dated. Manufacturer's instructions indicate to discard this medication 90 days after opening. - Lorazepam Intensol oral suspension 2 mg/ml opened and not dated. Manufacturer and pharmacy label on the packet of this medication indicated to refrigerate this medication and to discard it after 90 days. During a surveyor interview immediately following the above-mentioned observation with Staff B, she acknowledged the Morphine Sulfate and the Lorazepam Intensol were opened and not dated. Additionally, Staff B acknowledged the Lorazepam was not stored in the refrigerator, as required. 3. A surveyor observation on 5/20/2025 at 9:30 AM of the first-floor nurse medication cart in the presence of a Registered Nurse, Staff C, revealed two bottles of Morphine Sulfate 100 mg/5 ml opened and not dated. Manufacturer's instructions indicate to discard this medication 90 days after opening. During a surveyor interview immediately following the above-mentioned observation with Staff C, she was unable to provide evidence the Morphine Sulfate bottles were stored appropriately, as required. During a surveyor interview on 5/20/2025 at 1:08 PM with the Director of Nursing Services, she indicated that she would expect the above-mentioned medications to be dated when opened and would expect the Lorazepam to be refrigerated, as required.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident receives adequate supervision to prevent accidents for 1 of 1 resident reviewed who successfully eloped from the facility, Resident ID #2. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/27/2025, alleges that Resident ID #2 eloped from the facility on 2/3/2025, following a snowstorm. Additionally, upon return, the facility failed to perform an elopement assessment and had initially stated that the resident left against medical advice (AMA). Record review of a facility policy dated 11/1/2022 titled, Elopement Assessments states in part, .It is the policy of this facility to maintain a safe and secure environment for all residents. In order to achieve this goal residents who are at risk of wandering/elopement need to be identified and a care plan developed with interventions to minimize or eliminate the risk .an elopement assessment is to be performed whenever a resident exhibits a change in behaviors which signals an increased risk, such as verbalizing a wish to leave the building . Record review revealed the resident was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges). Review of an Admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 9 out of 15, indicating moderately impaired cognition. Further review revealed the resident is dependent upon staff for dressing and requires supervision or touching assistance for ambulation. Record review of a document titled; Elopement Evaluation dated 1/22/2025 revealed the resident was not at risk for elopement. Record review revealed a physician order dated 1/22/2025 which indicated the resident may not go out on leave of absence. Record review of a document titled, Smoking Risk assessment dated [DATE] revealed that the resident requires supervision for smoking and that s/he is an elopement risk. Record review revealed the following progress notes: - 1/26/2025 at 2:57 PM, the resident was oriented to person only and s/he was confused. - 1/27/2025 at 9:00 AM, the resident continued to ask multiple staff when s/he was going home. -1/28/2025 at 5:41 AM, the resident has expressed a strong desire to return home and s/he ambulates independently without the use of an assistive device. - 2/3/2025 at 10:07 AM, the resident left the facility and took a bus to his/her previous residence, an Assisted Living Facility (ALF) in the community, approximately 2 miles away. Additionally, the note indicates that a call was received from the ALF to inform the facility that the resident was there. Transport was arranged and a staff member was sent to pick up the resident and return him/her back to the facility. - 2/4/2025 at 10:30 AM, the resident left the facility AMA on 2/3/2025. - 2/8/2025 at 8:00 AM, the resident continues on 1:1 status due to being an elopement risk. - 2/26/2025 at 3:51 PM, the resident is an elopement risk. Record review failed to reveal evidence that an elopement assessment had been performed, and a care plan was developed with interventions to minimize risks per facility policy following the resident's successful elopement from the facility. During a surveyor interview on 3/27/2025 at approximately 2:15 PM with the Director of Nursing Services, she revealed that on 2/3/2025, the resident left the faciity on his/her own accord and since s/he is alert and oriented, it was her interpretation that the resident had left AMA from the facility. However, she was unable to provide evidence of a completed AMA discharge form. She acknowledged that the resident had a BIMS score of 9 out of 15, indicating moderate cognitive impairment and that s/he has a physician order indicating that s/he may not go out on a leave of absence from the facility. Further, she was unable to provide evidence that an Elopement Evaluation had been completed after s/he left the facility unsupervised on 2/3/2025. During a surveyor interview on 3/27/2025 at 2:44 PM with the Administrator, she acknowledged that an AMA discharge documentation or assessments had not been performed. She further acknowledged that the progress notes indicated that the resident had eloped, and that an Elopement Evaluation had not been completed, a care plan had not been developed, and appropriate interventions were not in put in place for the resident per facility policy following the above-mentioned incident.

Based on record review and staff interview, it has been determined that the facility failed to notify the resident and the resident's representative(s) of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 1 of 1 resident who was transferred to the hospital and discharged from the facility, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to The Rhode Island Department of Health on 1/15/2025, alleged that Resident ID #1 was not permitted to return to the facility, and s/he was not given a 30 day notice, as required. Record review revealed that the resident was admitted to the facility in July of 2019 with diagnoses of violent behaviors and dementia. Record review revealed a Quarterly Minimum Data Set Assessment, dated 12/2024, revealed a Brief Interview for Mental Status Score could not be completed as the resident has severe cognitive impairment. Record review further revealed that s/he was transferred to the emergency room for evaluation following an alleged resident to resident interaction on 1/14/2025 at 1:32 PM. Further record review revealed that the resident was documented as being discharged from the facility on 1/14/2025. Record review failed to reveal evidence that the facility notified the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. During a surveyor interview with the Administrator and the Director Of Nursing on 1/17/2025 at approximately 1:10 PM, they were unable to provide evidence that the resident and the resident's representative(s) were notified of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Cross Reference F 625 and F 626

Based on record review and staff interview, it has been determined that the facility failed to provide evidence that written notification was provided to the resident or resident representative(s) regarding a bed hold. Additionally, at the time of transfer the facility failed to provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy for 1 of 1 resident who was transferred to the hospital, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to The Rhode Island Department of Health on 1/15/2025, alleged that Resident ID #1 was not permitted to return to the facility, and s/he was not given a 30 day notice, as required. Record review revealed that the resident was admitted to the facility in July of 2019 with diagnoses of violent behaviors and dementia. Record review revealed a Quarterly Minimum Data Set Assessment, dated 12/2024, revealed a Brief Interview for Mental Status Score could not be completed as the resident has severe cognitive impairment. Record review further revealed that s/he was transferred to the emergency room for evaluation following an alleged resident to resident interaction on 1/14/2025 at 1:32 PM. Further record review revealed that the resident was documented as being discharged from the facility on 1/14/2025. Record review failed to reveal evidence that written notification was provided to the resident or resident representative(s) regarding a bed hold that specifies the duration of the state bed-hold policy during which the resident is permitted to return and resume residence in the nursing facility, the reserve bed payment policy in the state plan and the nursing facility's policies regarding bed-hold periods. Additionally, record review failed to reveal evidence that at the time of resident's transfer from the facility that the resident and the resident representative(s) were provided with written notice of the duration of the bed-hold policy. During a surveyor interview with the Administrator and the Director of Nursing on 1/17/2025 at approximately 1:10 PM, they were unable to provide evidence that the facility provided written information to the resident or resident representative(s) regarding a bed hold. Additionally, they were unable to provide evidence that at the time of transfer the resident or the resident representative was provided with written notice of the duration of the bed-hold policy. Cross Reference F 623 and F 626

37158 Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight for 2 of 14 residents reviewed for nutrition, Resident ID#s 115 and 93. Findings are as follows: Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, revised on 2/3/2023, reveals a weight loss of 5% in 1 month, 7.5% in 3 months, and 10% in 6 months is significant weight loss. Additionally, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months is severe weight loss. Review of the facility's policy and procedure, undated and untitled, was provided by the facility which states in part, .If the weight shows a discrepancy of (+) or (-) 5 pounds, the nurse is to be notified who will then be required to supervise the reweight . MONTHLY WEIGHTS: 1. Monthly weights will be obtained on first shift . 2. The charge nurse will ensure that the weight provided by the aid is accurate. 3. If the resident has a 5 pound variance, the nurse and the aid will re-check the weight within 24 hours. If the weight continues to show a variance, the nurse will contact the MD and Dietician at which time appropriate orders/recommendations will be made . 4. Weights will be recorded by the charge nurse (7-3), in the computer and signed off. 1. Record review for Resident ID #115 revealed s/he was admitted to the facility in March of 2023 with diagnoses including, but not limited to, adult failure to thrive and severe-protein calorie malnutrition. Record review of an Admission Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11 out of 15, indicating that the resident has mild cognitive impairment. Record review of the care plan initiated on 3/17/2023 with a focus for nutritional problem with interventions including, but not limited to, offering dietary supplements and snacks as the resident will tolerate. Further record review of the physician's orders revealed an order dated 4/26/2023 for ice cream with every meal. Record review of the resident's diet slip failed to reveal documentation indicating that the resident is to receive ice cream with every meal. Surveyor observations revealed ice cream was not provided to the resident during his/her meals on the following dates and meals: -6/5/2023 during the lunch meal -6/6/2023 during the lunch meal -6/7/2023 during the lunch meal During a surveyor interview on 6/7/2023 at 12:53 PM with Nursing Assistant, Staff C, she revealed she has been taking care of the resident since s/he was admitted . Staff C revealed the resident likes ice cream and if s/he wants ice cream, s/he will call the kitchen to have ice cream sent up for the resident. Record review revealed the resident was discharged to an acute care facility on 4/6/2023 and returned to the facility on [DATE]. Record review revealed the following weights on the following dates and times: -6/2/2023 125.0 Lbs. -6/1/2023 125.0 Lbs. -5/30/2023 123.2 Lbs. -5/24/2023 124.2 Lbs. -5/22/2023 122.0 Lbs. -5/18/2023 121.0 Lbs. -5/12/2023 134.2 Lbs. -5/11/2023 133.6 Lbs. -5/10/2023 135.2 Lbs. -5/9/2023 133.2 Lbs. -5/8/2023 133.4 Lbs. -5/7/2023 133.4 Lbs. -5/5/2023 133.8 Lbs. -5/4/2023 138.2 Lbs. -4/30/2023 128.8 Lbs. -4/29/2023 128.2 Lbs. -4/28/2023 130.6 Lbs. -4/27/2023 135.8 Lbs. -4/26/2023 135.0 Lbs. -4/26/2023 135.0 Lbs. -4/25/2023 138.2 Lbs. -4/24/2023 138.0 Lbs. -4/23/2023 141.0 Lbs. -4/20/2023 151.2 Lbs. -4/20/2023 154.5 Lbs. -4/19/2023 155.0 Lbs. -4/18/2023 154.6 Lbs. -4/17/2023 157.2 Lbs. -4/16/2023 159.0 Lbs. -4/13/2023 159.2 Lbs. Record review of the weights documented revealed the resident experienced a weight loss of 24.2 Lbs. (15.2%) in 13 days, from 4/13/2023 to 4/26/2023. Additionally, the facility obtained an order for ice cream to be given to the resident with all meals. Record review failed to reveal evidence that the ice cream was provided with all meals, as ordered by the physician on 4/26/2023. Further record review revealed the resident continued to lose an additional 10 Lbs. from 4/26/2023 to 6/2/2023, indicating a severe weight loss of 34.2 Lbs. (21.5%) since 4/13/2023. During a surveyor interview with the Registered Dietitian (RD) on 6/8/2023 at 11:58 AM, she revealed that the ice cream was ordered with the goal to help prevent further weight loss. Additionally, the RD could not explain why the ice cream order was not added to the resident's diet slip. During a surveyor interview with the resident on 6/7/2023 at 1:04 PM, the resident revealed s/he likes ice cream. The resident further revealed s/he could not recall the last time s/he received ice cream with his/her meal. During a surveyor interview on 6/7/2023 at 1:08 PM with Licensed Practical Nurse, Staff L, she revealed staff will call the kitchen if the resident requests ice cream as ice cream is not supplied on the unit. She further revealed she wrote the order for the ice cream with all meals. When asked how they communicate diet orders with the kitchen staff, she revealed they write the diet order on a diet slip and send that to the kitchen. Additionally, she acknowledged that the resident's diet ticket did not include ice cream with meals. During a surveyor interview with the Director of Nursing Services (DNS) on 6/7/2023 at 2:17 PM and again at 5:20 PM, she revealed that the ice cream is provided by the kitchen. Additionally, she could not explain why the ordered ice cream was not provided to the resident. During a surveyor interview on 6/8/2023 at 11:08 AM with the Food Service Director, she revealed she was unaware of the order for ice cream with meals and that no one sent the diet slip down to the kitchen for ice cream. 2. Record review for Resident ID #93 revealed s/he was admitted to the facility in September of 2018 with diagnoses including, but not limited to, severe protein-calorie malnutrition and Alzheimer's disease. Record review of the resident's weights revealed the following: -4/10/2023 107.3 Lbs. -5/16/2023 100.8 Lbs. -6/1/2023 99.8 Lbs. Record review revealed the resident had a weight loss of 7.5 Lbs. (6.99 %) from 4/10/2023 to 6/1/2023. Additionally, the record failed to reveal evidence that the resident was reweighed within 24 hours after s/he experienced a weight loss of > 5 pounds. During a surveyor interview on 6/8/2023 at 3:30 PM with the resident's provider, she revealed she was aware of the resident's weight loss and further revealed that she did not implement a new intervention. Additionally she acknowledged she did not contact the resident's family to discuss possible interventions that could have been implemented to address the resident's weight loss. During a surveyor interview on 6/8/2023 at 3:43 PM with the RD, she revealed she was unaware that the resident had a weight loss as indicated above. Additionally, she revealed that if she would have known about the weight loss, she would have reweighed the resident to verify the weight loss. Further, if the weight loss was accurate as documented above, she would have recommended weekly weights to be obtained, a speech evaluation and she would have the resident reviewed during the facility Risk Team Meetings. During a surveyor interview on 6/8/2023 at 4:02 PM with the Licensed Practical Nurse/Unit Manager (UM), Staff Q, she revealed the UM is supposed to review all the weights. Staff Q further revealed that both she and the RD missed the weight loss. During a surveyor interview with the DNS on 6/12/2023 at approximately 4:30 PM, she acknowledged the resident had a weight loss as indicated above. Additionally, she could not explain why the resident was not reweighed, per their policy.

Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 resident reviewed for pain management, Resident ID #159. Findings are as follows: Record review of the facility policy titled Pain Assessment states in part, .III. Intervention will be required for: 1. Any pain that is not managed. 2. If the resident's comfort goal has not been met . IV. Residents who experience pain shall have: . 2. All complaints of unrelieved pain reported to the physician for proper review of the pain relief regime. 3. Pain consults requested as per physician recommendation when necessary to eradicate previously unrelieved pain . Record review for the resident revealed s/he was admitted to the facility in November of 2022 with a diagnosis including, but not limited to, complex regional pain syndrome (CRPS) of bilateral lower limb. Review of the Minimum Date Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. During a surveyor interview with the resident on 6/5/2023 at 4:29 PM, s/he reported that his/her pain was not being managed properly. Record review of the June 2023 Medication Administration Record revealed the resident reported pain at a level of 10 out of 10 for 7 out of 16 opportunities from 6/1/2023 to 6/6/2023. Record review of the resident's neurology appointment report dated 2/8/2023 states in part, .Severe right foot and leg pain with causalgia [severe burning pain in a limb caused by injury to a peripheral nerve] that may be caused by CRPS since other organic causes have been excluded. Patient has severe pain despite taking three neuropathic pain medications, notably nortriptyline, gabapentin, and duloxetine [medications to treat pain]. Patient felt better on oxycodone, but it was discontinued recently. [S/he] is using Morphine currently, but [s/he] says that medication is also due to be stopped. [His/her] remaining treatment options for CRPS are a ganglion block [injection of anesthetic medication into a collection of nerves] to the right leg or treatment with a long-acting opiate such as suboxone or Butrans . Record review of the progress notes revealed a note dated 3/2/2023 which states in part, .Admission denied at Codac [an outpatient provider for opioid treatment in Rhode Island] due to patient denied opiate use history. New guideline from DOH [Department of Health]. No restriction in prescribing buprenorphine [Butrans]. Facility MD [Doctor of Medicine] can prescribe buprenorphine . Record review of the resident's neurology appointment report dated 5/9/2023 states in part, .Severe right foot and leg pain with causalgia attributed to CRPS which remains very severe on gabapentin 1100 mg [milligrams] tid [three times a day] and duloxetine 120 mg qd [daily] .[His/Her] treatment options are limited because [s/he] has already tried and failed nortriptyline and pregabalin [medication for nerve pain] and is using high dosages of gabapentin and duloxetine. Patient has also failed nerve blocks and a neurostimulator. [His/Her] remaining pain management options are a ganglion block or treatment with long-acting opiate such as Butrans, suboxone, or methadone [medications for treatment of pain] . Further record review of the above recommendations revealed that the resident's physician was notified of the above-mentioned recommendations from the neurologist appointment on 2/8/2023 and he was also notified of the subsequent recommendations from the neurologist on 5/9/2023, Additionally, the 5/9/2023 document from the neurologist was signed by the physician on 5/17/2023. During a surveyor telephone interview with the resident's physician on 6/7/2023 at 5:35 PM, he acknowledged that he reviewed the neurology recommendations on 5/9/2023 and revealed that he is not licensed to prescribe Butrans, suboxone, or methadone. Additionally, he was unable to provide evidence that an alternative pain management was initiated following the resident's neurology appointment on 5/9/2023. During a surveyor interview on 6/8/2023 at approximately 3:30 PM with the Director of Nursing Services and the Administrator, they were unable to provide evidence that the resident's pain was managed.

Based on record review and staff interview it has been determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice relative to having policies and procedures for dialysis care for 3 of 3 residents, not providing appropriate transportation for 1 of 3 residents, observation and assessment of access site for 2 of 3 residents, not monitoring fluid intake and for staff failing to report a resident missing dialysis appointments for 1 of 3 residents reviewed, Resident ID #'s 1, 2 and 3. Findings are as follows: 1. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, Nursing facilities .must develop dialysis specific policies/procedures, based upon current standards of practice. This includes the care of a resident receiving dialysis services whether in the facility or at an offsite location . During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the Director of Nursing Services (DNS) and the Administrator they revealed that they do not have a facility policy relative to care of a resident receiving dialysis services to include, but not limited to, methods of communication between the nursing home and the dialysis center, assessing, observing and documenting care of access sites, development of comprehensive care plans and monitoring fluid and nutrition. During a surveyor interview on 4/19/2023 at approximately 11:40 AM with the Administrator, DNS and the Regional Nurse they revealed that they created a policy for dialysis after it was brought to their attention by the surveyor. 2a. Review of a community reported complaint dated 4/17/2023 received by the Department of Health alleges that Resident ID #1 missed two dialysis treatments due to the facility not securing an appropriate mode of transportation and then was admitted to the hospital. Record review of Resident ID #1 revealed that s/he was admitted to the facility in April of 2023 with a diagnosis of, but not limited to, end stage renal disease. Review of the resident's orders revealed s/he is scheduled for dialysis on Tuesday, Thursday, and Saturday every week. During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the DNS and the Administrator, they revealed that the resident received his/her dialysis treatment on Saturday 4/8/2023 without any concerns. Additionally, they revealed that the resident missed his/her dialysis treatment on 4/11/2023 secondary to refusing to travel to dialysis via a wheelchair due to left hip pain. Per the DNS and the Administrator, the transport company arrived on 4/13/2023 with a wheelchair and the resident could not travel via the wheelchair due to left hip pain. Record review failed to reveal evidence that the facility staff attempted to get appropriate transportation for the resident to get to dialysis on 4/11/2023 or 4/13/2023. During a surveyor interview on 4/20/2023 at 8:55 AM with a representative from the state contracted transportation company revealed that the facility did not contact them for a level of care change or request a stretcher for transportation until 4/13/2023 after the resident had missed a second dialysis treatment. During a surveyor interview on 4/20/2023 at 11:40 AM with the facility transport aide, Staff B, he revealed that the first time he was told that the resident required a stretcher for transport to dialysis was on 4/13/2023 after s/he missed his/her second dialysis treatment. He revealed that the nursing staff did not make him aware of the residents' inability to be transported in a wheelchair due to him/her experiencing pain on 4/11/2023. Additionally, he revealed that he is the staff responsible to make such requests for changes to the transportation company. Record review reveals that facility obtained an x-ray of the left hip on 4/13/2023 for the resident's pain to the left hip. The x-ray results indicated the resident had a ltyic lesion with pathologic fracture involving the medical left acetabulum. Further record review reveals the resident was sent out to the hospital on 4/13/2023 due to the abnormal x-ray results. Record review of the hospital paperwork for Resident ID #1 dated 4/14/2023 revealed that s/he was sent to the hospital on 4/13/2023 due to a pathological fracture. S/he was found to have an altered mental status with confusion and somnolence (abnormally drowsy), decreased respirations down to 7 (normal respirations 16-20) and altered laboratory results due to missing two scheduled dialysis treatments. During a surveyor interview on 4/20/2023 at approximately 10:00 AM with the DNS and the Administrator they were unable to provide evidence that the facility attempted to obtain appropriate transportation for the resident to go to dialysis on 4/11/2023 and 4/13/2023, resulting in the resident missing two treatments. On 4/18/2023 the facility presented the surveyor with a Level of Need Assessment Form to request a stretcher for transportation to dialysis which is dated 4/11/2023. Further review of this document reveals that this document was altered as the date appeared whited out. During an interview with Registered Nurse, Staff F on 4/20/2023 at approximately 11:00 AM she acknowledged she altered the document with white out and indicated that the state contracted transportation company would have received a Level of Need Assessment Form dated 4/13/2023 not the Level of Need Assessment Form that was provided to the surveyor dated 4/11/2023. 2b. During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the DNS and the Administrator, they revealed that the resident missed his/her dialysis treatment on 4/11/2023 secondary to refusing to travel to dialysis via a wheelchair due to left hip pain. Per the DNS and the Administrator, the transport company arrived on 4/13/2023 with a wheelchair and the resident could not travel via the wheelchair due to left hip pain. Record review failed to reveal evidence that the staff notified the physician after the resident missed two dialysis treatments. During a surveyor interview on 4/18/2023 at 1:55 PM with Licensed Practical Nurse (LPN), Staff C, he revealed that he worked on 4/13/2023 as the nurse for Resident ID #1. Additionally, he revealed that he did not contact the doctor to make him aware of the resident missing dialysis on 4/13/2023. During a surveyor interview on 4/18/2023 at approximately 2:00 PM with the Nurse Practitioner (NP), Staff A, he revealed that he was unaware that the resident had missed two scheduled dialysis treatments until after the resident had been admitted to the hospital. Record review revealed a Nurse to MD communication form dated 4/11/2023 that indicates the resident refused dialysis on 4/11/2023 as s/he wanted to be transported via stretcher. This form has a column for both the nurse reporting the concern and the practioner acknowledging the concern. Although, this form was dated 4/11/2023 there was no indication that the physician reviewed this communication. Review of the resident's laboratory results dated [DATE] revealed a BUN of 38 (blood urea nitrogen test is used to determine how well your kidneys are working, normal values 8 - 23), a creatinine 5.33 a critically high result (creatinine blood test measures the level of creatinine in the blood, helps determine kidney function, normal values 0.8 - 1.40) and an eGFR of 5.2 (estimated glomerular filtration rate measures how much blood the filters clean every minute based on your body size, normal value is greater than 60). Review of results from 4/13/2023 following two missed dialysis treatments revealed a BUN of 92, a creatinine 9.47 a critically high result and an eGFR of 6. During a surveyor interview on 4/19/2023 at approximately 2:00 PM with the Medical Director he revealed that the resident was sent to the hospital due to an x-ray revealing a pathological hip fracture and that he was unaware that the resident had missed two dialysis treatments. Additionally, he revealed that he and the facility utilize the Nurse to MD communication form and indicates that if he did not sign the Nurse to MD communication form dated 4/11/2023 then he was not notified of the resident missing dialysis on 4/11/2023. 2c. Record review for the resident revealed a care plan dated 4/7/2023 for the need for dialysis treatment related to kidney failure and an intervention to monitor intake and output. Record review failed to reveal evidence of fluid intake being monitored for Resident ID #1. During a surveyor interview on 4/19/2023 at approximately 9:30 AM, with LPN Staff E, she revealed that if a resident is having fluid intake and output monitored, they have an order in the electronic medical record. During a surveyor interview on 4/19/2023 at approximately 11:40 AM, with the DNS and the Administrator, they were unable to provide evidence of the resident's fluid being monitored per the care plan. 3. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, .The nursing home staff must provide immediate monitoring and documentation of the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications . A. Record review of the physicians orders for Resident ID #1 revealed s/he was scheduled for dialysis on Tuesday, Thursday and Saturday every week. Review of hospital paperwork dated 4/6/2023 revealed that the resident had an AV fistula (connection of a vein and an artery, usually in the forearm, to allow access to the vascular system for hemodialysis) in his/her left upper extremity. Further record review failed to reveal evidence that the facility was assessing, observing and documenting the care of the access site, such as auscultation (the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope)/palpation (examine by touch) of the AV fistula to assure adequate blood flow. B. Record review of Resident ID #3 revealed that s/he was readmitted to the facility in January of 2023 with diagnoses of, but not limited to, chronic kidney disease and dependence on renal dialysis. During a surveyor interview on 4/18/2023 at 12:04 PM, with LPN Staff D, she was unable to reveal where Resident ID # 3's access sites were located and she was unable to provide evidence of assessments or documentation of the access sites. During a surveyor interview on 4/19/2023 at approximately 9:00 AM with Resident ID #3 s/he revealed that s/he has an old access site on the right upper extremity and a new access site on the left upper extremity that is being accessed for dialysis. During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the DNS and the Administrator they were unable to provide evidence that the facility was assessing, observing and documenting the care of the access sites per the regulation. Additionally, they were unable to provide evidence that a resident who requires dialysis receives such services, consistent with professional standards of practice.

Based on record review and staff interview, it has been determined that the Medical Director failed to implement a resident care policy to coordinate care for residents who require dialysis (a life sustaining therapy that can replace the work of non-functioning kidneys) for 3 of 3 residents reviewed, Resident ID #s 1, 2, and 3. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, Nursing facilities .must develop dialysis specific policies/procedures, based upon current standards of practice. This includes the care of a resident receiving dialysis services whether in the facility or at an offsite location . Record review of the facility assessment states in part, .facility must conduct and document a facility-wide assessment to define what resources are necessary to care for its resident competently during day-to-day operations and emergencies .An admission is presented to the nursing administrative team for review to determine acuity and appropriateness of the person for admission .The staff involved in the admission decision ensures that the facility has the appropriate equipment, resources, etc. to provide care and support for the person prior to admission . During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the Director of Nursing Services (DNS) and the Administrator they revealed that they do not have a facility policy relative to care of a resident receiving dialysis services to include, but not limited to, methods of communication between the nursing home and the dialysis center, assessing, observing and documenting care of access sites, development of comprehensive care plans and monitoring fluid and nutrition. Additional record review of the facility assessment last revised on 2/23/2023 revealed that dialysis residents make up 5% of the resident population. 1. Record review revealed Resident ID #3 was admitted to the facility in October of 2021 and readmitted in January of 2023 with a diagnosis including, but not limited to, dependence on dialysis as of April of 2022. 2. Record review revealed Resident ID #2 was admitted to the facility in January of 2011 and readmitted in August of 2022 with diagnoses including, but not limited to, chronic kidney disease stage 3, acute kidney failure, and a fistula (a surgical procedure usually in the arm made by connecting an artery to a vein in preparation for dialysis). Record review revealed a care plan dated 6/10/2022 indicating s/he has a fistula to his/her left arm and receives dialysis. 3. Record review revealed Resident ID #1 was admitted to the facility in March of 2023 and readmitted in April of 2023 with a diagnosis including, but not limited to, end stage renal disease. Additional record review reveals the resident had a care plan focus to monitor his/her intake. Further record review revealed s/he was dependent on renal dialysis and missed two consecutive treatments on 4/11 and 4/13/2023, as s/he was experiencing hip pain and was unable to tolerate sitting up in a wheelchair and requested a stretcher for transport to his/her dialysis treatments. Additional record review failed to reveal evidence that Resident ID #1's physician was notified that s/he had missed two consecutive dialysis treatments. Further record review failed to reveal evidence of orders for monitoring/care of the resident's dialysis site or that the resident's intake was being monitored. Additionally, the record lacks evidence that the facility staff attempted to obtain appropriate transportation for the resident to get to dialysis for treatment on 4/11/2023 or 4/13/2023. Record review of the hospital paperwork for Resident ID #1 dated 4/14/2023 revealed that s/he was sent to the hospital on 4/13/2023 due to a pathological fracture. S/he was found to have an altered mental status with confusion and somnolence (abnormally drowsy), decreased respirations down to 7 (normal respirations 16-20) and altered laboratory results due to missing two scheduled dialysis treatments. Record review failed to reveal evidence that a policy was developed and implemented to provide appropriate care, monitoring, and services for the dialysis resident population, specifically Resident ID #s 1, 2, and 3. During a surveyor interview on 4/18/2023 at 12:25 PM with the Director of Nursing Services in the presence of the Administrator, she revealed the facility does not have a facility care policy for their residents that currently receive dialysis. During a surveyor interview on 4/19/2023 at approximately 2:00 PM with the Medical Director he revealed that he was unaware that Resident ID #1 had missed two dialysis treatments. Additionally, he revealed he was unaware that the facility did not have a policy for the dialysis resident population. He further revealed he was unaware that it was his responsibility to ensure the facility developed and implemented a policy relative to the appropriate care, monitoring, and services required for the dialysis residents. (Refer to citation F698 for additional details).

Based on record review and staff interview, it has been determined that the facility failed to create and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 residents reviewed for refusal of care and medication non-compliance, Resident ID #1. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/10/2023 states in part, Resident was found on floor in [his/her] room .Blood sugar read high on glucometer [a device used to measure a persons blood glucose. A high reading is indicative of a blood sugar that typically exceeds 600 milligrams(mg) per deciliter]. Resident is a diabetic .often refuses medications .admitted with DKA [Diabetic ketoacidosis - A serious complication of diabetes that can be life threatening] . Record review revealed Resident ID #1 was admitted to the facility in October of 2021 and readmitted in January of 2023 with diagnoses including, but not limited to, diabetes mellitus type 2 with ketoacidosis, hypertension (high blood pressure), depression, dysthymic disorder (long-term form of depression), and adult failure to thrive. Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 4 out of 15, indicating severe cognitive impairment. Record review of a nursing progress note dated 4/8/2023 revealed s/he was found on the floor in his/her room at approximately 5:00 AM. Additionally, his/her blood sugar was measured, and the glucometer indicated the blood sugar was high. The progress note further revealed s/he was then transported to an acute care hospital. Record review of the hospital documentation dated 4/8/2023 revealed the resident arrived at the hospital lethargic after a fall at the facility. It further revealed s/he was found to be dehydrated and in renal failure (kidney failure) requiring a total of 5 liters of intravenous fluids. Additionally, s/he was diagnosed with DKA which required an insulin drip for a blood sugar of 994. Furthermore, it revealed a nurse at the facility indicated that Resident ID #1 has been a long-time resident at the facility and does not take his/her medications. Additionally, the nurse revealed s/he has not taken any of his/her antihyperglycemic medications (medication to control blood glucose levels) for a long time. Review of a care plan revealed a focus area dated 6/15/2022 indicating the resident can be resistive to care and often refuses care, meals, and medications with the following interventions: - Administer medications as ordered and monitor/document side effects and effectiveness. - Caregivers to provide opportunities for positive interactions and engage in conversation with the resident when passing by. - Intervene as needed to protect the rights and safety of others, maintain a calm demeanor with the resident, and distract and relocate him/her as needed. - The resident continues to refuse medications and care. - The resident to allow psychiatry services to follow as needed. Record review failed to reveal evidence that the above-mentioned interventions were resident specific and included measurable objectives and timeframes to meet the medical, nursing, mental and psychosocial needs of the resident. Additionally, the care plan interventions for the resident's well-documented, chronic non-compliance since being added to his/her care plan on 6/15/2022 failed to incorporate interventions to encourage and promote the resident's compliance with care and medications and direct staff on how to proceed in the event of the resident's continued non-compliance to ensure his/her well-being. Additional record review of the care plan revealed a focus area dated 6/27/2022 specific to diabetes revealed interventions to administer diabetes medication as ordered and to monitor/document the effectiveness, and for fasting serum blood sugars as ordered by the doctor. Further record review of the care plan revealed these interventions to address the resident's diabetes were not being followed as evidence below: 1. Record review of the Medication Administration Records (MAR) from January 4th through April 8th of 2023 failed to reveal staff was documenting the resident's continued non-compliance of his/her diabetic medications and monitoring for effectiveness as per the care plan. Additional record review of the above MARs revealed the resident refused his/her diabetic medications a total of 176 of 373 opportunities, approximately 47% of the time. 2. Record review revealed a physician's order dated 1/28/2023 to check blood sugars once a day for 30 days for monitoring. Record review failed to reveal evidence of the results for the above-ordered fasting blood sugars for 14 of the 30 days. Furthermore, the resident did not have his/her blood sugar monitored from 2/27/2023 through 4/8/2023, the day s/he fell in the facility and was subsequently admitted to an acute care hospital for a life threatening diabetes complication, dehydration, and renal failure. During a surveyor interview on 4/11/2023 at 12:45 PM with the Director of Nursing Services in the presence of the Administrator, she was unable to provide evidence that a comprehensive person-centered care plan including measurable objectives and timeframes had been formulated and implemented to meet the needs of the resident's medical, nursing, and mental and psychosocial needs to ensure the resident's well-being. Please refer to the tag F760 for more information regarding the extent of Resident ID #1's medication non-compliance.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 2 of 3 residents reviewed for medication administration, Resident ID #s 1 and 2. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/10/2023 states in part, Resident was found on floor in [his/her] room .Blood sugar read high on glucometer [a device used to measure a persons blood glucose. A high reading is indicative of a blood sugar that typically exceeds 600 milligram (mg) per deciliter]. Resident is a diabetic .often refuses medications .admitted with DKA [Diabetic ketoacidosis - A serious complication of diabetes that can be life threatening] . Record review of a facility policy titled, POLICY AND PROCEDURE states in part, .POLICY: It is the policy of this facility that resident shall receive medications in a safe and timely manner and in accordance with established regulations and guidelines PROCEDURE .6. Following the attempt to administer the medical record .shall be documented as administered or not administered, by the employee administering the meds). As necessary an explanation as to why the medication was not administered is then required to be documented . Further record review of a facility policy titled, .Medication Shortages/Unavailable Medications states in part, .Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose .If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service to speak with the registered pharmacist on duty to manage the plan of action .If the medication is unavailable from pharmacy .facility should obtain alternate physician/prescriber orders, as necessary. 1. Record review revealed Resident ID #1 was admitted to the facility in October of 2021 and readmitted in January of 2023 with diagnoses including, but not limited to, diabetes mellitus type 2 with ketoacidosis, hypertension (high blood pressure), depression, dysthymic disorder (long-term form of depression), and adult failure to thrive. Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 4 out of 15, indicating severe cognitive impairment. Record review of a care plan focus area dated 6/15/2022 revealed s/he often refuses medications with an intervention to administer medications as ordered and to monitor/document for side effects and effectiveness. Record review of a nursing progress note dated 4/8/2023 revealed the resident was found on the floor in his/her room at approximately 5:00 AM. Additionally, his/her blood sugar was obtained, and the glucometer indicated the blood sugar was high. It further revealed s/he was then transported to an acute care hospital. Record review of the Medication Administration Records (MAR)s from January 4th through April 8th of 2023 revealed that the resident's medications were not administered 1,113 of 1,810 opportunities, approximately 61% of the time due to the following reasons: - Refused: The resident refused his/her medication. - Not given: The medication was charted as not being given indicating to refer to the progress notes for a rationale that could not be found. - Omitted: The MAR was blank indicating the medication was not administered. - On hold: The medication was on hold indicating to refer to the progress notes for a rationale that could not be found. - Not available: The medication was not available to administer to the resident. Further record review of the above MARs revealed the following medications that were not administered to the resident: - Insulin glargine give 13 units in the morning for diabetes: was not administered 3 of 21 opportunities. Refused : 2 times Not given: 1 time - Centrum give 1 tablet daily for vitamin supplement: was not administered 67 of 91 opportunities. Refused: 61 times Not given: 4 times Omitted: 2 times - Glimepiride 2mg (milligram) give 3 tablets in the morning for diabetes: was not administered 6 of 14 opportunities. Refused: 5 times Not given: 1 time - Glimepiride 4mg give 1 tablet daily for diabetes: was not administered 18 of 37 opportunities. Refused: 16 times Omitted: 1 time Not available: 1 time - Glipizide ER (Extended release) 5mg give 1 tablet daily for diabetes: was not administered 10 of 22 opportunities. Refused: 9 times Omitted: 1 time - Lisinopril 5mg give 1 tablet daily for hypertension: was not administered 71 of 91 opportunities. Refused: 65 times Not given: 4 times Omitted: 2 times - Mirtazapine 30mg give 1 tablet at bedtime for depression: was not administered 40 of 91 opportunities. Refused: 38 times Not given: 2 times - Quetiapine 100mg give 1 tablet at bedtime for mood disorder: was not administered 40 of 92 opportunities. Refused: 34 times Not given: 4 times Omitted: 2 times - Quetiapine 25mg give 1 tablet in the morning for depression: was not administered 7 of 19 opportunities. Refused: 6 times Omitted: 1 time - Tradjenta 5mg give 1 tablet daily for diabetes: was not administered 60 of 91 opportunities. Refused: 54 times Not given: 4 times Omitted: 2 times - Metformin 500mg give 1 tablet twice a day for diabetes: was not administered 95 of 173 opportunities. Refused: 87 times Not given: 6 times Omitted: 2 times - Pantoprazole 40mg give 1 tablet twice a day for reflux: was not administered 112 of 183 opportunities. Refused: 106 times Not given: 3 times Omitted: 2 times Not available: 1 time - Quetiapine 25mg give 1 tablet twice a day for depression: was not administered 101 of 142 opportunities. Refused: 93 times Not given: 7 times Omitted: 1 time - Senna-Plus 8.6-50mg give 1 tablet twice a day for constipation: was not administered 111 of 182 opportunities. Refused: 101 times Not given: 8 times Omitted: 2 times - Gabapentin 100mg give 3 capsules three times a day for dysthymic disorder: was not administered 183 of 273 opportunities. Refused: 166 times Not given: 10 times Omitted: 5 times On hold: 2 times - Metformin 500mg give 1 tablet three times a day for diabetes: was not administered 7 of 15 opportunities. Refused: 7 times - Sucralfate 1 gram/10mL (milliliter) give 10mL three times a day for gastric ulcer: was not administered 182 of 273 opportunities. Refused: 161 times Not given: 12 times Omitted: 5 times Not available: 2 times On hold: 2 times Record review revealed that the physician or nurse practitioner were only notified occasionally when the resident did not receive his/her medications as ordered. During a surveyor interview on 4/11/2023 at 8:50 AM with the Unit Manager, Licensed Practical Nurse, Staff B, he revealed that staff should document when a resident does not receive his/her medications and that staff should notify the physician or nurse practitioner each time. During a surveyor interview on 4/11/2023 at approximately 12:45 PM with the Director of Nursing Services (DNS) in the presence of the Administrator, she revealed that the resident often refuses medications. Additionally, she was unable to provide evidence that the resident received his/her medication or that the physician or nurse practitioner were notified of each medication that was not administered. Record review of the hospital documentation dated 4/8/2023 revealed an active problem list for DKA with blood work indicating the resident's blood glucose level was elevated at 994 (normal level 70-100). Additionally, s/he was found to be dehydrated and in renal failure (kidney failure) and required a total of five liters of intravenous fluids. Furthermore, the documentation revealed a nurse at the facility indicated that Resident ID #1 has been a long-time resident at the facility and does not take his/her medications. 2. Record review revealed Resident ID #2 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, dementia and depression. Record review of the March 2023 MAR revealed s/he did not receive the following medications as ordered on the following dates and times: - Apixaban 5 mg give 1 tablet two times a day for blood clot: 2 doses not administered on 3/22/2023 and 3/28/2023 at 8:00 AM. - Dronabinol 2.5 mg give 2 capsules two times a day for pain: 4 doses not administered on 3/22/2023 and 3/26/2023 at 8:00 AM and 8:00 PM. - IFerex 150 mg give 1 capsule daily for low iron: 3 doses not administered on 3/22/2023, 3/23/2023, and 3/24/2023. - Pyridoxine HCL 100 mg give 1 tablet daily for immune health: 3 doses not administered on 3/22/2023, 3/23/2023, and 3/24/2023. - Sertraline HCL 100 mg give 1.5 tablets daily for depression: 1 dose not administered on 3/22/2023. - Divalproex Sodium 125 mg give 4 tablets twice a day for seizure for 30 days: 1 dose not administered on 3/22/2023 at 8:00 AM. - Metoprolol Tartrate 25 mg give 0.5 tablet every 12 hours for hypertension: 1 dose not administered on 3/22/2023 at 10:00 AM. - Potassium & Sodium Phosphates 280-160-250 mg give 1 packet two times a day for supplement: 4 morning doses not administered between 3/24/2023 through 3/27/2023. - Gabapentin 100 mg capsule give 2 capsules every 8 hours for pain for 30 days: 1 dose not administered on 3/22/2023 at 8:00 AM. Record review of the MAR notes for the above-mentioned medications revealed they were not administered to Resident ID #2 due to the medications being unavailable as s/he was a new resident and that either the staff was awaiting the pharmacy delivery or awaiting a physician prescription. Record review of the facility medication emergency supply inventory list revealed that sertraline, divalproex, and gabapentin, 3 of the above-mentioned medications documented as not available, were listed as inventory in the facility's emergency supply medications. Further record review failed to reveal evidence that the physician or nurse practitioner were notified that the resident did not receive the above-mentioned medications until 5 days later on 3/27/2023. Additionally, the record failed to reveal evidence that the physician or nurse practitioner were notified that the above medications were unavailable to administer or that staff made an attempt to obtain orders for alternate medications as necessary per the facility policy. Record review of the April 2023 MAR revealed s/he did not receive the following medication as ordered due to the resident refusing on the date below: - Lactulose 10 grams/15mL give 15 mL two times a day for constipation: 1 dose not administered in the evening on 4/3/2023. Record review failed to reveal evidence that the physician or nurse practitioner were notified of the resident's refusal of the lactulose. During a surveyor interview on 4/11/2023 at approximately 1:00 PM with the Nurse Practitioner, Staff A, in the presence of the DNS and Administrator, he acknowledged he would expect to be notified if a resident did not receive his/her medication. During a surveyor interview on 4/11/2023 at approximately 1:00 PM with the Administrator in the presence of the DNS, she revealed the resident was admitted to the facility and shortly after was transferred to the hospital after sustaining a fall and then returned to the facility that same night. She further revealed that staff did not complete the admission process because of the fall, and acknowledged that the medications were not available for the resident. Additionally, she was unable to provide evidence the resident received his/her medications as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality for 1 of 2 residents reviewed for appropriate monitoring and treatment for diabetes management. Findings are as follows: Record review of a facility policy and procedure document titled, Diabetes - Monitoring and treating. states in part, POLICY: It is the policy of this facility to monitor the diabetic status of those residents who are diabetic as per the order of the attending physician. The single most important factor in managing diabetes is achieving glucose control which can prevent many of the complications associated with diabetes. Symptoms of Hyperglycemia [high blood sugar] include .Acute = ketoacidosis (high level of ketones in the blood which affects the acid base balance of the body), decreased level of consciousness or confusion, dehydration, acute hunger or thirst, impaired cognitive function . Record review of Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/10/2023 states in part, Resident was found on floor in [his/her] room .Blood sugar read high on glucometer [a device used to measure a persons blood glucose. A high reading is indicative of a blood sugar that typically exceeds 600mg per deciliter]. Resident is a diabetic .often refuses medications .admitted with DKA [Diabetic ketoacidosis - A serious complication of diabetes that can be life threatening] . Record review revealed Resident ID #1 was admitted to the facility in October of 2021 and readmitted in January of 2023 with a diagnosis including, but not limited to, diabetes mellitus type 2 with ketoacidosis. Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 4 out of 15, indicating severe cognitive impairment. Record review of a nursing progress note dated 4/8/2023 revealed s/he was found on the floor in his/her room at approximately 5:00 AM. Additionally, his/her blood sugar was measured, and the glucometer indicated it was high. It further revealed s/he was then transported to an acute care hospital. Additional review of a nursing progress note dated 4/8/2023 revealed the resident was at the hospital in the Intensive Care Unit for DKA with a high blood sugar of 1000 (normal level 70-100). Record review of the hospital documentation dated 4/8/2023 revealed the resident arrived at the hospital lethargic after a fall at the facility. It further revealed s/he was found to be dehydrated and in renal failure (kidney failure) in addition to DKA which required an insulin drip for a blood sugar of 994 and a total of 5 liters of intravenous fluids. Furthermore, it revealed a nurse at the facility indicated that Resident ID #1 has been a long-time resident at the facility and does not take his/her medication. Additionally, the nurse revealed s/he has not taken any of his/her antihyperglycemic medications (medication to control blood glucose levels) for a long time. Record review of a care plan focus area dated 6/27/2022 revealed the resident has diabetes with interventions for diabetes medication as ordered by the physician and to monitor/document the effectiveness, and fasting serum blood sugars as ordered by the doctor. Additional review of the care plan revealed a focus area dated 6/15/2022 indicating the resident often refuses medications with an intervention to administer medications as ordered. Record review of the Medication Administration Records (MAR) from January 4th through April 8th of 2023 revealed that resident's diabetic medications were either refused, omitted or that the medication was not available to administer: - Insulin glargine give 13 units in the morning for diabetes: was not administered 3 of 21 opportunities. - Glimepiride 2 mg (milligram) give 3 tablets in the morning for diabetes: was not administered 6 of 14 opportunities. - Glimepiride 4 mg give 1 tablet daily for diabetes: was not administered 18 of 37 opportunities. - Glipizide ER (Extended release) 5 mg give 1 tablet daily for diabetes: was not administered 10 of 22 opportunities. - Tradjenta 5mg give 1 tablet daily for diabetes: was not administered 60 of 91 opportunities. - Metformin 500 mg give 1 tablet twice a day for diabetes: was not administered 95 of 173 opportunities. - Metformin 500 mg give 1 tablet three times a day for diabetes: 7 of 15 opportunities. Record review revealed the following physician orders relative to diabetes monitoring and management: - 10/26/2022 Hemoglobin A1C every 6 months (blood test to measure blood sugar levels over the prior 3 months, reference range 4.2% - 5.6%). - 1/5/2023 Check blood sugars two times a day. - 1/4/2023 Hemoglobin A1C one time for monitoring. Further record review failed to reveal that the Hemoglobin A1C blood test was completed as ordered on 1/4/2023. Additional record review revealed the resident's degree of glucose control was worsening as evidence by the Hemoglobin A1C blood test results below: - 9/1/2022: 6.2% (indicating increased risk of diabetes) - 10/26/2022: 6.7% (consistent with diabetes) Record review of a nursing progress note dated 1/27/2023 revealed the physician ordered an additional Hemoglobin A1C blood test to be obtained on the next lab day. Further record review failed to reveal evidence that the above-mentioned order for the Hemoglobin A1C blood test was obtained. Record review of a nursing progress note dated 2/1/2023 indicated the physician wanted the Hemoglobin A1C blood test to be obtained every 3 months. Further review of the record revealed the Hemoglobin A1C blood test to be obtained every 3 months was never transcribed. Further review of a nursing progress note dated 1/27/2023 revealed the physician also ordered the resident's fasting blood sugar to be obtained once a day for 30 days. Additional review of the record failed to reveal evidence of results for the above-ordered fasting blood sugars for 14 of the 30 days. Furthermore, the order dated 1/5/2023 to check blood sugars two times a day was discontinued without a physician's order to do so, indicating the resident did not have his/her blood sugar monitored from 2/27/2023 through 4/8/2023, resulting in the resident falling on that day and subsequently being admitted to an acute care hospital for life threatening diabetes complications, due to the failure to provide adequate monitoring and management of his/her diabetes. During a surveyor interview on 4/11/2023 at approximately 1:00 PM with the Nurse Practitioner, Staff A, he revealed he would expect the resident to have a hemoglobin A1C completed every 3 months and blood sugars monitored at least once or twice weekly. During a surveyor interview on 4/11/2023 at 12:45 PM with the Director of Nursing Services in the presence of the Administrator, she revealed the resident should have had the hemoglobin A1C labs completed every 3 months for monitoring. She was unable to provide evidence that the resident was monitored and treated appropriately relative to diabetes management.

Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that residents identified as an elopement risk received adequate supervision to prevent elopement from the facility for 1 of 1 residents reviewed for actual elopement, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/3/2023 states, .resident was attempting to elope at 6:30 PM .At 8:45 PM staff was unable to find resident .search was initiated .around 10:30 PM the temperatures were around 37 degrees and Administrator and DNS [Director of Nursing Services] decided to contact the [name redacted] Police .Between 1 AM and 2AM received a call from [name redacted] police .they have found the resident .they [facility] looked into the hospital system .resident admitted .has fractures . Record review of a facility policy titled, POLICY AND PROCEDURE Elopement Assessments states in part, POLICY: It is the policy of this facility to maintain a safe and secure environment for all of our residents. In order to achieve this; residents who are at risk for wandering/elopement need to be identified and a care plan developed to eliminate the risk. PROCEDURE .If the resident is determined to be at risk for elopement, then the appropriate interventions will be put in place to keep the resident safe .wander guard bracelet [device worn by a resident that sounds an audible alarm when a sensor is triggered to alert staff that a resident is attempting to exit the unit or building] and/or frequent checks, etc. and a care plan instituted . Record review of a facility policy titled, POLICY AND PROCEDURE .SUBJECT: Wander Guard states in part, PROCEDURE: 1. All Resident's that trigger on the elopement assessment as an elopement risk will have a wander guard bracelet place on them .2. The nurse will obtain a physician's order for wander guard placement and function daily. 3. Care plan will be updated as needed. Record review revealed the resident was admitted to the facility in January of 2023 and readmitted in March of 2023 to a semi-secured unit on the main floor with diagnoses including, but not limited to, neurocognitive disorder, dementia, and alcohol abuse. Record review of the EMS [Emergency Medical Services] Patient Care Report document dated 4/2/2023 revealed a call was received by dispatch at 11:02 PM and the unit responding to the call arrived on scene at 11:14 PM to a location near a highway, approximately 2.6 miles away from the facility and found a person (later identified as Resident ID #1) lying down on the ground with a noticeable deformity of the left leg and the left foot painfully rotated outward indicating a possible hip fracture. Additionally, the report revealed the resident had abrasions to the left elbow, right forehead, and right eye socket. It further indicated the resident arrived at the hospital at 11:31 PM. Record review of the hospital documentation dated 4/2/2023 revealed the resident had a fracture of the left hip and a subarachnoid hemorrhage (brain bleed) and subsequently underwent surgery to repair his/her left hip. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 7 out of 15, indicating severe cognitive impairment. Additionally, it revealed the wandering behavior of the resident placed him/her at significant risk of getting to a potentially dangerous place (stairs or outside the facility). It further revealed the resident was not utilizing a wander guard (elopement) alarm. Further review of the MDS assessment dated [DATE] revealed the resident triggered as a wandering risk on a Care Area Assessment (CAA - a tool that is designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been triggered, nursing home providers determine whether or not to care plan for it). Additional review of the resident's CAA worksheet revealed that the resident has an actual problem related to wandering and elopement attempt and required a care plan to be implemented to address behavioral symptoms to minimize the risks of elopement. Additional review of the residents CAA worksheet revealed the seriousness of the behavioral symptoms documents as Resident is immediate threat to self - IMMEDIATE INTERVENTION REQUIRED .Resident is immediate threat to others - IMMEDIATE INTERVENTION REQUIRED . Furthermore, the CAA worksheet revealed the behavioral symptoms will be addressed in the care plan to minimize risks. Record review of an admission elopement risk assessment dated [DATE] revealed the resident was at risk to wander. Further record review revealed another admission elopement risk assessment was completed on 3/23/2023 that revealed the resident was at high risk to wander. Additionally, the elopement risk assessment on 1/24/2023 indicated resident monitoring would increase should an elopement attempt occur. Record review revealed the resident was exhibiting exit seeking behaviors per two nursing progress notes that revealed the following: 1/26/2023 - Resident was confused and ambulating in the hallway entering other residents rooms, pushing on exit doors, pressing the exit door buttons, and fiddling with the fire alarms. 2/12/2023 - Resident needed redirection at the nurses station/entrance as s/he attempted to the leave the unit twice. Record review failed to reveal evidence that the facility initiated a care plan or implemented any interventions to prevent elopement for the resident that was identified as at risk until 4/2/2023, the day the resident successfully eloped from the facility resulting in a hospital admission for a hip fracture and a brain bleed on 4/2/2023. Record review of several nursing progress notes dated 4/2/2023 revealed the resident attempted to elope through the main doors after a fire alarm was triggered between 6:15 PM - 6:30 PM. It further revealed 15-minute checks were implemented at 6:30 PM and the resident was noted missing from the unit at 8:45 PM. Additionally, after the initial search of the unit was unsuccessful, a code purple (facility's protocol for missing persons) was initiated. Record review of a facility provided document revealed the facility first contacted the police at 10:30 PM, approximately 2 hours from when the resident was identified as missing. During a surveyor observation on 4/4/2023 at approximately 10:45 AM of the 1st floor unit, the semi-secured unit the resident resided on, revealed the resident had access to the main entrance through the unit dining room which was unsecured. During a surveyor interview on 4/4/2023 at 8:09 AM with the Administrator, she revealed she was aware the resident was an elopement risk. She indicated the resident resided on the 1st floor which is not a locked dementia unit, referring to 1st floor as a semi-secure unit. During an additional surveyor interview on 4/4/2023 at approximately 12:00 PM with the Administrator, she revealed a resident deemed an elopement risk that resided on the 1st floor that exhibited exit seeking behaviors would be monitored or sent out. During a surveyor interview on 4/4/2023 at 10:48 AM with the Unit Manager, Licensed Practical Nurse, Staff A, he revealed the 1st floor unit is not a locked unit. He was unaware the resident was deemed an elopement risk. Additionally, he revealed the resident would have a wander guard bracelet if s/he was an elopement risk. During a subsequent surveyor interview on 4/4/2023 at 11:12 AM with Staff A, he revealed that placement on the 1st floor unit would not be appropriate for a resident that is an elopement risk. During a surveyor interview on 4/5/2023 at 1:52 PM with the Director of Nursing Services, she revealed she would expect interventions be implemented to ensure the safety of a resident identified as an elopement risk. She was unable to provide evidence that the resident received adequate supervision or interventions were implemented to prevent elopement when s/he was initially identified as an elopement risk.

Based on record review and staff interview, it has been determined that the facility failed to implement care plan interventions to monitor a resident with a known history of wandering and exit seeking, which resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death., for 1 of 1 residents reviewed who successfully eloped from the facility, Resident ID #1. Findings are as follows: Record review of a facility policy titled, POLICY AND PROCEDURE Elopement Assessments states in part, POLICY: It is the policy of this facility to maintain a safe and secure environment for all of our residents. In order to achieve this; residents who are at risk for wandering/elopement need to be identified and a care plan developed to eliminate the risk. PROCEDURE .If the resident is determined to be at risk for elopement, then the appropriate interventions will be put in place to keep the resident safe .wander guard bracelet [device worn by a resident that sounds an audible alarm when a sensor is triggered to alert staff that a resident is attempting to exit the unit or building] and/or frequent checks, etc. and a care plan instituted . Record review revealed the resident was admitted to the facility in January of 2023 with a diagnosis including, but not limited to, dementia. Record review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status Score of 7 out of 15, indicating severe cognitive impairment. Additionally, the MDS Assessment revealed the resident had wandering behaviors that placed him/her at significant risk of getting to a potentially dangerous place (stairs or outside the facility). It further revealed the resident was not utilizing a wander guard (elopement) alarm. Further review of the admission MDS assessment dated [DATE] revealed the resident was triggered as being a wandering risk on a Care Area Assessment (CAA - a tool that is designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been triggered, nursing home providers determine what to care plan for). Additionally, the CAA worksheet revealed that the resident has an actual problem related to wandering and elopement attempts and required a care plan to be implemented to address behavioral symptoms to minimize the risk of elopement and ensure the resident's safety. Record review of an admission elopement risk assessment dated [DATE] revealed the resident was at risk to wander. Further record review revealed another admission elopement risk assessment was completed on 3/23/2023 that revealed the resident was at high risk to wander. Additionally, the elopement risk assessment on 1/24/2023 indicated resident monitoring would increase should an elopement attempt occur. Record review of the following progress notes revealed the resident was exhibiting exit seeking behaviors: 1/26/2023 - Resident was confused and ambulating in the hallway entering other resident rooms, pushing on exit doors, pressing the exit door buttons, and fiddling with the fire alarms. 2/12/2023 - Resident needed redirection at the nurses station/entrance as s/he attempted to the leave the unit twice. Record review of the care plan revealed that although the elopement risk, MDS and the CAA Assessments identified that the resident had wandering behaviors and elopement attempts, a care plan was not implemented for the resident who was at risk for elopement nor were any interventions implemented to ensure Resident ID #1's safety. Record review revealed that on 4/2/2023 the resident successfully eloped from the facility. Record review of the EMS [Emergency Medical Services] Patient Care Report document dated 4/2/2023 revealed a call was received by dispatch at 11:02 PM and the unit responding to the call arrived on scene at 11:14 PM to a location near a highway, approximately 2.6 miles away from the facility and found a person (later identified as Resident ID #1) lying down on the ground with a noticeable deformity of the left leg and the left foot painfully rotated outward indicating a possible hip fracture. Additionally, the report revealed the resident had abrasions to the left elbow, right forehead, and right eye socket. It further indicated the resident arrived at the hospital at 11:31 PM. Record review of the hospital documentation dated 4/2/2023 revealed the resident had a fracture of the left hip and a subarachnoid hemorrhage (brain bleed) and subsequently underwent surgery to repair his/her left hip. During a surveyor interview on 4/5/2023 at 2:02 PM with the Director of Nursing Services, she acknowledged the CAA worksheet stating the resident was at risk for elopement and that a care plan was not initiated to prevent this resident from eloping from the facility on 4/2/2023. She revealed a care plan for elopement should have been implemented when the resident was initially identified as an elopement risk. Additional review of the resident's care plan revealed that s/he was care planned for being an elopement risk after s/he successfully eloped from the facility and sustained multiple injuries on 4/2/2023.

Based on record review and staff interview, it has been determined that the facility failed to immediately consult with the resident's physician or notify the resident's representative when there was a significant change in physical, mental, or psychosocial status for a resident who experienced a fall for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint alleges in part, Pt [Patient] had an unwitnessed fall at 1 am, reportedly did not return to baseline post fall and EMS [Emergency Medical Services] was not contacted until 8:45 am. Review of a facility policy titled, Falls reduction program approved on 9/24/2021, states in part, .Residents are to be-assessed whenever they exhibit a change in status that may put them at risk for the fall .The licensed nurse on duty is responsible to institute a huddle investigation as soon after a fall as possible utilizing the input of the resident, employees and witnesses .the goal of the investigation is to identify possible contributing factors leading to a fall .the licensed nurse on duty is responsible to provide immediate care and intervention as appropriate .notify the doctor .notify the appropriate resident representative as soon as is practical . Review of an additional facility policy titled, Neurological Assessment states in part, .whenever a resident suffers an actual or a suspected head injury, that resident is to be carefully monitored at the frequency ordered by the physician for a period of no less than 3 days .record any observations noted that indicate a change from the resident's baseline. Results of the assessment above should be recorded on a neurological observation located in the electronic medical record. Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with diagnoses that include, but are not limited to, acute respiratory failure with hypoxia (abnormally low level of oxygen), bipolar disorder, anxiety disorder, and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident ID #1's admission Minimum Data Set (MDS) Assessment revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that his/her cognition is intact. Record review for Resident ID #1 revealed a physician's order dated 1/23/2023 for oxygen 2-4 liters via nasal cannula continuously. Record review for Resident ID #2 (Resident ID #1's roommate) revealed s/he was admitted to the facility in January of 2023 with diagnoses that include, but are not limited to, type 2 diabetes, morbid obesity, and obstructive sleep apnea (blockage in the airway while sleeping). Review of Resident ID #2's admission MDS revealed a BIMS score of 15 out of 15 indicating that his/her cognition is intact. During a surveyor interview with Resident ID #2 on 2/10/2023 at approximately 2:00 PM, s/he indicated that Resident ID #1 fell out of bed on the night of 2/9/2023 at approximately 12:30-1:00 AM. S/he revealed prior to the fall, Resident ID #1 was delusional, crawling out of his/her skin, was restless, putting his/her oxygen tubing on/off and was bouncing out of bed. Additionally, s/he indicated that staff was not coming to help him/her and so s/he gave Resident ID #1 his/her walker so that s/he could safely go to the nurses' station. Additionally, s/he revealed staff watched him/her for a while then brought him/her back to their room and put him/her to bed. Resident ID #2 further revealed that s/he saw an abrasion on Resident ID #1's forehead after s/he fell and that in the morning, s/he was unresponsive and was taken to the hospital at around 10:00 AM. Record review of a facility fall risk report completed on 2/9/2023 at 8:16 AM by Licensed Practical Nurse (LPN), Staff A, states in part, .Resident was found lying on the floor in [his/her] room at about 1:00 AM this morning. [S/he] was lying on [his/her] side. Resident was accessed [sic] and put back to bed. [S/he] denied any pain or discomfort at this time. Resident said [s/he] fell off the bed, bed lowered, vital signs taken and put back to bed .96% on RA [Room Air] . Further record review of the fall risk report indicates the resident did not have any injuries at the time of the incident, although the resident's roommate indicated the resident had a abrasion to his/her forehead after s/he fell . Additional review of the document failed to reveal evidence that Staff A had assessed the resident's mental status after the fall per the facility's policy. Review of a progress note dated 2/9/2023 at 8:19 AM, indicates that Nursing Assistant (NA), Staff B, alerted LPN, Staff C that the resident was acting strange and not at his/her baseline. Further review of the progress note revealed the resident had a fall the day before, had an abrasion to her/his right frontal lobe (front of head) and she contacted the doctor regarding this change. Review of an additional progress note dated 2/9/2023 at 10:14 AM, revealed Resident ID #1's oxygen saturation was 65% then increased to 85% (a normal oxygen saturation level is between 95% and 100%) after the head of his/her bed was raised to a 90-degree angle. The resident's oxygen saturation increased to 94% on 4 liters of oxygen. However, the note revealed that the resident wasn't at her/his baseline and was transferred to the hospital. Further record review of hospital documents for Resident ID #1 dated 2/9/2023 revealed s/he arrived at the hospital in rapid atrial (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) fibrillation. S/he was intubated and diagnosed with acute metabolic encephalopathy (a diffuse but potentially reversible disorder of cerebral function that often impairs the state of arousal and cognitive function) and acute hypoxemic respiratory failure (severe arterial hypoxemia that is refractory to supplemental oxygen. It is caused by intrapulmonary shunting of blood resulting from airspace filling or collapse). The resident was discharged from the hospital on 2/13/2023. During a surveyor interview with LPN, Staff A on 2/10/2023 at 10:51 AM, he revealed that when he arrived at the facility on 2/8/2023 for his 11:00 PM to 7:00 AM shift, Resident ID #1 was sitting in a chair at the nurses' station without his/her oxygen on. He revealed the nurse on the 3:00 PM to 11:00 PM shift was concerned that the resident would fall and was displaying signs of agitation that evening and that was why s/he was sitting at the nurses' station. Additionally, Staff A stated that the resident was found on the floor in his room by a NA during rounds at approximately 1:00 AM. When the surveyor questioned Staff A regarding Resident ID #1's fall, he indicated that he called the doctor and left a message. He was unable to recall the name of the doctor. He stated, I think I called Dr [name redacted]. Staff A then indicated in his interview that he did not leave message for the doctor as the doctor never picked up and the phone kept ringing and ringing. He indicated that he did not make any further attempts to contact any other providers. During a surveyor interview on 2/10/2023 at 2:57 PM with the Nurse Practitioner, she revealed she did not receive a call indicating Resident ID #1 had a change in condition or a fall during the evening of 2/8/2023 or the night of 2/9/2023. She further revealed that she received a call on 2/9/2023 at approximately 9:30 AM to notify the office that the resident was being sent to hospital for a change of mental status. During a surveyor interview with the Director of Nursing (DNS) in the presence of the Administrator on 2/10/2023 at approximately 3:00 PM, they acknowledged LPN, Staff A failed to appropriately assess the resident after the fall and indicated the abrasion to the head was from the fall. During a follow up interview on 2/14/2023 at 1:35 PM with Staff A, the surveyor questioned why Resident ID #1 was not wearing his/her oxygen as ordered as documented on the fall risk report on 2/9/2023. Staff A revealed that he must have incorrectly documented on the fall risk report that Resident ID #1 was on room air. During a follow up interview with the DNS on 2/14/2023 at 2:51 PM, she acknowledged Staff A documented Resident ID #1's oxygen saturation incorrectly.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed for physician order's related to insulin administration, Resident ID #10. Findings are as follows: Record review of a community reported complaint sent to the Rhode Island Department of Health on 10/27/2022 alleges in part, .[Resident] was treated 2 days in a row in the .ER [emergency room ] for extremely low blood sugar (61 .31) [normal blood sugar for an insulin dependent diabetic is between 80-130, when blood glucose is too low, this can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, drowsiness, seizures, coma, possibly and death]. ER MD states there are no known medical conditions that could cause this blood sugar dip outside of incorrect insulin dosing while at Berkshire .Berkshire told ER they gave high dose of insulin .Patient believes the nurse at the SNF [skilled nursing facility] gave [resident] an incorrect insulin dose .Patient is requiring Critical level of care at [hospital] . Record review for the resident revealed that s/he was admitted to the facility in May of 2022 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 indicating that s/he is cognitively intact. Review of a progress note dated 10/25/2022 at 2:41 PM states in part, Pt [patient] returned from [NAME] [Endocrinology] apt [appointment] at 1240 .N.Os [new orders] (to begin 10/26) for U-500 75 units BID [twice a day] .d/c [discontinue] [MEDICATION(S)] & [MEDICATION(S)] .orders verified by .NP [Nurse Practitioner]. Review of the October Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Resident received Insulin [MEDICATION(S)] (a short acting form of insulin administered by injection in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . - Resident received [MEDICATION(S)] Solution (a rapid acting insulin used to lower blood sugar) Sliding Scale injection 100 unit/mL on 10/25/2022, 2 units at 7:00 AM and 4 units at 11:30 AM. - Resident received [MEDICATION(S)] R U-500 (a concentrated human insulin used to control glycemic levels in adults and children) KwikPen Solution 75 units subcutaneously on 10/25/2022 at 8:00 PM after a blood sugar level of 143. Th above mentioned [MEDICATION(S)] R U-500 75 units was administered to the resident on 10/25/2022 at 8:00 PM in error due to the Endocrinologist recommending it to begin on 10/26/2022 and the Nurse Practitioner verifying this order. Review of a progress note dated 10/26/2022 at 4:29 AM states in part, .patient found unresponsive in left lying position face down on floor, unwitnessed fall, pt unresponsive to verbal and physical stimuli. Snoring and drooling observed .5 firefighters assisted with transfer to stretcher- transported to [hospital]. Review of a hospital emergency department document dated 10/26/2022 revealed in part, .patient was found on ground around 5 AM this morning. Patient reports that [resident] does not recall falling, however was sleeping in a chair and believes [resident] fell out of it. + LOC [loss of consciousness] for unknown amount of time . The document also indicated that the resident was being seen for [CONDITION(S)] (a condition in which one's blood sugar is lower than the standard range) and had a blood glucose level of 61 when arrived via ambulance to the hospital and then 34 after bloodwork was drawn. During a surveyor interview with the 2nd floor Unit Manager on 10/31/2022 at 1:36 PM, she revealed that she had spoken with the resident's Endocrinology office after the appointment and the new order for [MEDICATION(S)] R U-500 75 units subcutaneously twice a day was to start on 10/26/2022. She further indicated that she had told the nurse who was entering the order into the system to start it on 10/26/2022. Additionally, the unit manager indicated that she was unaware that the resident received a dose of the [MEDICATION(S)] R U-500 on the evening of 10/25/2022 and acknowledged that the order should not have been started until 10/26/2022 per the Endocrinologist orders. During a surveyor interview with the Nurse Practitioner on 10/25/2022 at 1:55 PM, he revealed that he would expect the order for [MEDICATION(S)] U-500 insulin to have been started on 10/26/2022 per the Endocrinologists orders. He further indicated that it is dangerous to give all three insulins on the same day, especially because the U-500 insulin is five times more potent. During a surveyor interview with the Director of Nursing Services (DNS) on 10/31/2022 at 2:30 PM, she acknowledged that the [MEDICATION(S)] R U-500 insulin should not have been administered on the evening of 10/25/2022 and should have been started on 10/26/2022 per the Endocrinologist orders. The DNS further indicated that the resident receiving the dose of [MEDICATION(S)] R U-500 75 units on the evening of 10/25/2022 put the resident in danger of becoming hypoglycemic. As a result of the facility's failure to prevent a significant medication error from occuring, the resident received a dose of 75 U of [MEDICATION(S)] R U-500 insulin, which caused him/her to be emergently transferred to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 2 sample residents, Resident ID #21. Findings are as follows: https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc- 214,[MEDICAL CONDITION] is a potentially life-threatening condition caused by the body's response to an infection. The body normally releases chemicals into the bloodstream to fight an infection.[MEDICAL CONDITION] occurs when the body's response to these chemicals is out of balance, triggering changes that can damage multiple organ systems. Review of a document titled, Policy and Procedure Title: Condition Change; Report to Physician stated in part, Policy: The nursing staff will observe, record and report any condition change to the Attending Physician so as to assure proper and timely interventions .Procedure: 1. Any time there is a change in status of the resident the nurse will complete the following .perform a complete assessment pertinent to the issue on hand .responsible party shall also be informed of the change in status .documents his/her assessment, interventions .nurse must also document on the report sheet and inform the oncoming nurse to the resident changes . Review of the clinical record for Resident ID #21 revealed that s/he was admitted to the facility in July 2020 with [DIAGNOSES REDACTED]. Review of his/her Admission Packet pertaining to skin conditions, revealed no open areas were noted. Review of a 7/15/2020 report titled, Skin Integrity Event-Altered Skin Integrity, revealed the resident was noted to have a wound on the 2nd toe of their left foot. Further record review failed to reveal any interventions were put in place to treat the wound after its discovery until two days later when the wound was noted to have signs of infection. Additionally, the record lacked evidence that the physician was notified of the changes to the wound until 7/17/2020. Review of two documents titled, VOHRA Wound Physicians Wound Evaluation & Management Summary, dated 7/29/2020 and 8/5/2020, each stated in part, . (Site 1) Wound to the left, second toe .Etiology (quality): Infection . Further record review revealed a hospital Continuity of Care (C.O.C.) form dated 8/16/2020 which reads in part, .ulcers .Rt great toe ?diabetic ulcer .pre-admission wound: Yes .posterior L second toe ? diabetic ulcer . pre-admission wound: Yes .Right second toe . pre-admission wound: Yes . Indicating the resident had developed a facility acquired second wound since the first wound was discovered on 7/15/2020. Review of a 8/26/2020 .Wound Physicians Wound Evaluation & Management Summary , stated in part, .(Site 1)Wound to the left, second toe .Dressing Treatment Plan Primary Dressing (s) Mupirocin apply once daily for 30 days .(Site 2) Wound of the right, first toe . Etiology (quality): Infection .Exudate: Light Purulent .Antibiotic choice: please begin [MEDICATION NAME] (antibiotic given through an IV) 1 gm q 12 .(Site 3) Diabetic wound of the right, second toe .Wound Size: 0.6 x 0.3 x Not Measurable cm . Review of August 2020 progress notes revealed that although the order for the antibiotic was given on 8/27/2020, the resident did not have a Peripherally Inserted Central Catheter (PICC) (used to administer IV medications), until 8/29/2020. Additional review of the progress notes revealed the resident was non-compliant with the placement of the PICC line and removed it themselves on several occasions, causing him/her to miss several doses of the [MEDICATION NAME] ordered to treat the infection in their wound. Review of the resident's Electronic Medication Administration Record [REDACTED] - [MEDICATION NAME] 1 gram intravenous, twice a day for one week, then adjust once wound culture results are obtained, 8/27/2020-9/1/2020, not administered for 7 of 9 opportunities - Left second toe: Cleanse with 1/4 strength Dakin's solution and apply mupirocin daily (topical antibiotic). The treatment was not completed as ordered for 2 out of 5 opportunities. Further review of the progress notes failed to provide any evidence that neither the wound doctor nor the attending physician were notified that the resident had missed any doses of their antibiotics. Additional review of the resident's progress notes revealed the following: -8/31/2020 at 4:28 PM: .Resident was awake at beginning of shift. C/O (complains of) pain to BLE (bilateral lower extremities) .Resident consumed breakfast with much cuing needed .slept rest of the shift, refusing to wake for lunch .Wound care to great toe completed. Foul odor, yellowish, dark wound bed. Awaiting for PICC line to be put in for medication administration . -8/31/2020 at 11:29 PM: .X-RAY .RESULT SHOWED .MILD PATCHY LEFT BASILAR DENSITY COMPATIBLE WITH PNA (pneumonia), (attending physician) NOTIFIED AND NNO (no new orders) . -9/1/2020 at 11:26 AM: .Resident found .on his/her knees at side of his bed around 8am .Weakness noted to extremities, pain when body is touched . -9/2/2020 at 11:11 AM Attending Physician note: .Patient noted to have sudden decline over past 2 days .requiring high flow o2 (supplemental oxygen) lungs diminished .right great toe deep tissue wound with scant drainage no [DIAGNOSES REDACTED] of foot extremities cool poor distal pulses .A/P [MEDICAL CONDITION]/[MEDICAL CONDITION] .initiating a workup to hopefully find an etiology of the decline that can be rectified in this facility .will obtain cxr, labs and ua . -9/2/2020 at 11:45 AM: .While CNA was feeding resident .resident was unresponsive but breathing, difficult to get a pulse reading and oxygen level .eyes closed shut .Sternal rub (the application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli. The sternum rub is the most common painful stimulus practiced in the field by EMTs and paramedics.) given to chest but no response. VS (vital signs) 96.2, 46/22 (blood pressure normal range 120/60), 73% (Oxygen saturation. normal range above 93%) 6L(liters) N.C (nasal cannula), 45(pulse normal range 60-80's), 28 (respiratory rate, normal range 12-16 breaths per minute) .MD came in building to see resident, new orders obtained, Chest x-ray . -9/2/2020 at 3:42 PM: .Resident is current sleeping .On 4L O2 with non breather mask. Responsive by squeezing staff had and moving head .Labs and chest x-ray results pending . -9/2/2020 at 11:37 PM: .Resident was sent out to (hospital) at 7:00 pm order by (attending physician) due to abnormal Labs values. Resident was responsive and lethargic . Review of a 9/2/2020, radiology report titled, Preventative Diagnostics Patient Report, stated in part, Procedure: Chest, single view .Findings: Correlative Films Provided: 8/31/2020 .Impression:1. Mild patchy left basilar density compatible with pneumonia .in clinical context of .elevated WBC (white blood cell) or other signs of lung infection, findings would be compatible with pneumonia . Review of a 9/2/2020 report titled, East Side Clinical Laboratory, stated in part, .WBC 14.5 (normal range 4.0-10.0 K/U) . Review of the 9/2/2020 emergency room Visit Notes, stated in part, .Primary Impression: [DIAGNOSES REDACTED] (inflammation of the bone, caused by an infection). Additional Impressions: [MEDICAL CONDITION] .Condition: Critical . During an interview with the LPN, Staff A, on 9/16/2020 at 8:47 AM, it was revealed that only a partial dose of the intravenous antibiotic was administered to the resident on 8/29/2020. He could not provide evidence of notifying either the attending physician or the wound physician that the intravenous medication doses were not administered or administered partially. Additionally, he could not provide evidence that he reported to the attending physician or the wound doctor that the resident had not been administered the mupirocin ointment as ordered for the treatment of [REDACTED]. During an interview with the Infection Control Nurse on 9/18/2020 at 9:48 AM, it was revealed that she was aware that the wound continued to show signs of infection and the intravenous medication was not administered as ordered. Additionally, she was unable to provide evidence that she reported any of these discrepancies in the patient's treatments to either the attending physician or the wound physician. During an interview with the DNS on 9/16/2020 at 1:54 PM, she stated that her expectation of the nurses would follow the policy and procedures for reporting that the resident was not receiving the appropriate care. Additionally, she was unable to provide evidence that the nursing staff alerted the attending or wound physician aware that the resident had missed any dosed of the antibiotics ordered to treat their wounds. During an interview with the resident's Attending Physician A, on 9/14/2020 at 3:42 PM, and a follow-up interview on 9/18/2020 at approximately 11:30 AM, it was revealed that he did not implement interventions for the abnormal chest x-ray results reported to him on 8/31/2020, because he believed the resident's order for [MEDICATION NAME] would treat the pneumonia. Additionally, he revealed he was not made aware at that time that the [MEDICATION NAME] was not administered to the resident as ordered. During an interview with the wound Physician on 9/16/2020 at 12:02 PM, he revealed his expectation is that he should have been made aware of the abnormal chest x-ray, the wound showing signs of a progressing infection and that the intravenous antibiotic medication was not administered as ordered.

Based on record review and staff interview it has been determined that the facility failed to ensure that the residents medication regimen was free from significant medication errors for 2 of 2 sample residents. (Resident ID# 20 & 21). Review of the Policy and Procedures document titled, Admission Nursing Assessments revealed in part, .the admission documentation checklist is to be initialized by the nurse who completes the specific assignment .Admission medication reconciliation to be done with admitting nurse and another nurse .If errors reached resident, complete medication error form and policy . 1) Resident ID# 20 was admitted to the facility in August 2020 with [DIAGNOSES REDACTED]. Review of an 8/26/2020 discharge report from the hospital indicates to start Xarelto (a medication to thin the blood). Take 20 milligrams (MG) by mouth daily. Review of the physician's orders [REDACTED]. 2) Resident ID #21 was admitted to the facility on [DATE], sent out to the hospital on [DATE] and then readmitted back to the facility on [DATE]. S/he had [DIAGNOSES REDACTED]. Review of the 7/6/2020 and 8/20/2020 hospital continuity of care forms revealed an order for [REDACTED]. Review of a physician's orders [REDACTED]. Review of the MAR from July through September 2020 revealed that s/he received the wrong dose of the [MEDICATION NAME] on the dates below: - [MEDICATION NAME] 25 mg was administered daily from 7/6/2020 through 8/16/2020 instead of the ordered 12.5 MG. - [MEDICATION NAME] 25 mg was administered daily from 8/21/2020 through 9/2/2020 instead of the ordered 12.5 MG. During an interview on 9/14/2020 at approximately 12:00 PM with LPN, Staff D, admitting nurse for both residents, she acknowledged that there was a discrepancy regarding the medications for both of these residents and she was not aware of the medication discrepancies until brought to her attention by the surveyor. She also acknowledged that she failed to utilize the admissions checklist form when reconciling admission medications. During an interview with the DNS on 9/16/2020 at 1:54 PM she stated that her expectation of the admission nurses would be that they follow the policy and procedures regarding medication reconciliation and for them to clarify the orders with the physician when discrepancies are noted. During an interview with the Attending Physician B for Resident ID #20, on 9/9/2020 at approximately 1:00 PM, it was revealed that he was unaware of a medication discrepancy and was unable to provide evidence that he ordered a dose change. During an interview with the Attending Physician A for Resident ID #21, on 9/18/2020 at approximately 11:30 AM, it was revealed that he was unaware of the medication discrepancy and was unable to provide evidence that he ordered a dose change.

Based on record review and staff interview it has been determined that the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings are as follows: Record review of a community reported incident dated [DATE] indicated a potential delay in medical treatment/care for Resident ID #4. Review of the clinical record revealed the resident was admitted to the facility in 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Code Status: Full Code . Review of the Care Plan for this resident, last reviewed/revised on [DATE], revealed, .Advance Directive FULL CODE .1. Nursing to follow md order . Review of the residents Advance Directive, dated [DATE], revealed the resident representative's initials on the line next to full code indicating, .FULL CODE: All life support and resuscitation efforts will be utilized by the staff of the facility until rescue personnel (911 medical emergency) arrive and take over and/or resuscitation efforts . Review of the record revealed a note written by Licensed Practical Nurse, Staff C, on [DATE] stated in part, Resident FULL CODE COVID 19 +ve. Found unresponsive . Further record review failed to reveal evidence that any basic life support measures, including CPR were initiated. During an interview with Staff C and the DON, on [DATE] at approximately 2:00 PM, it was revealed that Staff C found the resident unresponsive on [DATE] at approximately 11:55 AM. The DON entered the room at approximately 12:00 PM, both performed a respiratory assessment and checked for a pulse, none were detected. Staff C exited the room to retrieve the crash cart (a wheeled container carrying equipment for use in emergency resuscitations) and returned with it a few minutes later. It was revealed that both Staff C and the DON failed to initiate any basic life support measures, including CPR, per resident's code status at that time. According to the DON, the advanced directive was not followed due to the residents positive Covid-19 infection. Record review of the Emergency Medical Service Run report, requested by the surveyors, indicated that emergency personnel were dispatched to the facility on [DATE] at 12:30 PM. Record review of a written statement provided by the Assistant Administrator, dated [DATE], revealed, in part, .Resident is Covid positive and unresponsive .went downstairs and out to the parking lot to meet EMS to inform them of what was going on .I was called and informed that the nurse palpated for a carotid pulse and there was none detected. EMS arrived and spoke with [Medical Director] over the phone. [Medical Director] was made aware of the resident's status. EMS was also on the phone of the receiving ED. [Medical Director] and the paramedic from Providence EMS spoke and the doctor called the time of death. EMS did not enter the building .the resident has been unresponsive for more than 30 minutes now. [Medical Director] called the unit and spoke with the nurse and gave them time of death. During a telephone interview with the Medical Director on [DATE] at approximately 12:40 PM, it was revealed that CPR was not initiated for Resident ID #4 because of the .uncertainty of the virus . He further stated that at the time death was pronounced, he determined that more than 25 minutes time had elapsed since the resident was found unresponsive and decided that interventions at this point were .futile for rescue . The facility found Resident ID #4 unresponsive on [DATE] at approximately 11:55 AM (s/he was seen previously responsive approximately 30 mins prior). The facility failed to initiate CPR per the residents advanced directive.

Based on record review and staff interview, it has been determined that the facility has failed to ensure that each resident receive and the facility provide the necessary care and services to attain or maintain the highest practicable physical well - being in accordance with the comprehensive assessment and plan of care for 1 of 14 sample residents, (ID# 1) relative to medication, treatment and a change in condition and upon emergency transfer, and failed to provide appropriate medication information and failed to follow physician orders [REDACTED]. Findings are as follows: Resident ID# 1 was admitted to the facility on [DATE] from an acute care hospital due to deconditioning after a fall at home. Past medical history is significant for [MEDICAL CONDITION], end stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], [MEDICAL CONDITIONS], diabetes mellitus, pneumonia, and [MEDICAL CONDITIONS]. The resident has had 6 [MEDICAL CONDITION] (MI's) in the past. Review of the Care Area assessment dated [DATE] indicates the resident is weak and deconditioned, requires extensive assist with bed mobility, transfers and ambulation, toileting, bathing and dressing related to a [DIAGNOSES REDACTED]. There is a care plan dated 5/7/2015 for alteration in respiratory status related to [DIAGNOSES REDACTED]. The goal is to be free of any signs or symptoms of respiratory distress. Approaches include to monitor for changes in breathing pattern and shortness of breath, changes in lung sounds or increased respiratory rate, decrease in oxygen saturation level, provide oxygen as ordered, and report any changes to the physician. A care plan dated 5/7/2015 was developed for a fluid restriction due to receiving [MEDICAL TREATMENT] treatment and a risk for a urinary tract infection. An approach is to provide fluid intake as recommended by the dietician and the [MEDICAL TREATMENT] center. There is an admission nursing note dated 4/30/2015 at 3:00 PM which documents the resident has 3+ bilateral lower extremity [MEDICAL CONDITION]/fluid. Further review of the nurse's notes from 5/1 to 5/12/2015 revealed only 1 time on 5/5/2015 on the evening shift where the resident's [MEDICAL CONDITION] was assessed indicating 2+ [MEDICAL CONDITION] bilaterally below the kneecaps. On 5/10/2015 at 12:00 AM a nurse's note indicates the resident was complaining of right mid chest pain with increased palpations of the chest wall. The note indicates the resident's blood pressure was 98/60, the pulse was at 74, and the oxygen saturation level was at 91% on room air. The resident was instructed to do breathing exercises and stated pain was revealed. The resident's physician was interviewed on 5/27/2015 at 3:15 PM and revealed that she was not made aware that the resident experienced chest pain on 5/10/2015. Additionally, she stated that chest pain is concerning especially due to the resident's cardiac history and that a physician should be notified, The physician was notified on 5/12/15 that the resident was experiencing chest pain.An order was obtained to transport the resident to the hospital via emergency, 911. The nurse's note and the Continuity of Care form (COC) sent to the hospital indicates the resident now has gross [MEDICAL CONDITION], pedal to below kneecaps bilaterally. Additionally, the COC identifies the resident as having 6 MI's in the past. There is a physician order [REDACTED]. An admission nutrition assessment also dated 5/4/2015 revealed the resident is on a 1500 ml fluid restriction. A diet order slip dated 5/4/2015 for a diet change failed to identify that the resident is on a fluid restricted diet. Review of the medical record, including the nursing assistant flow sheets, failed to reveal evidence that this resident was placed on a fluid restriction. When interviewed on 5/27/2015 at 1:40 PM, Staff G was unable to produce evidence that the resident was placed on a fluid restriction nor was she aware that there was a physician order [REDACTED]. Staff H was also interviewed on 5/27/2015 at approximately 1:45 PM and stated she was unaware that the resident was on a fluid restriction. The resident receives [MEDICAL TREATMENT] treatment 3 times per week for end stage [MEDICAL CONDITION]. The resident has a physician order [REDACTED]. Check oxygen saturation level every shift. Review of the May 2015 Treatment Administration Record (TAR) revealed that no oxygen saturation levels were obtained on 5/11/2015 for the 7 AM to 3 PM and the 3 PM to 11 PM shifts. Review of the nurse's notes for this time period failed to reveal that the oxygen saturation levels were obtained. Additionally, review of the Continuity of Care form dated 5/11/2015 from the [MEDICAL TREATMENT] Center stated please be aware that patient arrived with complaints of SOB (shortness of breath). Patient had O2 (oxygen) on back of w/c (wheelchair) but was not placed on O2 D/T (due to) no cannula. Please have patient on oxygen upon transport to [MEDICAL TREATMENT]. When interviewed on 5/28/2015 at 11:00 AM, the Director of Nursing (DNS) was unable to explain why the oxygen saturation levels were not obtained. Additionally, she stated that the [MEDICAL TREATMENT] Director reported that when the resident arrived at the center he/she was in slight respiratory distress and did not have the nasal cannula in which to administer the oxygen. There is a physician order [REDACTED]. Review of the May 2015 TAR revealed that the TEDS were to be on in the morning and off at night. From 5/1 to 5/12/2015, on both the day and evening shifts, all entries on the TAR were circled (not administered) except for the evenings of 5/1, 5/4, and 5/5/2015, which were blank. There was an explanation on 5/3/2015 stating Resident does not have TEDS, its the weekend. Will request on Monday. All other entries had no explanation as to why they were not applied. Review of the nursing 24 Hour Shift Report dated 5/9/2015 for the 7 AM to 3 PM shift indicates .* Needs TEDS * . Although it was identified on the nursing shift report, the resident never received the TEDS. Review of the C.N.A. Resident Information Sheet failed to include that the resident was to wear TEDS. When interviewed on 5/27/2015 at 3:15 PM, the physician stated that shortly after admission, the resident was not wearing the TEDS due to tightness. The physician informed the staff that they needed to obtain TEDS that fit as it was important for the resident to wear them. When interviewed on 5/27/2015 at 1:40 PM, Staff G, who cared for the resident, was unable to explain why the TEDS were not applied or that the physician was notified. During an interview on 5/27/2015 at approximately 2:00 PM, the DNS indicated that she received a call from the admitting hospital, on 5/15/2015 stating that the resident was sent to the hospital with another resident's Medication Administration Record [REDACTED] The DNS stated that when a resident with a similar name to a current resident is admitted , that a name alert sticker is placed on the spine of both resident's medical records and stickers are placed on all MAR's and TAR's. The DNS further indicated that both resident ID#1 and the resident with the same first and last name (ID# 3) had name alert stickers placed on all MAR's and TAR's. The DNS provided the surveyor with the record and/or information used to conduct an internal investigation. This information included the medical records for resident ID#'s 1 & 3. On the MAR's and TAR's for resident ID# 1, a name alert was observed on these documents. However, on the MAR's and TAR's for resident ID# 3, there was no name alert on these documents. At this time, the DNS was unable to explain why there were no name alert stickers on the MAR's and TAR's for resident ID# 3 prior to 5/15/2015. The facility failed to provide care and services to maintain the resident's highest practicable well-being in accordance with the plan of care.

Based on record review and staff interview, it has been determined that the facility has failed to provide appropriate treatment and services to restore as much normal bladder function as possible for 1 of 10 sample residents relative to incontinence (ID# 2). Findings are as follows: Record review revealed resident ID# 2 was admitted to the facility on [DATE] for long term care with [DIAGNOSES REDACTED]. An Admission Minimum Data Set ((MDS) dated [DATE] indicated the resident was frequently incontinent of bladder and required extensive assistance for toileting. A review of the corresponding Care Area Assessment relative to Urinary Incontinence reveals that the resident will be trailed on a week long toileting program. Additionally, a urinary incontinence care plan initiated on 8/12/2014 and updated on 5/14/2015 was developed due to the resident being at risk for urinary tract infections, skin breakdown and indicates the resident is a candidate for a toileting plan. Approaches include the following: * Report changes in bladder status to the physician * Scheduled toileting plan, see incontinence assessment of 8/21/2014 Further record review revealed a bowel and bladder training schedule dated 8/22 through 8/28/2014 which was not completed. Although the resident is at risk for urinary tract infections and has increased incontinence, there is no evidence of any further interventions that determines the cause of this incontinence. A corresponding quarterly MDS dated [DATE] revealed the resident's bladder status has declined and is always incontinent. Review of the C.N.A. Flow Sheet for the month of May 2015 revealed the resident is always incontinent of bladder. When interviewed on 6/2/2015 at 10:30 AM, Staff B, who is responsible for continence training, was unaware that a training schedule was not put in place and that the resident is totally incontinent of bladder.