Every finding on record at Bethany Home of Rhode Island

Based on record review and staff interview, the facility policy for food brought in from an outside source failed to ensure safe and sanitary storage, handling, and consumption.Findings are as follows:Record review of a facility policy titled, Food Brought in From Outside the Facility Policy, dated 6/1/2021, states in part, [NAME] Home has no responsibility should any adverse reaction occur from food(s) when it has been brought into the facility from an outside source .The facility's policy failed to ensure the following requirements that are within regulations:-that staff assist the resident in accessing and consuming the food, if the resident is not able to do so independently-help visitors and family to understand safe food handling practices including, but not limited to, safe cooling and reheating processes, hot and cold holding temperatures, preventing cross contamination, and hand hygiene.During a surveyor interview on 11/26/2025 at approximately 11:30 AM with the Administrator, she acknowledged that the facility's policy related to food brought in from an outside source for residents failed address the facility's responsibilities in the safeguarding of food brought in from an outside source.

Based on record review, and resident and staff interview, it has been determined that the facility failed to ensure that self-administration of medications was clinically appropriate for 1 of 1 resident observed with an insulin pump (a computerized device that delivers a continuous dose of insulin to people with diabetes to manage blood sugar levels), Resident ID #9.Findings are as follows:Record review of a facility policy and procedure titled, Self-Administration of Medication by Resident, last revised on 10/16/2025, states in part, Residents may self-administer medications with a physician's orders.The resident will be instructed on the use and reason for the medication, reading of the label, the dosing and schedule. The resident shall then be evaluated on these tasks using the Assessment of Resident's Ability to Self-Medicate Form. The resident will be asked to read the label and indicate what time the medication should be administered. The resident's ability to perform this task will be evaluated by assessing the resident's cognitive, physical and visual ability to self-medicate .The Assessment of Resident's Ability to Self-Medicate.will be completed prior to him/her self-administration medication. Physician order must be obtained and documented in PCC [ Point Click Care - an electronic medical record software].Record review revealed the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus.Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating s/he is cognitively intact.Record review revealed a physician's order dated 10/17/2025 to monitor the insulin pump site for infection, battery life, insulin chamber levels, and kinks in the tubing every shift. Further review of the physician's orders failed to reveal evidence of an order specifying the necessity of the insulin pump, the type of pump being used, or the type of insulin being administered through the pump.During a surveyor interview on 11/25/2025 at approximately 11:20 AM with Resident ID #9, s/he revealed that s/he has an insulin pump in place and that s/he manages it independently.Record review failed to reveal evidence that the resident has received a self-administration assessment for the insulin pump. During a surveyor interview on 11/25/2025 at 12:42 PM with the Director of Nursing Services, he revealed that the insulin pump is managed by the resident. He acknowledged that the facility failed to complete an assessment of the resident's ability to self-administer medications.Refer to F 658, F 726 and F 842

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 1 of 1 resident reviewed for an insulin pump (a computerized device that delivers a continuous dose of insulin to people with diabetes to manage blood sugar levels) utilization, Resident ID #9, 1 of 2 residents reviewed with parameters for medication administration, Resident ID #22, 1 of 1 resident reviewed related to anticonvulsant symptom monitoring, Resident ID #4, and 1 of 2 residents reviewed related to antipsychotic symptom monitoring, Resident ID #16.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients .1. Record review revealed Resident ID #9 was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus.Record review of the care plan revised, 11/21/2025 revealed in part, .has insulin pump. Staff to.ensure proper insulin administration. If necessary, assist.to load pump.During a surveyor interview on 11/25/2025 at approximately 11:20 AM with Resident ID #9, s/he revealed that s/he has an insulin pump in place and that s/he manages it independently.Record review failed to reveal evidence of an order specifying the necessity of the insulin pump, the type of pump being used, or the type of insulin being administered through the pump.During a surveyor interview on 11/25/2025 at 12:42 PM with the Director of Nursing Services (DNS), he revealed that the insulin pump is managed by the resident and failed to reveal evidence that the facility identified the necessity of the insulin pump, the type of pump being used, or the type of insulin being administered through the pump.Refer to F 554, F 726 and F 8422. Record review revealed Resident ID #22 has a physician's order with a start date of 10/24/2025 for losartan potassium (a medication prescribed to treat high blood pressure), oral tablet 50 milligrams (mg), by mouth, every morning for hypertension. Additional review revealed instructions with a parameter to hold the losartan potassium if the resident's systolic blood pressure (SBP - the top number in a blood pressure reading that measures the force of blood against your artery walls when your heart beats and pumps blood) is less than 110 mmHg (millimeters of mercury).During a surveyor observation on 11/25/2025 at 8:16 AM, during the medication pass, Certified Medication Technician, Staff A, failed to obtain Resident ID #22's SBP to ensure that it is not less than 110 mmHg prior to administering the losartan, as ordered.Record review of Resident ID #22's vital sign record and Medication Administration Record/Treatment Administration Record (MAR/TAR) for November of 2025, failed to reveal evidence that his/her SBP was taken, 20 out of 24 opportunities.During a surveyor interview on 11/26/2025 at 11:58 AM with the DNS, he acknowledged Resident ID #22's SBP should be monitored and recorded prior to administering his/her losartan, per the physician's order.3. Record review revealed Resident ID #4 has a physician's order dated 4/6/2025 for Pregabalin (an anticonvulsant medication prescribed to treat seizures). Further record review revealed a physician's order dated 6/5/2025 to monitor Resident ID #4's blood pressure and heart rate changes every shift, related to anticonvulsant utilization.Record review of Resident ID #4's vital sign record and MAR/TAR for November of 2025, failed to reveal documentation that his/her blood pressure and heart rate were monitored every shift, as ordered.During a surveyor interview on 11/26/2025 at approximately 11:30 AM with the DNS, he was unable to provide evidence that the resident's blood pressure and heart rate were being monitored every shift.4. Record review revealed Resident ID #16 has a physician's order dated 2/18/2025 for clonazepam (a medication prescribed to treat panic disorders) 0.5 mg in the morning, and 0.25 mg in the evening. Further record review revealed a physician's order dated 3/7/2025 to monitor blood pressure, heart rate changes, changes in behavior, rash, fever, or dizziness, every shift while on clonazepam. Record review of the vital sign record and MAR/TAR for November of 2025 failed to reveal evidence of a documented blood pressure or heart rate every shift.During a surveyor interview on 11/26/2025 at 11:12 AM with Registered Nurse, Staff B, he could not provide evidence that the blood pressure or heart rate were taken each shift, per the physician's order.

Based on record review, and resident and staff interview, it has been determined that the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to provide quality care and respond to each resident's individualized needs for 1 of 1 resident reviewed who uses an insulin pump (a computerized device that delivers a continuous and precise dose of insulin to people with diabetes to manage blood sugar levels), Resident ID #9.Findings are as follows:Review of the Annual Facility Assessment, last revised on 10/17/2024, revealed in part, .Staff Competencies.nurses are competent in.diabetes .[NAME] Home encourages and financially supports all educational activities and certifications. Support for education in all areas are cornerstone of the mission to provide quality care.Record review revealed the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review of the care plan revised, 11/21/2025, revealed in part, .has insulin pump. Staff to.ensure proper insulin administration. If necessary, assist.to load pump.Record review revealed a physician's order dated 10/17/2025 to monitor the insulin pump site for infection, battery life, insulin chamber levels, and kinks in the tubing every shift. Further review of the physician's orders failed to reveal evidence of an order specifying the necessity of the insulin pump, the type of pump being used, or the type of insulin being administered through the pump.Record review of the insulin pump user's manual obtained by the facility upon surveyor request on 11/25/2025 revealed, the resident was using a t: slim X2 Insulin Pump. Additionally, it revealed in part, .WARNINGS.DO NOT start to use t: slim X2 Insulin Pump before reading the User's Guide. Failure to follow the instructions can result in over delivery or under delivery of insulin. This can cause very low or very high blood glucose which could result in serious injury or death.DO Not start to use your t: slim X2 system before you have been appropriately trained on its use by a certified t: slim X2 system trainer.Record review of the nursing staff competencies for Registered Nurse (RN), Staff B, Staff C, Staff D, and Staff E, failed to reveal evidence of training on the use of the insulin pump. During a surveyor interview on 11/25/2025 at approximately 11:20 AM with the resident s/he revealed that s/he has an insulin pump in place and that s/he manages it independently.During a surveyor interview on 11/25/2025 at approximately 12:30 PM, with RNs, Staff D and E, they revealed that they have not received any training from the facility regarding the use of the insulin pump. Staff D indicated to the surveyor that she looked up online for information about the pump. During a surveyor interview on 11/25/2025 at 10:45 AM with DNS, he revealed that he screens all the residents prior to arrival to ensure the facility can take care of the residents. Additionally, he revealed that he has not received or provided the nursing staff with any training on the use of the insulin pump. Lastly, he acknowledged that if the facility nursing staff were to manage the insulin pump, it would be out of their competencies.

Based on record review and staff interview, it has been determined that the facility failed to ensure that resident records are complete and accurately documented, relative to blood sugar monitoring for 1 of 1 resident reviewed, Resident ID #9.Findings are as follows:Record review revealed the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus.Record review revealed a physician's order dated 10/18/2025 to monitor blood glucose prior to meals from Dexcom (a continuous glucose monitor prescribed for people with diabetes to track their glucose levels in real time), prior to meals for type 2 diabetes mellitus.During a surveyor interview on 11/25/2025 at 11:57 AM with Registered Nurse (RN), Staff D, she stated that the resident was receiving finger sticks, three times daily with meals, to obtain the resident's blood sugar levels.Record review failed to reveal evidence of an order to monitor blood glucose utilizing finger sticks, three times daily with meals, to obtain the resident's blood sugar levels.During an additional surveyor interview on 11/25/2025 at 2:30 PM, with RN, Staff D, she could not provide evidence the physician was notified that the Dexcom has stopped working and that they have been obtaining the resident's blood sugar through a fingerstick three times a day with meals.Record review failed to reveal evidence that staff have been accurately documenting the resident's blood sugar results, as staff continued to record the fingerstick glucose readings as if they were obtained from the Dexcom monitor.During a surveyor interview on 11/25/2025 at 1:28 PM with the Director of Nursing Services, he revealed that the resident's Dexcom glucose monitor stopped working on 11/21/2025. He acknowledged that the physician should have been notified that the Dexcom glucose monitor stopped working and an order to obtain the resident's blood sugar through fingerstick before meals should have been obtained.

Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to protect identifying information about complainants or residents that were identified in the survey results binder. Findings are as follows:During a surveyor observation on 11/25/2025 at approximately 11:00 AM, of the main lobby, a black binder with a title of State Survey Results was stored on the reception area countertop, facing the public as they entered the facility.Record review of the binder revealed the following:2023 annual federal recertification survey results2024 annual federal recertification survey resultsAdditional record review revealed resident rosters (a list provided to a facility that corresponds to a number identifier use in a survey to protect privacy) included in the survey binder. During a surveyor interview on 11/26/2025 at 10:30 AM, with the Administrator, she acknowledged that the residents' names along with their corresponding number identifier were in the binder and available for the general public to view.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent an accident while ambulating for 1 of 1 resident reviewed for falls who sustained significant injuries, multiple fractures of his/her vertebral bones of the spine, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 11/4/2025 revealed that Resident ID #1 was being walked from the toilet to the sink by a staff member and caught his/her foot on the floor and fell, striking the left side of his/her head and landing on his/her back. Additionally, it revealed that the resident sustained multiple fractures to the bones of his/her spine.Record review of the Safe Patient Handling policy indicates that approved patient handling aids shall be used to prevent manual lifting and handling of residents.Review of a hospital Discharge summary dated [DATE] revealed a moderate T4 (the fourth thoracic vertebra) compression fracture (a break in a vertebra) with a 2-millimeter (mm) retropulsion (when a piece of the vertebra bone breaks away), a severe T12 compression fracture with a 7 mm retropulsion, and a compression fracture of the 5th Lumbar vertebrae. In addition, it revealed that the findings were absent on prior imaging.Record review revealed that Resident ID #1 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, generalized muscle weakness and back pain.Review of the Minimum Data Set assessment dated [DATE] revealed the resident requires assistance of 1 staff for walking 10 feet once standing and for toileting transfers. Further it indicates staff lifts, holds, or supports the trunk or limbs, but provides less than half the effort.Review of a care plan last revised on 9/23/2025, revealed that the resident can walk short distances around his/her room using a rolling walker with the assistance of 1 staff member.Record review of the Care Profile Report (a summary outlining the resident's current care status, medical conditions, and support needs) indicated that the resident requires assistance from one staff member for ambulation using a rolling walker and gait belt (a sturdy strap, usually made of canvas, nylon, or leather, that caregivers use to help safely support and assist a person when walking or transferring). Review of an Occupational Therapy document dated 11/5/2025 revealed that Resident ID #1 fell in the bathroom on 11/4/2025, was sent to the hospital, and returned to the facility with a severe decline from the fall. Additionally, it revealed that the resident is very fearful of all movement since his/her fall. Review of the resident's progress notes revealed the resident had not sustained any falls in the last 6 months. During a surveyor interview on 11/5/2025 at 11:21 AM with Resident ID #1 s/he revealed that s/he was coming out of the bathroom with his/her walker and fell. Additionally, s/he revealed that s/he began experiencing back pain as a result of the fall.During a surveyor interview on 11/5/2025 at 11:26 AM with Registered Nurse, Staff A, she revealed that the resident needs staff assistance ambulating in his/her room and requires a walker and a gait belt. During a surveyor interview on 11/5/2025 at 11:40 AM with Nursing Assistant (NA), Staff B, she revealed that she regularly assists Resident ID #1 and utilizes a gait belt when she ambulates with him/her.During surveyor interviews on 11/5/2025 at 12:00 PM and 12:44 PM with the Occupational Therapist, Staff C, she revealed that the resident has been receiving therapy in order to maintain his/her highest level of functioning and has never complained of back pain. Additionally, she revealed that the resident is now complaining of pain and had a significant decline after the fall on 11/4/2025. Furthermore, she revealed that she would expect staff to use a gait belt to ambulate the resident, as it is a standard of practice for all residents who require assistance.During a surveyor interview on 11/5/2025 at 12:22 PM with NA, Staff D, she revealed that she was the staff assisting the resident at the time of the fall and did not assist lift, hold, or support the trunk or limbs of Resident ID #1. Additionally, Staff D acknowledged that she had not applied the gait belt to the resident and was unable to assist in preventing the fall despite being near the resident. Staff D indicates that she normally utilizes a gait belt when assisting the resident. The facility's failure to ensure that staff followed the resident's care plan and implemented proper safety measures specifically, the use of a gait belt when assisting Resident ID #1 with ambulation resulted in the resident sustaining multiple spinal fractures and a significant decline, due to a preventable fall.

Based on record review and staff interview, it has been determined that the facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for 2 of 2 residents who were transferred to the hospital, Resident ID #s 16 and 77. Findings are as follows: 1. Record review revealed Resident ID #16 was initially admitted to the facility in March of 2021 with diagnoses including, but not limited to, history of pneumonia, hemiplegia (partial or total paralysis) and hemiparesis (weakness to one side of the body) following a stroke, chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breath) and gastrostomy status (is a surgical procedure to make a hole in the stomach through the abdomen to insert a feeding tube into the stomach). Record review revealed that the resident was transferred to the hospital on 5/2/2024, 5/30/2024 and 7/2/2024. Record review failed to reveal evidence that the Office of the State Long-Term Care Ombudsman was notified of the hospital transfers for Resident ID # 16. 2. Record review revealed Resident ID #77 was originally admitted to the facility in October of 2022 with diagnoses including, but not limited to, urinary retention, stroke and atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow). Record review revealed that the resident was transferred to the hospital on 7/12/2024 and 7/29/2024. Record review failed to reveal evidence that the Office of the State Long-Term Care Ombudsman was notified of the hospital transfers for Resident ID #77. During a surveyor interview with the Social Worker on 9/25/2024 at 12:52 PM, she was unable to provide evidence that the Office of the State Long-Term Care Ombudsman was notified of Resident ID #'s 16 and 77 transfers to the hospital. Additionally, she revealed that she only sends a notification to the Office of the State Long-Term Care Ombudsman for residents that are discharged from the facility or if a resident is transferred to the hospital and does not return to the facility.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Additionally, the facility failed to identify that trauma informed care assessments were not being completed, or that enhanced barrier precautions were not being followed appropriately for resident's with multi drug resistant organisms (MDROs) or indwelling medical devices. Findings are as follows: Review of the QAPI binder document titled Quality Assurance and Performance Improvement Projects 2024, revealed that relative to trauma informed care the facility would be reviewing each new admission chart within 24 hours or by the next weekday to ensure that trauma assessments have been completed. Further review failed to reveal evidence of maintenance of the plan, including tracking and measuring performance, and establishing goals and thresholds for performance measurement. Record review revealed that Resident ID #21 was admitted to the facility in September of 2024 with diagnosis including, but not limited to, dementia with psychotic disturbance. Record review of an admission preliminary baseline care plan dated 9/3/2024 revealed the resident has a history of trauma related to him/her being abused as a child. Further record review failed to reveal evidence a trauma screening assessment was completed upon admission by the social worker. Further review of the document titled Quality Assurance and Performance Improvement Projects 2024, revealed that relative to infection control, the facility would be monitoring quarantine and isolation compliance. Further review failed to reveal evidence of implementation or maintenance of the plan, including tracking and measuring performance, and establishing goals and thresholds for performance measurement. During surveyor observations from 9/23/2024 through 9/25/2024, Resident ID #s 17 and 18 failed to reveal evidence of isolation carts or signage posted outside of their rooms to indicate that they require Enhanced Barrier Precautions, due to their history of Extended-spectrum beta lactamases (ESBL-an infection resistant to multiple antibiotics) in the urine. During a surveyor interview on 9/26/2024 at 9:42 AM with the Director of Nursing Services, he acknowledged that Resident ID #21's chart failed to be reviewed within 24 hours or by the next weekday to ensure that a trauma assessment was completed. Additionally, he acknowledged that Resident ID #s 17 and 18 failed to be monitored for quarantine and isolation compliance as outlined in the facility's QAPI plan.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections by failing to place residents on Enhanced Barrier Precautions (EBP; involves using gown and gloves during high-contact resident care activities) for 2 of 2 residents reviewed for a Multi-Drug Resistant Organism (MDRO) infection, Extended Spectrum Beta Lactamase (ESBL-an infection that is resistant to multiple antibiotics) Resident ID #s 17 and 18. Additionally, the facility failed to conduct an annual review of written standards, policies, and procedures and update the infection control program as necessary. Findings are as follows: Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) last reviewed 8/1/2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents .with MDRO infection or colonization . 1. Record review revealed that Resident ID #17 was readmitted to the facility in March of 2022 with a diagnosis including, but not limited to, urinary tract infection. Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review revealed that the resident requires extensive assist of two staff members for toileting. Record review of the resident's urine culture results revealed the following: 5/22/2024- revealed that the patient had a urine infection which was positive for ESBL. 7/23/2024- revealed that the patient had a urine infection which was positive for ESBL. During multiple surveyor observations throughout the survey process from 9/23/2024 through 9/25/2024 failed to reveal evidence of an isolation cart or signage posted outside of the resident's room to indicate that s/he requires EBP due to his/her history of ESBL in his/her urine. During a surveyor interview on 9/25/2024 at 10:31 AM with Certified Medication Technician, Staff D, she revealed that the resident was on precautions maybe months ago for an infection in the urine but hasn't been on any precautions for a while. During a surveyor interview on 9/25/2024 at 10:35 AM with Registered Nurse, Staff A, she revealed the resident is not on precautions. During a surveyor interview on 9/25/2024 at 10:45 AM with the Director of Nursing Services (DNS), he acknowledged that the resident was not on precautions for the ESBL. Additionally, he could not provide evidence that a follow up urine culture was completed to test for ESBL. 2. Record review revealed that Resident ID #18 was readmitted to the facility in August of 2023 with diagnoses including, but not limited to, urinary tract infection and ESBL. Record review of the Minimum Data Set assessment dated [DATE] revealed that a Brief Interview for Mental Status score was not able to be completed due to severe cognitive impairment. Further review revealed that the resident is dependent on staff members for toileting. Record review of a care plan dated 6/26/2023 revealed that the resident is colonized with ESBL in his/her urine. During multiple surveyor observations throughout the survey process from 9/23/2024 through 9/25/2024 failed to reveal evidence of an isolation cart or signage posted outside of the resident's room to indicate that s/he requires EBP due to his/her history of ESBL in the urine. During a surveyor interview on 9/25/2024 at approximately 9:30 AM, with the DNS, he acknowledged that the resident was not on Enhanced Barrier Precautions for ESBL. 3. According to the State Operations Manual, Appendix PP, last revised in August of 2024, indicates that the facility will conduct an annual review of its Infection Prevention Control Program (IPCP) and update their program, as necessary. Record review failed to reveal evidence that the facility reviewed their IPCP annually and updated their program to include enhanced barrier precautions. During a surveyor interview on 9/25/2024 at 8:45 AM with the DNS, he acknowledged that the facility failed to review their IPCP annually and updated their program to include enhanced barrier precautions. 41729

39496 Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to respect the residents right of personal privacy for 3 of 3 residents reviewed relative to indwelling medical devices (devices that enter inside the body), Resident ID #s 16, 77 and 179. Findings are as follows: Review of a facility policy titled, Confidentiality of Resident Information states in part, .All facility employees are responsible to maintain the confidentiality of all resident protected health information .Resident health information shall not be left in public areas where unauthorized personnel may see it . 1. Record review revealed that Resident ID #16 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, dysphagia (difficulty swallowing) and gastrostomy (is a surgical procedure to make a hole in the stomach through the abdomen to insert a feeding tube into the stomach). Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating that the resident has severe cognitive impairment. Further review of the assessment revealed that the resident has a feeding tube. During a surveyor observation on 9/24/2024 at 11:05 AM, revealed a sign outside the resident's door that stated TF [tube feed] and foley written on the sign. The sign is visible to staff, residents, or visitors that pass by the room. 2. Record review revealed that Resident ID #77 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, history of urinary tract infections and retention of urine. Review of a MDS assessment dated [DATE], revealed a BIMS score of 6 out of 15, indicating that the resident has severe cognitive impairment. Further review of the assessment revealed that the resident has an indwelling catheter (foley catheter- a closed sterile system that drains urine from the bladder). During a surveyor observation on 9/24/2024 at 11:05 AM, revealed a sign outside the resident's door that stated TF [tube feed] and foley written on the sign. The sign is visible to staff, residents, or visitors that pass by the room. 3) Record review revealed that Resident ID #179 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, acute kidney failure and retention of urine. Review of a MDS assessment dated [DATE], revealed a BIMS assessment was unable to be completed due to severe cognitive impairment. Further review of the assessment revealed that the resident has an indwelling catheter. During a surveyor observation on 9/23/2024 at 10:28 AM, revealed a sign outside the resident's door that stated TF [tube feed] and foley written on the sign. The sign is visible to staff, residents, or visitors that pass by the room. During a surveyor interview on 9/25/2024 at approximately 12:15 PM with the Director of Nursing Services, he acknowledged that medical information about the residents' should not be posted outside of resident rooms.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care related to Enhanced Barrier Precautions for 7 of 7 nursing staff reviewed. Findings are as follows: Review of the Centers for Medicare and Medicaid Services (CMS) memorandum dated 3/20/2024, provided to the surveyor by the facility, states in part, .Many residents in nursing home are at increased risk of becoming colonized and developing infections with MDROs [Multidrug-resistant Organisms] .'Enhanced Barrier Precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are indicated for residents with .Infection or colonization with a CDC [Centers for Disease Control]-targeted MDRO .wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .high contact resident care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use .Wound care . Record review failed to reveal evidence that Enhanced Barrier Precaution competencies were completed for the following nursing staff: -Registered Nurse (RN), Staff B -RN, Staff C -Certified Medication Technician (CMT), Staff D -Nursing Assistant (NA), Staff E -NA, Staff F -NA, Staff G -NA, Staff H During a surveyor interview with Staff H, on 9/25/2024 at 12:03 PM, she indicated that she was unaware of what Enhanced Barrier Precautions were or when EPB should be implemented. During a surveyor interview with Staff C, on 9/25/2024 at 1:01 PM, he indicated that he was unaware of the term Enhanced Barrier Precautions and that he had not been educated on what those precautions were and when they were indicated for use. During a surveyor interview with the Director of Nursing Services on 9/25/2024 at 1:06 PM, he indicated that he was unaware of the indications for Enhanced Barrier Precautions and that competencies had not been completed for any of the nursing staff pertaining to Enhanced Barrier Precautions. Cross Reference - F 880

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to physician's orders for 1 of 1 resident reviewed with a physician's order for a lidocaine patch, Resident ID #179. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #179 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, chronic pain syndrome. Record review revealed a physician's order dated 8/26/2024 for a Lidocaine external patch 4% once a day for pain. Record review of the September 2024 Medication Administration Record revealed the Lidocaine was refused on 21 of 24 opportunities. Record review failed to reveal evidence that the physician was notified of the Lidocaine refusals in September 2024. During a surveyor interview on 9/25/2024 at 9:02 AM with Registered Nurse, Staff A, she acknowledged that the resident frequently refuses the Lidocaine patch, and that the physician was not notified. Additionally, she indicated that she would expect the physician to be notified if a resident refuses a medication. During a surveyor interview on 9/25/2024 at 9:13 AM with Director of Nursing Services, he indicated that he would expect the physician to be notified if a medication is refused.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident reviewed with the history of trauma, Resident ID #21. Findings are as follows: Record review of the facility's policy titled, Trauma Informed Care states in part, .A Trauma Survivor is someone who has been exposed to trauma and may include but is not limited to .Survivors of Abuse (physical, sexual .) .A trauma screening assessment will be done on each resident by the social worker as part of the admission social history .The particular type and extent of the trauma (as best can be determined) will be incorporated when planning culturally competent, resident centered care with the purpose of avoiding re-traumatization . Record review revealed the resident was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, dementia with psychotic disturbance. Record review of an admission preliminary baseline care plan dated 9/3/2024 revealed the resident has a history of trauma related to him/her being abused as a child. Record review of a care plan dated 9/6/2024 revealed the resident has past trauma related to a history of abuse. Further record review revealed a psychiatry progress note dated 9/6/2024 which failed to reveal evidence the resident's history of trauma was addressed by the provider during this evaluation. Additional record review failed to reveal evidence that a trauma screening assessment was completed upon admission by the social worker, as indicated in the facility's policy. During a surveyor interview with the Social Worker on 9/26/2024 at approximately 9:25 AM, she acknowledged that a trauma screening assessment had not been completed by a social worker upon the resident's admission. Additionally, she indicated that she was unaware of the facility's policy related to trauma screening assessments. During a surveyor interview with the Director of Nursing Services on 9/26/2024 at approximately 10:08 AM, he could not provide evidence that a trauma screening assessment was completed by the social worker.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 1 resident reviewed with a gradual dose reduction recommendation, Resident ID #7. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, major depressive disorder and adjustment disorder with mixed anxiety and depressed mood. Record review of a Psychiatric Consultation Report dated 8/16/2024 revealed the resident was receiving Sertraline 125 milligrams (mg) daily for depression. Further review of the report revealed a recommendation was made to decrease the Sertraline to 100 mg daily. Record review revealed the recommendation for Sertraline 100 mg was implemented on 8/17/2024. Record review of a subsequent Psychiatric Consultation Report dated 9/6/2024 revealed a recommendation was made to decrease the Sertraline to 50 mg daily. Record review of a nursing progress note dated 9/13/2024 revealed the psychiatric recommendations were reviewed with the resident's power of attorney and at that time, she did not want the recommendations implemented for the resident. Therefore, the resident remained on Sertraline 100 mg daily. Further record review revealed that the Sertraline was discontinued on 9/17/2024. Additional record review failed to reveal evidence of why the Sertraline was discontinued on 9/17/2024. During a surveyor interview on 9/24/2024 at 12:56 PM with Registered Nurse, Staff I, she revealed that she was unaware the Sertraline had been discontinued until it was brought to her attention by the surveyor on 9/24/2024. She was unable to explain why the medication was discontinued. During a surveyor interview on 9/24/2024 at 1:03 PM with the Director of Nursing Services, he acknowledged that the Sertraline was discontinued on 9/17/2024 in error. During a surveyor interview on 9/26/2024 at 10:03 AM with the resident's physician, she was unable to explain why the medication was discontinued. Additionally, after the facility notified her that the Sertraline was discontinued in error, she assessed the resident and reinstated the Sertraline as previously ordered seven days after it was discontinued in error.

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. Findings are as follows: The United States Food and Drug Administration Food Code 2022 Edition 3-501.13, states in part, .Thawing .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5 C (41 F) or less, or (B) Completely submerged under running water: (1) At a water temperature of 21 C (70 F) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow . Review of the facility's policy, titled, Food thawing Policy, states in part, .Method #3: thawing in cold water .One way to keep the water cold without having to continuously watch over it is to fill a bowl with cold water and leave the tap running over the food as it thaws. This does require a lot of water, but it will keep the surface temperature of your food from growing bacteria too rapidly . During a surveyor observation upon initially entering the kitchen on 11/6/2023 at approximately 11:45 AM through 12:28 PM failed to reveal evidence that the sink faucet was running tap water over five individually packaged frozen pork tenderloins that were in an empty sink thawing, as indicated in the facility policy. During a surveyor interview on 11/6/2023 at 12:30 PM with the Food Service Manager (FSM), Staff B, she indicated that she pulled the pork tenderloins from the freezer for thawing earlier that morning at 11:00 AM and was unable to provide evidence that the meat was submerged under running water while thawing. During a surveyor interview with the Director of Nursing Services on 11/7/2023 at 2:24 PM, it was indicated that he would expect that the FSM would follow the regulations and facility policy for thawing time/temperature control foods.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician orders for 1 of 3 residents reviewed for wearing [NAME] stockings (stockings that improve blood flow in the legs), Resident ID #22. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow a physician's order unless they believe the orders are in error or would harm the clients. Record review revealed the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, congestive heart failure and kidney failure. Further record review revealed a physician's order, dated 6/21/2023 for [NAME] stockings to be placed on the resident daily, in the morning, and removed at bedtime for edema (swelling) prevention. Record review of the November 2023 Treatment Administration Record revealed that the [NAME] stockings order was signed off as being placed on the resident on the mornings of 11/6/2023 and 11/7/2023. Surveyor observations of the resident sitting in his/her room revealed the following: -The resident was noted to be wearing black shoes and no [NAME] stockings on 11/6/2023 at 10:20 AM, 1:44 PM, and 3:51 PM. -The resident was noted to be wearing black shoes and no [NAME] stockings on 11/7/2023 at 8:36 AM, and 12:49 PM. During the above observations the resident was observed with mild edema in both ankles and feet. An additional surveyor observation of the resident on 11/7/2023 at 3:41 PM revealed the resident was noted to be wearing regular black socks which extended up to the middle of his/her lower legs. During a surveyor interview on 11/7/2023 at 3:44 PM with Registered Nurse, Staff A, she revealed that the black socks the resident had on his/her legs, were not [NAME] stockings. Record review failed to reveal evidence that the resident had refused to wear his/her [NAME] stockings as ordered on 11/6 and 11/7/2023. During an interview on 11/8/2023 at 11:43 AM with the Director of Nursing Services (DNS), he indicated that the staff had told him that the resident has been wearing black [NAME] stockings. During a surveyor observation of the resident in the presence of the DNS immediately following the above interview, the resident was observed wearing white [NAME] stockings. The DNS was unable to provide evidence that the resident [NAME] stockings were worn or refused by the resident on 11/6 and 11/7/2023. 21613

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 3 of 12 residents reviewed for Trauma Informed Care, Resident ID #'s 3, 15, and 16. Findings are as follows: Record review of a policy titled, Trauma Informed Care, states in part, .it is important for those taking care of individuals to be aware of any past trauma that may affect one's ability to care for that individual .it is [NAME] Home's policy to identify, on admission, any past trauma/PTSD [Post Traumatic Stress Disorder-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event] the resident may have experienced in the past so an individualized and specialized care plan can be created .1. Preliminary Baseline Care Plan Assessment (completed on admission) which includes the question about Trauma/PTSD . Review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP states in part, .Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being .Trauma-informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization . 1) Record review revealed Resident ID #3 was initially admitted to the facility in February of 2020, and readmitted in February of 2021, with diagnoses including, but not limited to, depression and Alzheimer's disease. Record review failed to reveal evidence of a trauma informed care assessment. 2) Record review revealed Resident ID #15 was initially admitted to the facility in March of 2021 and readmitted in October of 2023, with diagnoses including, but not limited to adjustment disorder with mixed anxiety and depressed mood and cerebral infarction (stroke). Record review failed to reveal evidence of a trauma informed care assessment. 3) Record review revealed Resident ID #16 was initially admitted to the facility in April of 2021, and readmitted in December of 2021, with diagnoses including, but not limited to, adjustment disorder with mixed anxiety and depressed mood and stroke. Record review failed to reveal evidence of a trauma informed care assessment. During a surveyor interview on 11/6/2023 at 4:36 PM, with the Director of Nursing Services, he acknowledged that the trauma informed care assessments were not completed on behalf of the above-mentioned residents until it was brought to his attention by the surveyor. 39496 41720

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 1 of 5 residents reviewed related to pharmacy recommendations, Resident ID #3. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2020 with a diagnosis including, but not limited to type 2 diabetes mellitus. Record review of a pharmacy recommendation dated 10/4/2023, revealed the physician agreed to reevaluate the resident's Protonix (a medication used to treat certain stomach and esophagus problems) order. The physician documented to decrease Protonix to 20mg (milligrams) daily. This response was signed and dated by the physician on 10/27/2023. Record review of the Order Summary Report revealed an order with a start date of 10/11/2022, for Protonix 40 mg once daily for gastrointestinal bleed (bleeding in the digestive tract). This order failed to be discontinued until 11/7/2023, after the surveyor brought the above pharmacy recommendation with the decreased Protonix order to the attention of the Director of Nursing Services (DNS). Record review of the October and November 2023 Medication Administration Records revealed that the resident continued to receive the Protonix 40 mg (milligram) daily from 10/27/2023 through 11/6/2023. During a surveyor interview on 11/7/2023 at 10:20 AM with the DNS, he acknowledged that the facility failed to decrease the dose of Protonix to 20 mg daily on 10/27/2023, when it was ordered by the physician. This failure to decrease the Protonix dose caused the resident to receive an extra 20 mg of Protonix for 11 days.

FACILITY Dining Observation 09/22/22 10:15 AM [NAME] ID 1 was served on 9/21 with no lip plate for lunch but on 9/22 breakfast received a lip plate 808- ID 1 monitoring intake- severed a chopped puree per ST, and order states puree ID # 2 given fluids via sips vs tsp ID #1 no lip plate given a sandwich as a meal - order for sandwich between meals 09/22/22 08:06 AM transporting food uncovered from truck to room 09/22/22 08:08 AM moved truck down hall handled plug and then severed food- toughing plates 09/22/22 08:09 AM grabbed ground pancake with gloved hands and sprinkled toppings on pancakes- 09/22/22 08:10 AM touched glasses and mask 09/22/22 08:10 AM touched plug 09/22/22 08:10 AM grabbed pancake with gloved hands 09/22/22 08:11 AM moved glasses down did not change gloves or clean hands 09/22/22 08:15 AM Id 1 only 1 drink served 09/22/22 08:17 AM id12 small portions served 2 pancakes and fruit 09/23/22 08:20 AM ID1 coughing- mechanical soft breakfast- only one thickened juice served not being monitored 1:1- had to go get CNA from next room for assistance when coughing [NAME]- diet is Regular(HOUSE) Diet Ground Meats texture, Regular consistency, for Diet minced and moist, puree fruits and vegetables. served whole banana left banana in room on tray with resident as she was eating- 09/23/22 08:19 AM interview with CNA and went in to mash her banana- 09/23/22 11:42 AM pockets strict 1:1 would expect them to follow it [NAME] physician surveyor notified that on 9/22 per diem CNA was assisting with no teaspoon [NAME] CNA 09/23/22 11:45 AM use the paper that come on tray 09/23/22 11:45 AM if they're they not eating i help and the nurse would tell us. Kitchen 09/21/22 08:58 AM food service director [NAME] [NAME]- initial tour completed at 8:35- clean, temps okay for storage, working on list of diets, no adaptive equipment and no food policy . ? food from visitors. two resident ID # 1 & 2 not following diets for teaspoon fluids and 2/2 lunches for adaptive equipment and sandwich vs Based on surveyor observation, and staff interview, it has been determined that the facility failed to distribute and serve food in accordance with professional standards for food service safety relative to food service from the steam table. Findings are as follows: The State of Rhode Island Food Code 2018 edition, titled 2-301.14 When to Wash stated in part, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD .(E) After handling soiled EQUIPMENT or UTENSILS .(H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. During a surveyor observation on 9/22/2022 at 8:09 AM Dietary Aide, Staff D was observed serving ground pancakes with gloved hands and without the use of a utensil. Additionally, she was observed touching her glasses and the mask on her face several times and continued to serve pancakes with the same gloved hand. The surveyor further observed her picking the electrical steam table plug from the floor and then touching clean plates. She did not change her gloves or sanitize her hands. During a subsequent surveyor observation on 9/22/2022 at 11:51 AM, Staff D was observed pushing the steam table with gloved hands. She then touched clean plates and served pasta with a gloved hand without the use of a utensil. She was also observed wiping her hands on her apron and then using the same gloved hands to pick up and serve pasta and add parsley to a dish. She did not change her gloves or sanitize her hands. During a surveyor interview with Staff D on 9/22/2022 at approximately 12:00 PM she acknowledged she touched the steam table and her apron and then used the same gloves to pick up clean plates and serve food. She further acknowledged that she should have sanitized her hands and changed her gloves after touching the equipment and should have utilized utensils to serve both the pancakes and pasta. During a surveyor interview with the Director of Nursing on 9/22/2022 at 1:38 PM, he acknowledged gloves should be changed and hands sanitized when touching equipment and then handling food.