Every finding on record at Eastgate Nursing & Rehabilitation Center

Based on clinical record review and staff interview, the facility failed to ensure that the residents and/or their representatives participated in the comprehensive and quarterly care plan reviews for 3 of 6 residents, Resident ID #s 7, 8, and 10.Findings are as follows:Record review of a facility policy titled Comprehensive Care Plans last reviewed on 9/30/2025 states in part, .Frequent care plan meetings are to be encouraged to address changing circumstances which affect the residents' well-being. 1. Record review revealed Resident ID #7 was admitted to the facility in September of 2021 with a diagnosis including, but not limited to, abnormalities of gait and mobility.Record review failed to reveal evidence that the following Minimum Data Set (MDS - a federally mandated, standardized comprehensive assessment tool used in Medicare/Medicaid certified nursing homes to evaluate the clinical, functional, and psychosocial status of residents) Assessments included documentation of participation or an explanation of non-participation of the resident and his/her representative:4/13/20259/15/202512/16/2025 2. Record review revealed Resident ID #8 was admitted to the facility in July of 2021 with diagnosis including, but not limited to, dementia.Record review failed to reveal evidence that the following MDS Assessments included documentation of participation or an explanation of non-participation of the resident and his/her representative:2/26/20255/26/20252/4/2026 3. Record review revealed Resident ID #10 was admitted to the facility in July of 2021 with diagnosis including, but not limited to, diabetes mellitus.Record review failed to reveal evidence that the following MDS Assessments included documentation of participation or an explanation of non-participation of the resident and his/her representative:3/10/20256/10/20259/10/2025During a surveyor interview on 2/19/2026 at 10:05 AM with the MDS nurse, Staff A, she revealed that care conferences are held quarterly by the interdisciplinary team and the residents and their representatives are invited. However, she acknowledged that Resident ID #7 and 8's failed to have documentation of non-participation of the residents or the residents' representatives following the above-mentioned MDS Assessments, as required.During a surveyor interview on 2/19/2026 at approximately 2:00 PM with the Director of Nursing Services, she was unable to provide evidence that the abovementioned residents' MDS Assessments included documentation of the participation or non-participation of the residents and their representatives quarterly, as required.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 6 residents reviewed for oxygen use, Resident ID #s 11 and 63. Findings are as follows: According to Lippincott Nursing Procedure Ninth Edition 2023, page 621, states in part, .Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed . 1. Record review revealed Resident ID #11 was admitted to the facility in October 2017 with diagnoses including, but not limited to, diabetes, and dementia. During surveyor observations on the following date and times, Resident ID #11 was observed receiving 2 liters (L) of oxygen via a nasal cannula: 2/17/2026 at 10:45 AM, 12:00 PM, 1:15 PM, and 2:00 PM. Record review failed to reveal evidence of a physician's order for the use of oxygen, as required. During a surveyor interview on 2/17/2026 at 2:25 PM with Registered Nurse, Staff B, she acknowledged that the resident was receiving 2 L of oxygen via nasal cannula. Staff B further acknowledged that the resident did not have a physician's order for the use of oxygen s/he was receiving, as required.2. Record review revealed Resident ID #63 was admitted to the facility in February of 2026 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and congestive heart failure (when the heart muscle is too weak or stiff to pump blood efficiently, causing blood and fluids to back up into the lungs, liver, or legs).Review of the resident's care plan revealed that the resident has an alteration in respiratory status related to a diagnosis of COPD with the goal that the resident will be free from acute signs or symptoms of respiratory distress with the approach including the administration of oxygen as ordered and monitoring for symptoms of respiratory distress.During surveyor observations on the following dates and times, Resident ID #63 was receiving oxygen via a nasal canula at 2 L per minute: 2/16/2026 at 9:00AM 2/17/2026 at 8:30 AM and 1:05 PM Record review failed to reveal evidence of a physician's order for the use of oxygen, as required. During a surveyor interview on 2/17/2026 at approximately 2:00 PM with the Director of Nursing Services, she acknowledged that Resident ID #63 failed to have a physician's order for the use of oxygen, as required.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to assess one of three residents for the use of an air mattress (a pressure redistribution mattress that utilizes low air loss and pulsation) for the potential risk of entrapment related to bed rails, Resident ID # 2.Findings are as follows:Record review of a policy titled Side Rail Use last reviewed on 12/18/2025 states in part, POLICY: This facility recognizes the potential for the hazard of entrapment related to side rail use .PROCEDURE:4. The assessment is to assess the risk of entrapment and will specify the medical/physical conditions that make the rail necessary .8. Side rails are to be ordered by the resident's physician. The order shall include the reason the rail is to be utilized. 9. The care plan will reflect the use of the side rail. Record review revealed the resident was admitted to the facility in December of 2025 with diagnoses including, but not limited to, congestive heart failure (when the heart muscle is too weak or stiff to pump blood efficiently, causing blood and fluids to back up into the lungs, liver or legs) and chronic kidney disease.Record review of a progress note dated 1/24/2026 revealed that the resident was receiving hospice care services. Further review revealed that the hospice provider would provide an air mattress for the resident. Record review of a Hospice Care Coordination Note dated 1/29/2026 revealed that the low air mattress would be delivered the next day.Surveyor observations on 2/16/2026 at 10:22 AM and 2/17/2026 at 9:10 AM revealed the resident was in lying in bed with an air mattress in place with (2) 1/2 bed rails in use. Record review failed to reveal evidence that a bed rail entrapment assessment had been completed following the implementation of an air mattress to the resident's bed. During a surveyor interview on 2/17/2026 at 2:09 PM with the Director of Nursing, she revealed that it was her expectation that upon receiving an air mattress, the resident would have been reassessed for risk of entrapment from the bed rails.

Based on surveyor observation, clinical record review and staff interview, the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to disinfecting blood glucose meters (a device used to monitor blood glucose) for 1 of 1 resident observed, Resident ID #32.Findings are as follows:According to the Centers for Disease Control and Prevention article titled Considerations for Blood Glucose Monitoring and Insulin Administration dated 8/7/2024 states in part, If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents.Review of the facility's policy revised on December 2025, titled, Diabetes - Care of equipment states in part, .If a glucometer is to be used for one resident and then reused for another, the device must be cleaned and disinfected between uses.Follow the manufacturer's recommendations for cleaning.Review of the [NAME] Quintet AC Blood Glucose Meters cleaning and disinfecting guide states in part, .[NAME] Quintet AC.are considered potentially infectious and capable of transmitting bloodborne pathogens.To clean and disinfect the meter, we recommend using CaviWipes Disinfecting Towelettes.During a surveyor observation on 2/19/2026 at 8:30 AM of Registered Nurse, Staff C, she obtained Resident ID #32's blood glucose level utilizing the [NAME] Quintet AC blood glucose meter. She then used an alcohol prep pad to clean it and failed to utilize an approved cleaner such as Caviwipes Disinfected Towelettes to disinfect the meter before putting it back in the medication cart.During a surveyor interview with Staff C following the above observation, she revealed that she only uses the alcohol prep pad to clean the glucose meter because that's what she's told. Additionally, she claimed that the glucose meter was for the sole use of Resident ID #32, however, she was unable to provide evidence or labeling confirming its dedicated use for Resident ID #32.During a surveyor interview on 2/19/2026 at 9:15 AM with the Director of Nursing Services, she acknowledged that she would expect Staff C to utilize the purple wipes (PDI - Professional Disposables International Super Sani-Cloth Germicidal Wipes) when cleaning the glucometer after each use. Additionally, she was unable to provide evidence that the glucose meter was solely dedicated for use by Resident ID #32.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food safety relative to food handling, and 1 of 1 ice machines observed. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 Edition, 216-RICR-50-10-1 subchapter 10 titled food contamination, section 1.5.1 Preventing Contamination from Hands states in part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use .single-use gloves . During surveyor observations of the meal service in the main kitchen of cook, Staff F, he failed to follow the single-use gloves protocol on the following dates and times: - 11/18/2024 from 11:50 AM to 12:11 PM, Staff F was observed touching the following equipment (oven, microwave, knives, and tongs), and food with the same gloves. Staff F then removed salad from a salad bowl and plated it for lunch service. Further, Staff F, with the same gloves on, put on an oven mitt, over his gloved hand, removed a pan of bacon from the stove and plated the bacon. Again, without changing his gloves, Staff F was observed handling cooked chicken and bread. - 11/19/2024 at 11:55 AM, Staff F was observed touching the microwave, checking the soup temperature, the cutting board and a resident's grilled sandwich, without changing his gloves. During a surveyor interview on 11/19/2024 at 12:02 PM with Staff F, he acknowledged that he failed to change his single use gloves after handling kitchen equipment and before handling ready to eat food. During a surveyor interview on 11/19/2024 at 12:10 PM with the Food Service Director (FSD), she indicated that she would have expected Staff F to change his gloves before touching ready to eat food. 2. The Rhode Island Food Code 2018 Edition 5-202.13, states in part, .an air gap between the water supply inlet and the flood level rim of the plumbing fixture equipment .shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) . During a surveyor observation, in the presence of the FSD on 11/20/2024 at 9:21 AM, revealed the facility's ice machine located in the main kitchen, had an air gap between the water supply inlet and the flood level rim of approximately 0.25 inches. During a surveyor interview on 11/20/2024 at 11:20 AM with the FSD, she acknowledged that the measurement between the water supply inlet and the flood level rim is less than 1 inch as required.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice relative to the failure to post cautionary and safety signs indicating that oxygen was in use for 3 of 3 residents observed, Resident ID #s 13, 36, and 52. Findings are as follows: 1. Record review revealed Resident ID #52 was admitted to the facility in May of 2024 with a diagnosis including, but not limited to, acute and chronic respiratory failure with hypoxia (low levels of oxygen in the blood). Record review revealed a physician's order dated 8/20/2024 to administer humidified oxygen at 2 liters per minute (LPM) continuously via a nasal cannula (a medical device used to provide supplemental oxygen therapy). Surveyor observation of the resident's room failed to reveal evidence that a cautionary and safety sign indicating oxygen was in use on the following dates and times: - 11/18/2024 at 9:09 AM and 11:31 AM - 11/19/2024 at 8:07 AM - 11/20/2024 at 8:02 AM During a surveyor interview on 11/20/2024 at 8:13 AM with the RN, Staff E, she acknowledged that Resident ID #52's room failed to have a cautionary and safety sign indicating oxygen was in use. 2. Record review revealed Resident ID #13 was admitted to the facility in November of 2014 with a diagnosis, including but not limited to, alcohol dependence. Record review revealed a physician's order dated 10/29/2024 to administer oxygen at 2 LPM via nasal cannula every shift. Surveyor observations of the resident's room failed to reveal evidence that a cautionary and safety sign indicating oxygen was in use on the following dates and times: - 11/18/2024 at approximately 10:30 AM - 11/20/2024 at 8:04 AM and 8:31 AM During a surveyor interview on 11/20/2024 at 8:31 AM with Registered Nurse (RN), Staff E, she acknowledged that Resident ID #13's room failed to have a cautionary and safety sign indicating oxygen was in use. 3. Record review revealed Resident ID #36 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, malignant neoplasm of the rectum (rectal cancer). Record review revealed a physician's order dated 11/18/2024 to administer oxygen at 2 LPM continuously via a nasal cannula. Surveyor observations of the resident's room failed to reveal evidence that a cautionary and safety sign indicating of oxygen was in use on the following dates and times: - 11/18/2024 at approximately 1:00 PM - 11/19/2024 at 8:54 AM and 9:44 AM During a surveyor interview on 11/20/2024 at approximately 1:00 PM with the Director of Nursing Services, she acknowledged that the facility failed to have a cautionary and safety sign indicating oxygen was in use for the above residents.

Based on record review and staff interview, it has been determined that the facility failed to document all required components of the facility-wide assessment. Findings are as follows: Review of a facility provided document titled, Facility assessment dated [DATE] failed to reveal the following required components: - The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population - The staff competencies and skill set that are necessary to provide the level and types of care needed for the resident population - All personnel, including managers, staff (both employees and those who provide services under contract), as well as their education and/or training and any competencies related to resident care - Include or address an evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, consistent with their expected roles - An evaluation of what policies and procedures may be required in the provision of care and that these meet current professional standards of practice - An evaluation of any contracts, memorandums of understanding including third party agreements for the provision of goods, services, or equipment to the facility during both normal operations and emergencies - Their process for overseeing these services and how those services will meet resident needs and regulatory, operational, maintenance, and staff training requirements - The overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs During a surveyor interview on 11/21/2024 at 9:48 AM with the Administrator, he acknowledged that the facility assessment failed to address the above required components.

Based on record review and staff interview, it has been determined that the facility failed to promptly notify the ordering physician or a provider of laboratory results that fell outside of clinical reference ranges relative abnormal urinalysis (U/A C&S - a test that checks for bacteria in your urine that could be causing an infection in your urinary system) results, for 1 of 3 residents reviewed, Resident ID #26. Findings are as follows: Record review revealed the resident was readmitted to the facility in October of 2024 with diagnoses including, but not limited to, cystitis (a urinary tract infection (UTI), that effects the bladder), cerebral infarction (stroke), and aphasia (a language disorder that affects the person's ability to communicate). Record review of a progress note dated 11/11/2024 revealed the resident's responsible party was requesting a urine test for the resident as s/he was noted to be urinating more than usual, grimacing when urinating and the behaviors s/he was displaying were similar to the behaviors s/he had when diagnosed with a UTI in the past. Record review revealed a physician's order dated 11/11/2024 for a U/A C&S. Record review revealed a urine sample was obtained for a U/A on 11/12/2024. Review of the Lab Results Report revealed the results of the urine test, for the sample obtained on 11/12/2024, indicated that the resident's urine contained multiple organisms. Further review failed to reveal evidence that the above-mentioned lab result was reported to the physician until it was brought to the facility's attention by the surveyor. Record review revealed a physician's order dated 11/14/2024 for another U/A C&S to be obtained. Record review revealed a urine sample was obtained 11/15/2024. Review of the Lab Results Report revealed the results of the urine test, for the sample obtained on 11/15/2024, indicated that the resident's urine contained multiple organisms, and the culture should be recollected if clinically indicated. Record review revealed a repeat urine sample was obtained for a U/A C&S on 11/18/2024. Review of the Lab Results Report, for the sample obtained on 11/18/2024, revealed the results of the urine test indicated the urine contained greater than 100,000 Colony Forming Unit/milliliter (CFU/ML, the number of bacterial cells capable of reproducing when grown) of gram-negative rods (most common pathogens associated with the that were isolated), indicating the resident had an infection but the organism causing the infection had not yet been identified, as the sensitivity results were pending. During a surveyor interview with Registered Nurse, Staff E, on 11/20/2024 at 11:16 AM, she revealed that she was not aware of the lab results report from the urine collected on 11/12/2024 and 11/15/2024. Additionally, she indicated that she had reviewed the U/A C&S results obtained on 11/18/2024 and that the results indicated the resident was positive for a UTI. Further, she revealed she would not be notifying the provider until the C&S results were received. During a surveyor interview with the Director of Nursing Services on 11/20/2024 at 12:18 PM, she was unable to provide evidence that the provider was notified of the U/A C&S results from the urine collected on 11/12, 11/15 and, 11/18/2024, until it brought to the facility's attention by the survey. She further revealed that she would have expected Staff E to review and report the resident's lab results from 11/18/2024 to the ordering physician and not wait for the C&S results before doing so.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases, relative to the disinfection of a multiuse glucometer. Findings are as follows: Record review of a facility provided document titled, Facility's Competency Validation for Blood Glucose Testing, revealed the glucometer should be wiped down with a low-level disinfectant wipe (per the manufacturer's instructions) before and after each use. Record review of the McKesson's Manufacturer Instruction Manual revealed that the glucometer is to be cleaned and disinfected only with PDI Super Sani Cloth wipes (or any disinfectant product with the Environmental Protection Agency *reg. no. of 9480-4). Record review revealed Resident ID #10 has a physician's order dated 8/24/2024 to obtain a finger stick blood sugar (FSBS) once a day at 12:00 PM. During a surveyor observation on 11/19/2024 at 11:16 AM with Licensed Practical Nurse, Staff G, she failed to wipe down the glucometer before and after obtaining the resident's FSBS. Additionally, Staff G failed to disinfect the glucometer prior to placing it back in its bag and placing it in the medication cart. During a surveyor interview on 11/19/2024 at 12:25 PM with Staff G, she acknowledged that she failed to wipe down the glucometer after she used it. Staff G then cleansed the used glucometer with an alcohol wipe. When questioned during the observation, Staff G revealed that it is her usual practice to wipe down the used glucometer with an alcohol wipe. During a surveyor interview on 11/19/2024 at 12:48 PM with the Director of Nursing Services and the Infection Control Nurse, they revealed Staff G should have wiped down the glucometer with the PDI Super Sani Cloth wipes as per the Manufacturer's instruction Manual.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan related to skin integrity for 1 of 1 resident observed, Resident ID #50, and a Hoyer lift (mechanical lift) transfer for 1 of 4 residents reviewed, Resident ID #48. Findings are as follows: Record review of the State Operations Manual (SOM) Appendix PP-Guidance to Surveyors for Long Term Care Facilities, updated on 8/8/2024, page 316 revealed that many clinicians recommended a position change (offloading) hourly for dependent residents who are sitting or who are in a bed or a reclining chair with the head of the bed or back of the wheelchair raised 30 degrees or more. Further review of the SOM revealed a micro shift, meaning a small change in the resident's position for a short period of time, may not be adequate since this approach does not allow sufficient capillary refill and tissue perfusion for a resident at risk of developing a pressure injury. 1. Record review for Resident ID #50 revealed s/he was admitted to the facility in August of 2023 with diagnoses including, but not limited to, dementia, cerebral infarction (stroke), and abnormal gait and mobility. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Record review of a care plan dated 6/5/2024 revealed the resident is unable to be independent with self-care secondary to physical limitations related to being status post stroke with right sided weakness, periods of increased confusion due to dementia, and a decline in physical and mental status. Further record review revealed a care plan dated 3/2/2024 that indicated the resident is at risk for skin breakdown due to impaired mobility, bowel incontinence, and fluctuation in intake. Interventions included, but were not limited to, receiving assistance with repositioning, incontinence care, or toileting during unit rounds, and as needed. Continuous surveyor observations revealed the resident was sitting in his/her Broda (a type of wheelchair) with the back of the chair reclined at approximately 75 degrees. The staff failed to assist the resident with repositioning, incontinence care, and/or toileting during the following continuous observations: -11/20/2024 from 9:45 AM through 1:50 PM (4 hours and 5 minutes) -11/21/2024 from 7:45 AM through 12:05 PM (4 hours and 20 Minutes) During a surveyor interview on 11/21/2024 at 12:08 PM with NA, Staff B, she revealed that the resident was on her assignment. Staff B further revealed that the resident was assisted out of bed to his/her wheelchair this morning between 7:30 AM and 7:45 AM, although Staff A had previously stated to the surveyor that the resident was in his/her chair at 7:00 AM. Additionally, Staff B revealed she has not repositioned, provided incontinence care, and/or toileted the resident. During a surveyor interview on 11/21/2024 at 12:12 PM with the Director of Nursing Services (DNS), she revealed ideally, staff should do their rounds (check for incontinence and repositioning) every 2 to 3 hours. When she was made aware of the above mentioned observations. The DNS stated, that is not acceptable. During a surveyor observation in the presence of the DNS on 11/21/2024 at 1:44 PM, revealed that the resident had a bowel movement. During a surveyor interview following the above observation with the DNS, she was unable to provide evidence that Resident ID #50's comprehensive person-centered care plan was followed. 2. Record review revealed Resident ID #48 was admitted to the facility in May of 2022 with diagnoses including, but not limited to, left side hemiparesis and hemiplegia (partial weakness and paralysis). Record review of a Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. During a surveyor interview on 11/18/2024 at 11:02 AM, and again on 11/19/2024 at 10:10 AM with Resident ID #48, s/he revealed that s/he was concerned for her/his safety because NA, Staff C, has been transferring her/him alone while utilizing the Hoyer lift. Record review of a care plan dated 2/26/2024 indicated the resident is a fall risk with interventions including, but not limited to, transfer via Hoyer lift with the assistance of two staff. During a surveyor interview on 11/19/2024 at 3:06 PM with NA, Staff C, she acknowledged two staff members are required to transfer a resident via a Hoyer lift. Additionally, she revealed that she has transferred the resident alone at times. During a surveyor interview on 11/19/2024 at approximately 3:15 PM with the DNS, she revealed that her expectation is to have two staff members present during Hoyer lift transfers per the resident's plan of care. 46338

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a resident with limited range of motion (ROM) appropriate treatment and services relative the use of a hand roll device (use to promote extension in contrasted hand) for 1 of 1 resident reviewed, Resident ID #32. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2017 with a diagnosis including, but not limited to, left hand contractures. Record review of the care plan dated 3/5/2024 revealed the resident is unable to be independent with self-care secondary to physical limitations. Record review of a physician's order dated 4/5/2024 revealed that the resident is to wear a left-hand roll with finger separators every morning for 6-8 hours, as tolerated. Record review of an Occupational Therapist (OT) note dated 11/11/2024, revealed that the resident was screened for the left-hand roll with finger separators and that s/he is appropriate to wear the device. During surveyor observations on the following dates and times, failed to reveal evidence that the left-hand roll with finger separators was in place: - 11/18/2024 at 12:16 PM - 11/19/2024 at 7:54 AM, 10:55 AM, and 12:00 PM - 11/20/2024 at 9:16 AM, and 11:40 AM During a surveyor observation of the resident in the presence of Licensed Practical Nurse, Staff D, on 11/20/2024 at 11:48, she acknowledged that the resident did not have his/her left-hand roll in place. Additionally, Staff D indicated that the resident might have refused. During the above interview, the resident responded to Staff D that s/he never refused the use of the hand roll. Furthermore, Staff D then applied the hand roll to the resident's left-hand. During a surveyor interview on 11/20/2024 at 12:00 PM with OT, Staff H, she indicated that the purpose of the left-hand roll is to keep the resident's left hand opened as much as possible, due to his/her contractures. During a surveyor interview on 11/20/2024 at 1:41 PM with the Director of Nursing Services, she indicated that she would have expected the staff to apply the left hand roll to the resident's hand unless it was refused.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of an undated facility provided policy titled, Medication Administration Safety Program states in part, . 4. Prior to actually giving the resident the medication(s), the licensed staff member must confirm the residents' identity . Record review of a community reported complaint sent to the Rhode Island Department of Health on 2/28/2024 alleges that the Medication Technician, Staff A, gave Resident ID #1 medications that were prescribed for Resident ID #2. Record review for Resident ID #1 revealed that s/he was admitted to the facility in January of 2024 with diagnoses which include but are not limited to, spinal stenosis, muscle weakness and insomnia. During a surveyor interview on 2/29/2024 at 10:30 AM with Resident ID #1, s/he revealed that s/he was told by the facility staff that s/he was given someone else's medications in error on 1/19/2024. Additionally, s/he stated that s/he does not know which medications s/he received but they made him/her lethargic. Record review revealed that Resident ID #1 received the following morning medications that were prescribed for Resident ID #2 on 1/19/2024: - Atenolol 50 milligrams (MG) (a medication prescribed for high blood pressure) - Eliquis 5 MG (a medication used to prevent blood clots) - Multivitamin with minerals - Lexapro Oxalate 10 MG (a medication used for depression) - Lasix 20 MG (a medication used to remove excess fluid accumulation) - Keppra 750 MG (a medication used to used to treat seizures) - Losartan 50 MG 1 (a medication used to treat high blood pressure) - Senna plus 8.5- 50 MG 2 (stool softener) - Acetaminophen 650 MG During a surveyor interview on 2/29/2024 at 12:12 PM with Licensed Practical Nurse, Staff B, she revealed that on 1/19/2024 at approximately 11:00 AM, Staff A, reported to her that she had mistakenly given Resident ID #1 Resident ID #2's morning medications. During a surveyor interview on 2/29/2024 at 1:41 PM with the Staff A, she revealed that on the morning of 1/19/2024 she gave Resident ID #1 the medications that she had prepared for Resident ID #2. Additionally, she indicated that the error occurred as she failed to properly identify Resident ID #1. She further revealed that she did not administer any of the above listed medications to Resident ID #2 on the morning of 1/19/2024. During a surveyor interview on 2/29/2024 at 11:52 AM and 3/1/2024 at 9:36 AM with the Director of Nursing Services, she acknowledged that Resident ID #1 received Resident ID #2's medications in error on the morning of 1/19/2024. Additionally, she stated she would expect the staff to properly identify the residents before medication administration.

Based on record review, and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from significant medication errors for 1 of 1 resident reviewed who experienced a significant medication error, Resident ID #24. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2022 with a diagnosis, including but not limited to, hypertension. Record review revealed the resident has the following physician orders: -9/19/2023, to treat high blood pressure and chest pain: Amlodipine 5 mg (milligrams) to be administered once daily. -9/19/2023, to treat high blood pressure and heart failure: Lisinopril, 10 mg tablet to be administered once daily. Further review of the above-mentioned orders revealed parameters to hold the medication if the diastolic blood pressure (DBP, the bottom number of a blood pressure that measures the force exerted on the blood vessels when the heart is at rest) is less than 60 mm Hg (millimeters of mercury). Review of the 9/20/2023 through 9/30/2023 Medication Administration Record (MAR) revealed the above-mentioned medications were administered when the DBP was less than 60 mm Hg on the following dates: - 9/23/2023: 57 - 9/26/2023: 52 - 9/29/2023: 55 Review of the October 2023 MAR revealed the above-mentioned medications were administered when the DBP was less than 60 mm Hg on the following dates: - 10/3/2023: 52 - 10/5/2023: 49 - 10/8/2023: 55 - 10/10/2023: 56 - 10/11/2023: 53 - 10/17/2023: 42 - 10/19/2023: 58 - 10/22/2023: 53 - 10/27/2023: 59 - 10/31/2023: 57 Review of the November 2023 MAR revealed the above-mentioned medications were administered when the DBP was less than 60 mm Hg on the following dates: - 11/2/2023: 57 - 11/4/2023: 58 - 11/5/2023: 55 - 11/14/2023: 56 - 11/15/2023: 50 - 11/16/2023: 55 - 11/21/2023: 43 - 11/24/2023: 52 - 11/28/2023: 50 During a surveyor interview on 12/1/2023 at 1:01 PM with Certified Medication Technician, Staff A, she acknowledged that she administered the Amlodipine 5 mg and the Lisinopril 10 mg on the majority of the above-mentioned dates. Additionally she acknowledged that she did not follow the diastolic blood pressure parameters for these significant medications, indicating it was, an oversight. During a surveyor interview on 12/1/2023 at 1:19 PM with the Director of Nursing Services, she was unable to provide evidence that the resident was free from significant medication errors as the resident received the above-mentioned medications outside of the ordered parameters. 41720

Based on surveyor observation and staff interview, it has been determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff, for 2 of 3 microwaves observed. Findings are as follows: Surveyor observation of the second floor, Unit 2A, on 11/29/2023 at 9:33 AM, revealed multiple rust spots on the inside ceiling of the microwave. One area, approximately the size of a half dollar, was located towards the front of the microwave and multiple small areas of rust were observed. Additionally, the rust debris was observed to flake off when touched. Further surveyor observation on the second floor, Unit 2B, on 11/29/2023 at 9:37 AM, revealed a brown and red colored buildup of an unidentified food substance on the inside ceiling and walls of the microwave. An additional surveyor observation of the microwave, located on the 2B Unit on 11/30/2023 at 7:59 AM, revealed the same brown and red colored food substance buildup on the inside ceiling and walls of the microwave as initially observed on the previous day. During a simultaneous surveyor observation and interview on 11/30/2023 at 8:22 AM, Licensed Practical Nurse, Staff B, acknowledged the rust areas in the microwave of the 2A Unit . During a surveyor interview with the Director of Nursing Services, on 11/30/2023 at 8:25 AM and again at 12:02 PM, she acknowledged the above-mentioned observations and indicated that the microwave on 2A was replaced after the surveyor brought her concerns to the facility's attention, due to the rust.

Based on surveyor interview and record review, it has been determined that the facility failed to identify hazards and risks to ensure an environment that is free from accident hazards as possible, for 1 of 3 residents reviewed who has a history of falls, Resident ID #2. Findings are as follows: Record review of a facility reported incident received by the Rhode Island Department of Health on 3/22/2023 indicates that the resident sustained a fall at 12:30 AM and was sent out to an acute care hospital for evaluation at approximately 7:00 AM. Record review revealed Resident ID #2 was admitted to the facility in March of 2023 with diagnoses including, but not limited to malignant neoplasm (abnormal mass of tissue that is cancerous) of left kidney and an occlusion (blockage) and stenosis (narrowing) of the carotid artery (major blood vessels that provide the brain's blood supply). Review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status Assessment Score of 7 out of 15, indicating the resident's cognition is moderately impaired. Additionally, the MDS reveals the resident has a history of falls within the last month, prior to admission. Record review of a baseline care plan upon admission revealed s/he was at risk for falls and a safety risk. Record review of a progress note dated 3/19/2023 revealed Resident ID #2 placed his/her feet off of the bed and onto the floor. Upon entering the resident's room Nursing Assistant, Staff A, told him/her, wait, I will help you. The resident then began to sit up and the bed moved sideways, and s/he began to slide off of the bed. During a surveyor interview on 4/13/2023 at approximately 3:25 PM with nursing assistant, Staff A she stated that the resident's bed was not locked and it could not be locked. During a surveyor interview on 4/13/2023 at approximately 3:35 PM with the Administrator he was unable to provide evidence that the bed had the capability of being locked. Additionally, the Administrator revealed that the resident's bed had been taken out of service.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms and 2 of 3 medication carts reviewed. Findings are as follows: Review of the facility policy titled; Medication Storage revealed in part: .In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications .are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by individuals with authorized access .Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used . 1) During a surveyor observation on 10/6/2022 at 11:15 AM, revealed Licensed Practical Nurse, Staff A, leave the medication cart unlocked and unattended with drawers facing out into the hallway when she entered a resident's room to obtain a blood sugar. She then returned to the cart, after getting an error message on the glucometer, to get more supplies. She again left the cart unlocked, to return to the resident's room to re-check the blood sugar. During a surveyor interview on 10/6/2022 at 11:30 AM with Staff A, she acknowledged leaving the medication cart unattended and unlocked in the hallway. 2) During a surveyor observation on 10/6/2022 at 12:08 PM of the second-floor medication room revealed a vial of Novolin N (insulin) 100 unit/ml (milliliter) opened and undated for Resident ID #99. Review of the record revealed Resident ID #99 was discharged from the facility on 7/13/2022. During a surveyor interview on 10/6/2022 at 12:10 PM with Staff A, she acknowledged that the vial was opened and undated. She further revealed that the resident no longer resides at the facility. 3) During a surveyor observation on 10/6/2022 at 12:37 PM with Staff A, she entered a resident's room to administer insulin at 12:38 PM and remained in the room until 12:43 PM while the medication cart was unattended and unlocked in the hallway with the keys hanging from the lock. During a surveyor interview on 10/6/2022 at 12:44 PM, Staff A acknowledged she left the keys in the unlocked medication cart while it was unattended. 4) During a surveyor observation on 10/7/2022 at 9:43 AM with Registered Nurse, Staff C, she was observed leaving the medication/treatment cart unlocked with the bottom drawer opened approximately 3 inches. Staff C walked away from the cart, down a hallway to the other first floor unit to get a staff member to assist her with a dressing change. She returned and locked the cart at 9:47 AM. During a surveyor interview on 10/7/2022 at 10:01 AM with Nurse Staff C, she acknowledged that the cart was left unlocked with the drawer opened while she went to get the other staff member. During a surveyor interview on 10/6/2022 at 12:13 PM with the Corporate Compliance Officer she revealed that she would expect insulin to be dated when opened, and that any cart left unattended should be locked.

39496 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 observation of blood glucose monitoring, Resident ID #153, and 2 of 4 units observed for the proper usage of personal protective equipment (PPE). Findings are as follows: 1) Review of the facility policy titled, Diabetes- Care of Equipment reveals in part: .If a glucometer is to be used for one resident and then reused for another, the device must be cleaned and disinfected between uses .Change gloves between resident contact and after every procedure that involves potential exposure to blood or body fluids. Discard gloves in appropriate receptacles .Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other residents . During a surveyor observation on 10/6/2022 at 11:15 AM, Licensed Practical Nurse, Staff A, was observed checking the blood sugar of Resident ID #153. The glucometer had a read error after the first finger stick, so Staff A removed the test strip containing blood from the glucometer and then, without performing hand hygiene or a glove change, proceeded to use the same gloved hand to remove a new test strip from the bottle. Additional observation revealed the glucometer was returned to the cart without disinfection after use. During a surveyor interview on 10/6/2022 at 11:30 AM with Staff A, she acknowledged that she did not remove her gloves and perform hand hygiene before obtaining a new test strip, after she touched the bloody test strip. She further acknowledged that she did not disinfect the glucometer before placing it back in the cart. 2) Review of the facility policy titled, Care of the Covid -19 Positive (or Suspected) Resident revealed in part: .Full PPE for Employees-N95 gowns, gloves, face shields/goggles will be worn during care of the COVID positive resident (on isolation) or (COVID status unknown - the resident on quarantine status) .Housekeeping employees (and other employees assisting in cleaning) should be aware of proper cleaning procedures for this type of isolation precautions (droplet). The employee will also wear full PPE [Personal Protective Equipment] (as above) when entering this room . During a surveyor observation on 10/7/2022 at 10:03 AM with Housekeeper, Staff D she was observed coming out of a Covid-19 positive resident's room (Resident ID #149) wearing only a surgical mask. During a surveyor interview immediately following the above observation, Staff D revealed that she took off all PPE including her N95 before exiting the Covid-19 positive room. During a surveyor interview on 10/7/2022 at 12:32 PM with the Corporate Compliance Officer, she revealed she would expect the staff to wear an N95 covered by a surgical mask into a Covid-19 positive room. When they exit the room, they would remove only the surgical mask. During the entrance conference on 10/4/2022 at approximately 8:40 AM, the Administrator revealed that surgical masks are to be worn while in the facility for all staff and visitors. During a surveyor observation on 10/7/2022 at 9:53 AM, Registered Nurse, Staff C was observed completing a dressing change for Resident ID #30, to a stage 4 ulcer on the coccyx. Staff C's surgical mask failed to cover her nose through the entire dressing change. No attempts were made by Staff C to correct the improper fit of the mask. During a surveyor interview on 10/7/2022 at 10:01 AM with Staff C she acknowledged that the surgical mask was down throughout the dressing change.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents that are at risk for pressure ulcers and residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 1 of 3 residents reviewed for pressure ulcers, Resident ID #27. Findings are as follows: Review of the policy titled Skin Care Protocol, states in part; .It is the policy of this facility to follow appropriate standards of care as they relate to residents' skin care .identification of those 'at risk,' weekly skin checks .PROCEDURE .weekly observations will be done and maintained in the residents' medical record .must be kept up to date with the resident's most recent condition and treatment . Record review revealed the resident was readmitted to the facility in May of 2022 with diagnoses that include but are not limited to, pressure ulcer of left heel, stage 4 (full thickness skin loss extending to muscle, ligaments, and bones), osteomyelitis (inflammation of bone caused by infection), and diabetes. Review of a Minimum Data Set Assessment, dated 8/22/2022 revealed a Brief Interview for Mental Status score of 7 out of 15 indicating s/he has severe cognitive impairment. Further review revealed s/he requires total assistance of two or more staff members for bed mobility, total assistance of one staff member for toileting needs, and s/he is incontinent of bowel. Review of a care plan dated 8/8/2022 states in part, .Resident is at risk for impaired skin integrity secondary to: Spends most of [his/her] time in bed . Interventions include but are not limited to, weekly skin checks . Additional record review revealed a nursing order dated 9/2/2022 which states in part, .Weekly skin assessment (document in observations) .weekly .on Tuesday days . Record review of the September 2022 Treatment Administration Record revealed the weekly skin assessments for 9/6/2022 and 9/13/2022 were signed off as completed. However, the record failed to reveal evidence that the skin assessments were completed on 9/6/2022 and 9/13/2022. Record review of the progress notes dated 9/6/2022 through 9/13/2022 failed to reveal evidence that the resident refused weekly skin assessments. Further record review of documents titled .WOUND PHYSICIANS .WOUND EVALUATION & MANAGEMENT SUMMARY . dated 9/19/2022 and 9/26/2022 revealed s/he has a stage 4 pressure wound of the left heel. Record review of the weekly skin assessments completed on 9/20/2022 and 9/27/2022 states in part, .Any Ulcers No .: The documentation failed to identify the resident's existing stage 4 pressure wound of the left heel. During a surveyor interview on 10/7/2022 at 2:17 PM with the Corporate Compliance Officer, she was unable to provide evidence of the resident's weekly skin assessments for 9/6/2022 and 9/13/2022. She further acknowledged that the weekly skin assessments dated 9/20/2022 and 9/27/2022 were documented inaccurately and would expect the resident's existing pressure ulcer to be included on the weekly skin assessments. Additionally, she revealed that she would expect the weekly skin assessments to be accurately completed and documented in the resident's medical record including any resident refusals.

Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 2 residents observed relative to falls, Resident ID #2. Findings are as follows: Record review of a facility reported incident sent to the Rhode Island Department of Health on 6/21/2022, states in part, .Resident had used the commode .lost .balance and fell .found on the floor . Record review for the resident revealed s/he was admitted to the facility in May of 2022 for short term rehabilitation after a fall at home which led to a hospitalization for a displaced malleolar fracture (ankle fracture) of the right lower extremity (RLE). Record review of a Brief Interview for Mental Status assessment performed upon admission revealed a score of 15 out of 15, indicating the resident is cognitively intact. Review of a physician order written on 5/23/2022 stated non-weight bearing right lower extremity. Every shift: Shift 1, Shift 2, Shift 3. Review of the Resident's Physical Therapy (PT) Evaluation and Plan of Treatment document dated 5/24/2022 revealed that due to non-weight bearing (NWB) to RLE, patient unable to ambulate. It also revealed that an additional goal had been added to assess if patient is able to hop safely and maintain NWB to RLE during gait. It also recommended safe patient handling of 2 assist with rolling walker for stand pivot transfers only due to NWB to RLE. Record review of the Minimum Data Set Assessment, dated 5/30/2022 revealed the resident required extensive assist of one staff member for toileting. Review of the resident's progress notes revealed that on 6/20/2022 the resident had an unwitnessed fall and was sent to the hospital. The resident was admitted with diagnoses of right radius fracture and transverse fracture of the sacrum. During a surveyor interview with the resident on 6/27/2022 at approximately 9:30 AM, s/he stated I had just had a shower and I was standing with my walker and the CNA said she'd be back in a second. I could see her out my door in the hallway. I suddenly lost my balance and fell forward, hitting my head. She should not have left me; this should not have happened! During an interview with the Director of Nursing Services on 6/27/2022 at 11:30 AM, she revealed that the resident was left standing up with his/her walker as the Certified Nursing Assistant (CNA) went to obtain supplies. When the CNA returned to the room the resident was on the floor. She acknowledged that the resident was left unattended, fell and sustained significant injuries.

Based on record review and staff interview, it has been determined that the facility failed to provide services that meet accepted standards of professional practice relative to physician orders for weights and vital signs for 1 of 2 residents reviewed, Resident ID# 1. Findings are as follows: Mosby's 4th Edition, Fundamental 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 . Review of the facility policy titled, Weight Loss/Gain Protocol and Heights, states in part, .a significant weight discrepancy is defined as: 1. A weight change of 3 pounds or more in one week .gain of 5% or greater in one month .when a significant weight gain is noted .the following interventions must occur: 1. Reweigh all residents who are reported to have a significant weight discrepancy .if the re-weigh is accurate .nursing must .report any and all findings to the physician. Documents all information in the medical record . Review of the facility policy titled, Notification of Clinicians, states in part, .All notifications to a clinician should be documented in the resident's medical record . Review of the clinical record revealed that s/he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 2/9/2021 care plan revealed in part, .Monitor VS [vital signs] and report abnormals [sic] .report increased SOB [shortness of breath] or [CONDITION(S)] .monitor for orthostatic signs [measurement of blood pressure and pulse rate while a patient is sitting, standing and lying down] prn [as needed] if c/o [complaints] dizziness or c/o lightheaded . Review of the February and March 2021 progress notes indicated s/he was experiencing symptoms of dizziness and/or lightheadedness on the following dates and shifts: - 2/10/2021- Second shift (3:00 PM -11:00 PM) - 2/18/2021-First shift (7:00 AM- 3:00 PM) - 2/22/2021-Third shift (11:00 PM- 7:00 AM) - 2/26/2021- First shift - 3/2/2021- Second shift - 3/4/2021-Second shift Review of the February and March 2021 Treatment Administration Record (TAR) revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .C/O dizziness **ortho signs if present** . Further review of the TARs revealed this order was documented as completed on 2/10/2021, 2/18/2021, 2/22/2021, 2/26/2021, 3/2/2021 and 3/4/2021. Additional review of the record failed to reveal evidence that the orthostatic vital signs were obtained or documented as indicated. Review of the Physician Order Report revealed the following order dated 2/24/2021, which states in part, obtain daily weights .notify MD if weight gain greater than 3# [pounds] in one day or 5# in one week . Review of the weight documentation for February 2021 revealed the following weight was not reported to the physician as ordered: - 195.3 on 2/26/2021 and 198.4 on 2/27/2021, indicating a weight gain of 3.1 lbs. in one day with no re-weight obtained. Further review of the March 2021 documentation revealed that on 3/1/2021 s/he weighed 194.2 lbs. and 202.2 on 3/10/2021, indicating a consistent weight gain of greater than 5 pounds in a week that was not reported to the physician until 3/12/2021. During an interview on 4/20/2021 at 1:00 PM with the Director of Nursing Services, she acknowledged that the resident's weights were not reported as ordered. Additionally, she stated that her expectation is that the orthostatic vital signs would be obtained and documented in the record as indicated on the TAR and care plan.