Every finding on record at Crystal Lake Rehabilitation and Care Center

Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually. Findings are as follows: 1. Record review revealed a document titled, Facility Assessment last updated 3/10/2025, which revealed the following participants were involved in the completion of the Facility Assessment: - Administrator - Director of Nursing Services - Director of Environmental Services - Medical Director Record review failed to reveal evidence of the involvement of direct care staff including, but not limited to, Registered Nurse, Licensed Practical Nurse, Nursing Assistant, or a representative of the direct care staff, in the completion of the Facility Assessment. Further review of the Facility Assessment failed to reveal evidence that the facility solicited and considered input received from the residents, resident representatives, and family members. 2. Review of the Facility Assessment failed to reveal evidence that the facility developed and maintained a plan to maximize recruitment and retention of direct care staff. During a surveyor interview on 4/17/2025 at 10:50 AM, with the Administrator, she revealed that direct care staff, residents, family, or resident representatives were not involved in the completion of the Facility Assessment. Further, she acknowledged that the Facility Assessment did not include a plan to maximize recruitment and retention of direct care staff, per the regulation.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: Review of the Rhode Island Food Code 2018 Edition 4-601.11, states in part, .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During surveyor observations on the initial tour of the main kitchen on 4/14/2025 at approximately 9:15 AM, in the presence of the Food Service Director (FSD), revealed the following: - A white colored component within the ice machine noted with black and pink matter, that was able to be removed by wiping it with a paper towel - A Kitchen Aid(R) appliance covered with a clear plastic bag, with a dark brown liquid matter leaking from a seam on the upper portion of the appliance onto the bag and appliance itself - An accumulation of a grease-like residue on the exhaust hoods above the stove and griddle. Additionally, a sticker was observed indicating that the hoods were last cleaned on 11/11/2024 During a surveyor interview immediately following the above observations on 4/14/2025 with the FSD, he acknowledged the discolored wipeable matter within the ice machine, the discolored liquid matter leaking from the kitchen appliance, and the grease-like accumulation on the exhaust hoods and indicated that they should be cleaned.

Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 residents reviewed for appointments, Resident ID #25. Findings are as follows: Record review revealed that Resident ID #25 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, adult failure to thrive and repeated falls. Record review revealed a physician's order dated 1/27/2025 to obtain a neurology consult. Review of the progress notes revealed the following: - 1/27/2025 the resident's diagnoses were reviewed by the Nurse Practitioner (NP), Staff B, and a new order was obtained for a neurology consult - 1/27/2025 authored by Staff B, which revealed that speech therapy was to see the resident due to increase tremors and trouble swallowing, as well as his/her diet had been downgraded to a chopped texture with thin liquids. Additionally, a neurology consult was placed for tremors and dysphagia, (difficulty swallowing) with concerns for Parkinson's disease versus medication induced tremors - 4/10/2025 revealed the resident had upper extremity tremors with holding objects most of the time Review a document titled, Occupational Therapy Treatment Encounter Note(s) dated 1/29/2025, revealed that the resident complained of bilateral hand tremors and complained of having difficulty with drinking with a regular cup. Record review failed to reveal evidence that a neurology consult appointment was scheduled, attended, or declined by the resident. Review of the transport calendar for the year of 2025, with the Administrator, failed to reveal evidence that a neurology consult appointment was scheduled for Resident ID #25. During a surveyor interview on 4/16/2025 at 11:00 AM with Licensed Practical Nurse, Staff A, she revealed that she was unable to find evidence that the neurology appointment was scheduled, attended, or declined by the resident. During a surveyor interview on 4/16/2025 at 11:18 AM, with the Director of Nursing Services (DNS), she revealed that the person in charge of setting up appointments for the residents was unaware that Resident ID #25 was ordered or needed a neurology consult appointment. During a surveyor interview and observation on 4/16/2025 at 11:25 AM, with the resident, in the presence of the DNS, the resident was observed to have tremors. Additionally, the resident revealed that s/he did not decline an appointment for a neurology consult. Furthermore, s/he revealed to the DNS and the surveyor that s/he was still having tremors and still needs to attend the neurology consult. During a surveyor interview on 4/18/2025 at approximately 12:30 PM with the DNS, in the presence of the Administrator, she was unable to provide evidence that the facility followed up and scheduled the neurology appointment as ordered by the provider on 1/27/2025.

46539 Based on record review and staff interview, it has been determined that the facility failed to ensure that the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for 2 of 2 residents reviewed for smoking, Resident ID #s 10 and 42, and 3 of 3 residents reviewed for restraints, Resident ID #s 9, 10, and 31. Findings are as follows: 1. Review of the Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual last revised in October 2024 states in part, .Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period . 1a. Record review revealed Resident ID #10 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, tobacco use. Record review revealed a care plan dated 1/21/2025 which revealed the resident uses a vape (a device used for inhaling vapor containing nicotine and flavoring) and tobacco products. Review of an MDS assessment dated [DATE], Section J, titled, Health Conditions revealed the resident was documented inaccurately as not using tobacco products during the 7-day look-back period. 1b. Record review revealed Resident ID #42 was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, type 2 diabetes. Record review revealed a care plan dated 3/25/2025 which revealed the resident utilizes tobacco products. Record review revealed a Smoking Evaluation dated 3/5/2024, which revealed that the resident utilizes tobacco products. Review of an MDS assessment dated [DATE], Section J, titled, Health Conditions revealed the resident was documented inaccurately as not using tobacco products during the 7-day look-back period. 2. Review of the RAI Manual dated October 2024 states in part, .The intent of this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time during the day or night, during the 7-day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories .DEFINITION PHYSICAL RESTRAINTS Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body . 2a. Record review revealed Resident ID #9 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, dementia. Record review revealed a physician order dated 2/15/2025 for two 1/4 top side rails as an enabler for bed mobility and transfers, as needed while in bed. Review of an MDS assessment dated [DATE], Section P, titled, Restraints revealed the resident was coded for the use of bed rails as a restraint during the 7-day look-back period. 2b. Record review revealed Resident ID #10 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, obesity. Record review revealed a physician order dated 2/15/2025 for two 1/4 top side rails as an enabler for bed mobility and transfers as needed while in bed. Review of an MDS assessment dated [DATE], Section P, titled, Restraints revealed the resident was coded for the use of bed rails as a restraint during the 7-day look-back period. 2c. Record review revealed Resident ID #31 was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to, dementia. Record review revealed a physician order dated 2/15/2025 for two 1/4 top side rails as an enabler for bed mobility and transfers, as needed while in bed. Review of an MDS assessment dated [DATE], Section P, titled, Restraints revealed the resident was coded for the use of a bed rails as a restraint during the 7-day look-back period. During surveyor interviews on 4/16/2025 at 10:28 AM and 4/17/2025 at 10:43 AM, with the MDS Coordinator, she revealed that Resident ID #s 10 and 42 are active smokers and utilize tobacco products. Additionally, she revealed that Resident ID #s 9, 10, and 31 utilize the side rails for bed mobility and transfers, but that they are not utilized as a restraint and do not meet the definition of a restraint. Furthermore, she revealed that the MDS Assessments for Resident ID #s 9,10, 31, and 42 were coded in error and would be modified with the correct information, after being brought to the facility's attention by the surveyor. During a surveyor interview on 4/17/2025 at 10:43 AM, with the Director of Nursing Services, she acknowledged that the above MDS assessments for Resident ID #s 9, 10, 31, and 42 were coded inaccurately. 47279

Based on record review and staff interview it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to insulin administration for 1 of 3 residents reviewed, Resident ID #42. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed that the resident was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, type II diabetes. Record review revealed the following physician's orders: - Insulin lispro (fast-acting insulin that starts to work about 15 minutes after injection) 100 units/ milliliter (ml), administer 3 units subcutaneously (the layer of tissue just below the skin) daily from 11:30 AM until 1:00 PM. - Insulin lispro 100 units/mL, administer 3 units subcutaneous daily from 4:30 PM until 6:00 PM - Insulin lispro 100 units/mL, administer 3 units subcutaneous from 4:00 PM until 5:30 PM. Record review revealed that on the following dates and times, the insulin lispro was not administered as ordered: - 4/7/2025 from 4:30 PM until 6:00 PM, with a documented blood sugar of 83 milligrams (mg)/ deciliter (dL) - 4/11/2025 from 11:30 AM until 1:00 PM, with a documented blood sugar of 71 mg/dL - 4/14/2025 from 4:00 PM until 5:30 PM, with a documented blood sugar of 88 mg/dL Record review failed to reveal evidence that the provider was notified of the insulin lispro not being administered on 4/7, 4/11 or 4/14/2025. During a surveyor interview on 4/16/2025 at 10:38 AM with Licensed Practical Nurse, Staff A, she revealed that there are no parameters to hold the insulin in the order. Additionally, she revealed that the insulin should be given during the meal and if the medication was held, it should be reported to the provider. During a surveyor interview on 4/16/2025 at 10:34 AM with the Director of Nursing Services, she was unable to provide evidence that the insulin lispro was administered, as ordered, on 4/7/2025, 4/11/2025 and 4/14/2025. During a surveyor interview on 4/16/2025 at 10:49 AM with the Nurse Practitioner, Staff B, she revealed that she would expect the staff to follow the order as written and if the medication is held, she would expect the staff to notify her.

Based on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing them of when changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan related to the Skilled Nursing Facility Notice of Medicare Non-Coverage (NOMNC), in a timely manner for 3 of 4 residents reviewed who were discharged from a Medicare covered Part A stay with benefit days remaining, Resident ID #s 353, 354, and 355. Findings are as follows: Review of the Center for Medicare and Medicaid Services (CMS) Form, CMS-10123, titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC), states in part, .A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily .Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual. A NOMNC must be delivered even if the beneficiary agrees with the termination of services . 1. Record review revealed that Resident ID #353's last covered day of Medicare Part A Services was on 3/13/2025 and s/he was discharged from the facility on 3/14/2025. Further record review failed to reveal evidence that the resident and/or resident representative was issued the NOMNC form. 2. Record review revealed that Resident ID #354's last covered day of Medicare Part A Services was on 3/12/2025 and s/he was discharged from the facility on 3/13/2025. Further record review failed to reveal evidence that the resident and/or resident representative was issued the NOMNC form. 3. Record review revealed that Resident ID #355's last covered day of Medicare Part A Services was on 11/10/2024 and was s/he discharged from the facility on 11/11/2024. Further record review failed to reveal evidence that the resident and/or resident representative was issued the NOMNC form. During a surveyor interview on 4/14/2025 at 2:27 PM, with the Minimum Data Set Coordinator, she acknowledged that Resident ID #s 353, 354, and 355 were not issued a NOMNC form. Additionally, she revealed that she did not know that the form was required when the resident agreed with the discharge. During a surveyor interview on 4/15/2025 at 1:39 PM, with the Administrator, she was unable to provide evidence that the resident and/or resident representative was issued the NOMNC form for Resident ID #s 353, 354, and 355.

Based on record review and staff interview it has been determined that the facility failed to ensure that staff are licensed, certified, or registered in accordance with applicable State laws for 1 of 1 staff reviewed, Staff A. Findings are as follows: Review of a facility reported incident received by the Rhode Island Department of Health on 11/3/2024 revealed that a Certified Medication Technician (CMT), Staff A, worked in the facility on 11/1/2024 and impersonated a licensed nurse. Additionally, it revealed that Staff A attempted to do this a second time on 11/3/2024 but was discovered to not have the proper credentials and was sent home. Review of the Rhode Island Department of Health licensing website revealed Staff A is licensed as a CMT. During a surveyor interview on 11/4/2024 at approximately 10:50 AM with the Director of Nursing Services (DNS) she revealed that Staff A, was scheduled to work as a CMT on 11/1/2024 and 11/3/2024. Additionally, she revealed that on 11/3/2024 Staff A, attempted to conduct the narcotic count and obtain the keys for the licensed nurse medication cart and was stopped by Nursing Supervisor, Staff B. Per the DNS, Staff B discovered that Staff A was a CMT and not a licensed nurse. Additionally, the DNS acknowledged that Staff A did work in the capacity of a licensed nurse on 11/1/2024 during the 3:00 PM to 11:00 PM shift and had completed the narcotic count and obtained the keys for the licensed nurse medication cart. During a surveyor interview on 11/4/2024 at 11:50 AM via the telephone with Licensed Practical Nurse, Staff C, she revealed that she conducted the narcotic count with Staff A on 11/1/2024. Additionally, Staff C revealed that Staff A was unsure how to complete a narcotic count and she instructed her how to do so. Staff C revealed that she felt unsure of Staff A competence but did not speak to the Director of Nursing Services about her concerns. A surveyor interview was attempted with Staff A on 11/4/2024 at 12:02 PM but she did not return the surveyor's call. During a surveyor interview on 11/4/2024 at 12:06 PM with Registered Nurse (RN), Staff D, she revealed that on 11/1/2024 Staff A told her she was a nurse. Per Staff D, Staff A completed the narcotic count and said that she would pass the narcotics and insulins for all of the residents. During a surveyor interview on 11/4/2024 at 12:20 PM via telephone with RN, Staff E, she revealed that she worked on 11/1/2024 with Staff A from 3:00 PM to 11:00 PM. Additionally, Staff E revealed that Staff A completed the narcotic count and was supposed to administer the narcotics and insulin to all of the residents. Staff E revealed that she was unaware that Staff A was not a nurse, however, she did acknowledge that Staff A appeared to be unsure about what she was doing while completing the narcotic count at the end of the night. Review of the November 2024 Medication Administration Record (MAR) for Resident ID #12 revealed oxycodone 5 milligrams (mg, a schedule 2 narcotic) was signed off as administered by CMT, Staff A on 11/1/2024. Review of the November 2024 MAR for Resident ID #13 revealed oxycodone 5 mg was signed off as administered by Staff A on 11/1/2024. During a surveyor interview on 11/4/2024 at approximately 1:30 PM with the DNS and the Clinical Consultant, they acknowledged that Staff A worked on 11/1/2024 and inaccurately portrayed herself as a nurse. Additionally, the DNS and Clinical Consultant acknowledged that administering schedule 2 narcotics is outside of the scope of practice for a CMT.

Based on record review and staff interview it has been determined that the facility failed to keep all residents free from significant medication errors for 5 of 6 residents reviewed relative to failing to administer insulin as ordered, Resident ID #s 1, 4, 5, 6 and 7. Findings are as follows: Review of a facility policy titled, Medication Administration dated 10/11/2017 states in part, It is the policy to ensure that resident medication administration is managed to ensure for resident quality of life, timeliness and safety .Medications are administered within one hour of the time noted on MAR [Medication Administration Record]. 1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, diabetes mellitus. Review of a care plan for Resident ID #1 revealed that s/he is at nutritional risk related to a diagnosis of diabetes with an intervention including, but not limited to, offer diabetic medications as ordered. Review of the physician's orders revealed the following: - An order dated 10/23/2024 to administer 8 units of Humalog insulin (fast acting insulin) between 4:00 PM and 6:00 PM daily. - An order dated 9/18/2024 to administer 20 units of Lantus insulin (long acting insulin) between 7:00 PM and 11:00 PM daily. Review of the November 2024 MAR revealed that Resident ID #1 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed doses of insulin on 11/1/2024. 2. Record review revealed that Resident ID #4 was readmitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #4 revealed that s/he is at risk for unstable blood sugars secondary to a diagnosis of diabetes with an intervention including, but not limited to, administer medication as ordered. Review of a physician's order with a start date of 10/24/2024 revealed to administer 5 units of insulin glargine (long acting insulin to treat diabetes) subcutaneous (below the skin) in the evening. Review of the November 2024 MAR revealed that Resident ID #4 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed dose of insulin on 11/1/2024. 3. Record review revealed that Resident ID #5 was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #5 revealed that s/he is at risk for unstable blood sugars secondary to a diagnosis of diabetes with an intervention including, but not limited to, administer medication as ordered. Review of a physician's order with a start date of 10/21/2024 revealed to administer 5 units of Lantus insulin subcutaneous every evening. Review of the November 2024 MAR revealed that Resident ID #5 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed dose of insulin on 11/1/2024. 4. Record review revealed that Resident ID #6 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #6 revealed that s/he is at risk for unstable blood sugars secondary to a diagnosis of diabetes with an intervention including, but not limited to, administer medication as ordered. Review of a physician's order dated 8/11/2024 revealed to administer 10 units of insulin glargine subcutaneous every evening. Review of the November 2024 MAR revealed that Resident ID #6 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed dose of insulin on 11/1/2024. 5. Record review revealed that Resident ID #7 was readmitted to the facility in August 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #7 revealed that s/he is at nutritional risk related to a diagnosis of diabetes with an intervention including, but not limited to, offer diabetic medications as ordered. Review of a physician order dated 10/21/2024 revealed to administer 20 units of insulin glargine subcutaneous every evening. Review of the November 2024 MAR revealed that Resident ID #7 did not receive his/her scheduled insulin as ordered on 11/1/2024. Record review failed to reveal evidence that the physician was made aware of the missed dose of insulin on 11/1/2024. During a surveyor interview on 11/4/2024 at approximately 1:30 PM with the Director of Nursing Services and the Clinical Consultant, they acknowledged that the above-mentioned insulin doses were not administered for Resident ID #s 1, 4, 5, 6 and 7. Cross Reference- F839

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 relative to following physician's orders for 8 of 8 residents reviewed relative to failing to check blood sugars as ordered, Resident ID #s 1, 4, 6, 7, 8, 9, 10, and 11. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, diabetes mellitus. Review of a physician's order dated 9/27/2024 revealed to check his/her blood sugar before meals and at bedtime daily. Additionally, the order revealed to contact the physician if the blood sugar is less than 70 or greater than 300. Review of the November 2024 Medication Administration Record (MAR) revealed that Resident ID #1 did not have his/her blood sugar checked at 4:30 PM or 9:00 PM on 11/1/2024, as ordered. 2. Record review revealed that Resident ID #4 was readmitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan revealed that s/he is at risk for unstable blood sugars related to a diagnosis of diabetes with an intervention including, but not limited to, check fingerstick blood sugar, as ordered. Review of a physician's order with a start date of 10/24/2024 revealed to administer 5 units of insulin glargine (long-acting insulin to treat diabetes) subcutaneous (below the skin) in the evening. Additionally, the order revealed to check the resident's blood sugar prior to administering the medication. Review of the November 2024 MAR revealed that Resident ID #4's blood sugar was not checked on the evening of 11/1/2024, as ordered. 3. Record review revealed that Resident ID #6 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan for Resident ID #6 revealed that s/he is at risk for unstable blood sugars secondary to a diagnosis of diabetes with an intervention including, but not limited to, check fingerstick blood sugar, as ordered. Review of a physician's order dated 8/2/2024 revealed to administer insulin Lispro (fast acting insulin) per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Review of the November 2024 MAR revealed that the resident did not have his/her blood sugar checked on 11/1/2024 at 4:30 PM, as ordered. 4. Record review revealed that Resident ID #7 was readmitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a physician's order dated 9/25/2024 revealed to administer insulin Lispro per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Review of a physician order dated 9/25/2024 revealed to check the resident's fingerstick blood sugar at bedtime daily. Additionally, it revealed to contact the physician if the fingerstick blood sugar is less than 70 or greater than 400. Review of the November 2024 MAR revealed that the resident did not have his/her fingerstick blood sugar checked on 11/1/2024 at 4:30 PM or at bedtime, as ordered. 5. Record review revealed that Resident ID #8 was readmitted to the facility in October of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a physician's order dated 10/9/2024 revealed to check his/her blood sugar twice daily and report to the physician if less than 70 or greater than 300. Review of the November 2024 MAR revealed that the resident did not have his/her blood sugar checked on 11/1/2024 in the evening, as ordered. 6. Record review revealed that Resident ID #9 was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of the physician's orders revealed the following: - An order with a start date of 2/13/2024 to check blood sugar three times a day 15 minutes prior to meals and notify the physician if blood sugar is less than 70 or greater than 400. - An order with a start date of 1/4/2024 to administer insulin Lispro per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Review of the November 2024 MAR revealed that Resident ID #9's blood sugar was not checked on 11/1/2024 at 4:30 PM, as ordered. 7. Record review revealed that Resident ID #10 was readmitted to the facility in October of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a physician order dated 10/18/2024 revealed to administer insulin Lispro per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Additionally, the order instructed to contact the physician if the resident's blood sugar is less than 70 or greater than 400. Review of the November 2024 MAR revealed that Resident ID #10's blood sugar was not checked on 11/1/2024 at 4:30 PM, as ordered. 8. Record review revealed that Resident ID #11 was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Review of a care plan revealed that s/he is at risk for unstable blood sugars related to a diagnosis of diabetes with an intervention including, but not limited to, check fingerstick blood sugar, as ordered. Review of a physician's order dated 9/3/2024 revealed to administer insulin Aspart (fast acting insulin) per a sliding scale based on the residents fingerstick blood sugar 3 times a day. Additionally, the order instructed to contact the physician if the resident's blood sugar is less than 70 or greater than 400. Review of the November 2024 MAR revealed that Resident ID #11 did not have his/her blood sugar checked on 11/1/2024 at 4:30 PM, as ordered. During a surveyor interview on 11/4/2024 at approximately 1:30 PM with the Director of Nursing Services and the Clinical Consultant they acknowledged that Resident ID #s 1, 4, 6, 7, 8, 9, 10, and 11 did not have their blood sugar checked, as ordered on 11/1/2024. Cross Reference- F839

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 2 residents reviewed for the transcription of admissions orders, Resident ID #1. Findings are as follows: 1) Record review revealed the resident was initially admitted to the facility in January of 2015 with diagnoses including, but not limited to, seizures and anxiety disorder. Record review of a nursing progress note dated 9/11/2024 at 1:41 PM revealed that the resident presented with seizure activity that lasted for approximately seven minutes. The resident was transported to the hospital. Further review revealed the resident was admitted to the hospital on 9/11/2024 with diagnoses including but not limited to; seizure, urinary tract infection (UTI), community acquired pneumonia, and acute hypoxic respiratory failure. The resident was discharged from the hospital on 9/13/2024 and readmitted back to the facility. Record review of a progress note dated 9/14/2024 at 1:13 AM, authored by Registered Nurse (RN), Staff A, revealed that the resident was readmitted to the facility at the beginning of the second shift at approximately 3:00 PM on 9/13/2024. The resident arrived lethargic and was not responsive to verbal stimuli. The resident was arousable with a sternal rub. New order for STAT (immediate) labs obtained due to resident's condition. Record review of the hospital continuity of care form date 9/13/2024 revealed the following medication orders: - Keppra (an anticonvulsant medication prescribed to treat seizures) 1000 milligrams two times daily - Aripiprazole (a medication prescribed to treat depression) 10 mg daily - Aspirin 81 mg once daily - Cefdinir (an antibiotic) 300 mg two times daily for five days - Cholecalciferol 1.25 mg daily - Gabapentin (a medication prescribed to treat and prevent seizures) 600 mg three times daily - Lactulose (a medication prescribed to reduce the amount of ammonia in the blood) 20 grams three times daily - Levothyroxine (a medication prescribed to treat hypothyroidism) 75 micrograms (mcg) once a day on Saturdays and Sundays before breakfast - Levothyroxine 50 mcg daily Monday through Friday before breakfast - Lipitor- 40 mg daily at hour of sleep - Ativan (an antianxiety medication which also can be used to control seizures)1 mg two times daily - Topamax (a medication prescribed to treat and prevent seizures) 200 mg twice daily - Trazodone (a medication prescribed for sleep) 50 mg at hour of sleep - Venlafaxine (a medication prescribed to treat depression) 225 mg daily in the morning with breakfast - Venlafaxine (a medication prescribed to treat depression) 75 mg daily at hour of sleep Record review of the September 2024 Medication Administration Record (MAR) failed to reveal evidence that the resident received the above-mentioned medications on the following dates and times: Keppra - 9/13/2024 - PM dose 9/14/2024- AM dose Ativan - 9/13/2024- PM dose 9/14/2024- AM dose Aripiprazole 9/14/2024- AM dose Cholecalciferol 9/14/2024- AM dose Aspirin- 9/14/2024- AM dose Gabapentin 9/13/2024- afternoon and PM doses 9/14/2024- AM dose Lactulose- 9/13/2024- PM dose 9/14/2024 - AM and afternoon dose Cefdinir- 9/13/2024- PM dose 9/14/2024- AM dose Levothyroxine - 9/14/2024-AM dose Lipitor - 9/13/2024-PM dose Topamax - 9/13/2024-PM dose 9/14/2024-AM dose Trazodone- 9/13/2024- PM dose Venlafaxine- 9/13/2024- PM dose 9/14/2024- AM dose Additional record review revealed a progress note dated 9/14/2024 at 1:40 PM, authored by Licensed Practical Nurse (LPN), Staff B, revealed that the resident's medications were not transcribed into the electronic medication record. The Nurse Practitioner (NP), Staff H, was aware and new orders were received for Keppra 1000 mg STAT, Ativan 1mg STAT, Topamax 200 mg STAT, Abilify 10 mg STAT, Aspirin 81 mg STAT and Gabapentin 600 mg STAT. Record review of the September 2024 MAR revealed the resident received the STAT medications at approximately 1:45 PM on 9/14/2024. This indicates that this resident did not receive any medications including his/her anti-seizure medications from 3:00 PM on 9/13/2024 until approximately 1:45 PM on 9/14/2024. Further record review revealed a progress note dated 9/14/2024 at 4:05 PM, authored by LPN Staff B, that the resident presented with seizure like activity and convulsions. The first episode lasted approximately 4 minutes and the resident then experienced a second seizure. After the second episode, Staff B called the NP on call, Staff I, and received an order to send the resident out to the hospital via 911. Record review revealed the resident was admitted to the hospital on 9/14/2024 with diagnoses of seizure and acute respiratory failure with hypoxia. During a surveyor interview on 9/23/2024 at 3:54 PM with NP, Staff H she revealed that on 9/14/2024 at approximately 1:30 PM she was reviewing Resident ID #1's admission from home, and she noticed that there were no medications scheduled for the resident and contacted the facility for clarification. Staff H spoke with Staff B, who was working in the facility at that time. Staff B confirmed Resident ID #1 was in the facility and revealed that his/her admission was never completed, which is why s/he had no medication orders. NP, Staff H then gave Staff B STAT orders to administer Keppra, Ativan, Topamax, Abilify, Aspirin and Gabapentin. Staff H acknowledged that the resident should have received all his/her medications listed on the hospital discharge paperwork as long as s/he was alert. She also acknowledged that this resident did not receive any of his/her medications on the evening of 9/13/2024 and the morning of 9/14/2024 and experienced seizure like activity and was sent to the hospital for evaluation on 9/14/2024. During a surveyor interview on 9/17/2024 at 1:45 PM with the Director of Nursing Services (DNS), she revealed that there is a protocol for the admission/readmission process which is included in every admission binder. Additionally, she was unable to provide evidence of an admission binder for Resident ID #1. Record review of a written statement authored by RN, Staff A dated 9/14/2024, indicates that she was behind on her nursing tasks on the evening shift of 9/14/2024 and the NP was in the building and two admissions were expected. She expressed her concerns to the DNS. The DNS told her that she would complete the admission orders, head to toe assessments, skin checks, and vital signs for both admissions. During a surveyor interview on 9/18/2024 at 12:19 PM with Staff A, she revealed that she was the nurse that worked the 3:00 PM to 11:00 PM shift on 9/13/2024, and acknowledged that she did not complete Resident ID #1's admissions to the facility as she was told by the DNS that the DNS was going to complete the admission for Resident ID #1. During a subsequent interview with the DNS on 9/23/2024 at 4:15 PM, she indicated that she did not complete the admission for Resident ID #1. She acknowledged that Resident ID #1 did not receive any of his/her medications including his/her anti-seizure medications on the evening of 9/13/2024 or the morning of 9/14/2024, and the resident was sent to the hospital for evaluation on 9/14/2024. 2) Record review revealed Resident ID #1 was readmitted to the facility on [DATE], from the hospital. Record review of the hospital paperwork indicates the resident is being treated for a UTI with an order for Cefdinir 300 mg capsules. Take 1 capsule by mouth two times a day, for 3 days. Record review failed to reveal evidence that the resident received the Cefdinir on 9/16/2024 during the 3:00 PM to 11:00 PM shift. During a surveyor interview on 9/18/2024 at 10:33 AM with RN, Staff G she revealed that she was the primary nurse on the 3:00 PM to 11:00 PM shift on 9/16/2024. She acknowledged that the resident did not receive the evening dose of the Cefdinir on 9/16/2024 as the DNS told her to change the start date to 9/17/2024. During an interview with the DNS on 9/23/2024 at 4:15 PM she indicated that she did not tell Staff G to change the administration date to 9/17/2024.

Based on record review, witness, resident, and staff interviews, 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 is defined as the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way .Procedure .The Licensed Nurse will conduct an Elopement Risk Screen on admission, quarterly, and upon change of condition .A care plan will be developed and implemented .The Licensed Nurse will have visual contact with each resident .and/or know where each resident is . Record review of a facility policy titled Wandering Management System states in part .A wander management is system is used for residents/patients at risk for elopement as assessed and determined by the interdisciplinary team .The wander management system bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed . Surveyor observation on 6/13/2024 at approximately 9:00 AM revealed the facility is equipped with a wander guard system. When a resident wearing bracelet attempts to leave the facility an alarm will go off alerting the staff. Record review revealed, the resident was readmitted to the facility in September of 2023 with diagnoses including, but not limited to, dementia, cognitive communication deficit and chronic obstructive pulmonary disease. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating s/he has severely impaired cognition. Record review of an incomplete elopement assessment dated [DATE] revealed that the resident is at minimal risk for elopement and an elopement care plan is not needed at this time. Although, the elopement assessment indicated that an elopement care plan was not needed at this time, record review revealed a baseline care plan dated 9/29/2023 was initiated . The baseline care plan indicated that the resident was at risk for elopement with an intervention to Re-direct from elevator and doorways if resident is seeking to exit. Engage in diversional activities and reassure as needed. When resident begins to wander or become restless provide basic needs and comfort measures. Record review of a progress note dated 11/20/2023 states in part, .Observed outside on patio, near gate. Question the need of a Wander guard. Elopement observation filed. Record review failed to reveal evidence that the facility completed an investigation to determine how the resident was able to get outside on the patio near the gate. Additionally, the facility was unable to provide evidence that a wander guard was implemented after the incident on 11/20/2023 per the facility policy. Record review of a facility document titled Elopement Evaluation dated 11/20/2023 indicated in part .Resident is cognitively impaired, poor decision-making skills, and/or pertinent diagnosis .History of wandering (into unsafe areas) .Resident is at risk for elopement .Elopement care plan initiated . Record review of the care plan failed to reveal evidence it was updated or that any new interventions were implemented following the incident on 11/20/2023. Further record review failed to reveal evidence that quarterly elopement evaluations were completed in February and May 2024, per the facility policy. Review of a facility reported incident sent to the Rhode Island Department of Health on 6/11/2024 revealed that on 6/9/2024 Resident ID #1 was observed in the road by a person in the community who called the neighboring facility. Record review of facility investigation statements for the 6/9/2024 incident indicate, staff recall seeing the resident between 9:00 AM and 9:30 AM, during morning care, but no one witnessed the resident exit the facility. During a surveyor interview on 6/11/2024 at 10:35 AM, with the witness who works at a neighboring facility, she revealed that she received a phone call of concern at approximately 9:00 AM on 6/9/2024 from an unknown caller. The caller indicated that an older person in a wheelchair was on the main road. When the witness arrived at the road, she noted Resident ID #1 was struggling to self-propel in the lane of traffic with several cars going around him/her. S/he had oxygen on, but the nasal cannula was on his/her forehead. The resident was not wearing shoes only slipper socks. The resident indicated that s/he resided at Crystal Lake and agreed to return with her. She assisted the resident back to Crystal Lake by pushing him/her in the wheelchair and spoke to the nurse on duty to report the incident. She further indicated the nurse was unaware that the resident had eloped from the facility. During a surveyor interview on 6/11/2024 at approximately 10:45 AM, with Nursing Assistant, Staff A, she revealed that on 6/8/2024, the day before this elopement, she witnessed Registered Nurse, Staff C, escorting the resident back from the front exit door. At that time the resident was in-between the two doors leading to the parking lot. She further revealed that she reported this to the Director of Nursing Services (DNS) on 6/10/2024, after s/he had already successfully eloped from the building on 6/9/2024 and was found in his/her wheelchair in the road. Record review failed to reveal evidence that Staff C reported the incident from 6/8/2024 to the DNS, or that any interventions were put into place to mitigate the resident from eloping, or that the assessment and care plan were updated. The surveyor made three attempts to contact Staff C. Staff C failed to return any of these phone calls. During a surveyor interview on 6/11/2024 at 12:10 PM with the DNS, she acknowledged that Resident ID #1 should have been assessed after the attempted elopement on 6/8/2024, which would include a progress note, an updated elopement evaluation, and an updated care plan. She further acknowledged that the facility policy was not followed, and a quarterly elopement observation should have been completed in February and May 2024. Additionally, she could not provide evidence that the facility ensured that the resident received adequate supervision to prevent an elopement. The facility's failure to provide adequate supervision and interventions, complete elopement assessments and update the care plan placed a cognitively impaired resident who was assessed as an elopement risk at risk for more than minimal harm, injury, impairment, or death These failures resulted in this resident exiting the facility unsupervised in his/her wheelchair, without shoes, self-propelling in the middle of a high traffic roadway, unsupervised by staff. Several cars were seen going around the resident to avoid hitting him/her.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 2 of 2 residents reviewed for pudding thick liquids (thickest of fluid consistency to resemble pudding), Resident ID #s 19 and 16 and 2 of 3 residents reviewed for nectar thick liquids (thicker than water, falls slowly from a spoon), Resident ID #s 12, and 100. Findings are as follows: 1a. Record review revealed Resident ID #19 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dysphagia (a condition resulting in difficulty swallowing food or liquid), aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, vomit) and stroke. Review of a care plan last revised on 1/31/2024 states in part, [Resident] is at nutritional risk .dysphagia, WT [weight] loss, dependent eater .Diet a/o [as ordered]. Review of a physician's order dated 4/26/2024 states, House, Pudding Thickened, Pureed. Special Instructions: NO STRAWS. ONLY NURSE TO PREPARE THIN LIQUIDS TO PUDDING CONSISTENCY. Record review revealed a physician's order dated 4/19/2024 for doxycycline hyclate (an antibiotic that treats various bacterial infections) 100 mg capsules. Take one capsule by mouth twice daily from 4/19/2024 through 4/29/2024. Review of a progress note dated 4/22/2024 authored by the facility Nurse Practitioner, states in part, .Limited ability to tolerate oral intake with assist. Lungs diminished and coarse. Weak/ineffective cough with occasional sputum unable to clear from oral at this time .Patient currently being treated for Aspiration PNA/Leukocytosis [higher than normal level of white blood cells in the blood]/Sepsis [blood poisoning] with antibiotics . Which indicated that the above-mentioned antibiotic order was related to the resident aspirating. Review of a progress note dated 4/25/2024 authored by Registered Nurse (RN), Staff C, states in part, .Resident had some difficulty swallowing and needed to be suctioned multiple times. Resident consumed about 50% of dinner and 360 mLs [milliliters] of fluid. Atropine [medication used to decrease saliva production] was administered with good effect. During a surveyor observation on 4/26/2024 at 10:10 AM with Licensed Practical Nurse (LPN), Staff A, she crushed the resident's medication in applesauce, then added one nectar thickener packet with instructions that indicate to add the packet to 4 ounces of fluid. The nurse was observed to add the nectar thickener packet to 8 ounces of fluid and continued to mix the fluid to a nectar thickened consistency to serve to the resident until stopped by the surveyor, as the order is for pudding consistency. The mixed fluids presented to the surveyor during this observation fell slowly from the spoon and did not hold its shape without flowing, like a pudding consistency should. During a subsequent interview with Staff A, she was unaware that the ordered fluid consistency for Resident ID #19 was pudding thick. Additionally, she was unable to determine how much thickener to mix in the fluid to reach pudding thick consistency. During a surveyor observation on 4/26/2024 at 1:06 PM with LPN, Staff B, she was observed to add one nectar thickener packet with instructions that indicate to add the packet to 4 ounces of fluid. Staff B was observed to add the nectar thickener packet to 8 ounces of fluid and continued to mix the fluid to a nectar thickened consistency to serve to the resident until stopped by the surveyor. Additionally, Staff B was unaware that the ordered fluid consistency for Resident ID #19 was pudding thick. Furthermore, she was unable to determine how to thicken the fluid to reach pudding thick consistency. During a surveyor interview on 4/26/2024 at 1:09 PM with the Director of Nursing Services (DNS) she acknowledged that the staff were unaware of how to thicken liquids to the correct consistency to achieve pudding thick. Additionally, the DNS was unaware how to achieve the appropriate consistency and could not locate the appropriate product to achieve this consistency in the facility. During a surveyor observation on 5/1/2024 at 8:50 AM with RN, Staff, L in the presence of the Compliance Monitor, he was attempting to thicken Resident ID #19's fluids and breakfast food to honey thick versus the pudding thick as ordered until the Compliance Monitor intervened. The facility's failure to provide food prepared in a form designed to meet the individual needs for residents requiring thickened fluids, places the residents at risk for serious harm, death or impairment, as Resident ID #19 was diagnosed with aspiration pneumonia and had swallowing issues which required the resident to be suctioned by facility staff. 1b. Record review revealed Resident ID #16 was readmitted to the facility in March of 2019 with diagnoses including, but not limited to, dysphagia and traumatic brain injury (TBI). Review of a physician's order dated 4/27/2024 states, Resident to be assisted with meals by nurse only - drinks pudding consistency to be prepared by the nurse only. Review of a physician's order dated 9/25/2023 states, Resident is to be totally 1:1 assisted with all meals, snacks, and supplements. No Straws / No cartons left with resident. ALL liquids at PUDDING-THICK. Review of a care plan last revised on 3/15/2024 states in part, .[Resident] is at nutritional risk r/t [related to] hx [history] TBI, dysphagia, poor vision, dependent eater. Additionally, it reveals the following interventions: Diet as ordered, liquid consistency is pudding to be prepared and administered by nurse only. Review of a progress note dated 4/29/2024, states in part, .resident is continuing to cough a little with pudding thick liquids. resident is on the most restrictive diet . During a surveyor observation on 5/1/2024 at approximately 9:00 AM RN, Staff L was observed thickening Resident ID #16's breakfast with food thickener. He was observed following the instructions for a 4 ounce cup versus the 8 ounce cup he was actually using. Staff L was unaware of why the fluid was not reaching the correct thickness as the fluid fell from a spoon and did not present as pudding like consistency, until it was brought to his attention by the surveyor that the cup was larger. Additionally, Staff L began mixing the fluids on the tray at approximately at 9:00 AM and was not finished preparing it until approximately 10:00 AM, causing the food to be cold and the fluids thickened beyond the pudding thick consistency . During the above-mentioned observation, Staff L was observed to be utilizing a product called Thick-It to thicken the fluids to a pudding like consistency. Review of the manufacturer's instructions state in part, Mixing Instruction .Pour 4 fl oz [fluid ounces] of cold or hot liquid into a glass .Slowly add level measured thickener to liquid, stirring with fork or whisk as you pour .stir briskly until thickener has dissolved .before serving let water and juices stand for at least 1 minute. Let milk and supplements stand for 5-10 minutes, stir and serve .consume within 30 minutes of mixing . 2a. Record review revealed Resident ID #12 was readmitted to the facility in May of 2022 with diagnoses including, but not limited to, Parkinson's and dysphagia. Review of a physician's order dated 4/22/2024 states, House, Nectar Thickened, Mechanical Soft. Special Instructions: mechanical soft, Nectar thick liquids NO STRAWS. All liquids at Nectar thick (supplements, gravies, sauces, milk/cold cereal, soup broth, magic cup) Record review of a progress note dated 4/10/2024 authored by the facility Dietician revealed, diet texture downgraded to Puree, Nectar thick liquids on 4/8/2024 related to dysphagia. Receiving antibiotic therapy for pneumonia. During a surveyor observation of the breakfast meal on 4/29/2024 at approximately 9:35 AM the resident was observed with a large pink container filled with thin fluid and 3 Styrofoam cups filled with a thin yellow fluids, all of which contained a lid with a straw. During a subsequent interview with the resident, s/he revealed, s/he was drinking the thin beverages with straws provided by the staff. During a surveyor interview on 4/29/2024 at approximately 9:35 AM, with Registered Nurse, Staff M, she acknowledged the resident was provided thin fluids that were not thickened to a nectar thick consistency and should not contain straws per the physician's order. Additionally, she removed the incorrect fluids and provided nectar thick fluids for the resident. During a surveyor interview on 4/29/2024 at approximately 10:00 AM with the Infection Preventionist, she was unable to provide evidence that the resident was served beverages and diet prepared in a form designed to meet individual needs. 2b. Record review revealed Resident ID #100 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, cerebral infarction (stroke) and dysphagia. Record review of a physician's order dated 4/25/2024 states , House No Banana, OJ, Prune, Nectar Thickened, regular Special Instructions: No Sugar Packet/ Nectar Thick Liquid . During a surveyor observation of the lunch meal on 4/26/2024 at approximately 12:58 PM of the resident, in the presence of his/her spouse, was observed with an 8-ounce cup of water and an 8-ounce cup of ginger ale both which were thin consistency. Additionally, there were two packets of nectar thickener packets on the tray. The resident's spouse was observed adding one packet of thickener to each drink. During a subsequent interview with the resident's spouse, s/he did not know how to mix the packets and denied receiving education from the staff related to the consistency of the resident's diet. Review of the instructions of the thickener package on the resident's tray revealed to add one packet of thickener to 4-ounces of liquid and stir until completely dissolved. During a surveyor interview on 4/26/2024 at approximately 1:02 PM, with LPN Staff A , she acknowledged that the resident beverages were in an 8 ounce cup and not in a 4 ounce cup, which indicated that the resident was not provided enough thickener packages to achieve the ordered consistency. Additionally, she revealed she was not aware of the amount of fluid required per packet of thickener per the manufacturer's instructions. During a surveyor interview on 4/30/2024 at approximately 8:40 AM, with the Rehab Director, she revealed the staff should be preparing the residents fluids per the physician's order. Additionally, she revealed the family member was not educated as it is the responsibility of the staff to prepare the fluids to ensure it is the right consistency. She was unable to explain why the liquids were not thickened by staff prior to providing the tray to the resident. The facility's failure to provide food prepared in a form designed to meet the individual needs for residents requiring thickened fluids, places the residents at risk for serious harm, death or impairment. Surveyor observations revealed that staff were providing the resident with the incorrect fluid consistency diet until the surveyor and/or Compliance Monitor intervened to ensure the safety of the resident. Cross reference F 726

46715 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, for 2 of 2 residents reviewed for the utilization of the facility bowel protocol, Resident ID #s 47 and 39, and 1 of 1 resident reviewed for wound care observation, Resident ID #4. Findings are as follows: 1. According to Nursing Health Assessment Clinical Judgement Approach, 4th edition, states in part, .Nurses use assessment information to identify patient outcomes .Constipation: Make sure to monitor last bowel movement and administer bulk stool softeners and laxatives as ordered . Review of a facility provided policy titled, Bowel Evacuation Protocol states in part, Policy: The facility has the responsibility to ensure that each resident develops regular bowel habits .The purpose is to prevent impaction and incontinence .Procedure: If the resident has had no bowel movement for 9 consecutive shifts, begin the bowel protocol on the next 3:00 p.m. - 11:00 p.m. shift. The bowel protocol is to give Milk of Magnesia (MOM) on the 3:00 p.m. to 11:00 p.m. shift. If the MOM is ineffective, then the resident is to receive a Bisacodyl suppository on the 11:00 p.m. to 7:00 a.m. shift. If the Bisacodyl suppository is ineffective, then the resident is to receive a Fleets enema on the 7:00 a.m. to 3:00 p.m. shift . a. Record review revealed that Resident ID #47 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to the buildup of plaque) and renal cancer. Review of a Bowel Movement Report for February of 2024 revealed, the resident's last recorded bowel movement was [DATE] at 10:40 PM. Additional review revealed that the resident did not have a bowel movement for 5 days or 14 consecutive shifts. Review of a progress note dated [DATE] revealed, the resident had not eaten lunch or dinner and had one episode of vomiting. Review of a progress note dated [DATE] at 6:00 AM revealed, that the resident complained of pain to his/her coccyx and was administered as needed Percocet (an opioid analgesic which includes constipation as a side effect) with only minimal effect. Additional review revealed that the resident refused to be repositioned due to increased pain when s/he was moving. Review of a progress note dated [DATE] on the 7:00 AM - 3:00 PM shift revealed that the resident complained of pain to his/her chest, abdomen, arms, and rectum throughout the day. It further revealed that the resident had no bowel sounds and staff was unaware of when his/her last bowel movement was. The resident received a fleet enema without any results and stool was visualized in his/her rectum. The note indicated that the doctor was informed of the resident's continued decline and received orders for labs, a KUB (an X-ray examination that allows doctors to assess the organs of your urinary and gastrointestinal systems) and medications. Review of a progress note dated [DATE] revealed, the resident expired at approximately 4:35 PM. Review of a Xray result report titled Patient Report dated [DATE] revealed, the resident had a colonic ileus (temporary condition where movement in the intestines either slows down or stops). Record review revealed that the resident did not receive Milk of Magnesia on [DATE] after 9 consecutive shifts without a bowel movement per the facility policy. Additional record review revealed that the resident did not receive a Bisacodyl suppository on the 11:00 PM to 7:00 AM shift per the facility policy. During a surveyor interview on [DATE] at 9:36 AM, with Registered Nurse, Staff E, she revealed that when she came on shift that the nurse from the prior shift revealed that there was something going on with Resident ID #47 and that s/he did not look good. She revealed that the resident was minimally responsive and was having some difficulty with breathing. She revealed that the resident also did not have bowel sounds. Additionally, she was unaware if the resident's bowels were assessed prior to her shift. During a surveyor interview on [DATE] at approximately 10:15 AM with the Medical Director, she revealed that she would expect the facility staff to follow the bowel protocol for all residents that require it. Additionally, she revealed that she could not recall if the staff had notified her of the resident not having a bowel movement for 5 days or 14 consecutive shifts. During a surveyor interview on [DATE] at 12:00 PM with the Infection Preventionist in the presence of the Compliance Monitor, she acknowledged that the bowel protocol was not followed for the resident and that the resident had a colonic ileus (a condition where your intestine can't push food and waste out of your body) at the time of his/her passing. b. Record review revealed that Resident ID #39 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, prostate cancer and protein calorie malnutrition. Review of a Bowel Movement Report revealed the resident's last recorded bowel movement was [DATE] on the first shift. No other bowel movement was recorded for 12 days or 36 consecutive shifts. Record review failed to reveal evidence that the staff initiated the bowel protocol per the facility policy, despite the resident not having a bowel movement for 12 days. During a surveyor interview on [DATE] at 10:36 AM with the resident, s/he revealed that s/he had a bowel movement on [DATE] and that s/he currently had no pain or discomfort. Additionally, s/he revealed that the staff had not assessed the resident to determine if s/he had any bowel concerns. Furthermore, the resident revealed that s/he wanted to speak with the nursing staff due to his/her concerns with constipation, as the resident was unaware that s/he could request medication to assist with constipation. During a surveyor interview on [DATE] at 10:46 AM with Registered Nurse, Staff D, she acknowledged that the resident did not have a bowel movement documented for approximately 12 days. Additionally, she revealed that the resident should have been started on the bowel protocol on day 3 with no bowel movement. Furthermore, she acknowledged that the resident was not administered any medication per the bowel protocol policy. During a surveyor interview on [DATE] at approximately 12:00 PM with the Medical Director, she revealed that she would expect the staff to initiate the bowel protocol for any resident that would require it. During a surveyor interview on [DATE] at 1:45 PM with the IP in the presence of the Compliance Monitor, she acknowledged that the last recorded bowel movement for the resident was on [DATE] and that the bowel protocol had not been initiated per the facility policy . 2. Review of a facility provided policy titled, Wound Care Policy states in part, .Licensed nurse will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of treatment .At each dressing change the wound will be assessed and documentation if wound has changed will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound condition. At least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present . Record review revealed that Resident ID #4 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, osteomyelitis (infection of the bone) of the right ankle and foot and peripheral vascular disease. Review of a physician's order for wound care dated [DATE] revealed, the dressing is to be changed three times a week with the following instructions. Wound Care--Cleanse wounds RLE [right lower extremity] with Vashe [antibacterial wound cleanser] and dry. Apply A and D [ointment]. Apply Hydrofera Blue [antibacterial wound dressing- needs to be moistened prior to applying] and kerramax [absorbent dressing]. Secure with Kerlix and hypafix tape three times per week. Record review failed to reveal evidence of documentation to include, how many wounds the resident had, where the wounds were located on the right lower extremity, the type of wounds, descriptions of the wounds or measurements of the wounds. Additional record review failed to reveal evidence that a care plan had been developed or implemented relative to the wounds on the right lower extremity. During a surveyor observation on [DATE] at 12:06 PM with Registered Nurse (RN), Staff E, of the resident's wound care the following was observed: -Three wounds were observed on the resident's right lower extremity, a large wound to his/her right medial (middle) ankle, a wound to his/her right heel and a wound to his/her right lateral (away from, the middle of the body) shin. -Staff E cleansed the wounds with skintegrity wound cleanser and not Vashe wash, as ordered. She did not apply A and D ointment to wounds, as ordered. Additionally, Staff E applied the hydrofera blue wound treatment without moistening prior to applying to wound bed. Lastly, Staff E was observed to dress the right medial ankle and the right lateral shin but did not dress the right heel, although assessing and acknowledging that there was a wound there. During a surveyor interview with Staff E, directly following the above observation, she acknowledged that she did not follow the physician's order as written. She did not cleanse the wound with vashe wash and did not apply A and D ointment. Additionally, she acknowledged that she did not moisten the hydrafera blue wound treatment prior to applying it to the wound bed. During a surveyor interview on [DATE] at approximately 10:30 AM with the Medical Director, she revealed that she would expect the staff to follow the physician's order for wound care. During a surveyor interview on [DATE] at approximately 2:15 PM with the IP in the presence of the Compliance Monitor, she acknowledged that Resident ID #4's medical record did not include the appropriate documentation for the wound that included, a treatment order for each wound, descriptions and measurements for each wound, and a care plan for wounds. Additionally, she revealed that she would expect the staff to follow the physician's order for wound care . 43376

Based on record review and staff interview, it has been determined that the facility failed to provide a minimum of 12 hours per year of in-service training to ensure the continuing competence of nurse aides for 3 of 3 Nurse Aides (NA) reviewed, Staff H, I and J. Findings are as follows: Record review of Staff H, I and J's employee records revealed that they have all worked in the facility greater than one year. Additional review failed to reveal evidence of a minimum of 12 hours per year of in-service training. During a surveyor interview on 4/30/2024 at 12:39 PM with the Administrator during the staffing task she acknowledged that annual 12-hour in-service training for NAs was not provided for the above-mentioned staff members. 47279

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 3 of 3 residents reviewed for antibiotic use, Resident ID #s 26, 29, and 39. Findings are as follows: According to the Centers for Disease Control and Prevention document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available .Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions .Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT [days of therapy] . 1. Record review revealed that Resident ID #26 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, diabetes and chronic obstructive pulmonary disease. Record review revealed a physician's order for Cipro (an antibiotic) 500 milligram (mg) capsule daily from 4/19/2024 through 4/26/2024 for a urinary tract infection (UTI). Record review failed to reveal evidence that the facility implemented an antibiotic review process, also known as an antibiotic time-out to determine if the antibiotic is still indicated or adjustments should be made. 2. Record review revealed that Resident ID #29 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and need for assistance with personal care. Record review revealed a physician's order for Augmentin (an antibiotic) 500/125mg tablet twice a day from 4/27/2024 through 5/1/2024 for UTI. Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made. 3. Record review revealed that Resident ID #39 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, malignant neoplasm of prostate (prostate cancer) and depression. Record review revealed a physician's order for Cipro (an antibiotic) 500 mg capsule twice a day from 3/17/2024 through 3/23/2024. Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made. During a surveyor interview on 4/29/2024 at 10:09 AM with the Infection Preventionist, she revealed that she does not have a process for reviewing residents receiving antibiotics, or obtaining of laboratory or diagnostic testing to determine if the antibiotic is still indicated or adjustments should be made, for current residents in the facility when started on an antibiotic.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store food in accordance with professional standards of food service safety relative to the main kitchen and kitchenette. Findings are as follows: 1. Record review of the Rhode Island Food Code, 2018 Edition, states: Section ,d+[DATE].17 Ready-to Eat, Time/Temperature Control for Safety, Date Marking .(B) .(1) The day the original container is opened in the Food establishment shall be counted as Day 1 . Section ,d+[DATE].11 Food Labels states, .(B) Label information shall include: (1) The common name of the food . During the initial tour of the main kitchen on [DATE] at 8:39 AM revealed the following observations in the walk-in refrigerator: - A long rectangular pan with sliced zucchini and squash, not covered or labeled with a small container resting directly on top of the squash medley - An opened clear plastic bag of shredded yellow cheese, not labeled or dated - An opened clear plastic bag of white shredded cheese, not labeled or dated Following the above observations, the Food Service Director (FSD) was unable provide evidence that the above items were labeled and dated or that the squash medley was kept free from contamination. 2. During the initial tour of the main kitchen on [DATE] at 8:39 AM revealed the following observations in the dry storage room: - 9 bags of pearled barley with an expiration date of [DATE] - 1 can of sausage gravy with an expiration date of [DATE] During a surveyor interview with the FSD immediately following the above observations he acknowledged the above items were expired. 3. During the initial tour of the main kitchen on [DATE] at 8:39 AM revealed the following observations in the dish room and in the wash room respectively: - the three bay sink pipe was leaking - 4 kick board ceramic tiles were missing and several separating from the wall where ants were observed During a surveyor interview on [DATE] immediately following the above observation, the FSD revealed pest control was at the facility last week to spray in the kitchen. Additionally, he let maintenance know that the pipe on the three bay sink needed repair as well as the kick board ceramic tiles. Review of the work order for the three bay sink revealed it was created on [DATE] by the FSD and indicated that a plumber was needed to fix the issue. Review of the work order for the repair of the ceramic tiles revealed it was created on [DATE] by the FSD and indicated that the facility was waiting on contractors to give quotes for the repair. During a surveyor interview with the Maintenance Director on [DATE] at 8:07 AM, he revealed that within the next week a plumber will be coming out to repair the sink after the surveyor brought this to his attention. Additionally, he revealed he is getting a floor contractor to come in to fix the ceramic tiles. 4. Record review of the Rhode Island Food Code 2018 edition, Section ,d+[DATE].112 states in part, Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 [degrees]C [Celsius] 194 degrees F [Fahrenheit] . During a surveyor observation on [DATE] at 10:23 AM with Dietary Aide, Staff O, of the hot water dish machine, the final rinse cycle reached 200 degrees F. A subsequent observation at 10:40 AM in the presence of the FSD, the final rinse cycle reached 195 degrees F. Review of the hot water dish machine log for April of 2024 revealed that on [DATE] for supper the temperature of the final rinse cycle reached 195 degrees F. Review of the hot water dish machine log for March of 2024 revealed the following dates when the temperatures of the final rinse cycle reached above 194 degrees F for supper: - [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and on [DATE]. During a surveyor interview on [DATE] at approximately 11:00 AM with the FSD, he revealed that he was unaware that the temperature of the final rinse cycle should not exceed 194 degrees F. Additionally, he revealed he would inform maintenance of the concern and the facility would utilize the three bay sink and use paper products until the dish machine is fixed. During a surveyor observation on [DATE] at 10:07 AM in the presence of Dietary Aide Staff P, the temperature of the final rinse cycle read 200 degrees F. During surveyor observations on [DATE] during the breakfast meal revealed the meals continued to be served on Styrofoam plates. 5. During a surveyor observation on [DATE] at 9:15 AM of the kitchenette resident refrigerator, revealed a thermometer temperature reading of 48 degrees F. Review of a form titled, UPPER LEVEL REFRIGERATION TEMPERATURE CHART attached to the refrigerator states, PLEASE CHECK REFRIGERATION TEMPERATURES AT THE TIMES SPECIFIED AND INITIAL. IF TEMP IS 40 OR OVER, NOTIFY THE SUPERVISOR ON DUTY. Further review of the form reveals the refrigeration temperatures are taken twice a day, once at 7:00 AM and then at 7:00 PM. Record review of the refrigerator temperature chart reveals 17 temperatures out of 59 were documented as being over 40 degrees F. There was no evidence that the supervisor on duty was notified of the temperatures of 40 degrees. During a surveyor interview with the FSD following the above observation, he was unable to provide evidence that the refrigerator was maintained at a safe temperature.

Based on record review, resident and staff interview, it has been determined that the facility failed to ensure nourishing snacks were offered to residents who desired them outside of scheduled meal service times for 5 of 5 residents reviewed for bedtime snacks, Resident ID #s 3, 7, 14, 21, and 99. Findings are as follows: Review of the meal service times revealed that breakfast is served at 8:00 AM, lunch is served at 12:00 PM, and supper is served at 4:30 PM. This indicates there is a 15 1/2 hour time span between a substantial evening meal and breakfast the following day. During surveyor observations of the breakfast meal throughout the survey from 4/26/2024 through 4/30/2024, breakfast was observed to be served no earlier than 8:10 AM. Record review of the menu for week 3 revealed the following snacks at night: Sunday: orange drink 1/2 cup and 1 cookie Monday: lemonade 1/2 cup and 3 vanilla wafers Tuesday: blush punch 1/2 cup and 1 pkg (package) of graham crackers Wednesday: orange drink and 1 assorted cookie Thursday: lemonade 1/2 cup and 3 vanilla wafers Friday: blush punch 1/2 cup and 1 pkg of graham crackers Saturday: orange drink and 1 assorted cookie Record review of the menu for week 4 reveals the same snacks and drinks as above. Week 3 and week 4 menus were used during the survey. During a resident council meeting held on 4/29/2024 at 11:10 AM, residents in attendance indicated bedtime snacks were not offered. These residents further indicated that they have to ask if they want a bedtime snack but would prefer to be offered a snack. During a surveyor interview on 4/29/2024 at 8:47 AM with Resident ID #99, s/he revealed that s/he would like to be offered a bedtime snack every night and is not. Record review of the resident's intake section for Bedtime Snack from 4/12/2024 to 4/26/2024, failed to reveal evidence that a bedtime snack was documented as received. During a surveyor interview on 5/1/2024 at approximately 10:30 AM with Resident ID #21, s/he indicated that it would be nice to have a bedtime snack offered to him/her. Record review of the resident's intake section for Bedtime Snack from 3/26/2024 to 4/26/2024, failed to reveal that a bedtime snack was documented as received. During a surveyor interview on 5/1/2024 at 8:47 AM with Resident ID #7, s/he revealed that no one passes out snacks at night and that s/he would like to be offered one. S/he further revealed that s/he is 6 feet 5 inches tall and would like a snack at night. Record review of the resident's intake section for Bedtime Snack from 1/1/2024 to 5/1/2024, failed to reveal evidence that bedtime snacks were documented as received. During a surveyor interview on 5/1/2024 at 10:20 AM with Resident ID #3, s/he revealed that s/he likes to be in bed by 7:00 PM. S/he further revealed s/he used to get a snack at night when the facility had a refreshment girl that went room to room delivering snacks after dinner. S/he indicated that no one passes out snacks anymore, so now s/he buys their own. During a surveyor interview on 5/1/2024 at 10:25 AM with Resident ID #14, s/he revealed that snacks after dinner are not offered, you have to ask for them. S/he indicated that there used to be someone that passed them out and would like them offered to him/her again. During a surveyor interview on 5/1/2024 at 8:08 AM with Nursing Assistant, Staff N, she revealed that if a resident wants a snack they can come to the nurses' station. Additionally, she added that no one passes them out. During a surveyor interview on 5/1/2024 at 8:17 AM with the Infection Preventionist, she acknowledged that there is more than 14 hours between a substantial evening meal and breakfast the following day. Additionally, she revealed not every resident is able to go to the nurses' station to get a snack. Furthermore, she revealed there is no designated person at night to go room to room to pass out the drinks and snacks and was unable to provide evidence that every resident is offered a nourishing snack at night. During a surveyor interview on 5/1/2024 at approximately 11:40 AM with the Registered Dietitian, she indicated that a nourishing snack for almost a 16-hour time span would include 2 food groups. Additionally, she acknowledged that one cookie and a 1/2 cup of lemonade is not a nourishing snack.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections relative to the disinfection of glucometers (a device used to monitor blood glucose). Additionally, the facility failed to ensure that staff utilized Personal Protective Equipment (PPE) properly for 2 of 2 residents reviewed relative to foley catheter (a device that drains urine from your bladder into a collection bag) care and multi drug resistant organism (MDRO), Resident ID #2 and #33. Findings are as follows: 1. Record review of a facility policy titled Glucose Monitoring Equipment states in part, .Glucometers will be cleaned with a bleach wipe and/or manufacturer guidelines after each use . During a surveyor observation on 4/26/2024 at approximately 9:28 AM, Registered Nurse, Staff E, was observed checking a resident's blood glucose level, she proceeded to remove her used gloves, utilize hand sanitizer and exit the room. She then continued to check another resident's blood glucose level immediately after and then placed the glucometer in a basket on top of clean supplies in the nurse's medication cart, failing to clean the glucometer after each use. During a surveyor interview on 4/26/2024 immediately following the above observations with Staff E, she revealed that the facility does not have the correct wipes to clean the glucometers and was unsure how long it has been since they have had them available. During a surveyor interview on 4/26/2024 at 9:45 AM with the Director of Nursing Services, she revealed the facility does have the correct wipes in the basement and it would be her expectation that the staff would go and get them prior to using the glucometer. 1b. During a surveyor observation on 5/1/2024 at approximately 8:21 AM, Registered Nurse, Staff Q, was checking a resident's blood glucose level, immediately after she was observed cleaning the glucometer with an alcohol wipe. During the above observation bleach wipes were observed in the nurse's cart drawer. During a surveyor interview on 5/1/2024 immediately following the above observations with Staff Q, she revealed that she would typically use an alcohol pad to clean the glucometer and not use the bleach wipe per the facility policy. During a surveyor interview on 5/1/2024 at 8:29 AM with the Infection Preventionist, she revealed that the staff should be using PDI wipes (Highly compatible disinfection wipe for non-invasive medical devices and non-porous hard surfaces) to clean the glucometers. Additionally, she was unable to provide evidence that the glucometers were cleaned per the facility policy and unable to provide evidence that the facility maintained an infection control program that provided a sanitary environment to help prevent the development of infections. 2. Record review revealed that Resident ID #33 was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, retention of urine. A surveyor observation on 4/26/2024 at 9:28 AM of the signage outside Resident ID #33's room, the sign stated in part, Enhanced Barrier Precautions, everyone must: wear gloves and gown for the following High-Contact Resident Care Activities .Device care or use .urinary catheter . A surveyor observation on 4/26/2024 at 9:28 AM revealed Licensed Practical Nurse, Staff A, assessing and then flushing the resident's urinary catheter wearing only gloves. During this observation Registered Nurse, Staff D, then entered the resident's room with supplies, wearing only gloves to assist Staff A in changing the residents foley catheter. During a surveyor interview immediately following the above observation with Staff A, in the presence of Staff D, she indicated that she was not aware of the required PPE that should have been worn and was unsure if the resident had an active infection. At this time Staff D, acknowledged they should have worn a gown while providing foley catheter care as indicated on the signage. During a surveyor interview on 4/29/2024 at 9:29 AM with the Infection Preventionist, she revealed that the staff should be wearing gowns and gloves while performing foley catheter care. She further acknowledged that the resident was on enhanced barrier precautions. 3. Record review revealed Resident ID #2 was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, urinary tract infection. Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed s/he requires dependent assistance for toileting. Additionally, the MDS Assessment revealed that the resident is always incontinent of bladder and occasionally incontinent of bowels. Record review of a facility document titled, Continuity of Care Consultation and Referral Form dated 3/30/2024 states in part, .ESBL [Extended-spectrum beta-lactamases: enzymes that confer resistance to most beta-lactam antibiotics]/CRE [carbapenem-resistant Enterobacterales: develop resistance to the group of antibiotics] in Urine . A surveyor observation on 4/29/2024 at 8:59 AM of the signage outside of Resident ID #2's room, the sign stated in part, Enhanced Barrier Precautions, everyone must: wear gloves and gown for the following High-Contact Resident Care Activities .Transferring .dressing . A surveyor observation on 4/29/2024 at 8:59 AM revealed Nurse Assistant, Staff I, boosting the resident in bed and then adjusting the resident's gown in bed. During a surveyor interview immediately following the above observation with, Staff I, she acknowledged that she should have been wearing a gown and gloves during patient care, as indicated on the Enhanced Barrier Precautions signage. During a surveyor interview on 4/29/2024 at 9:29 AM with the Infection Preventionist, she revealed that the staff should be wearing a gown and gloves while providing care for Resident ID #2, she further acknowledged that the resident was on enhanced barrier precautions related to an MDRO. Additionally, she was unable to provide evidence that the facility maintained an infection control program that provided a sanitary environment to help prevent the development of infections. 46539 50004

Based on record review, surveyor observation, 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 2 of 2 residents reviewed requiring pudding thick liquids, Resident ID #s 19 and 16 , for 40 of 48 residents reviewed relative to medication administration, Resident ID #s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, 99, 100, and 199, and for 1 of 1 resident reviewed for foley catheter (a flexible tube inserted into the bladder in order to drain urine) care, Resident ID #33. Findings are as follows: 1a. Record review revealed that Resident ID #19 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dysphagia (a condition with difficulty in swallowing food or liquid), aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, or vomit) and stroke. Review of a physician's order dated 4/26/2024 states, House, Pudding Thickened, Pureed. Special Instructions: NO STRAWS. ONLY NURSE TO PREPARE THIN LIQUIDS TO PUDDING CONSISTENCY. During a surveyor observation on 4/26/2024 at 10:10 AM with Licensed Practical Nurse (LPN), Staff A, she crushed the resident's medication in applesauce and then thickened the fluid to a nectar thick consistency to serve to the resident. The surveyor intervened to ensure the resident received the ordered pudding thick consistency. During a subsequent interview with Staff A, she was unaware of the correct consistency of fluid ordered. Additionally, she was unable to determine how to thicken the fluid to the pudding thick consistency. During a surveyor observation on 4/26/2024 at 1:06 PM with LPN, Staff B, she was observed thickening the resident's liquid on a lunch tray to a nectar thick consistency. Additionally, the nurse was unsure what the resident's fluid consistency order was and how to thicken to the pudding thick consistency. During a surveyor interview on 4/26/2024 at 1:09 PM with the Director of Nursing Services (DNS) she acknowledged that the staff was unaware how to thicken the correct consistency to achieve pudding thick. Additionally, the DNS was unaware how to achieve the appropriate consistency. During a surveyor observation on 5/1/2024 at approximately 8:50 AM of Registered Nurse (RN), Staff L, in the presence of the Compliance Monitor, he was attempting to thicken Resident ID #19's fluids and breakfast food to honey thick versus the ordered pudding thick consistency until the Compliance Monitor intervened. 1b. Record review revealed that Resident ID #16 was admitted to the facility in March of 2019 with diagnoses including, but not limited to, dysphagia and gastro-esophageal reflux disease. During a surveyor observation on 5/1/2024 at approximately 9:00 AM of Staff L, mixing fluids for Resident ID #16, he was observed mixing the incorrect amount of thicker as he was using a larger cup then the manufacturers instructions indicated. Cross Reference F 726 and F 805. 2. Record review of a Medication Compliance Report dated 4/26/2024 revealed that 40 residents did not receive medication scheduled during the 7:00 AM to 3:00 PM shift on 4/26/2024. During a surveyor interview on 4/30/2024 at approximately 2:10 PM with the Infection Preventionist and the Administrator they acknowledged that 40 residents did not receive their medications on 4/26/2024. Additionally, they were unable to explain the cause of the medication not being administered. Cross Reference F760 3. Record review revealed that Resident ID #33 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, urinary retention and low back pain. Review of the physician orders revealed the resident has a foley catheter with directions to flush the foley every shift. During a surveyor observation on 4/26/2024 at approximately 8:45 AM, the resident was observed with the door open while LPN, Staff A, and RN, Staff D, were observed flushing and then changing the resident's indwelling foley catheter. During this observation the resident was observed with his/her genitals uncovered and in full view of the hallway and his/her roommate. During a surveyor interview on 4/30/2024 with the Administrator on 5/1/2024 she acknowledged the above findings and indicated that the Compliance Monitor has been very beneficial to her. Cross Reference F 550, F 726 and F 880

Based on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident assessed for falls, with major injury, Resident ID #19. Findings are as follows: Record review revealed Resident ID #19 was readmitted to the facility in December of 2023 with a diagnosis including, but not limited to, subarachnoid hemorrhage (brain bleed). Review of a progress note dated 11/14/2023 at 11:51 PM, revealed the resident was found on the floor in his/her room. The resident complained of headache, nausea, change in vision, and lethargy. Resident was assessed by the nurse, 911 was then called for emergency transfer to the hospital. Review of a progress note dated 11/15/2023 at 11:06 PM, states, Call placed to [hospital name], Resident was admitted with a brain bleed at 4:14 PM on 11/15/2023 Record review of hospital documentation dated 12/11/2023, titled Inpatient Summary states in part, .a new large right IPH [Intraparenchymal hemorrhage, bleeding within the brain] . Record review of a Minimum Data Assessment (MDS) with an assessment reference date of 11/15/2023, completed on 3/25/2024 revealed, one fall with no injuries documented and no falls with major injury documented. During a surveyor interview on 4/30/2024 at approximately 10:00 AM with the Infection Preventionist (IP), she was unable to provide evidence that the resident's assessment was accurately documented for a fall with major injury. Additionally, she revealed that MDS assessments are being completed remotely and they do not have an MDS coordinator in the facility.

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 elopement for 1 of 1 resident reviewed who successfully eloped, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 3/29/2024 indicated that Resident ID #1 was found outside of the facility on 3/29/2024. Record review revealed that the resident was originally admitted to the facility in November of 2023 and was transferred to the hospital on 12/31/2023 for a change in mental status. S/he was readmitted to the facility in January of 2024 with diagnoses including, but not limited to, Wernicke's encephalopathy (a neurological disorder marked by mental confusion and unsteady gait), cognitive communication deficit, and abnormalities of gait (a person's manor of walking) and mobility. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 4 out of 15, indicating s/he has severe cognitive impairment. Review of a care plan dated 1/2/2024 revealed the resident was at risk for elopement. Further review revealed a care plan dated 3/8/2024 which indicated that the resident exhibits behaviors of removing his/her wander guard (a device that is placed on a resident who is at risk for elopement to alert the facility that s/he has exited through an outside door). Once this resident exits through a door an alarm with sound. Review of a Physical Therapy Discharge Summary dated 2/16/2024 revealed the resident required supervision with transfers and ambulation with his/her rolling walker. Record review revealed a physician's order dated 3/6/2024 indicating that a wander guard should be worn on the resident's left ankle. Further review revealed the site and function of the wander guard was to be monitored every shift. Record review revealed the following progress notes indicating that the resident displayed exit seeking behaviors, wandering, and s/he also had a history of removing or hiding his/her wander guard: -1/6/2024 at 1:15 PM- the Nurse Practitioner was made aware of the resident's behaviors of continuously attempting to leave the facility and packing his/her clothing to leave -1/6/2024 at 5:56 PM- Wander guard placed on resident's right wrist and found broken on the floor a couple of hours later -1/7/2024 at 2:12 AM- resident very restless and confused, continuous redirection needed due to exit seeking behaviors -1/8/2024 at 7:56 AM- wander guard found in laundry on 1/6/2024, wander guard put on resident's right wrist then on 1/7/2024 and 1/8/2024 wander guard was unable to be located -1/9/2024 at 5:48 PM- resident attempting to get outside to get to his/her truck and had removed wander guard -1/19/2024 at 12:20 PM- resident stating that s/he needs to leave the facility and was seen packing his/her belongings -1/21/2024 at 4:36 PM- resident attempting to leave the facility with his/her belongings -1/25/2024 at 5:46 PM- resident redirected related to walking out of his/her room with a bag of belongings and searching for his/her truck -1/26/2024 at 9:43 AM- wander guard attached to wheelchair pole -1/29/2024 at 12:43 PM- wander guard removed from wheelchair and placed on resident's right ankle -2/2/2024 at 10:36 AM- wander guard found on the floor of resident's room and reapplied to his/her right ankle -2/2/2024 at 3:33 PM- wander guard found on the floor of resident's room and reapplied to his/her right ankle for the second time today -2/3/2024 at 2:46 PM- resident removed the wander guard off his/her ankle, wander guard placed on his/her right wrist -2/4/2024 at 3:25 PM- wander guard found in the trash can and applied to the resident's wheelchair -2/6/2024 at 2:26 PM- resident wandering up and down the hallways -2/13/2024 at 7:04 AM- unable to locate resident's wander guard -2/17/2024 at 10:00 AM- unable to locate resident's wander guard however, the bracelet was found in the trash can -2/20/2024 at 10:32 AM- Director of Nursing Services was made aware that the resident's wander guard could not be located -3/1/2024 at 3:31 PM- resident stating s/he wants to go home, waiting by the elevator and was able to enter the elevator which took staff 15 minutes to get him/her out, difficult to redirect -3/3/2024 at 2:50 PM- resident continues to remove wander guard -3/5/2024 at 10:12 AM- wander guard was broken on third shift; another one was put on and the resident removed it again -3/6/2024 at 12:26 AM- resident stating They left me behind. I need to go. wander guard not found on resident; another one was applied to his/her left ankle -3/6/2024 at 3:30 PM- resident removed wander guard from left ankle at 3:00 AM, another wander guard applied to his/her left ankle and education was provided. Record review of a progress note dated 3/9/2024 revealed the resident was found outside lying on the ground. Further review revealed the resident was sent to the hospital for an evaluation to rule out injury. Record review of the hospital emergency department document dated 3/9/2024 revealed that the resident was sent to the hospital following a fall at the facility resulting in a wound to his/her finger. Further record review revealed the resident was reported to be increasingly confused and had been stating that s/he wanted to go home while at the facility. Additionally, the resident was discharged back to the facility after his/her finger wound was dressed and all tests were found to be unremarkable. During a surveyor interview on 4/1/2024 at 11:40 AM with Licensed Practical Nurse (LPN), Staff C, she indicated that the resident exited the facility via the alarmed dining room doors on 3/9/2024 and was not wearing a wander guard, as ordered, at that time. She further indicated that no new interventions were put into place at that time to prevent the resident from going outside unsupervised. Record review failed to reveal evidence that any new interventions had been implemented to prevent an elopement following the resident being found outside with an injury to his/finger and after s/he had removed the wander guard on the above-mentioned dates. Further record review revealed the following: -3/10/2024 at 7:54 PM- resident does not have wander guard on, each time it was applied s/he removes it -3/12/2024 at 8:03 PM- wander guard applied to left ankle multiple times throughout the day and resident removing it and hiding it in his/her room -3/13/2024 at 7:06 PM- wander guard worn as a necklace, resident removed it -3/17/2024 at 4:18 PM- wandering up and down the hallways, wander guard is attached to wheelchair Record review revealed a progress note dated 3/29/2024 indicating that the resident was found outside in the front of the facility with his/her rolling walker. During a surveyor interview on 4/1/2024 at 2:08 PM with LPN, Staff C, she indicated that on 3/29/2024 the resident's wander guard was placed on his/her wheelchair and was not on his/her body or walker. During a surveyor interview on 4/1/2024 at 10:28 AM with the Director of Nursing Services (DNS), she indicated that the resident was found walking outside by a neighbor of the facility. She further indicated that the neighbor witnessed the resident fall and assisted him/her up. Additionally, she indicated that the resident was outside unsupervised when staff went outside to assist the resident back into the facility. During a surveyor interview on 4/1/2024 at 3:00 PM with the neighbor, who witnessed the elopement, s/he revealed that while walking on the street in the front of the facility s/he noticed the resident in the grass, by the street, at the end of the entrance to the facility. S/he further indicated that she witnessed the resident fall twice while attempting to ambulate outside by him/herself. Additionally, s/he indicated that s/he assisted the resident to the door of the facility where s/he left the resident alone with his/her walker. Furthermore, s/he indicated that s/he did not see any staff at that time. During a surveyor interview on 4/1/2024 at 12:23 PM with the DNS, she acknowledged that no new interventions had been put into place following the resident leaving the facility unsupervised on 3/9/2024 and that the resident was not wearing a wander guard as ordered on 3/29/2024 when s/he exited the building unsupervised for a second time. Additionally, she could not provide evidence that the facility ensured that the resident received adequate supervision to prevent an elopement. Due to the facility's failure to provide adequate supervision, this resident was able to exit the facility which put the resident at risk for more than minimal harm, impairment, or death.

Based on record review, staff and resident interview, it has been determined that the facility failed to provide reasonable accommodation of resident needs and preferences, relative to individualizing the physical environment relative to the resident's bedroom and bathroom [ROOM NUMBER] of 1 resident reviewed, Resident ID # 1, who is visually impaired. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 2/22/2024, alleges that a resident was moved from his/her room while s/he was out of the facility. His/her room was moved without notification to the resident or the resident's representative. Additionally, the resident, who is legally blind, was moved out of a private room with a bathroom that s/he had resided in for several years, to a semiprivate room without a bathroom. Record review revealed that the resident was admitted to the facility in March of 2017 with diagnoses including, but not limited to major depressive disorder, visual hallucinations, low vision right eye, and blindness in the left eye. Record 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 s/he is cognitively intact. Additionally, the assessment revealed that s/he is independent with self-care including dressing and toileting tasks. During a surveyor interview with the resident on 2/26/2024 at 12:20 PM, s/he revealed that s/he was approached by the Administrator in the weeks previous requesting that s/he change rooms, as the Administrator wanted to make his/her private room an isolation room. The resident refused as s/he explained to the Administrator that s/he is legally blind and had been in his/her current room for 5 years. S/he indicated to the Administrator that s/he was familiar with the layout of the environment and it would be difficult to acclimate to a new room as s/he can't see. The resident further revealed during a brief hospital stay on 2/19/2024 s/he returned to the facility on [DATE] to find his/her belongings from his/her private room were packed into boxes and moved into a semi private room without his/her permission. Additionally, s/he revealed that while in the new room s/he tripped over his/her belonging that were packed into boxes and placed near his/her bed as s/he couldn't see them and was unfamiliar with the new environment that s/he has been involuntarily moved into. Record review of a progress note dated 2/19/2024 revealed the resident was sent to the emergency roiagnom on [DATE] by the facility Ophthalmologist, as the resident had increased pressure in his/her eyes. The resident was admitted and returned to the facility on [DATE] at 5:00 PM into a semi private room. Further record review revealed a progress note dated 2/21/2024 at 8:31 PM indicating that as soon as the resident returned from the hospital s/he was very upset that his/her room had been changed. S/he proceeded into his/her previous room, banging his/her fists on the walls and glass windows of the dining room. The resident began crying and making statements about harming him/herself and others. S/he stated its going to be a massacre. Further record review revealed the resident was inconsolable by the staff and had to be sent to the emergency room for his/her behaviors. The resident was admitted to hospital geri-psych unit on 2/21/2024. Further record review failed to reveal a past psych history. Record review of the hospital paperwork from the geri psych dated 2/21/2024 revealed that the resident was upset about his/her room change that occurred at the nursing home and denied any suicidal or homicidal ideations. The paperwork also states that they called the facility and spoke to the Administrator and she indicated that private rooms are for isolation and the resident can return into a semi private room. Record review revealed the Alliance for Better Long Term Care entered the facility on 2/23/2024 to speak to Resident ID #1 about the above complaint. Shortly after the Alliance exited the facility the resident was moved back to his/her original private room. During an interview with the Administrator on 2/27/2024 at 11:25 AM, she acknowledged that the resident's room was changed without his/her permission while at the hospital and the resident was moved into a room that s/he was unfamiliar with. The Administrator also acknowledged that she was aware that the resident tripped and sustained a fall over the boxes while in the semi private room. Additionally, she was unable to provide evidence that the facility provided reasonable accommodations of the residents needs and preferences relative to individualizing the physical environment relative to the resident's bedroom. Due to the facility failure of changing Resident ID #1's room without his/her permission and failing to individualize the physical environment relative to the resident's bedroom and bathroom due to his/her vision issues, caused this resident psychosocial harm as s/he had a behavioral outburst and was admitted to a geri-psych unit. Cross Reference: F 625 and F 684

Based on record review and staff interview, it has been determined that the facility failed to protect a resident's right to be free from sexual abuse for 1 of 5 residents reviewed, Resident ID #1. Findings are as follows: On [DATE] the Rhode Island Department of Health (RIDOH) received a facility reported incident that indicates that Nursing Assistant, Staff A, was unable to locate Resident ID #2 during rounds. Staff A continued her search and found Resident ID #2 in his/her roommates bed, Resident ID #1. Resident ID #2 had his/her pants down, his/her sexual organ was semi erect, thrusting Resident ID #1 from behind. Resident ID #1 had his/her arm over Resident ID #2 and was observed kissing Resident ID #1. Resident ID #1 had his/her brief on and was trying to push Resident ID #2 off of him/her and yelling stop. Record review of a facility policy revised [DATE], titled POLICY/PROCEDURE SUBJECT: Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention states in part, INTENT: The facility will develop policies and procedures for screening and training employees, protection of residents and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. DEFINITIONS: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . -Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault . -Physical Abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . -Residents of this facility shall be protected from occurrences of abuse . Identify, correct and intervene in situations in which abuse .is more likely to occur . -This includes the analysis of: Features of the physical environment that may make abuse/or neglect more likely to occur . -The supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling .and . -The assessment, care planning, monitoring of the residents with needs and behaviors which might lead to conflict or neglect, such as a resident with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms . Identification: Identify events such as .occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation . Investigation: Investigate different types of incidents .and reporting of results to the proper authorities. Protection: Protect residents from harm during an investigation. -When an allegation or suspicion of one of the activities set out in the definitions herein occurs the facility shall: 1. Promptly protect the resident(s) who is/are the alleged victim(s); 2. Monitor the resident . 3. Notify the resident's physician . 4. Protect other residents who might be at risk . Reporting/Responses: -Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation . -Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to further prevent occurrences. -In response to allegations of abuse . Ensure that all alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse result in serious bodily injury .to the administrator of the facility and to other officials .in accordance with state law through established procedures . Prevent further potential abuse .while the investigation is in progress . Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law .and if the alleged violation is verified appropriate corrective action must be taken. Record review revealed Resident ID #1 was admitted to the facility in June of 2021 with diagnoses including, but not limited to dementia, psychotic disorder with delusions (a false belief or judgement of external reality) and major depressive disorder (MDD). Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident ID #1 ambulates supervised with a walker and is assisted by staff for dressing, hygiene and bathing. Additional review of his/her BIMS (Brief Interview for Mental Status) assessment revealed a score of 3 out of 15, indicating severe cognitive impairment. Further review of Section E-Behaviors revealed the resident does not exhibit any behaviors. Record review for Resident ID #2 revealed s/he was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's Disease and senile degeneration of the brain. Record review revealed Resident ID #2 was admitted to Hospice Services while residing at home in August of 2023, and s/he continues to receive Hospice services while residing at the facility. Record review of an admission MDS assessment dated [DATE] revealed s/he ambulates with supervision and is provided set-up or assistance with all other activities of daily living. Additional review of his/her BIMS assessment revealed a score of 99, indicating the resident was unable to complete the assessment, s/he is coded as having a memory problem and his/her decision making is severely impaired. Further review of Section E-Behaviors revealed the resident does not exhibit any behaviors. Record review of Resident ID #2's behavioral symptom care plan with a problem start date of [DATE], revealed the resident is at risk for elopement/wandering due to dementia with interventions including, but not limited to, psych consult if agitation or change in behavior occurs. During a surveyor interview on [DATE] at 9:23 AM with the Administrator, she indicated that at approximately 3:00 AM on [DATE], Nursing Assistant Staff A found Resident ID #2 in Resident ID #1's bed. Resident ID #2 was lying behind Resident ID #1 with his/her pants down and his/her sexual organ semi-erect, thrusting Resident ID #1 from behind. Resident ID #2 was also observed with his/her right arm/shoulder over Resident ID #1 kissing his/her neck. Resident ID #1 was observed at the time wearing boxer briefs and s/he was trying to move Resident ID #2 off him/her with his/her right upper extremity. The Administrator further revealed that Staff A called Licensed Practical Nurse (LPN), Staff B, into their room and the residents were separated. She further revealed the unit nurse and the supervisor, Staff C, completed a body check on both residents, notified the resident's family, notified the provider, but the police were not notified. Additionally, one on one supervision was provided for Resident ID #2 until s/he was moved to a private room off the unit, which was at approximately 9:00 AM that morning. Further, she revealed that both residents are not able to consent, as they are both cognitively impaired. Further, she revealed Resident ID #2 wanders on the unit and s/he has been found in other resident's beds, but not when another resident was in that bed and staff provides redirection when this occurs. Lastly, the Administrator revealed that Resident ID #2 will continue to be monitored while upstairs and will remain in his/her private room. Record review failed to reveal evidence that the police were contacted at the time of the incident. Record review of Resident ID #2's nursing progress notes revealed s/he has had to be repeatedly redirected from his/her roommate's side of the room, attempting to get into his/her roommate's bed and other resident's beds on more than one occasion. Resident ID #2 has also exhibited various behaviors such as taking off his/her brief and urinating on floors, urinating on other resident's clothing, pacing, wandering, and stripping and remaking his/her bed. Resident ID #2 has also needed 1:1 supervision by staff due to his/her behaviors on more than one occasion as documented in the medical record, since admission to the facility, as documented below: -[DATE] at 5:17 AM Resident is alert and confused. Needs constant supervision and redirection. Out of bed (OOB) several times during the night with insomnia. Resident took his/her brief off and urinated in the corner of the room twice. The nurse attempted to introduce him/her to the urinal, but s/he became frustrated and was not interested. -[DATE] at 1:41 PM Resident is alert and oriented to person. Forgetful at times. Frequent reminders needed to which bed is his/hers. S/he is getting into the roommate's bed but is easily redirected. -[DATE] at 3:39 AM Resident had a very restless night. OOB to wander the hall multiple times. S/he also had to be redirected from roommate's side of the room at least three times. Writer posted outside of resident's room to prevent him/her from wandering into the other rooms. -[DATE] at 6:06 PM As needed (PRN) Ativan 0.25 ml was given as ordered for increased restlessness, agitation and looking for a way to get out with good relief. Resident continues with one-on-one all day long. -[DATE] at 6:00 AM Resident was up all night roaming, very intrusive tried getting in other resident's beds, not easily directed, PRN Ativan given x2 with no effect, staff was hands on all shift, will continue with plan of care. -[DATE] at 1:17 PM Resident is alert and confused. Restless walking back and forth on unit, unsteady on feet. Medicated with Ativan at 11:38 AM with very little effect, [s/he] sat in the chair for a couple of seconds was then up and ambulating on unit. Resident is sleepy but fights to stay up. Voiding on floor. Raises [his/her] voice and gets combative to staff. -[DATE] at 10:57 PM Resident extremely behavioral. Since change of shift at [7:00 PM], resident slept for a total of 15 minutes and has been up since. Resident has been exit seeking and becoming combative with staff. [S/he] has urinated on the floor five times already even after being escorted to the bathroom. [S/he] refuses to use the commode. Resident refuses to stay dressed or keep on brief. Very hard to redirect. Ativan ineffective. Furniture had to be moved from resident's room because [s/he] is trying to remove the drawers from the dresser, [s/he] is slamming the bedside table into the wall, trying to unplug the TV and dragging the chair across the room. [s/he] has almost fallen multiple times. Writer has been 1:1 with resident and posted at his/her door since beginning of shift. [S/he] is currently trying to grab laptop from writer. [S/he] refuses to lay down or even sit. -[DATE] at 4:17 AM Resident continues with erratic, manic behaviors all night. [S/he] has slept for a total of 45 mins [minutes] in 15 min increments. [S/he] has stripped the bed and has taken off [his/her] clothes along with the brief. Resident was intercepted by writer when [s/he] was noted standing up on the bed. [S/he] also climbed on the chair and sat knees to chest, facing the back of the chair. [S/he] was noted trying to pry the doorframe from the wall with [his/her] hands and remove the bedrails from the bed by shaking them furiously. [S/he] is hallucinating which is evidenced by [him/her] getting on the floor, crawling around and grabbing at things that are not there. Incontinent of bladder numerous times but still refuses to use the commode or wear a brief. When escorted to the bathroom, [s/he] tries to remove the seat from the toilet. Combative with staff and yelling out -[DATE] at 7:03 AM Call placed to hospice due to behaviors and resident not sleeping. Waiting for triage nurse to return call. -[DATE] at 8:02 AM The triage nurse from hospice returned call with new recommendation for Seroquel 25 mg every morning, 25 mg every afternoon and 50 mg at hour of sleep. New recommendations were verified with resident's provider. -[DATE] at 1:16 AM Resident attempted to go to roommate's side of room but was redirected back to [his/her] bed. -[DATE] at 5:18 AM .Resident in and out of bed multiple times during the night .Voided on floor x1. Resident finally went to sleep about 2 am . -[DATE] at 11:05 PM Resident was told many times to stop trying to take off [his/her] wrist band, resident then kept pulling at it until it ripped off . -[DATE] at 2:09 PM Resident is alert, sleepy this morning .No behavior issues today. [S/he] removed [his/her] wander guard yesterday and would not let me replace it today. -[DATE] at 6:09 AM .was restless throughout the night .[S/he] laid down for a short while but was back up pacing [his/her] room, stripping and remaking the bed. This behavior went on all night. [S/he] was and continues to be under 1:1 supervision after [s/he] was noted going into [his/her] bathroom but heard in the next room. Writer found that [s/he] had voided on the floor and wardrobe of the neighboring room. [S/he] was redirected back to [his/her] room and back to bed. [S/he] is currently laying down but is still not sleeping . -[DATE] at 5:40 AM .Continues to void randomly on the floor. Not easily redirected. Non-behavioral .Replaced wanderguard to L [left] wrist after resident pulled [his/her] off . -[DATE] at 2:10 PM Resident wanders aimlessly. Urinated in the corner of the room on the roommates side. -[DATE] at 8:17 PM Resident found sleeping in other residents beds continuous reminders to where [his/her] bed and room is. -[DATE] at 4:28 PM Resident had a restless night. [S/he] was redirected back to [his/her] bed after being found in roommates bed. Although supervision was ongoing through the night [s/he] did not stop trying. Several times [s/he] closed the door to the room, this writer reminded res [resident] the door must remain opened. Resident was upset that [s/he] could not stay in the desire bed and became combative attempting to hit this writer more than once. Resident expressed wanting to go home. [S/he] asked if the main road is dangerous and if this writer had a car to give [him/her] a ride home . -[DATE] at 2:16 PM [Resident] was quite agitated and restless this morning. [S/he] was yelling, slamming doors and waving [his/her] hands around. [Resident] was unable to tell me what was wrong. [S/he] just kept saying, Get out, go home. I explained to [him/her] that I was the nurse taking care of [him/her] and I wanted to help [him/her], but [s/he] would need to tell me what is wrong. [S/he] started to cuss and continued to slam [his/her] bedroom door. I told [resident] that the door to [his/her] room needed to remain open. [S/he] would yell louder . -[DATE] at 2:03 AM Resident restless and wandering intrusively at start of shift, frequent safety and redirection provided to encourage resident to remain in [his/her] own space or common area. Resident appears to be resting peacefully in [his/her] bed checks and redirection provided to encourage resident to remain in [his/her] own space or common area . -[DATE] at 5:45 PM [S/he] was wandering on the unit after [his/her] son left. Tried to open the door to the main hallway setting of the alarm. redirected without difficulty . Record review of the resident's nursing progress notes entered, after this surveyor entered the facility to investigate the allegation of sexual abuse reported to the RIDOH, revealed the following notes: -[DATE] at 3:20 AM (progress note recorded as a late entry on [DATE] at 10:29 AM by the Director of Nurses) At 3 am the CNA called the unit nurse to the room to observe resident laying on the B bed beside [his/her] roommate. Resident had [his/her] privates exposed and [his/her] roommate was fully dressed. Resident was immediately removed and assessed. Due to [his/her] poor cognition, [s/he] was unaware of [his/her] actions and very confused. [S/he] thought [s/he] was cuddling with [his/her] deceased [spouse]. DON [Director of Nurses] called and alerted of incident. NOK [next of kin] alerted. MD made aware. SW [Social Worker] and administrator also notified. DOH and RI Ombudsman notified . -[DATE] at 1:42 PM This writer made referral with [psychiatric consult services]. Faxed over facesheet, order and consent to treat. They will be out today but the latest tomorrow. -[DATE] at 5:20 PM This writer left a message for resident's daughter . to call me because her [parent] will need an evaluation of [his/her] behaviors from 11.28.23 at the hospital. Resident will be transported tonight. -[DATE] at 5:49 PM . resident was prepared for transfer to ER for psyche evaluation, stemming from incident of [DATE]' .Ambulance arrived at 8 pm and resident left the faciity on stretcher . -[DATE] at 2:14 PM [Recorded as Late Entry on [DATE] 08:16 PM] Placed call out to [hospital] for a status on [Resident]. Resident was admitted with a diagnosis of neurocognitive disorder with behavior disturbance. During a surveyor interview on [DATE] at 2:10 PM with Resident ID #2's physician, she revealed she had learned of the incident after calling the facility on [DATE] and she spoke with the day shift nurse, who informed her that Resident ID #2 was observed standing in his/her room naked. Further, she was unaware that both residents were in Resident ID #1's bed, and she was unaware of the interaction that occurred. Additionally, this surveyor read Resident ID #2's nursing progress notes dated ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE] to the physician. The physician revealed she was aware that Resident ID #2 is forgetful and occasionally urinated on the floor but was not aware of the extent of his/her behaviors including the need for increased supervision. During a surveyor interview on [DATE] at 10:43 AM with NA, Staff A, she revealed she was assigned to both Resident ID #1 and #2 on [DATE] during the overnight shift. Staff A further revealed that she went into the room of both Resident ID #1 and #2, during the first round to complete care and they were both observed in their own beds. Staff A then revealed when she went into their room again at approximately 3:00 AM, she did not see Resident ID #2 in his/her bed. She further revealed that she checked the resident's bathroom and she did not see him/her there and when she approached Resident ID #1's side of the bed she observed Resident ID #2 lying in bed behind Resident ID #1 with his/her pants down, thrusting him/her from behind. Staff A revealed she heard Resident ID #1 saying stop stop and Resident ID #1 was observed pushing Resident ID #2 with his/her right arm. Additionally, Staff A revealed she called for Staff B and both residents were separated. During a surveyor interview on [DATE] at 9:26 AM with LPN Staff B, she revealed she was assigned to both Resident ID #1 and #2 on [DATE] during the overnight shift. Staff B revealed she knows of Resident ID #2 to wander and knew that s/he needed to be watched. On the night of the incident, at approximately 3:00 AM, Staff B revealed Staff A called her into the room after she observed both residents in Resident ID #1's bed. Staff B further revealed Resident ID #2 was lying on his/her side behind Resident ID #1 with his/her pants down, thrusting Resident ID #1 from behind and s/he had his/her right arm over Resident ID #1. Staff B further revealed she heard Resident ID #1 say stop. Staff A and Staff B then separated both residents and escorted Resident ID #2 in his/her bed and she asked Staff A to watch him/her. Additionally, Staff B revealed she called the supervisor, Registered Nurse, Staff C, and when he arrived they both completed a body check on both residents which revealed no visible injuries. During a surveyor interview on [DATE] at 2:35 PM with Staff C, he revealed that he was the supervisor on the night of [DATE] when he was called to the unit by Staff B, who notified him of the incident between Resident ID #1 and #2. Staff C revealed when he entered the residents' room with Staff B, both residents were sleeping and the NA was sitting at the doorway of the room. Staff C further revealed he reported the incident via telephone to the Director of Nurses and he was instructed by her to obtain statements, write a statement and to assess both residents. Staff C revealed he assessed both residents, no injuries were noted and neither resident recalled the incident. Additionally, Staff C revealed he did not call the provider to report the incident. During a surveyor interview on [DATE] at approximately 1:30 PM with the Administrator, she was unable to provide evidence that Resident ID #1 was kept free from resident to resident sexual abuse.

Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and that his/her care plan is reviewed and revised accordingly for 1 of 2 residents reviewed, Resident ID #2. Findings are as follows: On [DATE] the Rhode Island Department of Health (RIDOH) received a facility reported incident that indicates that Nursing Assistant, Staff A, was unable to locate Resident ID #2 during rounds. Staff A continued her search and found Resident ID #2 in his/her roommates bed, Resident ID #1. Resident ID #2 had his/her pants down, his/her sexual organ was semi erect, thrusting Resident ID #1 from behind. Resident ID #1 had his/her arm over Resident ID #2 and was observed kissing Resident ID #1. Resident ID #1 had his/her brief on and was trying to push Resident ID #2 off of him/her and yelling stop. Record review revealed Resident ID #1 was admitted to the facility in June of 2021 with diagnoses including, but not limited to dementia, psychotic disorder with delusions (a false belief or judgement of external reality) and major depressive disorder (MDD). Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed s/he ambulates supervised with a walker and is assisted by staff for dressing, hygiene and bathing. Additional review of his/her BIMS (Brief Interview for Mental Status) assessment revealed a score of 3 out of 15, indicating severe cognitive impairment. Further review of Section E-Behaviors revealed the resident does not exhibit any behaviors. Record review for Resident ID #2 revealed s/he was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's Disease and senile degeneration of the brain. Record review revealed Resident ID #2 was admitted to Hospice Services while residing at home in August of 2023, and s/he continues to receive Hospice services while residing at the facility. Record review of an admission MDS assessment dated [DATE] revealed s/he ambulates with supervision and is provided set-up or assistance with all other activities of daily living. Additional review of his/her BIMS assessment revealed a score of 99 indicating the resident was unable to complete the assessment, s/he is coded as having a memory problem and his/her decision making is severely impaired. Further review of Section E-Behaviors revealed the resident does not exhibit any behaviors. Record review of Resident ID #2's behavioral symptom care plan with a problem start date of [DATE], revealed the resident is at risk for elopement/wandering due to dementia with interventions including, but not limited to, psych consult if agitation or change in behavior occurs. Further review of the care plan failed to reveal evidence of a subsequent review and revision to Resident ID #2's behavioral or psychosocial care plan, as a result of his/her behaviors. During a surveyor interview on [DATE] at 9:23 AM with the Administrator, she indicated that at approximately 3:00 AM on [DATE], Nursing Assistant (NA) Staff A found Resident ID #2 in Resident ID #1's bed. Resident ID #2 was lying behind Resident ID #1 with his/her pants down and his/her sexual organ semi-erect, thrusting Resident ID #1 from behind. Resident ID #2 was also observed with his/her right arm/shoulder over Resident ID #1 kissing his/her neck. Resident ID #1 was observed at the time wearing boxer briefs and s/he was trying to move Resident ID #2 off him/her with his/her right upper extremity. The Administrator further revealed that Staff A called Licensed Practical Nurse (LPN), Staff B, into their room and the residents were separated. She further revealed the unit nurse and the supervisor, Staff C, completed a body check on both residents, notified the resident's family, notified the provider, but the police were not notified. Additionally, one on one supervision was provided for Resident ID #2 until s/he was moved to a private room off the unit, which was at approximately 9:00 AM that morning. Further, she revealed that both residents are not able to consent, as they are both cognitively impaired. Further, she revealed Resident ID #2 wanders on the unit and s/he has been found in other resident's beds, but not when another resident was in that bed and staff provides redirection when this occurs. Lastly, the Administrator revealed that Resident ID #2 will continue to be monitored while upstairs and will remain in his/her private room. Record review failed to reveal evidence that the police were contacted at the time of the incident. Record review of Resident ID #2's nursing progress notes revealed s/he has had to be repeatedly redirected from his/her roommate's side of the room, attempting to get into his/her roommate's bed and other resident's beds on more than one occasion. Resident ID #2 has also exhibited various behaviors such as taking off his/her brief and urinating on floors, urinating on other resident's clothing, pacing, wandering, and stripping and remaking his/her bed. Resident ID #2 has also needed 1:1 supervision by staff due to his/her behaviors on more than one occasion as documented in the medical record, since admission to the facility, as documented below: -[DATE] at 5:17 AM Resident is alert and confused. Needs constant supervision and redirection. Out of bed (OOB) several times during the night with insomnia. Resident took his/her brief off and urinated in the corner of the room twice. The nurse attempted to introduce him/her to the urinal, but s/he became frustrated and was not interested. -[DATE] at 1:41 PM Resident is alert and oriented to person. Forgetful at times. Frequent reminders needed to which bed is his/hers. S/he is getting into the roommate's bed but is easily redirected. -[DATE] at 3:39 AM Resident had a very restless night. OOB to wander the hall multiple times. S/he also had to be redirected from roommate's side of the room at least three times. Writer posted outside of resident's room to prevent him/her from wandering into the other rooms. -[DATE] at 6:06 PM As needed (PRN) Ativan 0.25 ml was given as ordered for increased restlessness, agitation and looking for a way to get out with good relief. Resident continues with one-on-one all day long. -[DATE] at 6:00 AM Resident was up all night roaming, very intrusive tried getting in other resident's beds, not easily directed, PRN Ativan given x2 with no effect, staff was hands on all shift, will continue with plan of care. -[DATE] at 1:17 PM Resident is alert and confused. Restless walking back and forth on unit, unsteady on feet. Medicated with Ativan at 11:38 AM with very little effect, [s/he] sat in the chair for a couple of seconds was then up and ambulating on unit. Resident is sleepy but fights to stay up. Voiding on floor. Raises [his/her] voice and gets combative to staff. -[DATE] at 10:57 PM Resident extremely behavioral. Since change of shift at [7:00 PM], resident slept for a total of 15 minutes and has been up since. Resident has been exit seeking and becoming combative with staff. [S/he] has urinated on the floor five times already even after being escorted to the bathroom. [S/he] refuses to use the commode. Resident refuses to stay dressed or keep on brief. Very hard to redirect. Ativan ineffective. Furniture had to be moved from resident's room because [s/he] is trying to remove the drawers from the dresser, [s/he] is slamming the bedside table into the wall, trying to unplug the TV and dragging the chair across the room. [s/he] has almost fallen multiple times. Writer has been 1:1 with resident and posted at [his/her] door since beginning of shift. [S/he] is currently trying to grab laptop from writer. [S/he] refuses to lay down or even sit. -[DATE] at 4:17 AM Resident continues with erratic, manic behaviors all night. [S/he] has slept for a total of 45 mins [minutes] in 15 min increments. [S/he] has stripped the bed and has taken off [his/her] clothes along with the brief. Resident was intercepted by writer when [s/he] was noted standing up on the bed. [S/he] also climbed on the chair and sat knees to chest, facing the back of the chair. [S/he] was noted trying to pry the doorframe from the wall with [his/her] hands and remove the bedrails from the bed by shaking them furiously. [S/he] is hallucinating which is evidenced by [him/her] getting on the floor, crawling around and grabbing at things that are not there. Incontinent of bladder numerous times but still refuses to use the commode or wear a brief. When escorted to the bathroom, [s/he] tries to remove the seat from the toilet. Combative with staff and yelling out -[DATE] at 7:03 AM Call placed to hospice due to behaviors and resident not sleeping. Waiting for triage nurse to return call. -[DATE] at 8:02 AM The triage nurse from hospice returned call with new recommendation for Seroquel 25 mg every morning, 25 mg every afternoon and 50 mg at hour of sleep. New recommendations were verified with resident's provider. -[DATE] at 1:16 AM Resident attempted to go to roommate's side of room but was redirected back to [his/her] bed. -[DATE] at 5:18 AM .Resident in and out of bed multiple times during the night .Voided on floor x1. Resident finally went to sleep about 2 am . -[DATE] at 11:05 PM Resident was told many times to stop trying to take off [his/her] wrist band, resident then kept pulling at it until it ripped off . -[DATE] at 2:09 PM Resident is alert, sleepy this morning .No behavior issues today. [S/he] removed [his/her] wander guard yesterday and would not let me replace it today. -[DATE] at 6:09 AM .was restless throughout the night .[S/he] laid down for a short while but was back up pacing [his/her] room, stripping and remaking the bed. This behavior went on all night. [S/he] was and continues to be under 1:1 supervision after [s/he] was noted going into [his/her] bathroom but heard in the next room. Writer found that [s/he] had voided on the floor and wardrobe of the neighboring room. [S/he] was redirected back to [his/her] room and back to bed. [S/he] is currently laying down but is still not sleeping . -[DATE] at 5:40 AM .Continues to void randomly on the floor. Not easily redirected. Non-behavioral .Replaced wanderguard to L [left] wrist after resident pulled [his/her] off . -[DATE] at 2:10 PM Resident wanders aimlessly. Urinated in the corner of the room on the roommates side. -[DATE] at 8:17 PM Resident found sleeping in other residents beds continuous reminders to where [his/her] bed and room is. -[DATE] at 4:28 PM Resident had a restless night. [S/he] was redirected back to [his/her] bed after being found in roommates bed. Although supervision was ongoing through the night [s/he] did not stop trying. Several times [s/he] closed the door to the room, this writer reminded res [resident] the door must remain opened. Resident was upset that [s/he] could not stay in the desire bed and became combative attempting to hit this writer more than once. Resident expressed wanting to go home. [S/he] asked if the main road is dangerous and if this writer had a car to give [him/her] a ride home . -[DATE] at 2:16 PM [Resident] was quite agitated and restless this morning. [S/he] was yelling, slamming doors and waving [his/her] hands around. [Resident] was unable to tell me what was wrong. [S/he] just kept saying, Get out, go home. I explained to [him/her] that I was the nurse taking care of [him/her] and I wanted to help [him/her], but [s/he] would need to tell me what is wrong. [S/he] started to cuss and continued to slam [his/her] bedroom door. I told [resident] that the door to [his/her] room needed to remain open. [S/he] would yell louder . -[DATE] at 2:03 AM Resident restless and wandering intrusively at start of shift, frequent safety and redirection provided to encourage resident to remain in [his/her] own space or common area. Resident appears to be resting peacefully in [his/her] bed checks and redirection provided to encourage resident to remain in [his/her] own space or common area . -[DATE] at 5:45 PM [S/he] was wandering on the unit after [his/her] son left. Tried to open the door to the main hallway setting of the alarm. redirected without difficulty . Record review failed to reveal evidence that the resident was ever seen and evaluated by psychiatric services after the resident exhibited ongoing behaviors since his/her admission. Record review of the resident's nursing progress notes, after this surveyor entered the facility to investigate the allegation of sexual abuse reported to the RIDOH, revealed the following: -[DATE] at 3:20 AM (progress note recorded as a late entry on [DATE] at 10:29 AM by the Director of Nurses) At 3 am the CNA called the unit nurse to the room to observe resident laying on the B bed beside [his/her] roommate. Resident had [his/her] privates exposed and [his/her] roommate was fully dressed. Resident was immediately removed and assessed. Due to [his/her] poor cognition, [s/he] was unaware of [his/her] actions and very confused. [S/he] thought [s/he] was cuddling with [his/her] deceased [spouse]. DON [Director of Nurses] called and alerted of incident. NOK [next of kin] alerted. MD made aware. SW [Social Worker] and administrator also notified. DOH and RI Ombudsman notified . -[DATE] at 1:42 PM This writer made referral with [facility psychiatric consultant] Faxed over facesheet, order and consent to treat. They will be out today but the latest tomorrow. -[DATE] at 5:20 PM This writer left a message for resident's daughter .to call me because her [parent] will need an evaluation of [his/her] behaviors from 11.28.23 at the hospital. Resident will be transported tonight. -[DATE] at 5:49 PM .resident was prepared for transfer to ER for psyche evaluation, stemming from incident of [DATE]' .Ambulance arrived at 8 pm and resident left the faciity on stretcher . -[DATE] at 2:14 PM [Recorded as Late Entry on [DATE] 08:16 PM] Placed call out to [hospital] for a status on [Resident]. Resident was admitted with a diagnosis of neurocognitive disorder with behavior disturbance. During a surveyor interview on [DATE] at 2:10 PM with Resident ID #2's physician, she revealed she had learned of the incident after calling the facility on [DATE] and she spoke with the day shift nurse, who informed her that Resident ID #2 was observed standing in his/her room naked. Further, she was unaware that both residents were in Resident ID #1's bed, and she was unaware of the interaction that occurred. Additionally, this surveyor read Resident ID #2's nursing progress notes dated ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE] to the physician. The physician revealed she was aware that Resident ID #2 is forgetful and occasionally urinated on the floor but was not aware of the extent of his/her behaviors including the need for increased supervision. During a surveyor interview on [DATE] at 10:43 AM with NA, Staff A, she revealed she was assigned to both Resident ID #1 and #2 on [DATE] during the overnight shift. Staff A further revealed that she went into the room of both Resident ID #1 and ID #2, during the first round to complete care and they were both observed in their own beds. Staff A then revealed when she went into their room again at approximately 3:00 AM, she did not see Resident ID #2 in his/her bed. She further revealed that she checked the resident's bathroom and she did not see him/her there and when she approached Resident ID #1's side of the bed she observed Resident ID #2 lying in bed behind Resident ID #1 with his/her pants down, thrusting him/her from behind. Staff A revealed she heard Resident ID #1 saying stop stop and Resident ID #1 was observed pushing Resident ID #2 with his/her right arm. Additionally, Staff A revealed she called for Staff B and both residents were separated. During a surveyor interview on [DATE] at 9:26 AM with LPN Staff B, she revealed she was assigned to both Resident ID #1 and #2 on [DATE] during the overnight shift. Staff B revealed she knows of Resident ID #2 to wander and knew that s/he needed to be watched. On the night of the incident, at approximately 3:00 AM, Staff B revealed Staff A called her into the room after she observed both residents in Resident ID #1's bed. Staff B further revealed Resident ID #2 was lying on his/her side behind Resident ID #1 with his/her pants down, thrusting Resident ID #1 from behind and s/he had his/her right arm over Resident ID #1. Staff B further revealed she heard Resident ID #1 say stop. Staff A and Staff B then separated both residents and escorted Resident ID #2 in his/her bed and she asked Staff A to watch him/her. Additionally, Staff B revealed she called the supervisor, Registered Nurse, Staff C, and when he arrived they both completed a body check on both residents which revealed no visible injuries. During a surveyor interview on [DATE] at 2:35 PM with Staff C, he revealed that he was the supervisor on the night of [DATE] when he was called to the unit by Staff B who notified him of the incident between Resident ID #1 and #2. Staff C revealed when he entered the residents' room with Staff B, both residents were sleeping and the NA was sitting at the doorway of the room. Staff C further revealed he reported the incident via telephone to the Director of Nurses and he was instructed by her to obtain statements, write a statement and to assess both residents. Staff C revealed he assessed both residents, no injuries were noted and neither resident recalled the incident. Additionally, Staff C revealed that he did not call the provider to report the incident. During a surveyor interview with the Administrator on [DATE] at approximately 1:30 PM, she was unable to provide evidence that Resident ID #2 was seen by psychiatric services to assist in maintaining his/her highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care after s/he was observed exhibiting behaviors dating back to his/her admission in September of 2023. Additionally, she was unable to provide evidence that Resident ID #2's care plan was reviewed and revised since his/her admission to include new interventions for his/her behaviors. Lastly, the Administrator was unable to provide evidence of a current facility policy and procedure relative to behavioral health management.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure sores receives the necessary treatment and services to promote healing for 1 of 2 sample residents (ID #'s 7) and failed to provide the necessary care and services for 2 of 5 sample residents assessed at risk for pressure sores (ID #'s 5, 6) who reside on the first floor. Findings are as follows: 1. Record review of ID #7 revealed a CAA summary dated 5/14/2014 and the Braden Scale dated 9/8/2014 indicate the resident is at risk for pressure sores due to impaired bed mobility, [MEDICAL CONDITION] and incontinence of bowel and bladder. A review of the Braden Observation Report indicates as an intervention for the above identified risk a pressure relieving cushion is to be used when the resident is seated in a chair. Observations on 9/08/14 from approximately 8:05 AM until 12:30 PM revealed the resident lying in his/her gerri chair without a pressure relieving cushion in place. Additionally, no one was observed checking this resident for incontinence. At 12:40 PM in the presence of the DNS the resident was placed in their bed. At this time it was again noted by the surveyor that no pressure relief cushion was on the gerri chair. Additionally, the resident's pants and incontinence pad were saturated with urine. Further record review reveals an 8/12/2014 progress note which indicates the resident developed an unstageable pressure sore to the 2nd toe of his/her right foot. An 8/13/2014 physician's orders [REDACTED]. A review of the Treatment Administration Record failed to reveal evidence that the treatment was administered on 8/19, 8/26 to 8/28 and 8/30 to 9/1/2014 (total of 7 days). 2. Record review of resident ID #5 revealed the resident has a [DIAGNOSES REDACTED]. Although, the facility's policy indicates a Braden Scale will be done quarterly, record review revealed no evidence the Braden Scale had been done since 4/20/2014. A care plan updated on 7/24/2014 indicates the resident is at risk for impaired skin integrity due to decreased mobility, exposure to urinary/fecal incontinence and a history of pressure sores. As an approach to the above stated problem, the resident is to receive incontinence care as needed. Observation of the resident on 8/27/2014 between 8:30 AM and 12:30 PM (4 hours) revealed the resident sitting in his/her wheelchair. During this observation, no staff were observed checking the resident for incontinence or providing incontinence care. During separates interviews on 8/27/2014 at 1:20 PM and 1:30 PM, 2 NAs (staff B and C) stated the resident was checked for incontinence between 7:00 AM to 7:30 AM. They further stated that the resident was not checked for incontinence until 1 :15 PM. During further interview with Staff C, she stated the resident was incontinent of urine at 1 :15 PM. 3. Record review of ID #6 revealed the resident is at risk for pressure sore due to cognitive impairment, totally dependent on staff for all care and a history of pressure sores. Review of the 8/1/2014 Braden scale indicates the resident at risk for pressure sores. A review of the care plan dated 3/28/2014 to the present time has a stated problem which indicates the resident is at risk for skin breakdown due to impaired mobility and incontinence. As an approach to this problem the resident is to be provided with incontinence care. Observations of the resident on 8/27/2014 between 8:35 AM to 11:40 AM (3 hours and 5 minutes) revealed the resident lying in his/her bed. During these observations, no staff were observed assisting the resident. During a subsequent interview on 8/27/2014 at approximately 2:00 PM, the NA (staff B) indicated that she checked this resident for incontinence between 7:00 AM to 7:30 AM. She further stated that the resident was not checked for incontinence until approximately 11:45 AM (approximately 4 hours). At this time the resident was incontinent of urine.