Every finding on record at Cedar Haven Operations LLC DBA Lake Forest Health

Based on clinical record review and staff interview, the facility failed to provide specialized rehabilitation services for 1 of 3 residents reviewed relative to physical therapy services, Resident ID #1. Findings are as follows:Review of a complaint received by the Rhode Island Department of Health on 7/29/2026 alleges in part, .the facility lacks the training and knowledge needed to meet [the resident's] rehabilitative needs.[s/he] is being misclassified as someone with congenital/chronic conditions and not someone with restorative potential.this is leading to insurance denials when it comes to receiving therapy and improper care planning.Record review revealed that the resident was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, traumatic brain injury.Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 4 of 15, indicating severe cognitive impairment. Additional review of the MDS revealed s/he is dependent on staff for bed mobility and transfers.Review of a Continuity of Care Consultation and Referral Form from [NAME] University Medicine and Rehabilitation dated 1/27/2026 revealed a recommendation to resume physical (PT) and occupational therapy (OT).Review of a nursing progress note dated 1/27/2026 revealed that the recommendation to resume physical and occupational therapy was reviewed and approved by Physician Assistant, Staff A.Review of a Continuity of Care Consultation and Referral Form from [NAME] University Medicine and Rehabilitation dated 3/31/2026 revealed a recommendation to continue PT and OT for range of motion to bilateral upper and lower extremities.Review of a Continuity of Care Consultation and Referral Form from [NAME] University Medicine and Rehabilitation dated 5/21/2026 revealed the resident had a severe traumatic brain injury with significant recovery and recommendations for PT, OT, and speech therapy (ST) for the max allotted time allowed at the facility.Review of a Continuity of Care Consultation and Referral Form from [NAME] University Medicine and Rehabilitation dated 6/30/2026 revealed the resident has had amazing progress with communication and participation. Additionally, there were recommendations for PT, OT, and ST at regular intervals for the max allotted time weekly.Review of Procedure Visit Progress Notes authored by the Physical Medicine and Rehabilitation Medical Doctor, dated 6/30/2026 states in part, .strongly recommend resumption of PT/OT/ST at this time at max allocated intervals permitted at facility given ongoing functional gains.Record review failed to reveal evidence of a PT screen, evaluation, or treatment since it was first requested in January of 2026, indicating it has been more than 6 months without the resident receiving the recommended rehabilitative services.During a surveyor interview on 7/30/2026 at 1:04 PM with Physician Assistant, Staff A, she revealed that she approved the recommendations for Resident ID #1 to be seen by PT/OT and ST. Additionally, she revealed that she would expect the staff to follow recommendations made by the specialists.During a surveyor interview on 7/30/2026 at 1:20 PM with the Rehab Director, he acknowledged that Resident ID #1 had not been evaluated or treated by physical therapy since December of 2025, and was aware that PT had been requested several times since January of 2026.During a surveyor interview on 7/30/2026 at 1:37 PM, with the Administrator and Director of Nursing Services, they were unable to provide evidence that Resident ID #1 received the specialized rehabilitation services for physical therapy since it was approved by PA, staff A on 1/27/2026.

Based on clinical record review and staff interview, the facility failed to ensure services provided to residents met professional standards of nursing practice for 1 of 1 resident reviewed who had physician orders for thin liquids by spoon only and for obtaining vital signs every shift for 7 days, that were not followed, Resident ID #1.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 3/16/2026, alleged in part, that the complainant received a call and a video from a family member of Resident ID #1. The video was reportedly recorded from a video surveillance camera located in the resident's room. The video revealed that during the overnight shift on 3/16/2026, a nurse provided the resident with a drink using a straw while the resident was lying down. The resident has physician's orders to consume liquids via spoon only and while positioned upright. 1. Record review revealed Resident ID #1 was admitted to the facility in December 2024 with diagnoses including, but not limited to, seizure disorder, autonomic dysfunction (a condition in which the autonomic nervous system does not properly regulate involuntary bodily functions such as heart rate, blood pressure, and digestion), presence of a gastrostomy tube (a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications), bilateral upper extremity muscle contractures (permanent tightening of muscles, tendons, or skin causing reduced motion and joint deformity in both arms), and dysphagia (difficulty swallowing).Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed the resident was unable to self-feed and was dependent on staff for eating.Record review revealed a physician's order dated 1/6/2026 for the resident to receive a house diet, minced and moist texture, with thin liquids to be provided by a spoon only.Record review of a care plan initiated on 12/4/2024 revealed the resident had swallowing difficulty, with interventions including, but not limited to, providing thin liquids via spoon.Record review of a progress note dated 3/16/2026 at 3:00 PM revealed the nurse received a phone call from a family member who indicated that while viewing the camera footage on 3/16/2026 at approximately 4:14 AM, they witnessed a staff member giving the resident a drink using a straw while the resident was lying down.During a surveyor interview on 3/25/2026 at 1:37 PM with the Director of Nursing Services (DON), in the presence of the Administrator, she revealed that she had reviewed the video footage and acknowledged that a nurse provided thin liquids to the resident with a straw while s/he was not sitting upright in the bed, and continuing to do so while the resident was coughing. The DON indicated it was her expectation that all nurses would follow the physician's order to provide thin liquids by a spoon only due to the resident's aspiration risk.2. Record review revealed a physician's order dated 3/19/2026 to obtain the resident's vital signs, including lung sounds, oxygen saturation (blood oxygen level), temperature, and to document signs and symptoms of aspiration (the inhalation of, liquid, or foreign material into the airway and lungs), including coughing or runny nose, every shift for 7 days.Record review of the March 2026 Medication Administration Record revealed that the facility failed to obtain the resident's vital signs during the 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shifts on 3/23/2026, as well as the 11:00 PM to 7:00 AM shift on 3/24/2026.During a surveyor interview on 3/25/2026 at approximately 2:15 PM with the DON, in the presence of the Administrator, she revealed she would expect that vital signs would be obtained and documented each shift as ordered. Additionally, she acknowledged the facility failed to ensure physician orders were followed for Resident ID #1.

Based on clinical record review, surveyor observation, staff and resident interview the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to an unidentified respiratory illness for 2 of 3 nursing units and affecting Resident ID #s 7, 18, 29, 34, 36, 59, 62, 64, and 97. Additionally the facility failed to routinely clean a BiPap machine (a noninvasive ventilation that helps you breathe) for Resident ID #1. Furthermore, the facility failed to follow transmission-based precautions for 3 of 6 resident's reviewed, Resident ID #s 6, 14, and 39. Findings are as follows:1. According to the Viral Respiratory Pathogens Toolkit for Nursing Homes dated 12/11/2025 from the Centers of Disease Control (CDC) and Prevention states in part, .When an acute respiratory infection is identified in a resident or [healthcare personnel, HCP], it is important to take rapid action to prevent the spread to others in the facility.While decisions about treatment, prophylaxis, and the recommended duration of isolation vary depending on the pathogen, [infection prevention control] strategies, such as placement of the resident in a single-person room, use of a facemask for source control, and physical distancing, are the same regardless of the pathogen .[Healthcare personnel] who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 [covid-19] infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This PPE [personal protective equipment] can be adjusted once the cause of the infection is identified .Test residents and HCP with new respiratory illness signs or symptoms. Selection of diagnostic tests will depend on the suspected cause of the infection (e.g., which respiratory viruses are circulating in the community or the facility, recent contact with someone confirmed to have a specific respiratory infection) and if the results will inform clinical management (e.g., treatment, duration of isolation). At a minimum, testing should include SARSCoV-2 and influenza viruses with consideration for other causes (e.g., RSV) .Review of a facility policy titled Isolation states in part, It is the policy of this facility to prevent the spread of infection within the facility through the use of isolation precautions.transmission-based precautions, as defined by the CDC, will be employed for known or suspected infections for which the route/prevention is known.1a. Record review revealed Resident ID #59 was admitted to the facility in December of 2025 with diagnoses including, but not limited to, Respiratory Syncytial Virus (RSV) and pneumonia. Record review revealed the resident was on transmission-based precautions due to the diagnosis of RSV.1b. Record review revealed Resident ID #62 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, bipolar disorder.Record review revealed the resident was sent to the hospital on [DATE] for complaints of chest pain and returned to the facility on [DATE] with a diagnosis of RSV.1c. Record review revealed Resident ID #7 was readmitted to the facility in January of 2022 with diagnosis including, but not limited to, bipolar disorder and dementia.Record review revealed a physician's order with a start date of 12/23/2025 and an end date of 12/26/2025 for Guaifenesin Syrup (a cough suppressant) every 6 hours for 3 days.Record review failed to reveal evidence that an RSV, covid-19, or influenza swabs were obtained related to recent RSV positive residents in the building or that the resident was placed on transmission-based precautions.During surveyor observations on 12/29/2025 and 12/30/2025 failed to reveal evidence that the resident was placed on precautions related to signs and symptoms that are consistent with a communicable disease or infection.1d. Record review revealed that Resident ID #18 was admitted to the facility in March of 2022 with a diagnosis including, but not limited to, dementia.Record review revealed a physician's order for Guaifenesin Syrup every 6 hours as needed for cough.Review of the December 2025 Medication Administration Record (MAR) revealed the resident received the Guaifenesin cough medication on 12/23/2025 and 12/26/2025. Record review failed to reveal evidence that an RSV, Covid-19, or influenza swabs were obtained related to recent RSV positive residents in the building, the facility policy, or that the resident was placed on transmission-based precautions.During surveyor observations on 12/29/2025 and 12/30/2025 failed to reveal evidence that the resident was placed on precautions related to signs and symptoms that are consistent with a communicable disease or infection, until it was brought to the facility's attention by the surveyor.1e. Record review revealed that Resident ID #29 was admitted to the facility in March of 2021 with a diagnosis including, but not limited to, dementia.Record review revealed the resident presented with increased lethargy, poor appetite and cough on 12/22/2025. The provider was notified, and orders were obtained for an immediate chest x-ray, to administer duoneb (a medication that is inhaled for shortness of breath) ever 6 hours for 3 days, and if symptoms worsen to obtain a respiratory panel to test for covid-19, influenza and RSV.Record review revealed the resident was tested for Covid-19 on 12/22/2025.Record review failed to reveal evidence that RSV or influenza swabs were obtained related to recent RSV positive residents in the building, the facility policy, or that the resident was placed on transmission-based precautions.During surveyor observations on 12/29/2025 and 12/30/2025 failed to reveal evidence that the resident was placed on precautions related to signs and symptoms that are consistent with a communicable disease or infection, until it was brought to the facility's attention by the surveyor. 1f. Record review revealed that Resident ID #34 was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, dementia.Record review revealed the resident complained of cold like symptoms on 12/28/2025.Record review revealed the resident was tested for Covid-19 on 12/28/2025.Record review failed to reveal evidence that RSV or influenza swabs were obtained related to recent RSV positive residents in the building, facility policy, or that the resident was placed on transmission-based precautions.During surveyor observations on 12/29/2025, 12/30/2025 and 12/31/2025 failed to reveal evidence that the resident was placed on precautions related to signs and symptoms that are consistent with a communicable disease or infection, until it was brought to the facility's attention by the surveyor.1g. Record review revealed Resident ID #36 was admitted to the facility in July of 2023 with a diagnosis including, but not limited to, dementia.Record review revealed the resident complained of cold like symptoms on 12/28/2025.Record review revealed the resident was tested for Covid-19 on 12/28/2025.Review of the December 2025 MAR revealed the resident received Guaifenesin cough medication on 12/29/2025. Further record review revealed that on 12/30/2025, the resident was noted in respiratory distress and was sent to the hospital and admitted for pneumonia and influenza A.Record review failed to reveal evidence that RSV or influenza swabs were obtained related to recent RSV positive residents in the building, facility policy, or that the resident was placed on transmission-based precautions.During a surveyor observation on 12/29/2025, failed to reveal evidence that the resident was placed on precautions related to signs and symptoms that are consistent with a communicable disease or infection.1h. Record review revealed Resident ID #64 was admitted to the facility in May of 2024 with a diagnosis including, but not limited to, depression. Review of the December 2025 MAR revealed the resident received Guaifenesin cough medication on 12/21/2025.Record review revealed the resident complained of cold like symptoms, increased shortness of breath, had abnormal breath sounds, and a nonproductive cough on 12/23/2025.Record review failed to reveal evidence that an RSV, Covid-19, or influenza swabs were obtained related to recent RSV positive residents in the building, the facility policy or that the resident was placed on transmission-based precautions.During surveyor observations on 12/29/2025, 12/30/2025 and 12/31/2025, failed to reveal evidence that the resident was placed on precautions related to signs and symptoms that are consistent with a communicable disease or infection, until it was brought to the facility's attention by the surveyor.1i Record review revealed Resident ID #97 was admitted to the facility in June of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disorder and chronic respiratory failure.Review of the December 2025 MAR revealed the resident received the Guaifenesin cough medication on 12/26/2025 and 12/28/2025 for complaints of a cough. Record review revealed the resident complained of cold like symptoms on the following dates:12/25/2025: complaint of not feeling well with nasal congestion, shortness of breath with exertion.12/30/2025: complaint of productive cough and upper airway congestion.Record review failed to reveal evidence that RSV, Covid-19, or influenza swabs were obtained related to recent RSV positive residents in the building, the facility policy, or that the resident was placed on transmission-based precautions.During surveyor observations on 12/29/2025 and 12/30/2025 failed to reveal evidence that the resident was placed on precautions related to signs and symptoms that are consistent with a communicable disease or infection, until it was brought to the facility's attention by the surveyor.During a surveyor interview with the Infection Preventionist (IP) on 12/30/2025 at 1:06 PM, during the infection control task, he acknowledged that he was aware of a resident who had RSV. Additionally, he revealed he was aware of other residents with cold like symptoms but revealed he did not test any additional residents for RSV, influenza, or place them on transmission-based precautions. When presented with the list of residents who were symptomatic with a respiratory illness, he was unable to provide evidence of a tracking mechanism used to detect possible communicable diseases or infections and that the respiratory illness was identified and managed to prevent a potential outbreak of disease.Review of an email from the Rhode Island Department of Health Infectious Disease Surveillance Nurse, revealed that she recommended to the facility to implement empiric-based precautions for new respiratory symptoms (Empiric precautions are used when a resident presents with symptoms that may indicate an infectious disease, but the specific pathogen has not yet been identified. These precautions are critical in protecting healthcare workers and other residents from potential infections).During a surveyor interview with the Director of Nursing Services (DNS), on 12/31/2025 at 9:53 AM, she revealed that she was in contact with the Rhode Island Department of Health Infectious Disease Surveillance Nurse, who notified her over the phone to test residents who were developing symptoms of a respiratory virus. Additionally, she was unable to provide evidence that the above-mentioned residents were tested according to the facility policy and guidance until it was brought to the facility's attention by the surveyor. 2. Review of an undated facility policy titled CPAP and BIPAP VENTILATORY SYSTEMS, states in part, .It is the policy of this facility to ensure that ventilatory support is provided appropriately for patients diagnosed with obstructive sleep apnea.cleaning and Maintenance:.Mask or pillow and tubing will be cleansed with warm soapy water at least weekly.Mask or pillow and tubing should be inspected and changed per manufacture guidelines.Any consistent refusal to use equipment should be reported to the physician.Record review revealed that Resident ID #1 was readmitted to the facility in April of 2025 with a diagnosis including, but not limited to, obstructive sleep apnea.Record review revealed that the resident utilizes a BiPap machine at night.During a surveyor interview on 12/31/2025 at 8:03 AM, with the resident, s/he revealed that s/he uses the BiPap machine at night but that the machine has not been cleaned since s/he started using it.During a surveyor interview on 12/31/2025 at 8:05 AM with Licensed Practical Nurse, Staff A, she revealed that they should be cleaned on Tuesdays and that a task would populate in the MAR to be completed. Additionally, when asked by the surveyor about Resident ID #1's BiPap, she revealed that she was unable to find an order to clean his/her BiPap. Furthermore, she revealed that the respiratory therapist might clean the machine.During a surveyor interview with the DNS on 12/31/2025 at 8:12 AM, she revealed that she believed the respiratory therapist cleaned the machines. Additionally, she acknowledged there was not an order in place to clean the machine and would expect the machines to be cleaned weekly and as needed and was unable to provide evidence that this was being completed.During a surveyor interview on 12/31/2025 at 8:16 AM, with the Respiratory Therapist, she revealed that she does not clean the tubing or the masks. She indicated she may use a wipe to clean the outside of the machine but does not take it apart to clean. 3. Review of a facility policy titled Isolation states in part, It is the policy of this facility to prevent the spread of infection within the facility through the use of isolation precautions.transmission based precautions, as defined by the CDC, will be employed for known or suspected infections for which the route/prevention is known.3a. Record review revealed that Resident ID #6 was admitted to the facility in July of 2023 with a diagnosis including, but not limited to, dementia.Review of the resident's room on 12/31/2025, revealed signage posted outside the door to utilize contact and droplet precautions (the use of gown, gloves, mask and face shield) upon entering the resident room.Record review revealed an order dated 12/31/2025 which states in part, resident placed on contact and Droplet precautions 2nd to respiratory panel testing = every shift for prevention until result is in then re-evaluate.During a surveyor observation on 12/31/2025 at 11:58 AM, revealed LPN, Staff C enter Resident ID #6's room with his mask pulled down under his chin. Further, Staff C failed to wear a gown, face shield, and gloves when he entered Resident ID #6's room as required per the signage. Additionally, when Staff C exited Resident ID #6's room, went to the medication cart, and then immediately went into another resident's room, without performing hand hygiene.During a surveyor interview on 12/31/2025 at 11:59 AM with Staff C, he revealed the resident was on contact/droplet precautions due to being swabbed for a respiratory infection. He indicated that he entered the resident's room, and acknowledged the signage posted outside the room indicating what personal protective equipment is required. Further, he acknowledged that he should have worn a gown, face shield, gloves and his mask appropriately, so it was covering his nose and mouth prior to entering the resident's room.3b. Record review revealed that Resident ID #14 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, acute kidney failure.Review of the resident's room on 1/2/2026, revealed signage posted outside the door to utilize contact and droplet precautions upon entering the resident room.During a surveyor observation on 1/2/2026 at 9:45 AM, revealed Nursing Assistant (NA), Staff L, coming out of the resident's room without wearing a face shield. Staff L then took the resident to the shower. Staff L exited the shower room wearing the same gown and gloves used during care and proceeded to bring the resident back to his/her room. Staff L exited the resident's room into the main hallway while wearing the same gown and gloves in the hallway. Staff L then reentered the room to finish care without donning a face shield. During a surveyor interview with Staff L, she acknowledged that she failed to wear a face shield during care and wore her protective equipment in the hallway and failed to remove them after care. During a surveyor interview on 1/2/2026 at 10:23 AM with Registered Nurse, Staff E, he revealed that the resident was on precautions and would expect the staff to follow the signage.3c. Record review revealed that Resident ID #39 was admitted to the facility in June of 2020 with a diagnosis including, but not limited to, urinary tract infection.Record review revealed a physician's order with a start date of 3/17/2025 for enhanced barrier precautions, to utilize a gown and glove for care.Record review revealed a care plan initiated on 9/25/2024, which states in part, .Resident on Enhanced Barrier Precautions for [Carbapenem-resistant Enterobacterales, a multidrug resistant organism] colonization.During a surveyor observation on 12/29/2025 at 11:45 AM revealed a Hospice Nursing Assistant (NA), Staff M, in the resident's room providing morning care. Further observation failed to reveal evidence of the use of a gown during the care.During a surveyor interview on 12/29/2025 at 11:46 AM with LPN, Staff I, she acknowledged that Staff M was not wearing a gown and should have.During a surveyor interview with the DNS on 1/2/2026 at 10:41 AM, she revealed that she would expect all staff including hospice staff to utilize the use of the appropriate protective equipment per the signage posted on the door and would expect staff to perform hand hygiene when exiting a room whose resident is on precautions.

Based on clinical record review and staff interview, the facility failed to follow and implement a physician's order relative to the administration of insulin for 1 of 3 residents reviewed, Resident ID #3. Additionally, the facility failed to follow and implement physician's orders relative to the facility's Bowel Protocol for 2 of 2 residents reviewed who did not have a bowel movement (BM) for more than three days, Resident ID #s 8 and 77.Findings are as follows: 1. Review of the facility's undated policy titled, Medication Administration states in part, .If a resident refused the medication .Complete the information indicating the refusal inclusive of the reason, if known. Consistent refusals require notification to the attending physician and the nurse management.Record review revealed Resident ID #3 was admitted to the facility in May of 2022 with a diagnosis including, but not limited to, diabetes.Record review revealed a physician's order dated 4/3/2024 for Trulicity injection (a medication prescribed to treat diabetes) 0.74 milligrams (mg) once a week, on Wednesdays in the morning.Record review of the 2025 Medication Administration Records (MAR) revealed staff documented that the resident refused his/her Trulicity for 16 of 20 opportunities on the following dates: - August 20 and 27- September 3, 10, 17, and 24 - October 1, 8, 15, and 22 - November 5, 12, and 19 - December 10, 17, and 24Record review failed to reveal evidence that the attending physician and nurse management were notified that Resident ID #3 had refused his/her Trulicity on the above-mentioned dates, as required by the facility policy.During a surveyor interview on 12/30/2025 at 11:55 AM with Licensed Practical Nurse, Staff C, he indicated that he was unaware the resident had been regularly refusing his/her Trulicity on a weekly basis.During a surveyor interview on 12/30/2025 at 12:25 PM with Nurse Practitioner, Staff D, she revealed that she did not recall being notified of the resident's refusals and indicated she would have expected the staff to have notified her. She further indicated that if she had been informed, she would have re-evaluated the resident and adjusted the plan of care.During a surveyor interview on 12/30/2025 at 12:35 PM with the Director of Nursing Services (DNS), she acknowledged that she was unaware of the above-mentioned refusals and indicated that she would expected the staff to have notified both the physician and nursing leadership of the repeated refusals of the Trulicity. 2. Review of a facility's policy titled, Bowel Protocol dated 5/25/2021 states in part, .Each unit will review the report for residents that have not had a bowel movement or a small bowel movement in three days.The bowel protocol will begin as follows (unless contraindicated): the CMT [Certified Medication Technician] or nurse will administered the following: 3-11 shift administer 30 [milliliter] ml of Milk of Magnesium [MOM- a medication prescribed to treat constipation] and document it in the EMR [electronic medical record]. If no bowel movement by the end of the shift, then the 11-7 nurse will be made aware. 11-7 shift will verify that a resident has or had not had a bowel movement. If the resident had not had a bowel movement, the 11-7 nurse will administer a Dulcolax [a medication prescribed to treat constipation] suppository in the AM prior to the end of the shift. The nurse will report the 7-3 nurse the results of the suppository. 7-3 shift will administer a Fleet enema [a medication prescribed to treat constipation] in the morning and document the results. If there are no results from the above measures, the nurse will notify nursing management and the MD [medical doctor] for further interventions.a. Record review revealed Resident ID #8 was readmitted to the facility in October of 2021 with diagnoses including, but not limited to, dementia and constipation.Record review of the December 2025 and January 2026 Medication Administration Records (MAR) revealed the following physician's orders:- Prune juice 8 ounces every 24 hours as needed for constipation if no BM in 72 hours, give in AM.- Milk of Magnesia suspension 400 mg/5 ml (milligrams/milliliter), give 30 mL every 24 hours for constipation if no BM in 72 hours, give 30 ml on the 3-11 shift, if no results from the prune juice.Review of Resident ID #8s bowel log failed to reveal evidence of any bowel movements for five days from 12/28/2025 through 1/1/2026. Further review of the MAR failed to reveal evidence that any of the above medications were administered after three days (72 hours) without a bowel movement, as ordered until it was brought to the facility's attention by the surveyor on 1/2/2026.b. Record review revealed Resident ID #77 was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, end stage renal disease (kidney failure). Record review of the December 2025 MAR revealed a physician's order dated 10/16/2025 for Bisacodyl, insert 1 suppository rectally as needed for constipation if no BM in 72 hours, give on the 11-7 shift if no BM results after MOM.Review of the bowel log for Resident ID #77 revealed the following:- No BM from 12/6/2025 through 12/9/2025 (four days)- No BM from 12/20/2025 through 12/26/2025 (seven days)Further review of the MAR failed to reveal evidence that the Bisacodyl suppository was administered after three days without a BM, as ordered.During a surveyor interview on 1/2/2026 at 9:40 AM with Registered Nurse, Staff E, he acknowledged that Resident ID #8 did not have a BM documented for 5 days from 12/28/2025 through 1/1/2026. Additionally, Staff E acknowledged that Resident ID #77 did not have a BM documented for four days from 12/6/2025 through 12/9/2025 and for seven days from12/20/2025 to 12/26/2025. Staff E was unable to provide evidence that the bowel protocol or physician's orders were followed for the residents.During a surveyor interview on 1/2/2026 at 1:10 PM with the Director of Nursing Services, she was unable to provide evidence the bowel protocol and physician's orders were followed for Resident ID #s 8 and 77.

Based on clinical record review and staff interview, the facility failed to implement and maintain an effective training program for all employees, consistent with their expected roles, as outlined in the Facility Assessment relative to education on the use and maintenance of Bi-PAp (A bilevel positive airway pressure machine- a type of noninvasive ventilation that helps individuals breathe by delivering pressurized air through a mask) and C-Pap (a continuous positive airway pressure machine- a type of medical device that is prescribed to treat sleep apnea by delivering a constant stream of pressurized air to keep the airways open during sleep) for 5 of 5 nurses reviewed, Staff C, E, G, H, and K. Findings are as follows:Review of the Facility Assessment dated 7/16/2025 revealed, Existing Competency.on hire, quarterly, annually.Respiratory: Trach, C-Pap , Bi-Pap.Record review failed to reveal evidence of Staff C, E, G, H and K completing a competency-based education relative to the use or maintenance of a C-Pap or Bi-Pap machine.During a surveyor interview on 12/31/2025 at 11:13 AM with the Staff Developer, he acknowledged that staff have not completed training related to the use or maintenance of a C-Pap or Bi-Pap machine although it is listed as an existing competency in the facility assessment.During a surveyor interview on 12/31/2025 at 1:36 PM with the Director of Nursing Services she was unable to provide evidence that the facility provided competency-based education on C-Pap or Bi-Pap use to any of its nursing staff including Staff C, E, G, H and K.

Based on clinical record review, surveyor observation, and staff interview, the facility failed to ensure that each resident received adequate supervision and assistive devices for 1 of 1 resident reviewed for elopement, Resident ID #2. Findings are as follows:Review of an undated policy titled, Wanderguard System and Assessments; Check states in part, .The wanderguard bracelet will be applied to the resident's person. There may be an occasion when the resident will not allow application; if that is the case, the nurse manager/designee will determine next best placement options (i.e., walker, wheelchair). The bracelet will be checked each shift to assure placement; the nurse will sign this as checked in the treatment record.Record review revealed the resident was readmitted to the facility in November of 2024 with a diagnosis including, but not limited to, bipolar disorder.Review of a care plan focus area last revised 12/16/2025 revealed the resident is an elopement risk/wanderer, related to impaired safety awareness. Further review revealed the resident wanders aimlessly and had an elopement attempt on 12/16/2025. Interventions include, but are not limited to, residing on a secure unit and a wanderguard to his/her right arm.Record review revealed a progress note dated 12/16/2025 which states in part, resident with elopement attempt this afternoon, resident kicked the secure unit door and was able to make [his/her] way into the Lobby area, then [s/he] proceeded toward the front door, resident exited the building into parking lot. receptionist notified north B unit while she kept watching resident in parking lot, this nurse also notified, 2 CNA [Certified Nursing Assistants] and this nurse in parking lot with resident [s/he] was assisted into building and then into [his/her] unit, MD [Medical Doctor] notified with order to place wander guard on resident. new wander guard placed to resident [right] arm.Record review revealed the following physician's orders dated 12/16/2025:- Resident has wanderguard to the right arm, where staff are to check placement every shift- Check wanderguard functionality every night shift, for safetyReview of the December 2025 Medication Administration Record revealed the above wanderguard orders were signed off as completed. Additional record review revealed a progress note dated 12/28/2025 which states in part, .removed [his/her] wander guard handing it to staff no verbalization that [s/he] wanted to leave facility.During surveyor observations on 12/30/2025 at 11:07 AM and 12/31/2025 at 12:02 PM, no wander guard was noted on the resident's right wrist.During a surveyor interview on 12/31/2025 at 12:07 PM, with Licensed Practical Nurse, Staff C, he acknowledged that the resident did not have a wanderguard on his/her right wrist, as ordered.During a surveyor interview on 12/31/2025 at 12:09 PM, with Nursing Assistant, Staff F, she revealed that the resident's wanderguard was taken off the unit by the Director of Nursing Services (DNS) on 12/30/2025, indicating that the resident has not had it on, as ordered.During a surveyor interview on 12/31/2025 at 12:15 PM, with the DNS, she revealed that the resident had a recent elopement attempt and the wanderguard was ordered as a safety intervention. She further revealed that she was unaware that this resident did not have his/her wanderguard on and was unaware the wanderguard she removed from the unit belonged to this resident, indicating she was under the impression it was an extra wanderguard.Record review failed to reveal evidence that after the resident removed his/her wanderguard that the facility implemented any additional interventions to prevent a potential elopement.

Based on clinical record review, surveyor observation and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 1 resident reviewed for a fluid restriction, Resident ID #35.Findings are as follows:Review of a policy titled, I & O [intake and output] - Fluid Restriction, last revised 3/15/2024, states in part, .Process: 1. Verify order: order must include volume or range of fluid permitted during a 24-hour period. 2. Notify Dietary Department using Diet Order Communication Form. 2.1 Dietary to calculate amount of fluids to be provided on meal trays. 3. Calculate remaining amount of fluids to be provided by nursing. 3.1 Calculate amount allotted for each shift. 4. Monitor fluid intake.Record review revealed the resident was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, alcoholic cirrhosis of the liver with ascites (a severe condition caused by chronic alcohol abuse, leading to liver damage and fluid accumulation in the abdomen). Review of a care plan focus area initiated on 11/8/2025 revealed the resident has fluid overload or the potential for fluid volume overload, related to his/her disease process of cirrhosis with ascites. Interventions include, but are not limited to, provide diet as ordered.Record review revealed a physician's diet order dated 11/13/2025, for a 2-gram sodium diet, regular texture, and a fluid restriction of 1500 milliliters (mL).Further review of the above physician's order failed to reveal evidence of calculated fluid amounts to be provided on his/her meal tray. Further record review failed to reveal evidence of any calculated fluid amounts to be provided by nursing, per the facility policy.Review of the resident's dietary slip dated 12/30/2025 revealed s/he is on a 1500 mL fluid restriction. Further review failed to reveal evidence of calculated fluid amounts to be provided on his/her meal trays.During a surveyor observation on 12/30/2025 at 8:07 AM, the resident was noted to have 480 mL of fluids during breakfast.During a surveyor observation on 12/30/2025 at 11:41 AM, the resident was noted to have a 480 mL of soda at his/her bed side. Review of a paper tracker dated 12/30/2025 revealed the resident consumed 240 mL of fluids during breakfast, 480 mL of fluids during lunch, and 480 mL of fluids during dinner.Review of the computer task, which asks the question: How much did the resident drink (in mL), revealed that on 12/30/2025, s/he consumed 240 mL at breakfast, 240 mL at lunch, and 360 mL at dinner.Record review and surveyor observation of the above-mentioned documentation revealed inconsistencies with the amounts of fluid the resident consumed with his/her meals. During a surveyor observation and interview with the resident on 12/31/2025 at 7:41 AM, s/he was observed with 1070 mL at breakfast, 2 cups of 240 mL of fluid, 1 cup of 120 mL of fluid and a 470 mL bottle of soda. The resident revealed that s/he frequently visits the vending machine to buy a bottle of soda. Record review of the resident's fluid intake from meals and additional fluids documented in the electronic medical record revealed the following documentation:-12/1/2025 missing breakfast and lunch intake-12/6/2025 missing dinner intake-12/8/2025 consumed 2160 mL of fluids-12/12/2025 consumed 1560 mL-12/14/2025 consumed 1800 mL-12/17/2025 missing lunch meal documentation -12/21/2025 missing dinner intake -12/22/2025 consumed 1560 mL-12/23/2025 consumed 1560 mL -12/24/2025 missing dinner intake-12/27/2025 consumed 1560 mLDuring a surveyor interview on 12/31/2025 at 8:02 AM, with Licensed Practical Nurse, Staff A, she revealed that nursing staff do not total the resident's fluid intake per shift, including fluids provided during medication pass. Further, she revealed that they do not track what the resident receives on his/her meal tray. Lastly, she revealed that the resident will go to the vending machine to obtain his/her own soda and was unable to provide evidence where that was reflected in the medical record. During a surveyor interview on 12/31/2025 at 8:07 AM, with Nursing Assistant (NA), Staff B, she revealed that the NA who collects the resident's meal tray, documents the resident's fluid intake on a paper tracker and the NA assigned to the resident each shift documents as a task in the computer.During a surveyor interview on 12/31/2025 at 9:49 AM, with the Director of Nursing Services and the Administrator, they revealed that the resident's fluid restriction should be broken down, per facility policy by the amount for dietary and the amount for nursing to administer. Additionally, she acknowledged that there were inconsistencies with the documentation of fluid intake and that the staff were unaware of how much fluid the resident was actually consuming.

Based on surveyor observation, clinical record review, resident, and staff interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen use, Resident ID #97. Findings are as follows:According to Lippincott Nursing Procedure Ninth Edition 2023, page 621, states in part, .Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed .Review of an undated facility policy titled, Policy for Oxygen Management & Labeling Equipment states in part, .Oxygen therapy must be prescribed by a physician. The prescribed flow rate and delivery method must be documented in the patient's medical record.Record review revealed the resident was admitted to the facility in June of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD, an ongoing lung condition caused by damage to the airways and other parts of the lungs) and chronic respiratory failure with hypercapnia (a condition where there are abnormally high levels of carbon dioxide in the blood that could be caused by conditions like COPD).Review of the care plan dated 6/16/2025 revealed that the resident utilizes oxygen at 2 liters (L) continuously. 1a. Review of a physician's order dated 6/16/2025 revealed to administer oxygen at 2L every shift. Surveyor observations revealed the resident was receiving 5 liters (L) of oxygen instead of 2L, as ordered on the following dates and times:- 12/29/2025 at 12:48 PM- 12/30/2025 at 8:29 AM, 12:37 PM, 12:58 PM, and at 1:56 PM.During a surveyor interview with the resident on 12/30/2025 at approximately 1:00 PM, s/he indicated that his/her oxygen should be at 2L and indicated that the nurse sets up the oxygen.During a surveyor interview on 12/30/2025 at 1:59 PM with Licensed Practical Nurse, Staff C, he indicated the resident should be receiving 2-4L of oxygen. The surveyor then asked Staff C to review the order in the resident's electronic record; after reviewing the order, Staff C acknowledged the oxygen order was for 2L and not 2-4 L as he had previously indicated.During a surveyor observation and interview on 12/30/2025 at 2:00 PM in the presence of Staff C, he acknowledged the resident was receiving 5L of oxygen instead of 2L as ordered. Staff C then asked the resident if s/he had changed the oxygen liter flow and the resident denied changing the oxygen from 2L to 5L.1b. Record review revealed a physician's order dated 6/17/2025 to change the oxygen tubing weekly every Tuesday.Record review of the December 2025 Treatment Administration Record (TAR) revealed the order was signed off as completed on 12/30/2025.During a surveyor observation on 12/31/2025 at 9:16 AM in the presence of Registered Nurse, Staff E, revealed the resident was receiving oxygen via tubing that was dated 12/24/2025.During a surveyor interview with Staff E immediately following the above-mentioned observation, he acknowledged the oxygen tubing was dated 12/24/2025.During a surveyor interview on 12/31/2025 at 1:39 PM with the Director of Nursing Services, she indicated that she would have expected the resident to be receiving oxygen at 2L, as ordered. Additionally, she was unable to provide evidence the oxygen tubing was changed weekly as ordered.

Based on clinical record review and staff interview, the facility failed to ensure that pain management is provided to residents who require such services, for 1 of 1 resident reviewed for pain management, Resident ID #12. Findings are as follows: Review of the facility policy titled, Pain Assessment, states in part, .interventions will be required for.any pain that is not managed.if the residents comfort goal has not been met.residents who experience pain shall have.the problem indicated on their care plan together with interventions and measurable goals for elimination of pain. 1a. Record review revealed that Resident ID #12 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, Critical illness polyneuropathy (a condition characterized by acute or subacute onset of symmetric muscle weakness in critically ill patients), muscle spasm, and fracture of sacrum (coccyx).Record review revealed the resident had a significant change in status Minimum Data Set (MDS) Assessment on 10/15/2025. The resident was identified to have pain and was triggered in the Care Area Assessment (CAA) Summary and CAA Worksheet. Review of the CAA Summary and CAA Worksheet revealed a plan to proceed to the resident's care plan to address the resident's pain. Review of the resident's care plan failed to reveal evidence that the care plan was initiated for pain. During a surveyor interview on 12/31/2025 at 12:03 PM, with the MDS Nurse, Staff G, she acknowledged that the resident triggered on his/her MDS for pain. Additionally, she acknowledged that the CAA worksheet and summary indicated that a care plan for pain would be initiated. Furthermore, she was unable to explain why a care plan was not initiated for the resident's pain. During a surveyor interview on 12/31/2025 at 12:49 PM, with the Director of Nursing Services (DNS), she revealed that she would expect the resident to have a care plan for pain in place. 1b. Record review revealed an order that states in part, Monitor pain daily. Review of the December 2025 Medication Administration Record (MAR) revealed the resident's pain was monitored every other day and not daily as ordered. During a surveyor interview with the MDS Nurse, Staff H, on 12/31/2025 at 12:04 PM, she revealed that she transcribed the order incorrectly to only populate every other day. She revealed that the order should have been to monitor pain daily and not every other day. During a surveyor interview on 12/31/2025 at 12:40 PM with the DNS, she revealed that she would expect the order to be transcribed correctly, and that the resident's pain should be monitored daily and not every other day. 1c. Record review revealed the resident complained of pain on a scale of 1-10 1 being the least 10 being the worst, on the following dates and times: - 12/12/2025 at 10:23 AM with a rating of 2- 12/14/2025 at 11:00 AM with a rating of 4- 12/18/2025 at 9:59 AM with a rating of 3- 12/22/2025 at 1:07 PM with a rating of 3- 12/24/2025 at 10:57 AM with a rating of 7Record review revealed a physician's order for Tramadol HCl Oral Tablet 50 milligrams (mg). Give 50 mg by mouth four times a day scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Record review revealed the following as needed medications for pain management:- Acetaminophen Tablet 325 milligrams (mg) Give 2 tablet orally every 6 hours as needed for pain with a start date of 11/7/2025 - tramadol HCl Oral Tablet 50 mg (Tramadol HCl) Give 50 mg by mouth every 12 hours as needed for moderate breakthrough pain with a start date of 11/23/2025- Biofreeze Cool the Pain External Gel 4 % apply to bilateral legs topically every 6 hours as needed for pain. Record review failed to reveal evidence that the resident's complaints of pain on 12/12, 12/14, 12/18, 12/22, and 12/24/2025 were addressed with pharmacological or non-pharmacological interventions (a way to manage pain without medicine, examples include but are not limited to, repositioning relaxation techniques, music, heat or ice). During a surveyor interview with Licensed Practical Nurses, Staff A and I, on 12/31/2025 at 12:44 PM, they revealed that they were unable to find documentation of the resident's pain being addressed on 12/12, 12/14, 12/18, 12/22, and 12/24/2025 when s/he complained of break through pain. During a surveyor interview on 12/31/2025 at 12:49 PM with the DNS, she revealed that she would expect staff to utilize pharmacological or non-pharmacological interventions for pain management for the resident and was unable to provide evidence that pharmacological or non-pharmacological interventions were utilized on the above-mentioned dates.

Based on clinical record review, resident and staff interview, the facility failed to keep all residents free from significant medication errors for 1 of 1 resident reviewed who received his/her roommate's medication in error, Resident ID #5 and for 1 of 1 resident reviewed whose medication was omitted, Resident ID #53. Findings are as follows:Review of an undated facility policy titled, Medication Administration states in part, It is the intent of this policy to ensure that resident medication administration is managed to ensure for resident quality of life, timeliness and safety.Prior to administration ensure: The right resident, Identify by bracelet, photo or other means.1. Record review revealed Resident ID #5 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, chronic pain syndrome and multiple sclerosis.During a surveyor interview on 12/31/2025 at 11:27 AM with Resident ID #5, s/he revealed that at the beginning of the month an agency nurse gave him/her another resident's medication. Per Resident ID #5 the nurse did not identify him/her and told him/her that the medication in the cup was for them. Additionally, Resident ID #5 revealed that s/he took the medication and then the nurse asked him/her what his/her name was.Record review revealed a progress note authored by the Director of Nursing Services (DNS), dated 12/11/2025 that states in part, While passing meds this afternoon agency nurse went into resident's room and called the roommate's name. [Resident ID #5] responded and the nurse reports she asked [him/her] name and [Resident ID #5] responded. The nurse then stated I have your Oxy 5mg [Oxycodone 5 milligrams]. [Resident ID #5] took the medication and immediately swallowed it. [S/he] then turned to the nurse and laughed and stated 'oh I am not that patient. That is my roommate'.Review of a Medication Error Report dated 12/11/2025 revealed Licensed Practical Nurse, Staff J, administered Resident ID #5 his/her roommate's medication due to her failure to identify the resident.During a surveyor interview on 12/31/2025 at 11:58 AM with the DNS she acknowledged that Resident ID #5 was administered his/her roommate's medication due to Staff J, not appropriately identifying the resident.2. Record review revealed that Resident ID #53 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, dementia and anxiety.Record review revealed a physician's order for Seroquel 50 mg (an antipsychotic) daily in the afternoon.Review of the December 2025 Medication Administration Record revealed that on 12/28/2025 the Seroquel was not administered as ordered. During a surveyor interview on 1/2/2026 at 10:37 AM with the DNS she was unable to explain why the Seroquel was not administered on 12/28/2025 to Resident ID #53. Additionally, the DNS was unable to provide evidence that the facility kept Resident ID #s 5 and 53 free from significant medication errors.

Based on clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented, relative to 1 of 1 resident reviewed for elopement, Resident ID #2 and for 1 of 1 resident reviewed for Narcan (a medication that can reverse an opioid overdose), Resident ID #28 and 1 of 1 resident reviewed whose medication was omitted, Resident ID #53.Findings are as follows:1. Review of an undated facility policy titled, Wanderguard System and Assessments; Check states in part, .The wanderguard bracelet will be applied to the resident's person.The bracelet will be checked each shift to assure placement; the nurse will sign this as checked in the treatment record.Record review revealed the resident was readmitted to the facility in November of 2024 with a diagnosis including, but not limited to, bipolar disorder.Record review revealed the following physician's orders dated [DATE]:- Resident has wanderguard to the right arm, where staff are to check placement every shift- Check wanderguard functionality every night shift, for safetyRecord review revealed a progress note dated [DATE] at 4:46 PM, which states, .removed [his/her] wander guard handing it to staff .no verbalization that [s/he] wanted to leave facility.Review of the [DATE] Medication Administration Record (MAR) revealed the wanderguard order to check placement every shift was signed off inaccurately as completed on the following dates and shifts, after the resident removed his/her wanderguard: - [DATE]: 7:00 AM to 3:00 PM- [DATE]: 7:00 AM to 3:00 PM and 11:00 PM to 7:00 AM- [DATE]: 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, 11:00 PM to 7:00 AM- [DATE]: 7:00 AM to 3:00 PMFurther review of the [DATE] MAR revealed the wanderguard order to check functionality daily was signed off inaccurately as completed on the following dates, after the resident removed his/her wanderguard: 12/28, 12/29 and [DATE].During surveyor observations on [DATE] at 11:07 AM and [DATE] at 12:02 PM, a wanderguard was not noted to be on the resident's right wrist.During a surveyor interview on [DATE] at 12:07 PM, with Licensed Practical Nurse (LPN), Staff C, he acknowledged that he signed off the resident's wanderguard placement order on [DATE] in the MAR, as he had checked the resident's wrist that morning and indicated it was there.During a surveyor interview on [DATE] at 12:09 PM, with Nursing Assistant, Staff F, she revealed that the resident's wanderguard was taken by the Director of Nursing Services (DNS) on [DATE], indicating that the resident has not had it on as ordered.During a surveyor observation immediately following these interviews, in the presence of Staff C, he acknowledged that the resident did not have a wanderguard on his/her right wrist and revealed that he felt the resident's wrist that morning and what he thought was a wanderguard, was the resident's wrist bone.During a surveyor interview on [DATE] at 12:15 PM, with the DNS, she revealed that she would expect nursing staff to visualize the resident's wanderguard prior to signing off on the MAR.2. Record review revealed Resident ID #28 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, altered mental status.Record review revealed a physician order dated [DATE] for Narcan, 4 milligrams per 0.1 milliliters with instructions to administer one spray in the nostril, as needed, for opiate overdose.Record review revealed the above Narcan order was documented as being administered on [DATE] at 11:15 PM, by LPN, Staff K.Review of an order administration note dated [DATE] revealed the dose of Narcan was effective.During a surveyor interview on [DATE] at 10:22 AM, with Staff K, she revealed that Resident ID #28 was not administered Narcan, indicating that it was a documentation error.During a surveyor interview on [DATE] at 10:35 AM with the DNS, she revealed that she would expect all resident's records to be accurate.Review of a progress note dated [DATE], authored by Staff K, after this concern was brought to the facility's attention by the surveyor, states, It was bought to my attention that the narcan order was checked off that it was administered. This was in error, narcan was not administered to this resident.3. Record review revealed that Resident ID #53 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, dementia and anxiety.Record review revealed a physician's order for Seroquel 50 mg (an antipsychotic) daily in the afternoon.Review of the [DATE] Medication Administration Record revealed that on [DATE] the Seroquel was not administered as ordered. Additionally, the Seroquel was charted as - see nurses progress note.Review of the progress note dated [DATE] revealed that the Seroquel was not administered due to the resident being deceased .During a surveyor interview on [DATE] at 10:17 AM with LPN, Staff K, she acknowledged that she charted the resident was deceased although the resident was not.During a surveyor interview on [DATE] at 10:37 AM with the DNS she acknowledged that the Seroquel for Resident ID #53 was documented as not administered on [DATE] due to the resident being deceased although the resident is not. Additionally, the DNS was unable to provide evidence that Resident ID #s 2, 28, and 53 had complete and accurate medication records.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, relative to use of Enhanced Barrier Precautions (EBP, use of gown and gloves for high contact activities) for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Review of a facility policy titled, Guidelines for Management of MDROs [Multi-drug resistant organism] dated 4/15/2024 states in part, Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] beyond which exposure to blood and body fluids is anticipated and refers to gown and glove use during high contact resident care.for those with wounds or indwelling medical devices.examples of resident care activities requiring gown and glove use.dressing, bathing/showering.providing hygiene, changing linens, changing briefs.Record review revealed that Resident ID #1 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, altered mental status, gastrostomy (an artificial opening used to provide nutrition) status, and seizures.During a surveyor observation on 10/15/2025 at 9:37 AM of Resident ID #1's room revealed signage indicating that the resident is on EBP and staff is to wear a gown and gloves while performing care.During a surveyor observation on 10/15/2025 at approximately 8:00 AM, of the video surveillance footage provided by Resident ID #1's family, dated 10/6/2025 at 9:19 AM revealed Nursing Assistant (NA), Staff A, and NA, Staff B, in Resident ID #1's room providing morning care. Additionally, Staff A and Staff B did not have gowns on, as required.During a surveyor observation on 10/15/2025 at approximately 8:00 AM, of the video surveillance footage provided by Resident ID #1's family, dated 10/8/2025 at 8:59 AM revealed Staff A in the resident's room providing care. Additionally, Staff A did not have a gown on, as required.During a surveyor interview on 10/15/2025 at 11:22 AM with the Infection Preventionist he acknowledged that Resident ID #1 has been on EBP due to his/her gastrostomy since his/her admission and all staff providing care should be wearing a gown and gloves.During a surveyor interview on 10/15/2025 at 11:39 AM with Staff A, she acknowledged that she was not wearing a gown while providing care to Resident ID #1 on 10/6 and 10/8/2025.During a surveyor interview on 10/15/2025 at 12:41 PM with Staff B, she acknowledged that she was not wearing a gown while providing care to Resident ID #1 on 10/8/2025.During a surveyor interview on 10/15/2025 at approximately 1:00 PM with the Director of Nursing Services, she was unable to provide evidence that the facility maintained an infection control program to prevent the spread of infection relative to use of EBP for Resident ID #1.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, relative to the use of electronic monitoring for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Review of a facility policy titled, Abuse Prohibition dated 10/31/2022 states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity.Review of a facility policy titled, Electronic Monitoring dated 1/30/2025 states in part, It is the policy of this facility to comply with the electronic monitoring in Nursing and Assisted Living facilities Act (the Act). We will honor the Resident's (or Representative's) choice when electronic monitoring is requested.The Act allows for installation and use of electronic monitoring devices, including any photo, video, and/or audio surveillance equipment with a fixed position, that broadcasts or records activities or sounds occurring in the facility resident's room or private living area.Review of a community reported complaint received by the Rhode Island Department of Health on 10/10/2025 alleges that Resident ID #1 is not getting care, that a Nursing Assistant told him/her that s/he smells bad, and covered his/her electronic monitoring device.a. Record review revealed that Resident ID #1 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, altered mental status and seizures.During a surveyor observation on 10/15/2025 at approximately 8:00 AM, of the video surveillance footage provided by Resident ID #1's family, dated 10/8/2025 at 8:59 AM revealed that Nursing Assistant (NA), Staff A, is heard saying, [S/he] don't smell good at all, in front of the resident.During a surveyor interview on 10/15/2025 at 11:39 AM with Staff A, she acknowledged that she said the resident did not smell good while providing his/her care. Additionally, Staff A acknowledged that Resident ID #1 can understand what is being said and is able to answer yes/no questions when asked.During a surveyor interview on 10/15/2025 at approximately 1:00 PM with Director of Nursing Services (DNS) she acknowledged that Staff A, is heard commenting on Resident ID #1's smell in front of him/her. Additionally, she was unable to provide evidence that Resident ID #1 was treated with dignity and respect.b. Review of a consent form dated 1/27/2025 revealed the resident consented to the use of video surveillance monitoring.During a surveyor observation on 10/15/2025 at approximately 8:00 AM, of the video surveillance footage provided by Resident ID #1's family, dated 10/6/2025 at 9:19 AM revealed Staff A, covering the residents video surveillance camera with a pillow.During a surveyor observation on 10/15/2025 at 9:37 AM of the resident's room revealed signage posted on the door that states, Electronic monitoring in progress. Additionally, inside the room a camera is visible facing the resident's bed.During a surveyor interview on 10/15/2025 at 11:39 AM with Staff A, she acknowledged that on 10/6/2025 she covered the resident's video surveillance camera with a pillow.During a surveyor interview on 10/15/2025 at approximately 1:00 PM with the DNS she was unable to provide evidence that the resident was treated with respect and dignity relative to his/her right to use electronic monitoring equipment.

Based on record review and staff interview it has been determined that the facility failed to ensure 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, for 1 of 1 resident reviewed for significant medication errors, Resident ID #1. The failure of the facility to ensure that nursing staff followed established medication administration protocols, adhered to scope-of-practice requirements, and maintained safe medication-handling practices resulted in significant medication errors. This failure contributed to the resident receiving multiple medications not prescribed to him/her, requiring emergency intervention and a hospital transfer. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/17/2025 alleged that Resident ID #1 was administered the wrong medications and arrived at the hospital lethargic and minimally responsive to painful stimuli. Additionally, the resident immediately required activated charcoal (a medication used to treat an overdose).Further record review revealed that the resident received the following medications that were prescribed to another resident:10 milligrams (mg) of Diazepam (a benzodiazepine, a medication that is prescribed to slow down the activity in your brain and nervous system)10 mg of Oxycontin Extended Release (a Scheduled II narcotic prescribed to treat pain)5 mg of Oxycodone (a Scheduled II narcotic prescribed to treat pain)10 mg of Cyclobenzaprine (a medication prescribed to relax muscles)50 mg of Lyrica (an anticonvulsant, a medication prescribed to treat nerve pain)1200 mg of Gabapentin (an anticonvulsant prescribed to treat nerve pain)200 mg of Acyclovir (an anti-viral medication)10 mg of Cetirizine (an antihistamine)800 mg of Ibuprofen25 mg of Januvia (an oral diabetic medication)25 mg of Jardiance (an oral diabetic medication)450 mg of Lithium (an antimanic prescribed to treat bipolar disorder)1000 mg of Metformin Extended Release (an oral diabetic medication)20 mg of omeprazole (a medication prescribed to treat acid reflux)According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 7/23/2025 states in part, .To assure that all nursing staff possess the competencies, and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being .According to the state regulations for Nursing Assistants, Medication Aides, and the Approval of Nursing Assistant and Medication Aide Training Programs (216-RICR-40-05-22), which states in part, .Medication aides are not allowed to administer the following kinds of medications: a. Schedule II controlled substances.Record review revealed Resident ID #1 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, heart failure, intellectual disabilities, and chronic obstructive pulmonary disease.Record review revealed that Resident ID #2 was admitted to the facility in August of 2019 with diagnoses including, but not limited to, bipolar disorder, anxiety, and adjustment disorder.Review of a nursing progress note dated 11/16/2025 revealed that the resident appeared lethargic at 10:45 AM. An assessment was completed and revealed that Resident ID #1 was unresponsive with pinpoint pupils. S/he required two emergency doses of 4 mg of Narcan, and Emergency Medical Services (EMS) were called to transport to the resident to the hospital.Review of a medication error screening tool provided by the facility revealed that on 11/16/2025, the Certified Medication Technician (CMT), Staff A, administered the wrong medication to Resident ID #1. The report further revealed that the wrong medications were given to the wrong resident. The medications administered to Resident ID #1 in error included: narcotics, anticonvulsants, antipsychotics, antidiabetics, antidepressants, muscle relaxants and vitamins.Record review of an undated written statement authored by CMT, Staff A, revealed that on the morning of 11/16/2025 she was preparing medications when the nurse gave her a cup of medications to administer to Resident ID #2. When she went into Resident ID #2's room s/he was sleeping. She then placed the prepared cup of medications for Resident ID #2 in the drawer of the medication cart and started to prepare Resident ID #1's medications. She revealed at this time she was distracted and placed Resident ID #1's medication cup down to assist another resident. When she returned, she retrieved Resident ID #2's medications and administered them to Resident ID #1 in error. Record review of a written statement dated 11/16/2025 authored by Registered Nurse, Staff B, revealed that on the morning of 11/16/2025 she signed off narcotics for Resident ID #2 and then gave them to the CMT to administer. She then indicated the medications were subsequently given to Resident ID #1 by Staff A. Resident ID #1 was observed in his/her wheelchair with pinpoint pupils, lethargic and unresponsive. She administered two emergency doses of Narcan and called EMS.During a surveyor interview on 11/17/2025 at 2:04 PM with Staff A, she revealed that on 11/16/2025 during the morning medication pass she was distracted and inadvertently gave Resident ID #1 another resident's medications. She further revealed, the medications included Scheduled II narcotics that Registered Nurse, Staff B, had given to her to give to another resident. Additionally, she acknowledged that she should not have given the narcotics, and she should not have had Resident ID #2's medications pre-poured in the medication cart.During a surveyor interview on 11/17/2025 at 2:33 PM with Staff B, she indicated that on the morning of 11/16/2025 she retrieved Resident ID #2's narcotics that included, 10 mg of Oxycontin ER, 5 mg of Oxycodone and 50 mg of Lyrica from the locked narcotic box and then gave them to Staff A to administer to Resident ID #2 with his/her additional prescribed medications. She further revealed that approximately 30 minutes later Staff A told her that she accidently gave all Resident ID #2's medications to Resident ID #1. She went to assess Resident ID #1 who appeared lethargic, unresponsive with pinpoint pupils and administered two doses of 4 mg of Narcan and called 911.During a surveyor interview on 11/17/2025 at 2:45 PM, with the Director of Nursing Services, she acknowledged that Staff B should not have been pouring medications then having Staff A administer them. Her expectation would be that the nurse administers narcotics, and it would be out of the CMT's scope of practice to administer to the resident. She further acknowledged that medications for Resident ID #2 should not have been pre-poured and left in the medication cart by Staff A.The failure of the facility to ensure that nursing staff followed established medication administration protocols, adhered to scope-of-practice requirements, and maintained safe medication-handling practices resulted in significant medication errors that placed Resident ID #1 in immediate jeopardy. This failure contributed to the resident receiving multiple medications not prescribed to him/her, requiring emergency intervention and hospital transfer. Cross reference F760

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed who was administered an antipsychotic, antidiabetic agents, benzodiazepines (medications that are prescribed to slow down activity in your brain and nervous system), and narcotic medications that were prescribed for another resident, who required Emergency Medical Services (EMS), hospitalization, multiple doses of Narcan (a medication used to treat an opioid overdose) administration, and activated charcoal (a medication used to treat an overdose). These emergency interventions were necessary as a result of the medication errors involving Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/17/2025 alleged that Resident ID #1 was administered the wrong medications and arrived at the hospital lethargic and minimally responsive to painful stimuli. Additionally, the resident immediately required activated charcoal. Further record review revealed that the resident received the following incorrect medications:10 milligrams (mg) of Diazepam (a benzodiazepine, a medication that is prescribed to slow down the activity in your brain and nervous system)10 mg of Oxycontin Extended Release (a Scheduled II narcotic prescribed to treat pain)5 mg of Oxycodone (a Scheduled II narcotic prescribed to treat pain)10 mg of Cyclobenzaprine (a medication prescribed to relax muscles)50 mg of Lyrica (an anticonvulsant, a medication prescribed to treat nerve pain)1200 mg of Gabapentin (an anticonvulsant prescribed to treat nerve pain)200 mg of Acyclovir (an anti-viral medication)10 mg of Cetirizine (an antihistamine)800 mg of Ibuprofen25 mg of Januvia (an oral diabetic medication)25 mg of Jardiance (an oral diabetic medication)450 mg of Lithium (an antimanic prescribed to treat bipolar disorder)1000 mg of Metformin Extended Release (an oral diabetic medication)20 mg of Omeprazole (a medication prescribed to treat acid reflux)Record review of an undated facility policy titled, General Dose Preparation and Medication Administration, states in part, .Prior to administration of medication, Facility staff should take all measures required.but not limited to the following .Verify each time a medication is administered that it is the correct medication, at the correct dose .for the correct resident .Identify the resident .According to the state regulations for Nursing Assistants, Medication Aides, and the Approval of Nursing Assistant and Medication Aide Training Programs (216-RICR-40-05-22), which states in part, .Medication aides are not allowed to administer the following kinds of medications: a. Schedule II controlled substances.Record review revealed Resident ID #1 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, heart failure, intellectual disabilities, and chronic obstruction pulmonary disease.Record review revealed that Resident ID #2 was admitted to the facility in August of 2019 with diagnoses including, but not limited to, bipolar disorder, anxiety, and adjustment disorder.Review of a nursing progress note dated 11/16/2025 revealed that the resident appeared lethargic at 10:45 AM. An assessment was completed which revealed that s/he was unresponsive with pinpoint pupils. The resident required two emergency doses of 4 mg of Narcan, and EMS were called to transport to the resident to the hospital.Review of a nursing progress note dated 11/17/2025 revealed that the resident was admitted to the hospital with a diagnosis of an accidental overdose.Record review of an undated written statement authored by, Certified Medication Staff A, revealed that on the morning of 11/16/2025 she was preparing medications for Resident ID #2 when the nurse gave her additional medications to give. When she went into the resident's room s/he was sleeping. She then placed the prepared cup of medications in the drawer of the medication cart and started to prepare Resident ID #2's medications. She revealed that she was distracted and placed the cup down to assist another resident. When she returned, she retrieved Resident ID #2's medications and gave them to Resident ID #1.Record review of a written statement dated 11/16/2025 authored by Registered Nurse, Staff B, revealed that on the morning of 11/16/2025, she gave narcotics prescribed for Resident ID #2 and gave them to Staff A to administer. Staff A then subsequently gave Resident ID #2's medications to Resident ID #1 in error. Resident ID #1 was observed in his/her wheelchair, lethargic, unresponsive with pinpoint pupils. She administered two emergency doses of Narcan and called EMS.During a surveyor interview on 11/17/2025 at 2:04 PM with Staff A, she revealed that on 11/16/2025 during the morning medication pass she was distracted and inadvertently gave Resident ID #1 another resident's medications. She further revealed, the medications included Scheduled II narcotics that Staff B had given to her to administer to another resident. Additionally, she confirmed that the medications that were signed off by her in Resident ID #2's Medication Administration Record (MAR) on 11/16/2025 were given to Resident ID #1 in error. She acknowledged that she should not have given the narcotics, and she should not have had Resident ID #2's medications pre-poured in the medication cart.During a surveyor interview with Staff B, on 11/17/2025 at 2:33 PM, she indicated that on the morning of 11/16/2025 she retrieved Resident ID #2's narcotics that included, 10 mg of Oxycontin ER, 5 mg of Oxycodone and 50 mg of Lyrica from the locked narcotic box and then gave them to Staff A to administer to Resident ID #2 with his/her additional prescribed medications. She further revealed that approximately 30 minutes later Staff A told her that she accidently gave all of Resident ID #2's medications to Resident ID #1. She went to assess Resident ID #1 who appeared lethargic, unresponsive with pinpoint pupils, and administered two doses of 4 mg of Narcan and called 911. Additionally, she revealed that Resident ID #1 also received his/her prescribed 10 mg of morphine sulfate ER that morning at approximately 8:30 AM.Record review of Resident ID #1's November 2025 MAR states, Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 10 MG capsule by mouth two times a day.Do not administer oxycontin and morphine in same day. Additionally, the report revealed that s/he received this medication during the AM shift on 11/16/2025.Review of the prescriber information packet for Morphine Sulfate ER revealed the following adverse/side effects: using narcotic pain medications together with other medications like oxycodone that also cause central nervous system depression can lead to serious side effects including profound sedation, respiratory distress, coma, and even death.Record review of Resident ID #2's November 2025 MAR revealed the following medications were signed off by Staff A on the morning of 11/16/2025:10 mg of Diazepam10 mg of Oxycontin Extended Release5 mg of Oxycodone 10 mg of Cyclobenzaprine50 mg of Lyrica1200 mg of Gabapentin200 mg of Acyclovir10 mg of Cetirizine800 mg of Ibuprofen25 mg of Januvia25 mg of Jardiance450 mg of LithiumRecord review of the Emergency Medical Services Patient Care Report document dated 11/16/2025 at 10:50 AM, revealed that they responded to the nursing facility related to a patient receiving the wrong medications. Additionally, the report states, Pt [patient] was unresponsive, breathing and had reported 2 doses of Narcan.Record review of a hospital document dated 11/17/2025 revealed that the resident was admitted for an overdose after receiving another resident's medications. The medications included an antipsychotic, antidiabetic agents, benzodiazepines and narcotics. Additionally, the resident arrived somnolent, (unable to arouse) and required another dose of Narcan during transport to the hospital and received activated charcoal in the emergency room.During a surveyor interview on 11/17/2025 at 2:45 PM, with the Director of Nursing Services she acknowledged that Resident ID #1 received Resident ID #2's medications on 11/16/2025, required emergency doses of Narcan, and was admitted to the hospital for an overdose.As a result of this survey, it has been determined that Resident ID #1 was at risk for serious harm, injury, impairment or death due to Staff A's failure to administer medications according to the facility's policy. Resident ID #1 was administered medications intended for Resident ID #2 which resulted in Resident ID #1 exhibiting adverse effects which resulted in Resident ID #1 being admitted to a hospital, where s/he required treatment for a drug overdose Cross reference F 726

Based on record review, resident and staff interview, it has been determined that the facility failed to keep a resident free from abuse for 1 of 1 resident reviewed, Resident ID #2.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 10/8/2025, revealed in part, that a Nursing Assistant (NA), Staff C was witnessed talking to Resident ID #2 telling her how pretty and sexy s/he was. Staff C, then proceeded to lift up her shirt and show the resident that she too is sexy. This incident was witnessed by NA, Staff D and reported to the Director of Nursing Services (DNS).Review of a facility policy titled, Abuse prohibition states in part, .It is the policy of this facility to identify abuse, neglect, and exploitation of residents .This includes but is not limited to identifying and understanding the different types of abuse and possible indicators .The resident has the right to be free from abuse .Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at have the capacity to consent. Sexual abuse includes, but is not limited to .Unwanted intimate touching of any kind especially of breasts or perineal area .Generally, sexual contact is nonconsensual if the resident either .appears to want to contact to occur, but lacks the cognitive ability to consent; or .does not want the contact to occur .Record review revealed that Resident ID #2, the alleged victim, was admitted to the facility in August of 2019 with diagnoses including, but not limited to, bipolar disorder, anxiety, and adjustment disorder.Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the resident's cognition is intact.During a surveyor interview on 11/17/2025 at 10:22 AM with Resident ID #2, s/he revealed that s/he had no recollection of the incident.Surveyor telephone interviews with Staff C were attempted on 11/17/2025 at 10:33 AM and 11/18/2025 at 9:57 AM, however, she did not answer and has not returned the surveyor's calls.Record review of the facility investigation revealed that at approximately 12:35 PM it was reported that an agency Nursing Assistant, Staff C went into Resident ID #2's room and proceeded to make small talk by telling [the resident] how pretty and sexy [s/he] was. [Staff C] then proceeded to lift her top and show [the resident] that she too is sexy. This was witnessed by Nursing Assistant, Staff D who immediately reported the incident. Staff C was interviewed in the presence of the Administrator and removed from the facility after she admitted to the inappropriate act and provided a statement.Record review of a statement dated 10/7/2025 authored by Staff C states, On [DATE]:45 PM, I entered the patient room and was inappropriate by exposing my top chest keeping my sport bra on.Record review of a statement dated 10/7/2025 authored by Staff D states, Today Tuesday October 7 an agency [nursing assistant] came to work with me. While I was doing [Resident ID #2] she came into the room talking about [him/her] nationality.she then told [the resident] that [s/he] dresses .nice and sexy. Suddenly she lifted her top up showing her bra and stomach, showing how sexy she was too.Record review of a facility document titled, Results of Investigation revealed that Resident ID #2 was interviewed in the presence of the Social Worker and the Administrator and reports that Staff C is .crazy and doesn't belong here. Additionally, the report revealed that the facility apologized to the resident and reassured him/her that Staff C will not be returning to the facility.During a surveyor interview on 11/18/2025 at 2:28 PM, with the DNS revealed that Staff C was added to a Do Not Return list and reported to the State Licensing Department and Agency that she was employed by. Additionally, she was unable to provide evidence that the facility kept Resident ID #2 free from sexual abuse.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality, relative to not following physician's orders for 1 of 3 residents reviewed regarding obtaining weights, Resident ID #1. Findings are as follows: Record review of two community reported complaints submitted to the Rhode Island Department of Health on 3/21/2025, revealed allegations that Resident ID #1 had not been eating and s/he had lost approximately 20 pounds since being admitted to the facility. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed that the resident was readmitted to the facility in March of 2025 with diagnoses including, but not limited to, congestive heart failure (a condition where the heart can't pump blood as efficiently as it should), chronic obstructive pulmonary disease (a lung disease causing restricted airflow), and acute kidney failure. Review revealed a physician's order dated 3/3/2025 for weekly weights to start on 3/8/2025. Record review of the weights in the resident's electronic medical record and progress notes failed to reveal evidence that the resident's weight was obtained on 3/8/2025 or 3/15/2025, as ordered. During a surveyor interview on 3/24/2025 at 1:53 PM with the Director of Nursing Services, she acknowledged that the resident's weights were not completed as ordered on 3/8/2025 and 3/15/2025.

Based on record review, resident, 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 1 resident reviewed relative to a missed medication administration, Resident ID #2. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/10/2025 alleges that the resident has not received his/her Bictegravir-Emtricitabine-Tenofovir (BIKTARVY: a medication prescribed to treat, human immunodeficiency virus disease: HIV). Review of the manufacturer guidelines for Bictegravir-Emtricitabine-Tenofovir's states in part, .Inform patients that it is important to take BIKTARVY on a regular dosing schedule with or without food and to avoid missing doses as it can result in development of resistance . Record review revealed the resident was admitted to the facility in March of 2025 with diagnoses including, but not limited to, HIV and dialysis dependence (a life-sustaining treatment that is used to remove waste products and excess fluid from the blood when a person's kidneys are no longer functioning). Record review revealed a physician's order for Bictegravir-Emtricitabine-Tenofovir oral tablet 50-200-25 milligram (MG), 1 tablet by mouth one time a day to start on 3/6/2025. Review of the Electronic Medication Administration Record (EMAR) for March 2025 failed to reveal evidence that the resident received the above-mentioned medication on the following dates: - 3/6/2025 AM - 3/7/2025 AM - 3/8/2025 AM - 3/9/2025 AM Review of nursing progress notes dated 3/8/2025 and 3/9/2025, authored by Registered Nurse, Staff A, revealed that the resident's family is expected to bring the BIKTARVY to the facility. Additional review of the progress note dated 3/9/2025 at 7:38 PM authored by Licensed Practical Nurse (LPN), Staff B, revealed that there was a filled prescription bottle of the medication waiting for pick up at the resident's community pharmacy. During a surveyor interview on 3/11/2025 at 1:53 PM with the resident, s/he acknowledged that s/he did not receive the BIKTARVY for 4 days and indicated that s/he was made aware by a nurse at the facility that the medication was not available. Additionally, the resident indicated that s/he informed the facility that the BIKTARVY should not be missed. Further, the resident indicated that s/he had made a call to a family member to bring this medication from home however, it was not brought in. During a surveyor interview on 3/11/2025 at 2:10 PM with Staff A, he acknowledged that the resident did not receive the BIKTARVY on 3/6, 3/7, 3/8 and 3/9/2025, as ordered. Additionally, Staff A revealed that when he notified the Director of Nursing Services (DNS) and the Administrator on 3/6/2025 that the BIKTARVY was not available, he was told to call the resident's family to bring it from home. During a surveyor interview on 3/11/2025 at 2:45 PM with LPN, Staff B, she indicated that when she notified the Administrator about the resident's medication, she was told that there was an agreement for the medication to be brought from home. Additionally, Staff B revealed that after speaking to the resident, she contacted his/her community pharmacy where a filled prescription was ready to be picked up. During a surveyor interview on 3/11/2025 at 3:09 PM with the Administrator, she acknowledged that the resident was not administered his/her doses of BIKTARVY on 3/6, 3/7, 3/8 and 3/9/2025 because a family member was supposed to bring it from home. Additionally, she indicated that there was an agreement between the facility and the hospital case manager prior to the resident's admission to the facility that the family will be providing the medication. Further, the Administrator was unable to provide evidence of this agreement. During a surveyor interview on 3/11/2025 at 3:30 PM with the DNS, she acknowledged that the resident did not receive his/her BIKTARVY on 3/6, 3/7, 3/8 and 3/9/2025. Additionally, she was unable to provide evidence of an agreement. During a surveyor interview on 3/11/2025 at approximately 5:00 PM with the Medical Director, he indicated that on 3/6/2025, he was made aware that the resident's madication is not available for administration because the facility was waiting for the family member to bring it in. Additionally, the Medical Director indicated that he was not aware that the resident missed the medication from 3/7, 3/8 and 3/9/2025.

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 following physician's orders for administering nutrition via a gastrostomy tube (G-tube, a tube that is inserted through the wall of the abdomen into the stomach to deliver nutrition, fluids, and medication) for 1 of 2 residents reviewed, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error of would harm the clients. Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/26/2024 alleges that the resident is not receiving his/her G-tube nutrition, as ordered. Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, protein-calorie malnutrition, dysphagia (difficulty swallowing), and gastrostomy tube. Record review revealed a physician's order dated 12/20/2024 for Isosource (a nutritional formula) 1.5 Cal 400 milliliter (ML) four times a day with a discontinue date of 12/23/2024. Record review of nursing progress notes revealed the resident received Isosource 1.5 Cal without a physician order on the following dates and times: - 12/27/2024 at 6:50 PM - 12/27/2024 at 8:13 PM - 12/28/2024 at 12:03 PM - 12/28/2024 at 11:31 PM - 12/29/2024 at 9:27 AM - 12/29/2024 at 8:00 PM Record review failed to reveal evidence that the resident had a current physician's order for Isosource 1.5 Cal that had been documented as being administered on the above-mentioned dates and times. During a surveyor observation on 12/31/2024 at 12:44 PM in the presence of Licensed Practical Nurse, Staff A, the resident was observed being administered Isosource 1.5 Cal at 60 ml/hour. During a surveyor interview immediately following this observation with Staff A, he acknowledged the resident was receiving Isosource 1.5 Cal at 60 Ml/hour. Staff A further indicated that the resident had been receiving the Isosource 1.5 Cal since s/he was admitted . Additionally, Staff A was unable to provide evidence that the resident had a physician's order for Isosource that was being administered. During a surveyor interview on 12/31/2024 at 1:01 PM with the Director of Nursing Services (DNS), she acknowledged that the resident did not have a physician's order for Isosource 1.5 Cal. Additionally, she was unable to provide evidence why the Isosource 1.5 Cal was discontinued on 12/23/2024.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practice for 1 of 2 residents reviewed receiving nutrition via a gastrostomy tube (G-tube, a tube that is inserted through the wall of the abdomen into the stomach to deliver nutrition, fluids, and medication), Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/26/2024 alleges that the resident is not receiving his/her G-tube nutrition as ordered. Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, protein-calorie malnutrition, dysphagia (difficulty swallowing), and gastrostomy tube. Record review revealed the following physician's orders: - 12/23/2024 for Nutren 2.0 (a tube feeding formula used to provide complete or supplemental nutrition) 300 millimeters (ml) four times a day via the G-tube. - 12/20/2024 for Two Cal HN 2.0 (a calorie and protein dense nutritional tube feeding formula) 300 ml via the G-tube four times a day. Record review of the Medication Administration Record (MAR) for December 2024 revealed the Nutren 2.0 formula was signed off as administered to the resident on the following dates and times: - 12/23/2024 at 8:00 PM - 12/24/2024 through 12/30/2024 at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM - 12/31/2024 at 8:00 AM Record review of the MAR for December 2024 revealed the Two Cal HN 2.0 formula was signed off as administered to the resident on the following dates and times: - 12/21/2024 through 12/26/2024 at 8:00 AM, 12:00 PM, 8:00 PM, and 8:00 PM - 12/27/2024 at 8:00 AM and 12:00 PM - 12/28/2024 at 8:00 PM - 12/30/2024 at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM - 12/31/2024 at 8:00 AM During a surveyor observation on 12/31/2024 at 12:44 PM in the presence of Licensed Practical Nurse, Staff A, the resident was observed being administered Isosource 1.5 Cal (a nutritional formula) at 60 ML/hour instead of the above-mentioned formulas that were being signed off by the staff. During a surveyor interview immediately following this observation, Staff A acknowledged the above-mentioned observation. Staff A further indicated that the Nutren and Two Cal HN 2.0 were not available in the facility and that the resident had been receiving Isosource 1.5 Cal instead since his/her admission. During a surveyor interview on 12/31/2024 at 12:48 PM with the Administrator, she acknowledged that the facility did not have either the Nutren 2.0 or Two Cal HN formula at the facility prior to this observation. Additionally, she acknowledged that the Nutren 2.0 formula was ordered on 12/23/2024 and was delivered on 12/31/2024. During a surveyor interview on 12/31/2024 at 1:01 PM with the Director of Nursing Services (DNS), she indicated that when the resident was admitted to the facility, there was an order for Two Cal HN 2.0 formula four times a day. She indicated that the order was changed by the physician to Nutren 2.0 formula because the facility did not carry this brand. She acknowledged that the orders for the Nutren 2.0 and Two Cal HN formula were signed off inaccurately as being administered when both formulas were not not available.

Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an accident for 1 of 3 residents reviewed for elopement, Resident ID #1. Findings are as follows: Record review of a facility policy titled Elopement states in part, .Elopement- leaving the facility without permission and/or notification to the facility .Assessment: An assessment will be completed within 24-hours of admission. 1. A determination of residents at risk will be made through the assessment process, observation and information received from other sources, such as family and medical records 2. A re-assessment will be completed for any resident who demonstrates any of the following . 3. A resident assess to be at risk. The following actions may be employed: 1. Application of a wanderguard [a system used to prevent residents with a tendency to wander from leaving monitored areas. It consists of wearable bracelets for residents, door sensors] 2. Initiation of frequent checks 3. Room transfer to a secured area 4. Residents at risk for elopement identified to appropriate staff 5. Facility transfer to a more suitable health care provider . Surveyor observation on 7/15/2024 at approximately 12:00 PM revealed the facility is equipped with a wander guard system. When a resident is wearing a wander guard bracelet attempts to leave the facility, an alarm will go off alerting the staff. Record review revealed the resident was admitted to the facility in May of 2024 with diagnoses including, but not limited to, dementia, Wernicke's encephalopathy (a brain and memory disorder due to a lack of vitamin B1 that can cause confusion and memory loss), and traumatic brain injury. Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, indicating s/he has moderately impaired cognition. Record review of a Wandering Risk assessment dated [DATE], indicated the resident was at a moderate risk for wandering. Additional record review failed to reveal evidence of interventions to prevent the resident from wandering after s/he was assessed to be a moderate risk for wandering. Record review of a subsequent Wandering Risk assessment dated [DATE], found the resident to be at a low risk for wandering as it was not completed in its entirety. The assessment failed to identify the cognitive orientation of the resident, any behaviors/mood the resident may exhibit and any antipsychotics, antidepressants, anti-anxiety/hypnotics, narcotic medications that the resident is taking. If this assessment had been completed in its eternity, the resident would have remained at a moderate risk for elopement. Review of a facility reported incident sent to the Rhode Island Department of Health on 7/14/2024, revealed that on 7/14/2024 the facility staff reported that Resident ID #1 eloped. At approximately 10:45 AM, a police officer arrived at the facility and informed the facility staff they had found Resident ID #1 and s/he was being transported to the hospital. Record review of a police report titled Incident Report revealed that the local police department was notified at 10:05 AM on 7/14/2024 by a member of the community that a person who appeared to be confused .was laying in the roadway .I responded to [facility] and advised the weekend nursing supervisor .of the incident [facility nurse] advised [Resident ID #1] is a dementia patient at the facility . Record review of a hospital document dated 7/14/2024, titled emergency room VISIT NOTES revealed that Resident ID #1 was brought to the hospital by rescue after s/he was found sleeping on the roadway wearing unseasonably heavy clothing and sweating profusely. Additionally, the report revealed that s/he was not sure where s/he was or what happened. During a surveyor interview with Licensed Practical Nurse, Staff A, on 7/16/2024 at 9:02 AM, he revealed that the last time facility staff had seen the resident on the morning of 7/14/2024, prior to his/her elopement was at approximately 9:00 AM, when s/he was observed sitting on a chair outside of the facility to the left of the entrance door. During a surveyor interview with the Smoking Attendant on 7/15/2024 at 1:35 PM, she revealed that Resident ID #1 was a smoker and required supervision with smoking. She indicated she typically holds the materials for the residents that smoke, supervise the residents while they are smoking, and assists any residents that require help with lighting their cigarettes. Additionally, she indicated that she does not supervise the residents when they are not in the smoking area. Furthermore, she stated that she does not monitor the comings and goings of residents who ambulate to and from the smoking area independently. Record review of a smoking safety screen assessment dated [DATE], indicated the resident has cognitive loss and required supervision to smoke. During a surveyor interview with the Assistant Director of Nursing on 7/15/2024 at 1:56 PM, she indicated that when a resident is assessed as being a wander risk and they are a smoker, they are accompanied to and from the smoking area by staff. During a surveyor interview with the Administrator on 7/15/2024 at approximately 2:30 PM, she acknowledged that the wandering risk assessment dated [DATE] was incomplete. Additionally, she could not provide evidence that the facility ensured that the resident received adequate supervision to prevent an elopement. Record review revealed that Resident ID #1 returned to the facility after the hospital evaluation and now resides on a secured unit. The facility's failure to provide adequate supervision, interventions, to accurately complete the wander risk assessment, and provide updates to the care plan, has placed a cognitively impaired resident who was a wander risk at risk for more than minimal harm, injury, impairment, or death. These failures resulted in this resident exiting the facility unsupervised by staff in unseasonably heavy clothing, and laying on the roadway approximately 1 mile from the facility.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to keep a resident free from sexual abuse for 1 of 2 residents reviewed, Resident ID #1. Findings are as follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised February 2023, indicates that sexual abuse is defined as .any sexual contact of any type with a resident .Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area .forced observation of masturbation .Generally, sexual contact is nonconsensual if the resident .lacks the cognitive ability to consent . Review of a facility reported incident submitted to the Rhode Island Department of Health on 6/20/2024 alleges in part, that Nursing Assistant (NA), Staff A, noticed that Resident #1's door was closed and when she opened it, she observed Resident ID #2 holding Resident ID #1's genitalia and was observed to be stroking it. Record review revealed that the alleged victim, Resident ID #1, was admitted to the facility in March of 2024 with diagnoses including, but not limited to aphasia (inability to speak), Alzheimer's disease, and dementia without behavioral disturbance. Additionally, s/he resides on a secured (locked) unit. Review of Resident ID #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. Record review revealed that the alleged perpetrator, Resident ID #2, was admitted to the facility in December of 2023 with diagnoses including, but not limited to, major depressive disorder with severe psychotic disorder (symptoms that affect the mind with loss of contact with reality), anxiety disorder, and insomnia. Additionally, s/he resides on a secured (locked) unit. Review of Resident ID #2's MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15, indicating severely impaired cognition. During a surveyor interview on 6/20/2024 at approximately 12:00 PM with the Assistant Director of Nursing Services (ADNS), she revealed that Resident ID #1's room is like a dormitory where many residents gather, including Resident ID #2, to eat and watch television. She further revealed that she has never observed Resident ID #2 touch other residents inappropriately, although, she indicated to the surveyor that Resident ID #2 attempted to kiss her a couple of weeks ago. Record review failed to reveal evidence that after Resident ID #2 attempted to kiss the ADNS that the physician was notified of Resident ID #2's inappropriate sexual behaviors or that the care plan for Resident ID #2 was updated to include interventions to mitigate or monitor for such behaviors. During a surveyor interview on 6/20/2024 at 11:41 AM and at 4:43 PM with NA, Staff A, she revealed that she had worked the 11:00 PM to 7:00 AM shift on 6/19/2024 and indicated that at approximately 3:00 AM, she found Resident ID #2 in Resident #1's room, sitting in the chair. She indicated that she was unable to remove Resident ID #2 from Resident ID #1's room, as s/he became combative. Staff A revealed that at this time, she left Resident ID #2 in Resident ID #1's room unsupervised and did not return until 4:30 AM. She indicated that at this time, she was able to redirect Resident ID #2 back to his/her own room. She further revealed that at approximately 7:00 AM on 6/20/2024, she was sitting at the nurse's station when a nurse asked her to open Resident ID #1's door because it was closed. Staff A revealed that when she opened the door, she found Resident ID #2 sitting on Resident ID #1's bed and observed Resident ID #1 with his/her eyes closed, his/her adult incontinent brief was pulled to the side and his/her legs were resting on Resident ID #2's lap while s/he stroked Resident ID #1's genitalia. During a surveyor interview on 6/21/2024 at 1:39 PM with Licensed Practical Nurse, Staff D, she revealed that she worked the 11:00 PM to 7:00 AM shift on 6/19/2024 and indicated that at approximately 3:00 AM, she saw Resident ID #2 enter Resident ID #1's room and shut the door, as s/he does most nights. Staff D further revealed that Resident ID #2 became combative when she asked him/her to leave Resident ID #1's room, so she left him/her in the room, unsupervised, until approximately 4:30 AM when Staff A got him/her out. Furthermore, she indicated that she did not know when Resident ID #2 went back to Resident ID #1's room. Record review revealed the resident had previously exhibited inappropriate behaviors towards staff and other residents, including Resident ID #1, as evidenced by the following progress notes: - 1/2/2024 authored by Registered Nurse, Staff B, states in part .resident inappropriate with staff, walking around naked from the waist down motioning for someone to get in bed with [him/her]. resident redirected back to [his/her] room and given pants to put on . - 6/11/2024, authored by Licensed Practical Nurse, Staff C, indicated that Resident ID #2 was found sitting in a chair in Resident ID #1's room as [s/he] always does. Staff was alerted to the room and observed Resident ID #2 standing over Resident ID #1 telling [him/her] to get out in an aggressive manner. The staff explained that this is Resident ID #1's room and that s/he needed to return to his/her own room. Resident ID #2 refused to leave and just kept staring at Resident ID #1 trying to intimidate [him/her]. Resident ID #2 was pulling Resident ID #1's blanket away from a staff member that was trying to place the blanket on Resident ID #1. Staff C felt at this time that situation wasn't going to pass so staff removed Resident ID #1 from his/her room and sat him/her outside of the nurse's station. Resident ID #2 walked over to Resident ID #1 and kept starting at him/her. Resident ID #2 returned to Resident ID #1's room and won't keep [his/her] eyes off other resident and is occasionally walking to the doorway looking at Resident ID #1. Record review failed to reveal evidence that following the above-mentioned incidents, the physician was notified of Resident ID #2's behaviors, or that the care plan for Resident ID #2 was updated to include interventions to mitigate or monitor for inappropriate behaviors directed towards others. Review of a document titled, PSYCHIATRIC EVALUATION AND CONSULTATION, dated 4/16/2024 failed to reveal evidence that Resident ID #2's inappropriate behaviors from 1/2/2024 were addressed. Additionally, it stated that Nursing denies concerns and to monitor for behaviors. During a surveyor interview on 6/21/2024 at 4:37 PM with the Administrator, in the presence of the DNS, they were unable to provide evidence that Resident ID #1 was kept free from sexual abuse. Due to the facility's failure to contact the provider, update the resident's care plan to include interventions to mitigate and monitor for behaviors on 1/2/2024, 6/11/2024, when Resident ID #2 attempted to kiss the ADNS, and throughout the duration of the 11:00 PM to 7:00 AM shift on 6/20/2024, resulted in Resident ID #1 being sexually abused by Resident ID #2 as s/he was unable to form consent due to his/her cognitive impairment. Additionally, these failures placed all the cognitively impaired residents who reside on the secured unit at risk for more than minimal harm. Cross Reference F 679

Based on record review and staff interview it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice and failed to promptly identify and intervene during acute changes in condition for 2 of 2 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/28/2024, alleged concerns regarding Resident ID #1's wound care and ascites (a buildup of fluid in the abdomen) management as the resident was admitted to the hospital and needed 5 Liters of fluid drained from his/her abdomen. 1a. According to Nursing Health Assessment: A clinical Judgement Approach 4th edition, 2023 published by Wolters Kluwer, it has been revealed that characteristics of a deep vein thrombosis, (DVT) also known as a blood clot, include, but are not limited to, pain and swelling at the site. Record review revealed that Resident ID #1 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, chronic pain and pancreatic cancer. Review of the resident's admission assessment dated [DATE], revealed that the resident presented with 3+ pitting edema (swelling that occurs in your feet, ankles, or legs, but may also occur in the face, hands, or arms. When the edema is pressed it leaves a dimple this is called pitting edema. A 3+ pitting edema this indicates severe edema and can take up to 30 seconds or more to rebound) to his/her bilateral lower extremities. Record review revealed the following: 5/17/2024 at 6:13 AM- The resident presented with 2+ pitting edema (2+ pitting edema indicates slight swelling that can take up to 15 seconds to rebound) to his/her bilateral lower extremities. 5/17/2024 at 12:25 PM- The Nurse Practitioner assessed the resident and indicated that s/he has 4+ edema (4+ pitting edema indicates a very deep pit that takes approximately 2-5 minutes to rebound) to his/her bilateral lower extremities. Record review revealed that although the Nurse Practitioner assessed the 4+ pitting edema on 5/17/2024 no interventions or orders were implemented. 5/18/2024 at 1:41 PM- The resident presented with 2+ pitting edema noted in all extremities. Record review failed to reveal evidence that the provider was notified of the documented edemas that was in all extremities and failed to reveal any new interventions or orders that were implemented for the edema noted to all extremities. 5/18/2024 at 5:28 PM - The provider completed an examination on the resident and no indication of edema was present (despite the previous assessments on 5/15, 5/16, 5/17 and 5/18/2024 that indicate varying fluctuations and locations of the resident's edema). 5/19/2024 at 7:12 PM - The resident presented with 3-4+ pitting edema. Record review failed to reveal evidence that the provider was notified of the increased edema or that any new interventions or orders were implemented from 5/18/2024 to 5/19/2024. 5/20/2024 at 10:29 AM- The resident presented with 4+ pitting edema to his/her bilateral lower extremities. The resident also has a blister to his/her right foot due to the edema. Further record review revealed the resident requested to go to the hospital on 5/20/2024 as s/he was experiencing discomfort. Review of the hospital's emergency department [ED] documentation revealed, the resident presented to the hospital and that the Patient started to have pain in [his/her] R [right] leg 3 days ago which has been getting worse. R leg is more swollen as well. It is 10/10, constant, sharp pain at the back of [the] R leg with no radiation. [S/he] was able to walk with a walker but has been lying in bed more recently in [the] nursing home. Since the pain started, [s/he] hasn't been able to bear weight as it makes the pain even worse. [S/he] also has abdominal distention and pain as well. [S/he] had paracentesis [removal of fluid from the abdomen] 3 weeks ago during previous hospitalization . [His/Her] abdomen has been getting more and more distended since then. Denies [nausea /vomiting/diarrhea /constipation]. In ED, [s/he] was found to have [an] acute DVT [Deep Vein Thrombosis, blood clot] in [his/her] R leg. During a surveyor interview on 5/29/2024 at 10:48 AM with the facility's wound nurse, he revealed that he saw the resident for the first and only time on 5/20/2024. He indicated that the resident's legs were very swollen and that it was very painful for him/her when his/her wounds were assessed. He revealed that if the resident was not on hospice, he would have assessed him/her for a DVT due to the amount of pain s/he was in. Furthermore, he was unaware that the resident was diagnosed with a DVT while hospitalized . During a surveyor interview on 6/3/2024 at approximately 10:00 AM with the Nurse Practitioner she acknowledged that she assessed the resident on 5/17/2024 as having 4+ pitting edema to his/her bilateral lower extremities but did not implement any new orders or interventions. During a surveyor interview on 5/29/2024 at 11:12 AM with the Director of Nursing Services (DNS), she revealed that the resident was on hospice services, but that she would have expected the staff to notify the provider or hospice of the resident's increasing edema and pain. She further revealed she would have expected an ultrasound (a procedure used to assess a vein for a blood flow and identification of a DVT) to have been obtained to rule out a DVT due to the resident's increased edema. 1b. Record review revealed that the resident complained of abdominal pain on 5/18/2024 and required an as needed dose of morphine (an opiate medication) for pain management. Record review revealed a physician's order dated 5/18/2024 to measure the resident's abdominal girth every morning related to ascites. Record review of the May 2024 Medication and Treatment Administration Record notes revealed, on 5/19/2024 and 5/20/2024 the abdominal girth was not measured due to the facility not having a measuring tape available. Further record review revealed on 5/20/2024, the resident complained of abdominal discomfort and requested to go to the hospital for a paracentesis [a procedure to remove fluid from the abdomen] and was admitted to the hospital. Review of the hospital's emergency department [ED] documentation dated 5/20/2024 revealed, the resident presented to the hospital and a paracentesis was scheduled. Review of a hospital provided procedure document revealed a paracentesis procedure was completed on 5/21/2024 and the resident had a Large volume of ascites and that 4800 milliliters of clear yellow fluid was removed from his/her abdominal cavity. During a surveyor interview with the DNS on 5/29/2024 at 11:10 AM, she revealed she would have expected the resident's abdomen to have been measured on 5/19/2024 and 5/20/2024 and that she would have expected someone to notify management staff that a measuring tape was unavailable. 1c. Record review of a progress note authored by Registered Nurse, Staff A, dated 5/16/2024 revealed, the resident bumped the back of his/her right lower extremity on the bed frame and a small open area was noted. The note indicates that the wound nurse was notified and saw resident. The note further indicates that an abdominal pad was placed over night. Record review failed to reveal evidence that the provider was notified of the open area to his/her right lower extremity and or that any new interventions or orders were implemented by the provider. Record review reveals that on 5/17/2024 at 12:25 PM the Nurse Practitioner assessed the resident and indicated that s/he has 4+ edema to his/her bilateral lower extremities but there was no assessment of the open area to his/her lower extremity that occurred on 5/16/2024. Review of a progress note dated 5/19/2024 revealed, the resident had visitors present and there were complaints that his/her right leg was weeping (oozing fluid). The resident's Tubi-grip (compression wrap) on his/her right leg was removed and two wounds were identified one on the top of his/her right foot and another on the back of his/her right lower leg, both were weeping. The note further states, .cleansed and bacitracin with dry dressing applied .Hospice called and informed of above. Hospice team will follow up tomorrow .Visitors took pictures of wounds . Record review failed to reveal evidence that the provider was notified of the open areas to his/her right foot or lower leg and or that any new interventions or orders were implemented by the provider. Further record review failed to reveal evidence of an assessment completed by the wound nurse on 5/16, 5/17, 5/18 or 5/19/2024. Review of the May 2024 Medication and Treatment Administration Records failed to reveal evidence that any treatment orders were implemented between 5/16/2024 through 5/20/2024 for the wounds that were identified on 5/16/2024 and 5/19/2024. Review of a progress note dated 5/20/2024 revealed, the resident was seen regarding a broken saline blister to his/her right dorsal foot. The blister measured 5 x 4 centimeters (cm) with an opening of 1 x 1 cm and a dressing was applied. Further review of the 5/20/2024 progress notes revealed, the resident and his/her friend .had concerns about wound care pertaining to a blister that popped . During a surveyor interview on 5/29/2024 at 10:48 AM with the wound nurse, he revealed that he initially assessed the resident's wounds on 5/20/2024 and that the resident was in a lot of pain during the dressing change. He indicated that he was unaware that a new wound was identified to the resident's right lower extremity on 5/16/2024. Additionally, he revealed that it was not until 5/20/2024, 5 days after the wound had been observed by nursing staff that he was made aware the resident had any new wounds. During a surveyor interview on 5/29/2024 at 11:08 AM with the DNS, she revealed that she would have expected an order to have been obtained on 5/16/2024 when the new wound was identified to the resident's right lower extremity was first identified. She was unable to explain why the nurse implemented treatments on 5/16/2024 and 5/19/2024 without contacting the provider. 1d. Record review of a progress note dated 5/17/2024 at 5:58 PM revealed the resident was found kneeling on the floor on the side of his/her bed. The progress note further indicated, the resident stated they had tried to lay on the bed but rolled over onto the floor. Record review failed to reveal evidence that the resident was assessed after the fall, that the physician was notified, or any interventions were put in place to prevent future falls from occurring. During a surveyor interview on 5/31/2024 at 1:07 PM with Licensed Practical Nurse, Staff B, she indicated that the Nurse Practitioner was in the facility and went to the room to assess the resident. During a surveyor interview on 6/2/2024 at approximately 10:00 AM with the Nurse Practitioner she was unaware that the resident experienced a fall on 5/17/2024 and did not assess him/her specifically for a fall on 5/17/2024. She indicated she saw him/her for the first time earlier in the day for an admission assessment and was never called back to assess him/her for a fall. 1e. Record review revealed a physician's order dated 5/16/2024 to obtain an admission weight. Record review failed to reveal evidence of an admission weight. Further record review revealed a physician's order dated 5/16/2024 to weigh the resident on the second day after admission. Record review failed to reveal evidence of a weight on the second day after admission. Further record review failed to review that a weight was ever obtained on this resident. During an interview on 5/31/2024 at approximately 1:00 PM with Registered Nurse, Staff A, she indicated she completed the admission for the resident but did not get an admission weight. 2a. Record review revealed that Resident ID #2 was admitted to the facility in December of 2018 with diagnoses including, but not limited to, dementia and type two diabetes mellitus. Record review revealed a nursing note dated 4/30/2024 at 2:59 PM, authored by, LPN, Staff C, that she responded to the activity room as the resident was not responding at baseline. Resident was noted to be awake in the wheelchair but was not speaking. The resident seemed weak and his/her limbs were somewhat floppy. The note indicates that a call was placed to the Nurse Practitioner and a message was left on her voicemail. Further record review reveals a second nursing note written on 4/30/2024 at 10:01 PM that the Nurse Practitioner did not return the call. Record review failed to reveal evidence that the provider was notified of the incident on 4/30/2024 or that any interventions were put in place for his/her unresponsive incident on 4/30/2024. 2b. Record review revealed a nursing note dated 5/4/2024 at 2:06 PM, authored by Staff C that indicates the resident became pale and unresponsive and was incontinent of stool. Record review failed to reveal evidence that the provider was notified of the incident on 5/4/2024 or that any interventions were put in place for his/her unresponsive incident on 5/4/2024. During a surveyor interview on 6/4/2024 at approximately 2:30 PM with the Nurse Practitioner she indicated that she was not aware of the unresponsive incidents that Resident ID #2 experienced on 4/30/2024 and 5/4/2024. She indicated that if she was aware she would have conducted an assessment and ordered labs. She also indicated that staff should be calling the on-call provider if they were unable to reach her. During a surveyor interview on 6/4/2024 at 2:45 PM with the Administrator and Director of Nursing they were unable to explain why staff did not alert the provider of the resident's change in condition on 4/30/2024 and 5/4/2024.

Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards as possible for 2 of 6 residents reviewed relative to smoking, Resident ID #s 1 and 2. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 7/3/2023 revealed that a fire started on 7/1/2023 in a resident's trash can. Resident ID #2 and a staff member were transferred to the hospital to be evaluated for smoke inhalation. 1. Record review of the facility policy titled Smoking Policy states in part, .5. Residents who are identified as smokers are required to follow the following rules . - They must follow the recommendations of the team including but not limited to smoking in the designated area/wearing protective garments/using adaptive devices and/or being supervised . Record review revealed Resident ID #1 was readmitted to the facility in March of 2023 with diagnoses including, but not limited to, right femur (thigh bone) fracture and a family history of tobacco abuse and dependence. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Record review of the smoking assessments completed on 1/29/2023, 3/24/2023 and 6/23/2023 for Resident ID #1 revealed s/he was safe to smoke with staff supervision. Record review of a progress note dated 7/1/2023 at 10:52 PM, authored by the agency nurse, Staff A, indicated that Resident ID #1's room had a strong cigarette odor which traveled throughout the unit. Resident ID #1 admitted to Staff A that s/he was smoking a cigarette in his/her room. The resident's room was searched, and the note indicates that no more cigarettes were found. Further record review of the progress notes revealed a late entry note, authored by Registered Nurse (RN), Staff F, dated 7/2/2023 at 1:57 PM that indicates on 7/1/2023 at 11:00 PM, resident was caught smoking in [his/her] room and [his/her] trashcan caught fire. During a surveyor interview with Resident ID #1 on 7/3/2023 at 11:45 AM, s/he admitted to smoking a cigarette in his/her room on the evening of 7/1/2023. S/he indicated that s/he threw the cigarette in a sprite can in the trash along with the lighter. During a surveyor interview with RN, Staff B, on 7/5/2023 at approximately 1:00 PM, she revealed that Nursing Assistant (NA), Staff C, discovered a fire in the trash can in Resident ID #1's room on 7/1/2023. She indicated that Staff C ran out of the room and requested her assistance. Staff B indicated that she put out the fire with a fire extinguisher and then the smoke alarm sounded, which alerted the fire department. The fire department responded within 15 minutes. Staff B revealed that she was advised to go to the emergency room along with the Resident ID #2, to be evaluated for smoke inhalation. Additional record review of Resident ID #1's progress notes revealed Resident ID #1 has a history of noncompliance: - 3/14/2023 at 11:43 PM revealed the resident went outside with a friend to smoke against facility rules. -3/23/2023 at 3:01 PM, authored by Social Worker, Staff D, indicates that the resident was non-complaint with the smoking policy and a family meeting will be scheduled. -4/4/2023 at 3:22 PM, authored by Social Services, Staff E, revealed a meeting was held regarding Resident ID #1's non-compliance with smoking. Resident ID #1 and his/her significant other agreed with the plan which was for all smoking materials to be left with staff. - 5/30/2023 at 3:01 PM revealed that his/her room smelled like smoke and a search was conducted which yielded 4 packs of cigarettes being taken away from the resident's room and were placed in the facility's smoking cart. 2. Record review of the document titled [Facility] Smoking Rules states in part, .15. AT NO TIME IS ANYONE WITH OXYGEN TO BE SMOKING OR NEAR A SMOKER . Record review revealed Resident ID #2 was readmitted to the facility in June of 2023 with diagnoses including, but not limited to, acute and chronic respiratory failure with hypoxia (low oxygen in the blood), chronic obstructive pulmonary disease, and heart failure. Record review of Resident ID #2's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15 indicating intact cognition. Further record review revealed Resident ID #2 had a physician's order dated 6/28/2023 to give oxygen 1-4 liters per minute via nasal cannula as needed for shortness of breath or comfort as tolerated. Record review revealed Resident ID #2 was the roommate of Resident ID #1 when the fire occurred on 7/1/2023. Record review of the July 2023 Medication Administration Record revealed that Resident ID #2 was receiving oxygen on 7/1/2023 when the fire started. During a surveyor interview with Resident ID #2 on 7/3/2023 at 2:35 PM, s/he revealed that s/he utilizes oxygen as needed. Additionally, Resident ID #2 reported that s/he was utilizing oxygen at the time the fire started. S/he also indicated that s/he was transported to the emergency department for evaluation, and s/he received a nebulizer treatment. During a surveyor interview with the Director of Nursing Services on 7/3/2023 at approximately 1:00 PM, in the presence of the Assistant Director of Nursing Services, Infection Control Nurse, and a compliance consultant, she was unable to provide evidence that the facility ensured Resident ID #1 received adequate supervision after s/he was identified to have smoked in his/her room on 5/30/2023 and 7/1/2023. Additionally, she was unable to provide evidence that the facility implemented adequate interventions to reduce hazards and risks in the residents' environment. The facility failed to ensure that the resident environment remains as free of accident hazards as possible as Resident ID #1 who was known to be non-complaint with the smoking policy started a fire on 7/1/2023. This system failure placed all residents at risk for serious injury, impairment, or death as a fire was started by a cigarette in Resident ID #1 and 2's room, resulting in Resident ID #2 requiring an evaluation at an acute care hospital.

Based on surveyor observation, record review and staff interview it has been determined that the facility failed to implement infection control measures for the prevention of the spread of Coronavirus Disease (COVID-19) relative to properly screening everyone entering a healthcare facility for signs and symptoms of COVID-19. The facility also failed to ensure that healthcare personnel (HCP) utilized Personal Protective Equipment (PPE) according to professional standards to prevent the potential of the transmission of COVID-19 for 1 of 4 units observed, Pavilion unit. Findings are as follows: 1) A Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic updated on 2/23/2021, states in part, . Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 . Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed [CONDITION(S)]-CoV-2 infection and that they are practicing source control. Options could include (but are not limited to): individual screening on arrival at the facility . Review of the facility policy titled, COVID-19: General Screening and Health Care Personnel (HCP)/Visitor Response revised on 10/13/2020, states in part, .Screening of all staff and any *visitors is done upon entrance into the facility. The screening should be done in area of the facility where there no residents and minimal staff in the area (ie lobby, foyer) . A. On 5/2/2021 at approximately 7:35 AM, a team of surveyors entered the facility through two unlocked doors at the main entrance to conduct an off hours recertification survey. Prior to entering the facility there was no evidence of visible signage on the doors related to the screening process or protocols for visitors. Upon entering the facility there were no staff screening or any visible COVID-19 screening forms. The survey team was able to freely enter and access the building without facility staff being aware of their presence. At approximately 7:40 AM this surveyor walked to the employee break room and asked a house keeper, Staff G, who they could speak to for assistance. He then indicted for a surveyor to go to the Pavilion unit to speak with unit Registered Nurse, Staff D. At approximately 7:45 AM a surveyor went to the Pavilion unit and at this time Staff D called the Administrator to inform her of the survey team's arrival. At this time the survey team was still not screened for COVID-19. A surveyor observation on 5/2/2021 at approximately 8:00 AM revealed an activity aide, Staff H, entered the building without being screened for COVID-19, punched in, then proceeded to the activity room located off of the lobby area, which is also being used as the family visitation area. At approximately 8:30 AM this surveyor asked Staff H if someone could screen the surveyors. She then left the area, and upon returning, informed the survey team that the receptionist would be in at 9:00 AM to do the COVID-19 screening. At approximately 8:52 AM the Administrator and Director of Nursing (DON) arrived at the facility and at this time the survey team was screened for COVID-19. This is approximately 1 hour and 20 minutes after the team had initially entered the facility. During an entrance conference interview on 5/2/2021 at 9:57 AM with the Administrator, DON, and Vice President of Operations they indicated that the facility is following the CDC and the Rhode Island Department of Health guidance relative to COVID-19. B. Surveyor interviews on 5/2/2021 at approximately 9:00 AM with Pavilion unit staff revealed the following: -Certified Nursing Assistant (CNA), Staff H, revealed she was not screened for COVID-19 on this day. -CNA, Staff J, revealed she was not screened for COVID-19 on this day. -Registered Nurse, Staff D revealed he was not screened for COVID-19 on this day. C. Surveyor interviews on 5/2/2021 at approximately 9:30 AM with North A unit staff revealed the following: - CNA, Staff F, revealed that on this day she entered the facility, reported to her scheduled unit, and then completed the COVID-19 screening tool on the unit. - Certified Medication Technician/CNA, Staff K, revealed that on this day, she entered the facility, reported to her scheduled unit, and then completed the COVID-19 screening tool on the unit. - Unit Licensed Practical Nurse (LPN), Staff L, revealed that on this day, he entered the facility, reported to his scheduled unit, and then completed the COVID-19 screening tool on the unit. -Infection Control Nurse, revealed that on this day, he entered the facility, reported to work on the North A unit, and then completed the COVID-19 screening tool once on the unit. D. Surveyor interviews on 5/2/2021 at approximately 10:00 AM with North B unit staff revealed the following: - CNA Staff A revealed that on this day, she entered the facility, reported to her scheduled unit, and then completed the COVID-19 screening tool on the unit. -Unit LPN Staff M revealed that on the weekends the staff complete the COVID-19 screening tools on their units. During a surveyor interview on 5/2/2021 at approximately 12:30 PM with the Administrator, DON, and Vice President of Operations, they revealed that all staff should be screened upon entering the facility and before heading to their scheduled units, and staff are expected to follow the facility's screening policy. On 5/2/2021 at approximately 1:30 PM the Administrator, DON, and Vice President of Operations, were presented with the Immediate Jeopardy template. At this time, they revealed there is signage posted on the front entrance doors. Several surveyors along with the Vice President of Operations went to observe the signage. It was revealed at this time that when the front door opens automatically the sign posted is not visible as it retracts behind the other door. Additional review of this signage revealed in part, *Reminder To All Staff* Monday - Friday: .11-7 staff need to stop on Pavilion after entering the building to check temperature and answer questionnaire .Saturday/Sunday: .3-11 and 11-7 staff need to stop on Pavilion after entering the building to check temperature and answer questionnaire . At the time of the above observation the Vice President of Operations acknowledged the signage was not visible when the door opened. Additionally, she acknowledged the above signage was inaccurate as it directed staff to the Pavilion unit to be screened for signs and symptoms of COVID-19, instead of following the facility's policy which is to be screened upon entering the building. She also acknowledged there was no signage related to the screening process or protocols for visitors entering the building. 2) A CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic updated on 2/23/2021, states in part, 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection .The PPE (personal protective equipment) recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: Respirator Put on an N95 respirator (or equivalent or higher-level respirator) before entry into the patient room or care area . A surveyor observation on 5/2/2021 at approximately 9:20 AM of the quarantine area located on the Pavilion unit revealed CNAs Staff I and Staff J, preparing to enter the area while wearing surgical masks underneath their KN95s. During a surveyor interview with both Staff I and J immediately following the above observation, they revealed it is their practice to wear a surgical mask under their KN95s while providing care to residents residing in the quarantine area. During a surveyor interview on 5/2/2021 at approximately 9:22 AM with the DON, she also observed the above two staff and acknowledged that they were wearing their PPE incorrectly.

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 6 of 6 COVID-19 positive residents, Resident ID #'s 1-6. This failure resulted in an actual decline in a resident's physical well-being, Resident ID #1. Findings are as follows: During an interview on 1/11/2021 at 12:57 PM with the Infection Preventionist, he revealed that the facility had a COVID-19 outbreak in December of 2020. During the month of December through 1/11/2021, a total of 90 residents and 46 staff tested positive for COVID-19. Additionally, he stated that 16 COVID-19 positive residents had passed away during this same time period. Review of the facility's policy titled Care of the COVID-19 Positive (or Suspected) Resident/Patient updated on 11/30/2020 states in part: .g. Vital signs (including temperature) must be taken no less than every shift (or per MD order) during the course of the illness . During an interview on 1/8/2021 at 10:30 AM with the Vice President of Operations, she clarified that as per the above policy, COVID-19 positive residents should be getting full vitals every shift, including, pulse, blood pressure, respirations, temperature and pulse oximetry. Review of the facility's COVID-19 Protocol document dated 12/1/2020 revealed the following is to be implemented for a resident who tests positive for COVID-19: -COVID-19 Supplements: Vitamin D 50,000 units two times a week; Magnesium 400 milligrams (mg) daily; [MEDICATION NAME] (Vitamin B1) 100 mg two times a day; Zinc 200 mg daily; Vitamin C 500 mg two times a day; [MEDICATION NAME] (medication for relief of heartburn) 20 mg daily. -COVID-19 LABS: weekly: complete blood count with differential, comprehensive metabolic panel, Magnesium, [MEDICATION NAME] dehydrogenase test (test that looks for signs of damage to body tissues), C-reactive protein (blood test marker for inflammation), D-dimer (test to rule out a blood clot); biweekly: Vitamin D -Chest x-ray 2 views During an interview on 1/7/2021 at 9:03 AM with the Director of Nursing Services (DNS), she revealed that the facility's COVID-19 protocol is implemented right away when a resident tests positive for COVID-19. 1) Resident ID #1 was admitted to the facility in April of 2020 with [DIAGNOSES REDACTED]. Review of a laboratory order collected and received on 12/30/2020 revealed the resident was positive for COVID-19. Record review of a progress note dated 1/4/2021 at 9:50 AM by Nurse Practitioner A, revealed in part, .asked to see patient by nursing to eval medical status due to newly diagnosed covid-19 and multiple falls. (Resident ID #1) had PCR (polymerase chain reaction- nasal swab) 12/29 resulting positive for covid-19. On chart review, covid labs, chest xray, and supplements had not been initiated yet. (Resident ID #1) had multiple falls yesterday, no notes describing circumstances. Upon entering room (this) writer noted patient to be writhing around on mattress, visibly tachypnic (rapid breathing) and unwell appearing. (His/Her) vitals were taken with pulse ox 58% (normal values are 95-100% ) on RA (room air) 78% on 15 L (liters) NRB (non rebreather mask). Unable to obtain temperature. Patient is a full code .Patient sent to (hospital) via 911 due to [MEDICAL CONDITION] (deprived adequate oxygen at the tissue level) tachypnea (abnormally rapid breathing), unable to follow commands. admitted to (hospital) ICU (intensive care unit) with [MEDICAL CONDITION] . Review of an emergency room (ER) visit progress note dated 1/4/2021 revealed in part, .This patient presents to the ER with [MEDICAL CONDITION] secondary to COVID-19 pneumonia .attempt [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) but the patient's pulse ox remained in the 70's and (s/he) remained lethargic. Because of (his/her) continued [MEDICAL CONDITION], I did decide to electively intubate (him/her) using rapid sequence intubation .Additionally, the patient came with a core body temperature of 88 degrees (normal body temperature is 97- 99 degrees) .A bear hugger (forced air warming system to help maintain body temperature) was used to warm the patient and a rectal probe was inserted for continuous temperature monitoring. The patient's x-ray confirms bilateral pneumonia, likely consistent with COVID-19 infection. However, the patient's white blood cell count was elevated and the patient was given antibiotics for possible bacterial superinfection .Admission to the ICU was discussed . Further review of hospital documents revealed Resident ID #1 was admitted to the ICU. Review of the ICU assessment dated [DATE] revealed in part, .#Sepsis. At the time of admission patient presented with hypothermia (dangerously low body temperature), [MEDICAL CONDITION] (low blood pressure) and had leukocytosis (high white blood cell count). Source appears to be urinary tract infection. (S/he) also has bilateral lung infiltrates (a substance denser than air in both lungs) .#Acute [MEDICAL CONDITION]. Likely due to [MEDICAL CONDITION] pneumonia. Superimposed bacterial pneumonia cannot be excluded .#Acute [MEDICAL CONDITION]. Likely ATN (acute tubular necrosis-damage to kidneys) due to prolonged [MEDICAL CONDITION] (low blood pressure). The patient has [MEDICAL CONDITION] (high potassium level). (His/her) creatinine (measures kidney function) has increased. S/he has a borderline acidosis (buildup of carbon [MEDICATION NAME] in the blood) with CO2 (carbon [MEDICATION NAME]) of 20 (normal range is 23 to 29) .#COVID-19 .(His/her) D-dimer is significantly elevated .(His/her) ferritin (measures iron storage protein) is significantly elevated . Record review for Resident ID #1 revealed the following: -There was no evidence that full vital signs were obtained every shift as per the facility's policy when it was determined the resident was COVID-19 positive. Additionally, the only vital sign documented on 1/3/2021 was a temperature, which was obtained on the day shift. -The January Treatment Administration Record (TAR) revealed an order with the start date of 10/15/2020 to Assess and document resident signs and symptoms for COVID-19 .every day and evening shift. If resident has signs and/or symptoms of COVID-19, document sign or symptoms in progress note and document intervention . - During the evening shift of 1/2/2021 staff documented yes for signs and/or symptoms. - During the day shift of 1/3/2021 staff documented yes for signs and/or symptoms. - During the evening shift of 1/3/2021 there was no documentation. - Review of the resident's clinical record failed to reveal evidence of documentation on 1/2/2021 and 1/3/2021 of what signs and/or symptoms s/he was exhibiting, or interventions implemented. -There were no progress notes indicating Resident ID #1 was COVID-19 positive or being assessed for COVID-19 symptoms. Additionally, there were no progress notes indicating any assessment of the resident since 12/5/2020. 2) Resident ID #2 was admitted to the facility in October of 2014 with [DIAGNOSES REDACTED]. Review of a laboratory order collected and received on 12/30/2020 revealed the resident was positive for COVID-19. Record review for Resident ID #2 revealed the following: -There was no evidence that the facility's COVID-19 protocol was initiated when it was determined that Resident ID #2 was COVID-19 positive. -There was no evidence that full vital signs were obtained every shift as per the facility's policy when it was determined the resident was COVID-19 positive. -The TAR revealed an order with the start date of 10/15/2020 to Assess and document resident signs and symptoms for COVID-19 .every day and evening shift. If resident has signs and/or symptoms of COVID-19, document sign or symptoms in progress note and document intervention . -The January 2021 TAR revealed the facility failed to assess the resident on 3 out of 11 opportunities between 1/1/2021 and 1/6/2021. 3) Resident ID #3 was admitted to the facility in October of 2018 with [DIAGNOSES REDACTED]. Review of a laboratory order collected and received on 12/30/2020 revealed the resident was positive for COVID-19. Record review failed to reveal evidence that the facility's COVID-19 protocol was initiated when it was determined that Resident ID #3 was COVID-19 positive. Further record review failed to reveal evidence that full vital signs were obtained every shift as per the facility's policy when it was determined the resident was COVID-19 positive. 4) Resident ID #4 was admitted to the facility in February of 2013 and passed away in December of 2020. S/he had [DIAGNOSES REDACTED]. Review of a laboratory order collected and received on 12/15/2020 revealed the resident was positive for COVID-19. 5) Resident ID #5 was admitted to the facility in June of 2016 and passed away in December of 2020. S/he had [DIAGNOSES REDACTED]. Review of a laboratory order collected and received on 12/15/2020 revealed the resident was positive for COVID-19. 6) Resident ID #6 was admitted to the facility in April of 2016 with [DIAGNOSES REDACTED]. Review of a laboratory order collected and received on 12/30/2020 revealed the resident was positive for COVID-19. Record review for Resident ID #'s 4-6 failed to reveal evidence that full vital signs were obtained every shift, as per the facility's policy, when it was determined they were COVID-19 positive. During a telephone interview on 1/7/2021 at 8:25 AM with Resident ID #1 and 2's primary physician, he revealed that when any resident tests positive for COVID-19 it is expected that the nurse will implement the standing COVID-19 protocol. During an interview on 1/11/2021 at 1:18 PM with the DNS, she was unable to provide evidence that the facility's COVID-19 protocol was initiated for Resident ID #'s 1, 2, and 3. Additionally, she could not provide evidence that full vitals were obtained every shift or assessments were completed as outlined above for Resident ID #'s 1-6.

Based on record review and staff interview, it has been determined that the facility failed to protect the resident's right to be free from neglect for 1 of 6 residents reviewed for neglect, Resident ID #1. Findings are as follows: Review of the facility's policy titled, Abuse prohibition 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 and/or misappropriation of their personal property .Neglect: failure to provide goods and/or services necessary to avoid physical harm, mental anguish, or mental illness . Resident ID #1 was admitted to the facility in April of 2020 with [DIAGNOSES REDACTED]. Review of a laboratory order collected and received on 12/30/2020 revealed the resident was positive for COVID-19. Record review of a progress note dated 1/4/2021 at 9:50 AM by Nurse Practitioner A, revealed in part, .asked to see patient by nursing to eval medical status due to newly diagnosed covid-19 and multiple falls. (Resident ID #1) had PCR (polymerase chain reaction- nasal swab) 12/29 resulting positive for covid-19. On chart review, covid labs, chest xray, and supplements had not been initiated yet. (Resident ID #1) had multiple falls yesterday, no notes describing circumstances. Upon entering room (this) writer noted patient to be writhing around on mattress, visibly tachypnic (rapid breathing) and unwell appearing. (His/Her) vitals were taken with pulse ox 58% (normal values are 95-100% ) on RA (room air) 78% on 15 L (liters) NRB (non rebreather mask). Unable to obtain temperature. Patient is a full code .Patient sent to (hospital) via 911 due to [MEDICAL CONDITION] (deprived adequate oxygen at the tissue level) tachypnea (abnormally rapid breathing), unable to follow commands. admitted to (hospital) ICU (intensive care unit) with [MEDICAL CONDITION] . Review of an emergency room (ER) visit progress note dated 1/4/2021 revealed in part, .This patient presents to the ER with [MEDICAL CONDITION] secondary to COVID-19 pneumonia .attempt [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) but the patient's pulse ox remained in the 70's and (s/he) remained lethargic. Because of (his/her) continued [MEDICAL CONDITION], I did decide to electively intubate (him/her) using rapid sequence intubation (the preferred method of endotracheal tube intubation in the emergency department. This is because it results in rapid unconsciousness and neuromuscular blockade) .Additionally, the patient came with a core body temperature of 88 degrees (normal body temperature is 97- 99 degrees) .A bear hugger (forced air warming system to help maintain body temperature) was used to warm the patient and a rectal probe was inserted for continuous temperature monitoring. The patient's x-ray confirms bilateral pneumonia, likely consistent with COVID-19 infection. However, the patient's white blood cell count was elevated and the patient was given antibiotics for possible bacterial superinfection .Admission to the ICU was discussed . Further review of hospital documents revealed Resident ID #1 was admitted to the ICU. Review of the ICU assessment dated [DATE] revealed in part, .#Sepsis. At the time of admission patient presented with hypothermia (dangerously low body temperature), [MEDICAL CONDITION] (low blood pressure) and had leukocytosis (high white blood cell count). Source appears to be urinary tract infection. (S/he) also has bilateral lung infiltrates (a substance denser than air in both lungs) .#Acute [MEDICAL CONDITION]. Likely due to [MEDICAL CONDITION] pneumonia. Superimposed bacterial pneumonia cannot be excluded .#Acute [MEDICAL CONDITION]. Likely ATN (acute tubular necrosis-damage to kidneys) due to prolonged [MEDICAL CONDITION] (low blood pressure). The patient has [MEDICAL CONDITION] (high potassium level). (His/her) creatinine (measures kidney function) has increased. S/he has a borderline acidosis (buildup of carbon [MEDICATION NAME] in the blood) with CO2 (carbon [MEDICATION NAME]) of 20 (normal range is 23 to 29) .#COVID-19 .(His/her) D-dimer (test to rule out a blood clot) is significantly elevated .(His/her) ferritin (measures iron storage protein) is significantly elevated . I. Review of the facility's policy titled Care of the COVID-19 Positive (or Suspected) Resident/Patient updated on 11/30/2020 states in part: .g. Vital signs (including temperature) must be taken no less than every shift (or per MD order) during the course of the illness .8. The resident's care plan will be revised to reflect the infection status and care of the individual resident's needs . During an interview on 1/8/2021 at 10:30 AM with the Vice President of Operations, she clarified that as per the above policy, COVID-19 positive residents should be getting full vitals every shift, including, pulse, blood pressure, respirations, temperature and pulse oximetry. Record review for Resident ID #1 revealed the following: -There was no evidence that full vital signs were obtained every shift as per the facility's policy when it was determined the resident was COVID-19 positive. Additionally, the only vital sign documented on 1/3/2021 was a temperature, which was obtained on the day shift. -The January Treatment Administration Record (TAR) revealed an order with the start date of 10/15/2020 to Assess and document resident signs and symptoms for COVID-19 every day and evening shift. If resident has signs and/or symptoms of COVID-19, document sign or symptoms in progress note and document intervention . -During the evening shift of 1/2/2021 staff documented yes for signs and/or symptoms. -During the day shift of 1/3/2021 staff documented yes for signs and/or symptoms. -During the evening shift of 1/3/2021 there was no documentation. -Review of the clinical record failed to reveal evidence of documentation on 1/2/2021 and 1/3/2021 of what signs and/or symptoms s/he was exhibiting, or interventions implemented. -There were no progress notes indicating Resident ID #1 was COVID-19 positive or being assessed for COVID-19 symptoms. Additionally, there were no progress notes indicating any assessment of the resident since 12/5/2020. -The care plan failed to reveal evidence of Resident ID #1's COVID-19 positive status or interventions related to COVID-19 care. II. Review of the facility's COVID-19 Protocol document dated 12/1/2020 revealed the following is to be implemented for a resident who tests positive for COVID-19: -COVID-19 Supplements: Vitamin D 50,000 units two times a week; Magnesium 400 milligrams (mg) daily; [MEDICATION NAME] (Vitamin B1) 100 mg two times a day; Zinc 200 mg daily; Vitamin C 500 mg two times a day; [MEDICATION NAME] (medication for relief of heartburn) 20 mg daily. -COVID-19 LABS: weekly: complete blood count with differential, comprehensive metabolic panel, Magnesium, [MEDICATION NAME] dehydrogenase test (test that looks for signs of damage to body tissues), C-reactive protein (blood test marker for inflammation), D-dimer; biweekly: Vitamin D -Chest x-ray 2 views Record review revealed that the facility failed to implement the COVID-19 protocol when it was determined that Resident ID #1 was COVID-19 positive. III. Review of the facility's policy and procedure titled Monoclonal Antibody Treatment: Medical treatment of [REDACTED].It is the policy of this facility to follow the physician's orders [REDACTED].Per RIDOH guidance posted in a memo dated December 23, 2020; RIDOH requires that nursing homes offer monoclonal antibody treatment to every resident who has recently been diagnosed with [REDACTED]. The Physician will write an order for [REDACTED]. Record review revealed the facility to discuss the Monoclonal Antibody Treatment with the resident or his/her representative. During a telephone interview on 1/7/2021 at 8:25 AM with Resident ID #1's primary physician, he revealed that when any resident tests positive for COVID-19 it is expected that the nurse will implement the standing COVID-19 protocol. Additionally, he revealed that when Resident ID #1 tested positive for COVID-19, he would expect nurses to obtain consent to initiate monoclonal antibody treatment. During a telephone interview on 1/11/2021 at 9:15 AM with Resident ID #1's family, s/he revealed that s/he was never notified by the facility that the resident had tested positive for COVID-19. S/he was only notified of his/her positive result by hospital staff after s/he was admitted on [DATE]. IV. Review of the facility's policy and procedure titled Fall Prevention Program revealed in part, POLICY: .Residents are to be reassessed whenever they fall or when they exhibit a change in status that may put them at risk for a fall .PROCEDURE: .4. When a resident experiences a fall, complete and accurate Post fall investigation form is to be filled out by the licensed nurse on duty .7. The licensed nurse on duty is responsible to: .Provide immediate care and interventions as appropriate .Document the facts of the fall, his/her assessment of the residents condition, any treatment provided as well as the resident's response to the treatment in the resident's medical record .Notify the doctor; preferably utilizing the SBAR (situation background assessment and recommendation, a technique for appropriate communication) format .Notify the appropriate family member/resident representative as soon as is practical .Document in the resident record the time he/she spoke with the family representative and the name of the person she spoke with . Review of a progress note dated 1/4/2021 at 9:50 AM by Nurse Practitioner A, revealed Resident ID #1 had multiple falls yesterday, no notes describing circumstances. Further record review failed to reveal documentation or assessments relating to the above-mentioned falls. During a telephone interview on 1/7/2021 at approximately 1:55 PM with Staff Nurse B, she revealed she was the resident's nurse for the 11-7 shift on 1/3/2021. She further revealed that on 1/4/2021 at approximately 5:30 AM she entered Resident ID #1's room and found him/her with his/her knees on the floor and his/her back against the side of the bed. She then assisted the resident back into bed and as she was leaving the room, the resident put his/her legs off the side of the bed again. This nurse then moved the resident's mattress off the bed frame and placed it directly onto the floor. She acknowledged that when she found the resident on the floor, this event was unwitnessed, and she should have completed a fall report. Review of a Rhode Island Emergency Medical Services Patient Care Report document dated 1/4/2021 revealed that when they arrived on scene at the facility at approximately 9:40 AM, Resident ID #1 was found lying on a mattress on the floor (this was approximately 4 hours after Staff B indicated to the surveyors that she had first placed the mattress on the floor). During an interview on 1/11/2021 at 1:18 PM with the DNS, she was unable to provide evidence that the facility's COVID-19 protocol and assessments, monoclonal antibody treatment, or fall protocol were implemented for Resident ID #1. She further revealed that placing a resident's mattress directly on the floor is not an intervention that the facility utilizes. The facility failed to protect the resident from neglect when they failed to initiate their COVID-19 protocol and assess Resident ID #1 as per policy, after determining s/he was COVID-19 positive. Additionally, the facility failed to assess the resident post-fall, or notify the resident's family member when s/he tested positive for COVID-19.

Based on record review and staff interview it has been determined that the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 1 of 8 sample residents (Resident ID #1). Findings are as follows: Resident ID #1's record was reviewed during a complaint investigation of allegations of poor quality of care and over medication. Resident ID #1 was admitted to the facility on [DATE] was discharged to an acute care hospital on [DATE] and readmitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Record review of the resident's orders upon readmission on 08/28/2018 revealed the following orders for psychoactive medications: [REDACTED] [MEDICATION NAME] 25 mg four times a day related to dementia with behavioral disturbance. [MEDICATION NAME] solution 500 mg every morning and 500 mg at bedtime. [MEDICATION NAME] HCL 50 mg by mouth at bedtime [MEDICATION NAME] tablet 3 mg by mouth at bedtime On 08/31/2018 the resident was seen by psychiatric services for ongoing problem of behavioral disturbances, previously aggressive behavior to staff, along with an associated symptom of weight loss. Medication recommendations were made, (and implemented by order of the residents physician) to 1. Continue current Psych meds 2. Continue close monitoring of behaviors 3. start [MEDICATION NAME] (another psychoactive medication) 15 mg daily for mood and appetite. Record review of the residents physician's orders [REDACTED]. Review of a nurses note from 09/10/2018 by staff nurse D revealed, .Resident began hitting writer .resident continued with increased aggressive and punched writer in the neck . On 09/14/2018 the resident was seen by psychiatric services for ongoing problem of behavioral disturbances, very physical and also yelling at staff when redirected. Medication recommendations were made and implemented by the resident's physician to increase [MEDICATION NAME] solution to 750 mg in the morning and 500 mg in the evening. Review of a nurses note from 9/27/2018, ten days after the increase in the [MEDICAL CONDITION] medications, by staff nurse C revealed . in bed today & is exhibiting increased lethargy & did not get OOB(out of bed) today, he was fed by staff . Daughter voiced concern that this is a change in condition & would like a med review. Review of a social service note dated 09/27/2018 revealed in part, . daughter is aware that her father has had a decline however she would like to 1. have a med review 2. psych see him .She does not want to put him on hospice without having everything ruled out for him medically. She verbalized that if he needs to be sent out to the hospital , to send him out . Review of the primary physician's note dated 09/28/2018, revealed in part, . Discussed with nursing , residents level of activity has decreased lately. His daughter is concerned and wants to know if there is any medical reason or medication effect causing his decline . Further review of a Rehabilitation Screen from 09/28/2018, reveals the following observations attempted to evaluate resident multiple time this week but patient too lethargic to participate at this time. Resident requires further medical assessment before further rehab can occur to adequately y establish functional needs . On 10/03/2018, due to the residents difficulty in swallowing, the order was changed to [MEDICATION NAME] sprinkles delayed release 500 mg in the evening and [MEDICATION NAME] sprinkles delayed release 750 mg in the morning. The equivalent dose in a form easier for the resident to swallow. Record review reveals that the resident was seen by psychiatric services on 10/04/2018, the examination details reveal in bed, is a total feed, sig weight loss, not easy to wake today. Recommendations were made to decrease [MEDICATION NAME] sprinkles to 250 mg BID and discontinue scheduled [MEDICATION NAME] and start [MEDICATION NAME] 50 mg at bedtime as needed. Review of a nurses note from 10/4/2018 at 10:04 PM by staff nurse D revealed .Daughter questioned recent (psychiatric services) visit. Writer informed daughter that resident was seen by (psychiatric services) however the recommendations are not available at this time but will follow up tomorrow . Review of a nurses note from 10/08/2018 at 11:09 PM by staff nurse D revealed- Resident was seen by (psychiatric services) at the end of last week . At this time, we are still awaiting recommendations. Family expressed concern regarding current medication regimen. Wife stated that resident is stoned and that he is on too much medication, just look at him, he looks stoned, he's stoned out of his mind. Resident has been noted to have increased lethargy however it is unclear at this time if this could be from medication or an overall decline in condition .writer inform family the rec should be available tomorrow and the delay was related to weekend as well as holiday .Family questioned if resident was due for any more medication this evening. Medication reviewed with family. Family requested medication to be held .Writer stated that if resident was awake and alert then resident should received prescribed/scheduled medication. It was reported to writer that resident was in fact awake, alert, and responsive and therefore did receive all scheduled medications. Writer assured family that report will be passed on and management will be contacted in the morning regarding (psychiatric services) recs . Review of social services note dated 10/9/2018 at 2:42 PM revealed the following, SW spoke with residents dtr (daughter) today she still would like to see how her father does if there is any med changes, currently waiting on psych recs at this time . On 10/09/2018 the order for [MEDICATION NAME] Sprinkle was changed to 250 mg in the morning and at bedtime. On 10/09/2018 the order for routine [MEDICATION NAME] was discontinued and changed to [MEDICATION NAME] HCL Tablet 50 mg as needed for [MEDICAL CONDITION] at bedtime. As shown above, though the recommendation was made by psychiatric services to decrease the [MEDICATION NAME] sprinkles from a total daily dose of 1250 mg to 500 mg , along with changing [MEDICATION NAME] from 50 mg daily to [MEDICATION NAME] 50 mg only as needed on 10/04/2018, these recommendation were not ordered by the physician until 10/09/2018. Review of the Medication Administration Record [REDACTED]. Additionally, [MEDICATION NAME] 50 mg continued to be given nightly until 10/08/2018 ( for 5 days), instead of only as needed as recommended on 10/4/2018. During surveyor interview with the Assistant Director of Nursing Services (ADNS) on 10/25/2018 at 2:48 PM, he revealed that psych services saw resident on 10/04/2018 and it was recommended to decrease the medications as stated above, the recommendations were not received by the facility until 10/9/2018. He was unable to explain why the recommendation were not available and provided to the physician prior to 10/09/2018, even though the family was requesting the medications be decreased and the resident was becoming more lethargic. The facility was unable to provide evidence of any attempts to obtain the psych services report and recommendation until 10/9/2018. During surveyor interview with the resident's primary physician on 10/26/2018, he revealed that when he requested that psychiatric services evaluate the resident, he would have expected they would have decreased something. He further revealed that he approved the recommendations when he received them on 10/09/2018. During surveyor interview with the psychiatric services consultant on 11/02/2018 at 10:10 AM, she revealed that her visit report with recommendation goes to the cloud where it is retrievable by the facility. Staff members of the facilities choice get an email that a report is ready, so they can retrieve it. She further revealed that there is someone on call at psychiatric services 24 hours a day. During surveyor interview with the ADNS on 11/02/2018 at a 2:30 PM, he revealed he was the only person who receives the email alert from psych services that the reports are ready to be retrieved. He further acknowledged that he is the one who retrieves the reports, then he prints them out and brings them to the unit.

Based on record review and staff interview it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical,mental and psychosocial well being of each resident for 1 out 1 residents relative to medications, weights and resident rights. (ID#1). Findings are as follows: 1. During surveyor interview on 11/2/2018, relative to availability of psych services with the DNS (Director of Nursing Service) and the Administrator, they revealed that they were unaware that the staff did not have contact information to reach psychiatric services to retrieve the report containing the recommendation for medication reductions. The DNS stated that if she was contacted by staff she would have contacted the consultant. Additionally, relative to the family's right as the resident's POA (power of attorney) to refuse continuing administering the medications, the DNS revealed that the families wishes to hold the medication should have been honored and that the nurse should have contacted the physician. She was unaware of the families request until 10/09/2018 when the social worker filed a grievance at the request of the family, alleging that the resident continued to receive all of the medication even when lethargic and they had asked that the resident not be given any more medication. The DNS and the administrator were unaware that the staff lacked the knowledge of how to retrieve the report when it was not provided to the unit by the ADNS. They were further unaware that the ADNS was the only staff member who could retrieve the reports from the cloud, and that the facility didn't maintain a current list of residents being seen by the psychiatric consultant. 2. Review of a physician's progress note dated 9/28/2018 at 10:21 AM states in part, .His/her daughter is concerned and wants to know if there is any medical reason or medication effect causing his/her decline . Under Assessment and plan in the same note, .Weight loss, approximately 12-pound weight loss since admission and 16-pound weight loss since maximum weight on 7/23/2018 which was prior to hospitalization . At risk for further weight loss, Monitor, dietary consultation. This signifies a weight loss of 22.22% or 27.6 lbs between the dates of 7/12/2018 and 10/4/2018. The DNS was unable to provide evidence that the reweighs were conducted as per facility policy for variation in weight of 3 lbs. Record review shows only a singular reweigh was conducted on 10/4/2018, and there was no indication of contacting the dietician, notifying the physician, or addressing weight loss in a care plan. During Surveyor interview on 10/29/2018 at 11 AM with the Dietician, she acknowledged that she was not following her/him for weight loss. When questioned about the physician's progress note dated 09/28/2018 relative to the dietary consult , she revealed she had never received an order for [REDACTED]. During surveyor interview with the DNS on 10/29/2018 at approximately 11:30 AM she revealed she was unaware that the resident was not being followed by the dietician. She further revealed that the dietician was present at the risk meetings, the resident was listed on the notes from the risk meetings as having a weight of 118.6 on 09/05/2018 and as having a weight of 112.8 lbs on 09/26/2018. The DNS was unable to explain why the dietary consult requested by the physician on 09/28/2018 was never written as an order. Additionally, she was unable to produce evidence that even though the resident was discussed at the weekly risk meeting, that there was a system in place to assure follow up that the residents are seen by the dietician to address the continued weight loss. Refer to F 689, F 692, F744 & F757 You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities they are deficiencies under State Regulations and grounds for licensure sanctions.

Based on record review and staff interview, it was determined that the facility has failed to ensure that the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision to prevent accidents for 1 of 8 sample residents with falls (Resident ID#1). Findings are as follows: Record review for Resident ID# 1 revealed [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE], was discharge to an acute care hospital on [DATE] and readmitted to the facility on [DATE]. An admission Minimum Data Set ((MDS) dated [DATE] indicated the resident has memory impairment and has severely impaired cognitive skills for daily decision making. The resident did not have a score for a (BIMS) Brief Interview for Mental Status as it is recorded that the resident is not able to complete the interview. Fall risk assessments dated 7/12/2018 & 8/30/2018 were completed,which indicate resident is at high risk for falls. The resident was evaluated by PT on 7/12/2018 and seen until 7/25/2018 when he/she was discharged from PT. The discharge summary from physical therapy states that on 7/25/2018, resident has met goal of ambulating 300 ft with supervision and able to safely transfer from bed to wheelchair requiring supervision and verbal cueing. Review of the record and nurse's notes revealed that the first of the residents 9 falls occurred on 7/26/2018, and the remaining 8 falls were between when the resident was readmitted to the facility on [DATE] and 9/28/2018. Additionally there are progress notes within the above time frame where it is noted that resident is sitting self on the floor. Review of the nurse's notes and incident reports revealed that 8 of the 9 falls were not witnessed. The resident sustained [REDACTED]. 8/29/2018 found laying with head in trash bin . red 1 1/2 wide mark on left side of forehead. Resident unable to say what happened. 9/9/2018 Hit top of head leaving a reddened area and skin tear to left knee 9/19/2018 skin tear left wrist and elbow 9/23/2018 found on floor, small abrasion on right knee 9/28/2018 found on floor, skin tear to left knee In review of the Fall Policy it states in part : 4. Ensure that the resident is safe to continue former level of activity, complete assessment and communicate to the staff the need for additional supervision and or assistance. 6. complete incident report including information regarding the presence of a witness and the intervention. The intervention implemented is related to the cause of the fall and is aimed at prevention. 8. Update the resident's care plan to identify the fall and new intervention. 9. Inform on-coming shifts of the event by documenting on the 24-hour report sheet. 10. Review all falls at the following Risk meeting. 11. Inform CNAs of fall during shift report. In review of the initial care plan dated 7/19/2018 it indicates that the resident is at risk for falls related to gait/balance problems, wandering, incontinence and [MEDICAL CONDITION] drug use, and poor safety awareness. Goal free from falls and fall related injuries, interventions ensure cal light and personal items are within reach, keep room free of clutter, PT screen as needed, needs activities that minimize the potential for falls while provide diversion and distraction. Review of the initial care plan indicated that even though the resident had multiple falls, there were no additional or new interventions put into place to prevent the falls from reoccurring. Record review revealed there is no evidence of an adequate care plan or implementation of procedures to prevent the resident from falls. Review of the record failed to reveal that the resident was seen by the physician or sent to the hospital for evaluation of any of the reported injuries noted from the falls including the two where it was noted that the resident hit his/her head and had red marks. Review of the resident record from the hospital to which he/she was admitted on [DATE], reveals in the history and physical found to have bilateral subdural hematoma's (likely due to recent falls) that are stable s/p Cat scan of head x' 2. Additionally patient has notably lost 30 lbs since (MONTH) and is now cachectic. Psychiatry was consulted due to worsening sedation and the concern that it is being caused by polypharmacy with [MEDICAL CONDITION] medications. Additional review of the falls reports, reveal PT referrals for falls on 8/28 & 8/29/2018 and OT referral on 9/5/2018, neither of these referrals resulted in recommendation or new interventions to prevent further falls. In an interview on 10/25/2018 at approximately 2:00 PM with the Director of Nurses Service (DNS) she was unable to provide evidence that interventions had been put into place to prevent future falls, that the facilities policy for falls was followed, and that even though the falls were reviewed at risk meetings there was no evidence of any follow up interventions.

Based on record review and staff interview it has been determined that the facility failed to maintain acceptable parameters of nutrition status, such as usual body weight or desirable body weight range for 1 of 8 residents (ID # 1). Findings are as follows: During a complaint investigation of allegations of poor quality of care the following were reviewed. Resident ID #1 was admitted to the facility on [DATE],was discharged to an acute care hospital on [DATE] and readmitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the facility policy on weights and weight fluctuation under Procedures, reveals in part: .3. If there is a variation of three (3) pounds more or less from the previous weight, then the resident is reweighed. If the weight continues to show the variation, the charge nurse is notified. 4. Charge nurse will ensure that the weight obtained is accurate. 5. A decision will then be made to either begin to weight the resident more frequently, perhaps weekly to more closely monitor the weight. Weight loss or gain in excess of 5% from the previous weight will require further assessment . 6. Discuss the resident's condition and physical findings with the Dietician and determine the need to assess further by conducting a calorie count or adding a supplement. 7. Notify the physician and process new orders. 8. Notify family/responsible party . 9. Monitor resident progress at weekly Resident at Risk Meetings 10. Update care plan with new approaches. Review of the resident's record revealed a Dietician note dated 7/20/2018 at 10 :44 AM which reveals in part, .Presents at moderate nutritional risk r/t PMH(past medical History), polypharmacy .Regular diet with thin liquids in place, po intake good 75-100% most meals . Will continue to monitor quarterly/PRN. Further record review reveals a weight loss of 22.22 % or 27.6 lbs between the dates of 07/30/2018 and 10/04/2018. This includes a 6.8 lb weight loss during an acute care hospitalization between the dates of 08/2/2018 and 08/28/2018. During this resident's stay at the facility the following weights were noted in the record: 7/30/2018-124.2 lbs. 8/28/2018-117.4 lbs. 9/3/2018-118.6 lbs. 9/10/2018-116.8 lbs. 9/17/2018-113.0 lbs. 9/24/2018-112.8 lbs. 10/4/2018-101.0 lbs. 10/4/2018- 96.6 lbs. The DNS was unable to provide evidence that the reweighs were conducted as per facility policy for variation in weight of 3 lbs. Between the dates of 9/10/2018 and 9/17/2018 the record reveals a weight loss of 3.8 lbs with no evidence of a reweigh or notification of the dietician or physician. Record review shows a reweigh was conducted on 10/4/2018, but there was no indication of contacting the dietician, notifying the physician, or addressing weight loss in a care plan. Review of Nurse Practitioner's note dated 09/4/2018, reveals in part, .Will add [MEDICATION NAME] 15mg q hs (at bedtime) for mood and appetite, as well as [MEDICAL CONDITION]. Monitor for changes in cognition, function, mood, behavior, sleep, appetite, and energy. A physician's progress note dated 9/28/2018 at 10:21 AM states in part, .His/her daughter is concerned and wants to know if there is any medical reason or medication effect causing his/her decline .Weight loss, approximately 12-pound weight loss since admission and 16-pound weight loss since maximum weight on 7/23/2018 which was prior to hospitalization . At risk for further weight loss, Monitor, dietary consultation. There lacked evidence that this consultation was ever ordered or completed. A nurses note on 10/2/2018 at 5:34 AM by staff nurse D reveals in part, .S/He is responsive to verbal stimuli however unable to elaborate if something is wrong .Resident had refused his dinner. Staff reports resident appeared to have some difficulty chewing on food and ultimately refused food . A nurses note on 10/4/2018 at 10:04 PM by staff nurse D, reveals in part, .Daughter also wanted to know how resident has been doing with consuming food- Speech in at dinner time to evaluate resident. Speech recommended downgrade diet to puree due to resident pocketing food as well as having increased difficulty chewing and swallowing food . A nurses note on 10/8/2018 at 11:09 PM by staff nurse D revealed in part, . Residents weights also reviewed with the family. Resident noted to have lost approximately 30 lbs. since July. Record review reveals that the resident was seen by psychiatric services on 10/04/2018, the examination details reveal in bed, is a total feed, sig weight loss, not easy to wake today. A Nurse Practitioner's progress note dated 10/11/2018 at 5:14 AM, reveals in part, S/He has had a decrease in dietary intake but is on supplement Review of the resident's record reveals no care plan relative to nutrition or weight loss. Further review of the residents record revealed meal intake documentation as; Consuming 51%-100% of meals between the dates of 08/28/2018- 09/11/2018, (except for two meals where the resident's meal intake was less than 50% on 8/28/2018 and 8/30/2018). From 09/12/2018- 10/11/2018, the resident refused 22 meals, 6 meals intake was 0-25% , and 14 meals intake was 26%-50% . During interview with the resident's primary Physician on 10/26/2018 at 2:17 PM, in the presence of two surveyors, he revealed that resident ID #1 had some weight loss while at the hospital, this weight loss did not stabilize when s/he got back to the facility. During Surveyor interview on 10/29/2018 at 11:00 AM with the Dietician, she acknowledged that she had only written one note in the resident's chart as she was not following her/him for weight loss. When questioned about the physician's progress note dated 09/28/2018 relative to the dietary consult , she revealed she had never received an order for [REDACTED]. During surveyor interview with the Director of Nursing Service on 10/29/2018 at approximately 11:30 AM she revealed she was unaware that the resident was not being followed by the dietician. Additionally, she was unable to produce evidence that the facility followed its weight policy relative to reweighs, or of the dietician and or the physician being notified of weight changes of 3 or more pounds per policy.

Based on record review and staff interview it was determined the facility failed to provide for a resident who is diagnosed with [REDACTED].# 1 relative to behaviors, medications, weight loss and falls. Findings are as follows: Review of the record for resident ID # 1,which was conducted during a complaint investigation, reveals that the resident was admitted to the facility on [DATE], after an acute psychiatric hospital stay, with [DIAGNOSES REDACTED]. The resident was at the facility for approximately two weeks and readmitted to the hospital on [DATE] secondary to behaviors. Upon admission to the facility on [DATE] the progress notes reveal, that the resident was observed ambulating in halls with unsteady gait, and excellent appetite. On 7/13/2018 the resident is noted to become verbally aggressive and tell staff to get out of his room. The physicians note on 7/13/2018 reveals that the resident has [DIAGNOSES REDACTED]late onset with psychotic condition, history of aggressive, threatening behaviors, has attacked caregivers, monitor for changes in mood and behaviors, continue [MEDICATION NAME] acid, .continue [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION]. On 7/15/2018 the record reveals an order for [REDACTED]. From 7/15/2018 through 8/2/2018 the resident is noted to have behaviors of striking out at staff and hitting staff, becoming verbally abusive towards staff and other residents. Review of the PA (Physician Assistant) note on 7/19/2018 states, psych to see resident due to aggressive behaviors. However review of the record fails to reveal that psych services saw the resident, until 8/31/2018 when he/she was readmitted to the facility. On 7/26/2018 the resident who had been ambulating in the halls was found on the floor in the alcove between the sets of doors. Resident unable to state what happened. Review of progress note dated 8/2/2018, reveals this resident and another resident, were in the resident's room, holding each other by the upper arms and resident ID# 1 punched the other resident causing him/her to fall backwards on the floor. During the course of this initial admission the record fails to reveal that interventions were put into place relative to the residents behavior, that the psych consult was completed, that the initial care plan was updated, or interventions were put in place. The resident was discharged from the hospital and readmitted to the facility on [DATE]. The residents code status remained a full code upon readmission. The resident continued to have a steady decline in weight, nutritional intake, behaviors, appetite, level of assistance needed with care and an increase in falls. During the course of this admission, the following were noted. The resident's weight decrease from 117.4 lbs on 8/28/2018 to 96.6 lbs on 10/4/2018. The record lacks evidence that the dietician had any other involvement in the care of the resident, and upon interview on 10/29/2018 at 11 AM with the Dietician, she acknowledged that she was not following him for weight loss. When questioned about the physician's progress note regarding 16 lb weight loss and dietary consultation. She denies being notified after resident continued to have weight loss. Additionally the resident's initial care plan dated 7/19/2018 fails to address the residents weight loss or nutrition status. Interview with the ADNS on 10/25/2018 at approximately 10:15 AM, when asked about interventions relative to there resident's decline, he stated that the facility had offered the family hospice care on more than one occasion. 2. Review of the Minimum Data Set ((MDS) dated [DATE] indicated the resident has memory impairment and has severely impaired cognitive skills for daily decision making. The resident did not have a score for a (SIMS) Brief Interview for Mental Status as it is recorded as resident not being able to complete. The resident had a fall risk assessments dated 8/30/2018 indicating this resident is at high risk for falls. Review of the record and nurse's notes, revealed that the resident had 8 falls between 8/28/2018 and 9/28/2018. Review of these falls reveals that only one was witnessed, and that the resident sustained [REDACTED]. Review of the initial care plan indicated that even though the resident had multiple falls, there were no revisions to document the falls and or any additional or new interventions put into place to prevent the falls from reoccurring. Record review revealed there is no evidence of development of an adequate person centered care plan or implementation of procedures to prevent the resident from falls. In an interview on 10/25/2018 at approximately 2:00 PM with the Director of Nurses Service (DNS) she was unable to provide evidence that interventions had been put into place to prevent future falls, that the facilities policy for falls was followed, and that even though the falls were reviewed at risk meetings there was no evidence of any follow up interventions to modify the environment to accommodate resident care needs. 3. Review of the residents medication, reveal the resident was on the following medications on 8/28/2018, [MEDICATION NAME] (an Antipsychotic) 25 mg four times a day, [MEDICATION NAME] solution( an anticonvulsant)500 mg every morning and 500 mg at bedtime, [MEDICATION NAME] HCL(a sedative and antidepressant) 50 mg by mouth at bedtime and [MEDICATION NAME] (a sleep aid) tablet 3 mg by mouth at bedtime. The resident was seen by psych services on 08/31/2018, for ongoing problem of behavioral disturbances, recommendations were made to current Psych meds, close monitoring of behaviors and to start [MEDICATION NAME] 15 mg daily for mood and appetite. On 09/14/2018 the resident was seen by psych services for ongoing problem of behavioral disturbances, recommendations to increase [MEDICATION NAME] solution to 750 mg in the Morning and 500 mg in the evening, which were implemented by the physician. On 10/04/2018 the resident was seen by psych services, and the report reveals, in bed, is a total feed, sig weight loss, not easy to wake today. Recommendations were made to decrease [MEDICATION NAME] sprinkles to 250 mg BID and di:continue [MEDICATION NAME] and start [MEDICATION NAME] 50 mg at bedtime as needed. During surveyor interview with the assistant DNS on 10/25/2018 at 2:48 PM, he revealed that psych services saw resident on 10/04/2018 and it was recommended to decrease the medications as stated above, the recommendations were not received by the facility until 10/9/2018. He was unable to explain why the recommendation were not available and provided to the physician prior to 10/09/2018, even though the family was requesting the medications to be decrease and the resident was becoming more lethargic. The facility was unable to provide evidence of any attempts to obtain the psych services report and recommendation until 10/9/2018. During surveyor interview with the resident's primary physician on 10/26/2018, he revealed that when he requested psych services evaluate the resident, he would have expected they would have decreased some medications. He also reveals for this type of medication he deferred to the psych consultants for their expertise. He further stated that he approved the recommendations to decrease the medications as soon as he received them. 4. Relative to change in condition, the social worker noted on 9/27/2018, that the resident's daughter is aware that her father has had a decline however she would like to have his medications reviewed, for psych services to evaluate him and does not want to put him on hospice without having everything ruled out for him medically. Review of a physician's note dated 09/28/2018, revealed in part, . Discussed with nursing, residents level of activity has decreased lately. His daughter is concerned and wants to know if there is any medical reason or medication effect causing his decline . Review of a Rehabilitation Screen from 09/28/2018, which was emailed on 10/30/2018 from the facility Administrator, reveals the following observations attempted to evaluate resident multiple time this week but patient too lethargic to participate at this time. Resident requires further medical assessment before further rehab can occur to adequately establish functional needs . A nurses note from 10/08/2018 revealed that the resident was seen by psych services at the end of last week, we are still awaiting recommendations. Family expressed concern regarding current medication regimen. Wife stated that resident is stoned and that he is on too much medication. Family requested medication to be held however the nurse, staff D, informed the family, that if resident was awake and alert then resident should received prescribed/scheduled medication. Review of the (MAR) Medication Administration Record [REDACTED]. The record lacks evidence that the families request to hold the medication was communicated to the physician. On 10/9/2018 a social worker note reveals the following, social worker spoke with residents daughter today, she would still would like to see how her father does if there is any med changes, currently waiting on psych recommendations at this time. She is not willing to do hospice at this time. On 10/10/2018, a progress note reveals family still concerned about resident still receiving too much medication. The nurse explained to the family that the medication will take time to get out of his system and that it may not be known for a few days if the lethargy and decline is a result from over medication or a change/decline in condition. On 10/11/2018 the progress notes reveal that PA was asked to see resident for shortness of breath and lethargy, family at bedside requesting resident be sent to acute care hospital. Review of the resident record from the hospital to which he/she was admitted on [DATE], reveals in the history and physical found to have bilateral subdural hematomas (likely due to recent falls) that are stable s/p Cat scan of head x' 2. Additionally patient has notably lost 30 lbs since (MONTH) and is now cachectic. Psychiatry was consulted due to worsening sedation and the concern that it is being caused by polypharmacy with [MEDICAL CONDITION] medications. At the request of the family on 10/11/2018 the resident sent to the hospital emergency room , Review of the ER(emergency room ) physician's documentation reveals, that the EMS (emergency medical services) report states, wife was with the resident around dinner time and noted resident with mild confusion that is worse than his baseline dementia. This AM had increased lethargy and confusion, and needed a sternal rub I to wake up. Vital signs, febrile 100.6, and hypoxic to 84% on 3 liters of oxygen. EMS took him off 3 liters, and the resident desated on room air, and improved with 15 liters. Blood pressure was 92.62 and blood sugar was 169. The resident required [MEDICAL CONDITION], was started on D5W for the [MEDICAL CONDITION], and found to have 4.5 liter free water deficit, subsequently admitted to the respiratory intensive care unit for further treatment. The records reveal that the resident began inproving with treatment for [REDACTED]. Additionally, the residents medications, [MEDICATION NAME] and Trazadone were held upon admission and [MEDICATION NAME] was decreased to 250 mg BID, [MEDICATION NAME] was decreased on 10/13/2018 and discontinued on 10/14/2018. The resident was discharged from the hospital to another long term care facility on 10/18/2018. The facility failed to identify, address or obtain services necessary for care of this residents with dementia, as evidenced above, relative to weight loss, falls, medication and change in mental status and AOL decline. Additionally the facility failed to update the resident's plan of care relative to decrease in activities of daily living, cognition, nutrition, and medication. After rev·1ew of the staff personnel files they lacked evidence of dementia training. Upon interview with the DNS on 11/02/2018 at 11:45 AM,she stated the facility provides ongoing dementia training, however she was unable to produce evidence of dementia training for the dietician, the ADNS, and staff nurses D and E. Refer to F692, F689 & F 757

Based on record review and staff interview it was determined the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source are reported immediately (within 24 hours) to the State Survey and Certification Agency in accordance with State law for 1 of 12 sample residents, ID #1. The facility also failed to fully investigate and prevent further potential abuse while the investigation is in progress for ID #1 and failed to report the result of all investigations within 5 working days of the incident for ID#(s) 1, 2 and 3. Findings are as follows: 1. Resident ID #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident is incontinent and is dependent on staff for personal hygiene. A review of nurses' notes revealed the following: 1. On 8/10 and 9/13/2011 the resident's daughter(s) inspected her peri (genital) area. 2. On 10/16/2011 the resident choked and spit out her medications when her daughter took the medication cup from the nurse and put the medications into the resident's mouth. 3. On 11/20/2011 a nursing assistant informed the nurse in charge that the resident's daughter removed food from her mother's tray stating, "You are going to get too fat, Mom" and that this has been happening more. The entry further indicated the "daughter was seen inspecting her mother's genital area". 4. On 11/24/2011, 9 days following a readmission on 11/15/2011 from the hospital, the nurse noted a 3-inch, deep purple bruise on the resident's right upper forearm... "Family notified - dtr (daughter) said that bruise happened in the hospital - no one noted this bruise prior to today - cont (continue) to monitor". There lacked any evidence the facility conducted any investigations, reported the above incidents or implemented and monitored the daughters' physical contact with the resident. When interviewed separately on 12/20/2011 at 12:30 PM and 12:45 PM, the Director of Nurses (DNS) and Administrator respectively revealed that a representative from the Alliance for Better Long-term care (Alliance) had contacted the DNS on 11/21/2011 about receiving an anonymous complaint regarding the resident's daughter being observed with her head under the resident's blanket close to the resident's "bottom". Additionally, the complainant alleged that the daughters have been seen touching the resident in her genital area and then smelling their fingers. The DNS and Administrator further revealed that they met with the daughters on 11/21/2011 and discussed the allegations in the complaint to the Alliance. Additionally, they met with staff on 11/23/2011 when staff reported additional inappropriate behaviors by the daughters and again on 11/30/2011 when a NA (employee I) reported observing reported observing the resident's daughters spreading the resident's labia and running their fingers down and into the resident's vagina on 11/23/2011. Although the NA did not report the 11/23/2011 incident timely, the DNS was unable to provide evidence the NA had been counseled or re-educated regarding timely reporting of abuse, neglect and mistreatment. Additionally, the Administrator revealed he had met with the daughters sometime in March 2011 to discuss staff reports that they were touching the resident's peri and buttock areas to check for wetness. Although the Administrator advised the daughters to not continue, he was unable to provide any evidence of reporting to the state agency or of monitoring the daughters' compliance. When interviewed on 12/21/2011 at 2:20 PM, a NA (employee K) revealed that on 2 occasions she observed the resident's daughters putting their hand in the resident's brief between the brief and vagina or anus and then trying to put their hand up to the NA's face and asking if their hands smelled clean. The NA further revealed that these incidents happened as long ago as June or July 2011 and she reported both incidents to the nurse in charge. Although the Administrator and DNS were aware of these allegations as early as March 2011 they failed to provide evidence of any reporting, investigating or implementation of a plan to protect the resident until 11/30/2011 when, on the advice of a representative of the Alliance for Better Long Term Care, they faxed a "Documentation of Required Reporting" (R23-17-NF-Appendix E) to the Department of Health, Division of Facilities Regulation, (DOH), invoked a "No Trespass" order on the daughters and called the police. The above reporting was not immediate but rather 10 days after 11/21/2011 when the Alliance contacted the facility about the allegations. A summary report was faxed to the DOH on 12/8/2011 which was not within 5 working days of the allegations but rather 8 days after 11/30/2011 and 18 days 11/21/2011. 2. An incident of verbal abuse by a NA (employee T) toward resident ID #2 was reported to the DOH on 11/19/2011. A Facility Incident Summary Report was faxed to the DOH on 11/25/2011, which was 7 days after 11/19/2011 rather than 5 days as required. When interviewed on 12/22/2011 at 9:45 AM the DNS was unable to provide evidence that the results of the investigation were reported to the DOH within 5 days of the allegation. 3. An incident of inappropriate behavior by a NA (employee U) toward resident ID #3 was reported to the DOH on 11/23/2011. A Facility Incident Summary Report was faxed to the DOH on 12/1/2011, which was 9 days after 11/23/2011 rather than the 5 days as required. When interviewed on 12/21/2011, at 9:45 AM, the DNS was unable to provide an explanation for the late reporting.

Based on record review, family and staff interviews, it was determined the facility failed to ensure that residents are free from neglect for 2 of 12 sample residents (ID#(s) 1 and 7). Findings are as follows: 1. Resident ID #1 was re-admitted to the facility on [DATE]. She has lived in the facility since 8/31/2007 and has a [DIAGNOSES REDACTED]. The resident is incontinent and is dependent on staff for personal hygiene. A review of information attached to a complaint of alleged abuse by family revealed numerous accounts by staff (nursing assistants and nurses) reporting concerns regarding what they considered to be inappropriate touching and inspection of the resident's private areas by both of her daughters. This information included "Journal Entries" written by a representative from the Alliance for Better Long Term Care (Alliance), an Incident Report and Witness Statements from the local police department and written statements by witnesses. All above staff reported they had reported these incidents to their supervisors, including the Director of Nurses and the Administrator. A review of nurses' notes revealed the following: 1. On 8/10 and 9/13/2011 the resident's daughter(s) inspected her peri (genital) area. 2. On 10/16/2011 the resident choked and spit out her medications when her daughter took the medication cup from the nurse and put the medications into the resident's mouth. 3. On 11/20/2011 a nursing assistant informed the nurse in charge that the resident's daughter removed food from her mother's tray stating, "You are going to get too fat, Mom" and that this has been happening more. The entry further indicated the "daughter was seen inspecting her mother's genital area". 4. On 11/24/2011, 9 days following an 11/15/2011 readmission from the hospital, a nurse noted a 3-inch, deep purple bruise on the resident's right upper forearm... "Family notified - dtr (daughter) said that bruise happened in the hospital - no one noted this bruise prior to today - cont (continue) to monitor". A review of the Witness Statement from the Smithfield Police Department relative to the allegation of abuse revealed that on 12/2/2011 a Nursing Assistant (NA) (employee I) told police of witnessing the resident's daughters with their heads underneath the resident's blanket in the area of her genitals. Additionally, the NA reported that in September 2011, she witnessed one daughter spread her mother's labia and insert her right index finger into the resident's vagina. On another occasion, the NA witnessed the other daughter "spread her mother's cheeks and rub her anus". On 11/24/2011, the NA witnessed a daughter inserting a finger into her mother's rectum. Although the facility uses briefs which show a blue line when the brief is wet, the NA saw both daughters put their hands down their mother's brief to see if she was wet on several occasions. The NA further told police that she reported all of these incidents to the nurses in charge (employees J, Q and R). Further review of Witness Statements revealed that 2 NA(s) (employees I and E) also witnessed the resident calling out "No" and "Stop it" when the daughters were with the resident. Although the facility was made aware of the above alleged incidents, the facility neglected to conduct any investigations and allowed the daughters to visit their mother twice daily without ever assessing or monitoring these visits in order to determine the validity of these allegations reported by staff. When interviewed separately by the surveyor on 12/20/2011 at 12:30 PM and 12:45 PM, the Director of Nurses (DNS) and Administrator respectively revealed that in addition to the previously reported allegations, the Alliance had contacted the DNS on 11/21/2011 regarding an anonymous complaint regarding the resident's daughter being observed with her head under the resident's blanket close to the resident's "bottom". Additionally, the complainant alleged that the daughters have been seen touching the resident in her genital area and then smelling their fingers. The DNS and Administrator revealed that they met with the daughters on 11/21/2011 and discussed the allegations in the complaint. They further stated they met with staff on 11/23/2011 after staff reported additional information of alleged inappropriate touching by the daughters and again on 11/30/2011 when a NA (employee I) reported observing the resident's daughters spreading the resident's labia and running their fingers down and into the resident's vagina on 11/23/2011. Although the NA did not report the 11/23/2011 incident timely, the DNS was unable to provide evidence the NA had been counseled or re-educated. Additionally, when the Administrator was interviewed on 12/21/2011 at 11:00 AM he revealed he had met with the daughters sometime in March 2011 to discuss staff reports that they were touching the resident's peri and buttock areas to check for wetness. Although the Administrator advised the daughters to not continue with these behaviors, he was unable to provide any evidence of investigation of the above-alleged incidents and of protecting the resident by any monitoring and supervision of the daughters. When interviewed on 12/21/2011 at 12:45 PM, the social worker (SW) who attended the 11/23/2011 meeting confirmed that the staff was specific in reporting that the daughters were continuing to touch the resident's peri area and opening her labia to see if it was wet. Staff also reported observing the daughters putting their hand in the resident's brief and putting their heads under the sheets near the resident's peri area and buttocks. The SW could not provide evidence of any investigation of the alleged incidents. Additionally, she could not provide evidence of any system in place to protect the resident. When questioned on 12/21/2011 at 1:45 PM regarding the incident of the resident's daughter taking the pills from the nurse on 10/16/2011, the DNS revealed she became aware of the incident on 11/13/2011 when reviewing the resident's chart. When asked if she spoke to the nurse or the family, the DNS revealed she had only spoken to the nurse about timely reporting but had not spoken to the family because the incident had already happened. When asked what system the facility has put in place to protect the resident, the DNS revealed that the facility has yet to determine what steps needed to be taken as the investigation was not yet complete. When interviewed on 12/21/2011 at 2:20 PM, a NA (employee K) who has provided care to the resident revealed that on 2 occasions she observed the resident's daughters putting their hand in the resident's brief between the brief and vagina or anus and then trying to put their hand up to the NA's face and asking if their hands smelled clean. Although the NA could not recall the specific dates, she revealed that these incidents happened as long ago as June or July 2011 and she reported both incidents to the nurse in charge. The surveyor conducted a telephone interview on 1/10/2011 at 3:50 PM with an RN (employee F) who is the 3-11 PM supervisor. The RN supervisor revealed that she was made aware of the above allegations over a period of time, perhaps as long ago as July 2010. The allegations were reported to her by virtually all the NA(s) and nurses who provided care for the resident, which included employees E, I, K and S who are NA(s) and employees J, Q and R who are nurses. Additionally, she witnessed one daughter checking the resident's peri area and the resident saying: "No, no, it hurts." The daughter replied: "I'm doing this for you". Although the RN supervisor could not recall the specific date, she revealed that she reported this incident to the DNS just as she had previously reported every allegation and concern brought to her attention by staff. The RN supervisor continued to reveal that the DNS responded by saying that meetings were being held with the daughters and that the situation was being handled. In response to the RN supervisor asking about what limitation could be placed on the family, the DNS responded that the facility could not prohibit them from interfering with or providing care to their mother. Although the RN supervisor revealed that she and other staff were very frustrated by the lack of action by the DNS and Administrator, she revealed that she neglected to report any of the allegations to the Department of Health. Although the Administrator, DNS, SW and RN supervisor were aware of these allegations as early as March 2011 the facility failed to provide evidence of any protection provided to the resident prior to 11/30/2011 when, on the advice of the Alliance, the facility invoked a "No Trespass" order against the daughters and contacted the police. 2. Resident ID #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident is occasionally incontinent and needs staff assistance for toileting, and is dependent on staff for bathing and personal hygiene. A review of the resident's "ADL Deficit Care Plan" reveals interventions to assist with bathing as the resident allows, encourage her to shower on her shower days and monitor her refusals as well as monitor for changes in decline in personal care. A review of information attached to a complaint by the resident's family of alleged neglect revealed an allegation the resident had not received foot care since her admission on 2/18/2011. Additionally, the family alleged the resident had a strong odor like she had not been bathed in days. Review of the resident's Treatment Administration Records from 2/18/2011 through 11/5/2011 revealed that the resident had skin checks weekly with no areas of concern noted. The 11/12/2011 skin check identified long overgrown toenails. The subsequent weekly skin checks from 11/19 to 12/31/2011 continue to document no areas of concern, although the resident had seen a podiatrist on 12/29/2011 and returned with a surgical wound from debridement of ulceration over the bunion area of the right foot. Furthermore, review of the facility's Daily Shower Log for this resident revealed that the resident was to have showers twice weekly. The shower logs from February through July 2011 could not be produced by the facility. A review of the shower logs from August 2011 through 1/9/2012 revealed that 2 resident refusals to have a shower over a 4-month period was the only documentation. Additionally, the family arranged for and transported the resident to the podiatrist on 12/29/2011 due to their concerns about the condition of her foot. The surveyor reviewed the 12/29/2011 Podiatry Office Note with the podiatrist on 1/6/2012 at 1:00 PM. The podiatrist revealed the resident was a long-term patient from 2007 to 2010. He further revealed that the resident appeared to not have her feet cared for in some time. The resident's [DIAGNOSES REDACTED]. The podiatrist's note continues to say, "Examination of her toes shows severely neglected feet with dystrophic elongated nails so long that they have begun and pinching on the surrounding skin and the skin of the neighboring toes... she has developed a grade 1 ulceration... at the bunion area on the right foot... Based on the appearance is likely been present for over a month probably longer..." Surveyor interview with the resident's daughter on 1/9/2012 at 10:15 AM revealed that, since the resident's admission, she expected the facility to be providing care for her mother's feet and toes. When the family saw the condition of their mother's feet and toes during a visit on 12/24/2011, they realized that the facility was not addressing foot care. She added that the family was surprised by the condition of the resident's feet because they brought their concerns about the condition of her feet to the facility approximately 8 weeks prior to 12/24 visit. Additionally, the daughter revealed that, for as long as she could remember, her mother did have a chronic bunion but never had any pressure blisters, or broken skin conditions on that area before. When interviewed on 1/9/2012 at 2:00 PM the Director of Nurses (DNS) could not produce evidence the resident was bathed twice weekly or that routine foot care was provided.

Based on record review and staff interview, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and maintain the highest practicable physical, mental and psychosocial well being of each resident. Findings are as follows: 1. As evidenced by the facility's failure to ensure that residents are free from neglect as referenced in F224 with S/S at the K level and resulting in the potential for serious harm. 2. As evidence by the facility failure to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source are reported immediately (within 24 hours) to the State Survey and Certification Agency. The facility failed to fully investigate and prevent further potential abuse while the investigation is in progress and failed to report the result of all investigations within 5 working days of the incident as referenced in F225 with S/S at the K level and resulting in the potential for serious harm. 3. As evidence by the facility failed to implement its own written policies and procedures that prohibit mistreatment, neglect, and abuse of residents as referenced in F226 with S/S at the K level and resulting in the potential for serious harm. 4. As evidence by the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity as referenced in F241 with S/S at the K level and resulting in the potential for serious harm. Refer to F224, F225, F226 and F241

Based on record review and staff interview it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 3 of 5 sample residents (ID #s 1, 2 and 3). Findings are as follows: The facility's policy and procedure titled "Abuse Prohibition" states: "II. Procedure: To protect the resident from abuse, mistreatment, neglect and/or misappropriation of their personal property and to further the goal of providing respectful treatment..." D. Identification and Reporting... Any instance of actual or suspected abuse, neglect... including injuries of unknown origins including bruises, skin tears... must be reported immediately to the supervisor on duty and an incident report is to be filled out. E. Investigation... It is the supervisor's responsibility to act immediately to: Begin the initial investigation... Intervene to ensure that the resident is safe and protected from further harm... Obtain statements from witnesses... Notify the appropriate administrative personnel so that a comprehensive internal facility investigation can be carried out... Carry out proper staff interventions and include all interventions in the resident's care plan... It is the responsibility of the Director of Nursing to ensure that: The incident reports are accurately and completely filled out; personnel and witness statements are obtained timely; the investigation is comprehensive and documented appropriately... It is the responsibility of the Nursing Home Administrator to... Notify the appropriate agencies in writing... Submit the report of allegations and the results of the internal investigation to the Department of Health. F. Timelines of investigation All allegations of violations in this policy must be reported immediately to the Department of Health Division of Facility Regulation. The facility must then begin the internal investigation, which is to be completed and forwarded to the Department of Health within 5 days." 1. A review of nurses' notes from 8/10 to 11/14/2011 in the clinical record for resident ID #1 revealed 3 instances of the resident's daughter(s) being observed touching and inspecting her peri (genital) and anal areas, an instance of the resident's daughter giving her mother medication resulting in the resident choking and spitting out the medication, an instance of the resident's daughter removing food from the resident's tray and referring to her getting too fat, and the discovery of a bruise on the resident's arm which could not be explained. There lacked evidence the facility completed incident reports, conducted investigations and/or reported, developed, monitored and reassessed intervention strategies and included the interventions in the resident's care plan. Additionally, there was no evidence the facility notified the appropriate agencies or submitted the report of allegations and the results of the internal investigation to the Department of Health in accordance with the facility's policy and procedure. On 11/21/2011, an allegation of abuse toward the resident by her daughters was reported to the facility. When questioned on 12/22/2011 at 10:00 AM, the DNS and Administrator were unable to provide evidence of any investigation and reporting prior to 11/30/2011 when, on the advice of a representative for the Alliance for Better Long Term Care, the facility faxed a "Documentation of Required Reporting" (R23-17-NF-Appendix E) to the Department of Health, Division of Facilities Regulation, (DOH). The above reporting was not immediate but rather 10 days after 11/21/2011 when the Alliance contacted the facility about the allegations. A summary report was faxed to the DOH on 12/8/2011 which was not within 5 working days of the allegations but rather 8 days after 11/30/2011 and 18 days 11/21/2011. The above timelines are not in accordance with the facility's policy and procedure. The DNS and Administrator were also unable to provide evidence they had developed, monitored and reassessed intervention strategies and included the interventions in the resident's care plan as specified in the facility's policy and procedure. 2. An incident of verbal abuse by a NA (employee T) toward resident ID #2 was reported to the DOH on 11/19/2011. A Facility Incident Summary Report was faxed to the DOH on 11/25/2011, which was 7 days after 11/19/2011 rather than the 5 days specified in the facility's policy and procedure. A review of the 11/22/2011 staff's written statement and the 11/22/2011 Facility Witness Statement/Interview Documentation Form revealed the incident occurred on 11/18/2011, however, the witness (employee D) did not report the incident immediately to the nursing supervisor on duty but rather 1 day later on 11/19/2011. When questioned on 12/22/2011 at 9:45 AM, the DNS indicated that the alleged perpetrator continued to work after the incident on 11/18 and was not suspended until 11/19 when the DNS began the investigation. The DNS was unable to provide evidence that the witness reported the above allegation of verbal abuse immediately to the supervisor on duty and the resident was protected by the immediate removal of the alleged perpetrator or that the results of the investigation were reported to the DOH within 5 days of the incident in accordance with the facility's policy and procedure. 3. An incident of inappropriate behavior by a NA toward resident ID #3 (employee U) was reported to the DOH on 11/23/2011. A Facility Incident Summary Report was faxed to the DOH on 12/1/2011, which was 9 days after 11/23/2011 rather than the 5 days required by the facility's policy and procedure. When interviewed on 12/21/2011, at 9:45 AM, the DNS was unable to provide evidence the facility followed it's policy and procedures that prohibit mistreatment, neglect, and abuse.

Based on record review and staff interview it was determined the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity for 1 of 12 sample residents, ID #1. Findings are as follows: Resident ID #1 was readmitted to the facility 1/31/2011. She has lived in the facility since 8/31/2007 and has a [DIAGNOSES REDACTED]. The resident is incontinent and is dependent on staff for personal hygiene. A review of information attached to a complaint of alleged abuse by family revealed numerous accounts by staff (nursing assistants and nurses) reporting concerns regarding what they considered to be inappropriate touching and inspection of the resident's private areas by both of her daughters. This information included "Journal Entries" written by a representative from the Alliance for Better Long Term Care (Alliance) and an Incident Report and Witness Statements from the local police department. A review of nurses' notes revealed that on 8/10, 9/13 and 11/20/2011 the resident's daughter(s) were seen touching/inspecting her peri (genital) areas. Additionally, the 11/20 note reveals the resident's daughter removes food from her tray and referring to her getting too fat and that this is happening more often. When interviewed separately on 12/20/2011 at 12:30 PM and 12:45 PM, the Director of Nurses (DNS) and Administrator revealed respectively that a representative of the Alliance for Better Long-term care (Alliance) had contacted the DNS on 11/21/2011 about an anonymous complaint regarding the resident's daughter being observed with her head under the resident's blanket close to the resident's "bottom". Additionally, the complainant alleged that the daughters have been seen touching the resident in her genital area and then smelling their fingers. The DNS and Administrator further revealed that they met with the daughters on 11/21/2011 and discussed the allegations in the complaint. Additionally, they met with staff on 11/23/2011 when staff reported additional inappropriate touching and inspection by the daughters and again on 11/30/2011 when a NA (employee I) reported observing the resident's daughter spreading the resident's labia and running her fingers down and into the resident's vagina on 11/23/2011. Additionally, when the Administrator was interviewed on 12/21/2011 at 11:00 AM, he revealed he had met with the daughters sometime in March 2011 to discuss staff reports that they were touching the resident's peri and buttock areas to check for wetness. Although the Administrator advised the daughters to not continue with this behavior, he was unable to provide any evidence of monitoring their compliance. When interviewed on 12/21/2011 at 12:45 PM, the social worker (SW) who attended the 11/23/2011 meeting revealed that the staff was specific in reporting that the daughters were continuing to touch the resident's peri area and opening her labia to see if it was wet. Staff also reported observing the daughters putting their hand in the resident's brief and putting their heads under the sheets near the resident's peri area and buttocks. When interviewed on 12/21/2011 at 2:20 PM, a NA (employee K) who has provided care to the resident revealed that on 2 occasions she observed the resident's daughters putting their hand in the resident's brief between the brief and vagina or anus and then trying to put their hand up to the NA's face and asking if their hands smelled clean. The NA further revealed that these incidents happened as long ago as June or July 2011 and she reported both incidents to the nurse in charge. There lacked any evidence the facility addressed the issue of dignity with the resident's daughters or staff or that the resident's dignity was ensured by evidence of a care plan to prevent further occurrences. Although the Administrator and DNS were aware of the daughters' inappropriate behavior as early as March 2011 they were unable to provide evidence the facility promoted care in a manner and in an environment that maintains or enhances each resident's dignity.

Based on record review, and staff interviews, it was determined the medical director failed to assist the facility to identify, evaluate and address medical and clinical concerns and issues that affect resident care, medical care, quality care and coordinate medical care in the facility. Findings are as follows: 1. As evidenced by the facility's failure to ensure that residents are free from neglect as referenced in F224 with S/S at the K level and resulting in the potential for serious harm. 2. As evidence by the facility failure to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source are reported immediately (within 24 hours) to the State Survey and Certification Agency. The facility failed to fully investigate and prevent further potential abuse while the investigation is in progress and failed to report the result of all investigations within 5 working days of the incident as referenced in F225 with S/S at the K level and resulting in the potential for serious harm. 3. As evidence by the facility failure to implement its own written policies and procedures that prohibit mistreatment, neglect, and abuse of residents as referenced in F226 with S/S at the K level and resulting in the potential for serious harm. 4. As evidenced by the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity as referenced in F241 with S/S at the K level and resulting in the potential for serious harm. Refer to F224, F225, F226 and F241

Based on review of the Quality Assurance (QA) meetings and staff interview, it was determined the facility failed to implement appropriate plans of action to correct identified quality deficiencies noted during the 7/19/2011 survey, relative to implementing their written policy and procedure for immediate reporting and the protection of a resident following an abuse allegation. Findings are as follows: Although the facility was previously cited on 7/19/2011 for failure to implement their written policy and procedure for immediate reporting and the protection of a resident following an abuse allegation, there lacked evidence the facility developed and implemented measurable goals and monitoring of compliance as part of the Quality Assurance Program. When questioned on 12/22/2011 at 9:30 AM, the Administrator and the Director of Nursing Services were unable to provide evidence the facility had developed and implemented a QA program appropriate to correct the above identified quality deficiencies. Refer to: F224, 225 and 226. "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions."

Based on record review and interviews with a representative for the Alliance for Better Long Term Care (Alliance) and the DNS (Director of Nurses), it was determined the facility failed to ensure that each resident receives assistance devices to prevent accidents for 1 of 12 sample residents (ID #4). Findings are as follows: Surveyor review of 10/31/2011 complaint revealed an allegation by family that resident ID #4 had three falls and sustained injuries requiring emergency room (ER) visits within her four month stay at the facility. The complainant alleged that the resident's safety measures (grippers socks, call light and bed/chair alarms) were not in place according to the plan of care. The complainant indicated that on the advice of the Alliance the resident was moved to another facility on 9/23/2011 because of concerns for her safety. Record review revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. A review of the 5/31 and 8/23/2011 Minimum Data Sets indicated the resident had cognitive impairment and she needed assistance with her ADL(s) {Activities of Daily Living} including bed mobility, transferring and ambulation. Fall Risk Assessments dated 5/23, 5/28, 8/2 and 9/6/2011 indicated the resident was at high risk for falls. A 6/3/2011 Interdisciplinary Care Plan indicated the resident needed assistance with her ADL(s) due to poor balance, poor safety awareness, forgetfulness and needing assistance with bed mobility and transfers and was incontinent of urine at times. The care plan also indicated the resident was at risk for falls due to anti-depressant and anti-anxiety use and a history of multiple falls at her prior living facility. In addition the resident was to have a call light within reach and staff would provide assistance with her ADL(s) as needed. Further record review revealed that on 6/7/2011, the resident was found sitting on the floor with a small abrasion to her right shoulder and a small laceration to her right scalp. The resident was transported to the emergency room (ER). The family met with the DNS and was assured that the safety measures in the care plan would be in place. Gripper socks were added to the care plan. A 6/21/2011 nurse's note indicated the resident frequently did not have her call light within reach while she was in the bed or chair. Although, the resident had periods of forgetfulness, the note further indicated that the resident was encouraged to remind staff to attach the call light and put on the gripper socks. On 8/2/2011, the resident was found on the floor on the side of her bed during rounds at 7:00 AM. The resident was noted with a bump and small cut over her right eye and a skin tear on her right elbow. The resident was sent to the ER due to hitting her head. An 8/2/2011 nurse's note, written at 8:00 AM indicated the resident's personal alarm was in place but didn't sound due to needing replacement batteries. The nurse's note also indicated the resident now complained of pain in her neck and a headache and she was discouraged that she had fallen again. The family again met with the DNS and was told that more safety protocols would be put into place. Record review revealed both bed and chair alarms were added to the resident's plan of care to increase resident safety after the fall incident on 8/2/2011. During a phone interview on 12/22/2011 at 10:15 AM, the Alliance revealed visiting the resident on 9/21/2011. The resident was lying in bed without gripper socks on, without a call light within reach and although the alarm was on, it was not working. The Alliance immediately informed the DNS. When questioned on 12/22/2011 at 10:30 AM the DNS revealed she was aware the gripper socks, alarms and call bell were not consistently working and/or provided to the resident as assistance devices to ensure the resident's safety. She was unable to produce evidence the facility had implemented and/or monitored staff compliance with these interventions to prevent accidents.

Based on record review, family and staff interviews, it was determined the facility failed to provide foot care for 1 of 6 sample residents whose feet were observed, ID #7. Findings are as follows: Resident ID #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident is occasionally incontinent and needs staff assistance for toileting, and is dependent on staff for bathing and personal hygiene. A review of the resident's "ADL Deficit Care Plan" reveals interventions to monitor for changes in decline in personal care. A review of information attached to a complaint by the resident's family of alleged neglect revealed an allegation the resident had not received foot care since her admission on 2/18/2011. Review of the resident's Treatment Administration Records (TAR) from 2/18/2011 through 11/5/2011 revealed that the resident had skin checks weekly, which indicated there were no areas of concern noted. The 11/12/2011 skin check identified long overgrown toenails. The subsequent weekly skin checks from 11/19 to 12/24/2011 continue to document no areas of concern. Additionally, the family arranged for and transported the resident to the podiatrist on 12/29/2011 due to their concerns about the condition of her foot. The surveyor reviewed the 12/29/2011 Podiatry Office Note with the podiatrist on 1/6/2012 at 1:00 PM. The podiatrist revealed the resident was a long-term patient from 2007 to 2010. He further revealed that the resident appeared to not have her feet cared for in some time. The resident's [DIAGNOSES REDACTED]. The podiatrist's note continues to say, "Examination of her toes shows severely neglected feet with dystrophic elongated nails so long that they have begun and pinching on the surrounding skin and the skin of the neighboring toes... she has developed a grade 1 ulceration... at the bunion area on the right foot... There is a large dorsal eschar... which appears to be secondary to an older blood blister. Based on the appearance is likely been present for over a month probably longer..." The podiatrist further revealed to the surveyor that the area he removed the dark and necrotic looking area from the bunion with a surgical blade. Surveyor interview with the resident's daughter on 1/9/2012 at 10:15 AM revealed that, since the resident's admission, she expected the facility to be providing care for her mother's feet and toes. When the family saw the condition of their mother's feet and toes during a visit on 12/24/2011, they realized that the facility was not addressing foot care. She added that the family was surprised by the condition of the resident's feet because they brought their concerns about the condition of her feet to the facility approximately 8 weeks prior. Additionally, the daughter revealed the resident's toenails were properly maintained prior to admission to the facility. She added that for as long as she could remember, her mother did have a chronic bunion but never had any pressure blisters, or broken skin conditions on that area before. When interviewed on 1/9/2012 at 2:00 PM the Director of Nurses (DNS) could not produce evidence the resident was bathed twice weekly or that routine foot care was provided.