Every finding on record at Elmhurst Rehabilitation and Healthcare Center

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide necessary services to a resident who was unable to carry out activities of daily living relative to incontinence care for 1 of 1 resident observed, Resident ID #1. Findings are as follows:Review of the facility's policy titled Activities of Daily Living (ADL), Supporting, dated April 2025, states, in part, .Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain.grooming, and personal hygiene.and in accordance with the plan of care, including support and assistance with.elimination (toileting).A resident's ability to perform ADLs is measured using clinical tools, including MDS [Minimum Data Set] .using the following MDS definitions.substantial/maximum assistance-if the helper does MORE THAN HALF the effort.Review of a community-reported complaint summited to the Rhode Island Department of Health on 8/3/2026 alleged that residents were not receiving the appropriate care at the facility.Record review revealed that the resident was admitted to the facility in November of 2024 with a diagnosis of Alzheimer's disease.Review of a quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 1 out of 15, indicating that the resident has severe cognitive impairment. Additionally, the resident was coded as being incontinent of bowel and bladder and required substantial-to-maximum assistance from staff with his/her personal hygiene.Review of a care plan dated 12/20/2025 revealed that the resident has an ADL self-care performance deficit related to Alzheimer's disease. Staff interventions included, but are not limited to, monitoring for any changes in ADL ability and/or inability to perform ADLs; providing staff assistance with grooming/personal hygiene and toileting; and providing incontinence care.During a surveyor observation on 8/12/2026 at 12:00 PM, the resident was observed from the hallway of the unit lying in bed with a white blanket covering him/her. The blanket had dried, spattered brown stains that were visible from the hallway of the unit.During a surveyor observation and interview immediately following the above-mentioned observation, in the presence of the Unit Manager, Staff A, she acknowledged that the dried, spattered brown stains on the blanket covering the resident were feces. Staff A then proceeded to assist the resident from the bed and as the resident stood up, the bedding on which s/he had been lying on also had spattered brown stains. Further observation of the resident as s/he stood, revealed dried, brownish stains on the front area of his/her pants as well. The surveyor then asked Staff A if the resident had received care that morning and Staff A stated No.During a surveyor observation and interview on 8/12/2026 at 12:02 PM with Nursing Assistant, Staff B in the presence of Staff A, she stated that she had provided care to the resident at approximately 8:00 AM that morning and had not been back into the resident's room since. Staff B further acknowledged that the resident had feces on the blanket and sheets. Staff B further stated that she had been alerted by a housekeeping staff member regarding the resident's condition earlier but did not go to the resident's room to address his/her condition when it was brought to her attention at that time.During an additional surveyor observation on 8/12/2026 at 12:05 PM, Staff A and Staff B accompanied the resident to the shower room and as the resident stood up from the shower chair, the back of his/her pants also had dried, brownish stains. The resident was then taken into the shower stall and when his/her pants were removed, a large amount of feces was observed covering the resident's pants.During a surveyor interview immediately following the above-mentioned observation with Staff A, she acknowledged the above-mentioned observation and also acknowledged that the resident was incontinent of feces. Staff A was unable to provide evidence that the resident had received the appropriate care and assistance in a timely manner to address his/her incontinence, as required. During a surveyor interview on 8/12/2026 at 1:12 PM with the Staff Developer, who was covering for the Director of Nursing Services, she stated that she would expect the staff to conduct toileting rounds on residents during the shift in addition to providing care in the morning. Additionally, she stated that the resident's bedding should have been changed when it was noted by the staff to be soiled immediately, and the resident should have been assisted with care at that time. She was unable to provide evidence that the resident had received ADL and toileting assistance in a timely manner, as required.

Based on clinical record review and staff interview, the facility failed to implement their staffing guidelines as indicated in the facility's assessment relative to scheduling Certified Medication Technicians (CMTs) on each unit. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/20/2026 alleges that the facility does not staff the unit with the appropriate number of CMTs. Record review of a document titled .Facility Assessment. Appendix B- Staffing Guidelines last reviewed on 1/5/2026 revealed a staffing pattern indicating that four CMTs should be scheduled to work on the 7:00 AM-3:00 PM shift and the 3:00 PM-11:00 PM shift.Review of the nursing staff scheduled from 7/12/2026 through 8/12/2026 failed to reveal evidence that four CMTs were scheduled and worked on the following dates and shifts per the facility's assessment staffing guidelines: 7/12: 7:00 AM -3:00 PM shift: 3 CMTs scheduled and worked 7/12: 3:00 PM - 11:00 PM: 3 CMTs scheduled and worked7/13: 3:00 PM - 11:00 PM: 3 CMTs scheduled and worked7/14: 3:00 PM -11:00 PM: 3 CMTs scheduled and worked7/16: 7:00 AM - 3:00 PM: 3 CMTs scheduled and worked7/17: 7:00 AM -3:00 PM: 3 CMTs scheduled and worked7/18: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked7/18: 3:00 PM-11:00 PM: 2 CMTs scheduled and worked7/19: 3:00 PM-11:00 PM: 1 CMT scheduled and worked7/20: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked7/20: 3:00 PM -11:00 PM: 3 CMTs scheduled and worked7/21: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked7/22: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked7/22: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked7/23: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked7/24: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked7/26: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked7/28: 7:00 AM -3:00 PM: 3 CMTs scheduled and worked7/28: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked7/29: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked7/30: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked7/31: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked8/1: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked8/1: 3:00 PM-11:00 PM: 2 CMTs scheduled and worked8/2: 7:00 AM-3:00 PM: 2 CMTs scheduled and worked8/2: 3:00 PM-11:00 PM: 2 CMTs scheduled and worked8/2: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked8/3: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked8/3: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked8/4: 7:00 AM-3:00 PM: 2 CMTs scheduled and worked8/4: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked8/6: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked8/7: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked8/7: 3:00 PM-11:00 PM: 3 CMTs scheduled and worked8/8: 3:00 PM-11:00 PM: 2 CMTs scheduled and worked8/9: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked8/9: 3:00 PM-11:00 PM: 2 CMTs scheduled and worked8/11: 7:00 AM-3:00 PM: 3 CMTs scheduled and worked8/12: 7:00 AM-3:00 PM: 3 CMTs scheduled and workedDuring a surveyor interview on 8/12/2026 at 12:39 PM with the Scheduler, she acknowledged that she was not aware of the facility's assessment related to the staffing guidelines for scheduling four CMTs, as required. Additionally, she acknowledged that the CMTs that were scheduled and worked on the above-mentioned dates and shifts did not match the staffing guidelines as indicated in the facility's assessment.During a surveyor interview on 8/12/2026 at approximately 3:00 PM with the Staff Developer, she was unable to provide evidence that the required number of CMTs were scheduled and worked on the above-mentioned dates and shifts, as indicated in the facility's assessment.

Based on clinical record review and staff interview, the facility failed to provide adequate supervision and failed to ensure an effective elopement prevention system for 1 of 1 resident reviewed, Resident #1. The resident, who resides on a secured unit due to impaired safety awareness and a high risk for elopement, requires a wander guard device (a safety mechanism intended to monitor and prevent at-risk residents from exiting unsupervised). Despite this intervention, the facility failed to prevent unsafe exit-seeking behaviors. The resident was able to self-propel while in his/her wheelchair to a stairwell door, manipulate the handle until it released, and exited into the stairwell, resulting in him/her falling down approximately 10 stairs with the wheelchair positioned over him/her. This represents an immediate and serious breakdown in supervision and safety systems, placing the resident at risk for serious harm, serious injury, serious impairment or death.Findings are as follows: Record review of a facility-reported incident submitted to the Rhode Island Department of Health on 4/13/2026 indicated Resident #1 has a Brief Interview for Mental Status (BIMS) score of 3/15, consistent with severe cognitive impairment. The resident has dementia, poor safety awareness, and self-propels rapidly in his/her wheelchair throughout the unit. The resident was found lying in a stairwell and was subsequently hospitalized and admitted with a subdural hematoma (a collection of blood found between the brain and the outer most covering typically caused by head trauma) and subarachnoid hemorrhage (a type of hemorrhagic that occurs between the brain and the membrane that protects it).Record review revealed Resident ID #1 was initially admitted to the facility in September of 2024 with a diagnosis including but not limited to dementia.Record review of an elopement assessment dated [DATE] identified the resident at high risk for elopement and indicated the use of a wander guard bracelet to his/her right wrist.Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident has a BIMS score of 3 out of 15, indicating severe cognitive impairment. Additionally, the record indicates that the resident has the ability to independently wheel him/herself in a wheelchair at least 150 feet down the corridor. During a surveyor interview on 4/21/2026 at 11:25 AM with the Administrator, she confirmed through her investigation on the day of the incident, Resident #1 was self-propelling in his/her wheelchair on the secured unit, approached the stairwell exit door, and held the fire bar until the door released. The resident then exited into the stairwell and fell down a flight of approximately 10 stairs. When staff responded to the door alarm, they found the resident lying on the stairwell landing. Additionally, the Administrator acknowledged that the alarm to the stairwell door was not loud enough to be heard by all the staff located on the secured unit.During a surveyor interview on 4/21/2026 at 3:32 PM with Nursing Assistant, Staff A, she revealed that at the time of the incident she was assisting another resident in the shower room. She indicated that she did not hear the alarm until opening the shower room door, at which time she responded to the exit stairwell door and observed Resident ID #1 lying on the landing. During a surveyor interview on 4/21/2026 at 3:41 PM with the Supervisor, Registered Nurse, Staff B, she revealed that she observed Resident ID #1 in the dining room minutes before s/he fell. Additionally, she revealed that she did not hear the door alarm sounding from the dining room. During a surveyor interview on 4/24/2026 at 9:12 AM with Unit Manager, Licensed Practical Nurse, Staff C, she revealed that she was in her office, located near the dining room, when the incident occurred and she did not hear the alarm from her office.Record review of a nursing progress note dated 4/9/2026 revealed the resident was found in the stairwell and assessed with a bump to the back of his/her head. Emergency Medical Services (EMS) was called to transfer the resident to the hospital for an evaluation and Resident ID #1 was kept in place until their arrival.Record review of the EMS Patient Care Report, dated 4/9/2026 revealed that EMS was dispatched to the facility for a traumatic injury resulting after Resident ID #1 fell down 10-12 stairs. Further review of the report indicated that staff from an adjacent medical office reported hearing a door open and an alarm sounding upstairs from the facility's dementia unit, followed by significant noise and someone screaming for help. The report indicates that the resident managed to open a locked door, rolled down the stairs while in his/her wheelchair, and was found on the stairwell landing with the wheelchair on top of him/her. Upon further assessment, the resident was noted with a hematoma (a collection of clotted or partially clotted blood) to the back of his/her head and a contusion to his/her right forearm. Record review of the hospital documentation, dated 4/9/2026, revealed the resident presented to the Emergency Department with a hematoma to his/her posterior scalp and a contusion (soft tissue injury) to his/her tongue. Additionally, a CT scan (is a diagnostic imaging test that uses X-rays and computer processing to create detailed cross-sectional images of the body) was completed and the results indicated that the resident sustained a subdural hematoma and right-sided subarachnoid hemorrhage and s/he was admitted .The facility failed to provide adequate supervision and elopement protection for Resident ID #1, who was a known high elopement risk. This failure enabled the resident to exit a secured unit door undetected, roll down multiple stairs, falling to the stairwell landing and s/he subsequently sustained a subdural hematoma and subarachnoid hemorrhage from the trauma. This lapse of supervision placed the resident at risk for more than minimal harm, serious injury, or death.

Based on clinical record review, and resident and staff interview, the facility failed to maintain accurate and complete medical records in accordance with accepted professional standards and practices for 1 of 3 residents reviewed related to medication administration, Resident ID #1. Specifically, the facility failed to ensure accurate, timely, and consistent documentation of the administration of Mounjaro, a medication prescribed to treat type 2 diabetes mellitus.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 4/3/2026 alleged that the resident did not receive a scheduled dose of Mounjaro; however, nursing staff documented the medication as administered.Review of a facility policy titled Documentation of Medication Administration (November 2022) indicated, in part, that medications are to be documented immediately after administration and that documentation must include reasons when a medication is withheld, not administered, or refused.Record review indicated the resident was admitted in November 2025 with diagnoses including, but not limited to, type 2 diabetes mellitus. The Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact.During a surveyor interview on 4/7/2026 at approximately 12:20 PM, the resident reported not receiving the scheduled Mounjaro injection on 3/13/2026 and stated that s/he was later informed the dose had been documented as administered by Licensed Practical Nurse (LPN), Staff A.Record review revealed a physician's order with a start date of 11/28/2025 for Mounjaro 5 milligrams (mg)/0.5 milliliters (ml) inject 5 mg once every 7 days.Review of the March 2026 Medication Administration Record (MAR) indicated that LPN Staff A documented administration of Mounjaro on 3/13/2026.During a surveyor interview on 4/7/2026 at 12:32 PM, the Director of Nursing Services (DNS) revealed that facility practice is for Mounjaro to be counted in the narcotic book to ensure ongoing accountability of the medication due to its high cost. Record review of pharmacy records and the narcotic count book revealed that four Mounjaro injection pens were delivered on 3/6/2026 and a total of four were available for administration.Record review of a written statement authored by Registered Nurse (RN) Staff B, Unit Supervisor, indicated that on 3/15/2026 the resident reported not receiving the scheduled dose. RN Staff B and Staff C verified that both the narcotic count record and physical inventory in the refrigerator remained unchanged from 3/6/2026 through 3/15/2026, indicating that the medication had not been administered as documented in the MAR.During a surveyor interview on 4/7/2026 at 1:22 PM, the Assistant Director of Nursing (ADON) revealed that on 3/16/2026, the narcotic count reflected three remaining Mounjaro injection pens, and the narcotic book was updated accordingly. The ADON later identified that Staff A had documented administration of a dose on 3/13/2026; however, this documentation was inconsistent with prior verification on 3/15/2026 that no dose had been removed or administered.During a telephone interview on 4/7/2026 at 2:34 PM, Staff A acknowledged that although the narcotic book entry was dated 3/13/2026, the documentation was not completed until 3/15/2026, which is not consistent with facility policy requiring documentation immediately after medication administration.Record review of the conflicting documentation between the MAR, narcotic count records, and staff interviews, demonstrates that the facility failed to ensure that the resident's medical record accurately reflected whether the medication was administered. Additionally, the delayed documentation in the narcotic record further reflects failure to adhere to accepted standards of timely documentation.During a surveyor interview, the DNS and Administrator were unable to provide evidence that the documentation supporting administration of the 3/13/2026 Mounjaro dose was accurate or reliable.These findings demonstrate the facility's failure to maintain accurate, complete, and timely medical records in accordance with professional standards of practice.

Based on record review, interviews with the home care agency staff, the complainant, and facility staff, the facility failed to ensure that the appropriate resident information was communicated to the receiving health care providers at the time of discharge for 1 of 1 resident reviewed for discharge, Resident ID #1. Specifically, the facility failed to communicate that the resident's primary care physician (PCP) was a new provider who would be unable to sign home health orders until the resident was established as a patient in that practice. Additionally, the facility failed to respond to requests of the home care agency to have the facility's Medical Director sign homecare orders to enable to resident to receive skilled nursing and therapy services as ordered, following his/her discharge.Findings are as follows:Review of a community-reported complaint submitted to the Rhode Island Department of Health on 3/4/2026 by Resident ID #1's family member, alleged that the resident experienced an unsafe and poorly coordinated discharge which resulted in the resident not receiving ordered home care services following his/her discharge from the facility on 2/15/2026.Record review revealed the resident was admitted to the facility in January of 2026 with diagnoses including, but not limited to, dementia and heart failure (a chronic condition in which the heart muscle is unable to pump blood efficiently).Review of a Brief Interview for Mental Status (BIMS) evaluation dated 2/3/2026 revealed a score of 9 out of 15, indicating moderate cognitive impairment.Review of a Discharge summary dated [DATE], authored by the facility's Medical Director (MD) revealed that home health services were medically necessary for the resident, including skilled nursing and therapy services.Further record review revealed the resident was discharged home on 2/15/2026 with services from a home care agency.Review of progress notes obtained from the home care agency revealed that the resident had an initial assessment by the home care agency on 2/17/2026; however, the new primary care physician (PCP) would not sign the orders until the resident was seen in their office on 2/26/2026, and established as their patient.Additional review of progress notes dated 2/18/2026 revealed the agency contacted the facility and left a voicemail for the facility's social worker inquiring whether the facility's MD would be willing to sign home care orders until the resident could be seen by their new PCP in the community. Further review of the home care agency progress notes dated 2/26/2026 and 2/27/2026 revealed the agency again contacted the facility and left voicemails requesting that the facility's MD sign the orders so home care services could be provided to the resident prior to the 2/26/2026 appointment. Further record review revealed the facility did not return these calls until 3/5/2026.Record review failed to reveal evidence that the facility communicated with the homecare agency that the resident's primary care physician (PCP) was a new provider who would not sign home health orders until the resident was seen in the office and failed to respond to requests from the home care agency to have the facility's MD sign homecare orders. As a result, the resident did not receive skilled nursing and therapy services as ordered following his/her discharge.During surveyor interviews on 3/9/2026 at 11:15 AM and 3:57 PM with the Quality Manager from the home care agency, she stated that the agency received and accepted the referral from the facility for services beginning on 2/15/2026. She indicated the facility informed the agency the resident had a PCP appointment scheduled for 2/26/2026 but did not inform the agency that this PCP was a new provider who had never seen the resident. She further stated that on 2/17/2026, following the agency's first visit with the resident, staff contacted the PCP to obtain signed orders, but were informed the PCP would not sign orders until the resident was seen in the office on 2/26/2026. She indicated agency staff contacted the facility three times beginning on 2/18/2026 requesting that the facility MD sign the orders so services could begin prior to the PCP appointment; however, the facility did not return the calls until 3/5/2026. She confirmed the resident had not received home health services since 2/17/2026.During a surveyor interview on 3/9/2026 at 11:45 AM with the complainant, the resident's family member, s/he stated that s/he informed the facility a few days after the resident's admission that the resident did not have a PCP in the community. S/he stated the resident was discharged home on 2/15/2026 with skilled nursing and therapy services from a home care agency but had not received those services because the facility failed to relay accurate information to him/her or the home care agency. The complainant stated that after learning from the home care agency that services could not begin because the PCP would not sign orders until the 2/26/2026 appointment, s/he attempted to contact the facility's social worker on 2/24/2026 at 3:08 PM, 2/25/2026 at 2:41 PM, and again on 2/27/2026 using the telephone number provided by the facility. S/he stated s/he did not receive a return call until 3/5/2026. S/he further stated that the facility's social worker had previously assured him/her that the new PCP had agreed to sign the home care orders prior to the 2/26/2026 appointment.During surveyor interviews on 3/9/2026 at 12:16 PM and 1:07 PM with the facility social worker, Staff A, she stated the facility was aware shortly after admission that the resident did not have a PCP. Staff A stated a PCP was obtained and an appointment was scheduled for 2/26/2026. She confirmed the resident was discharged home on 2/15/2026 with skilled nursing and therapy services. Staff A acknowledged that she was aware that the new PCP would not sign the home care orders until the resident was seen on 2/26/2026. She was unable to provide evidence that the PCP had agreed to sign orders prior to that appointment. Additionally, she was also unable to provide evidence that the home care agency had been informed that this was a new PCP who had not previously seen the resident. When asked by the surveyor whether she had received calls from the home care agency or the resident's family member following the discharge, she denied receiving calls; however, she acknowledged the telephone number provided to the surveyor by the home care agency and the complainant to leave the voicemails was her correct telephone number.During an interview on 3/9/2026 at 2:26 PM with the MD, he stated that he had been informed by facility staff that the new PCP had agreed to sign the home care orders when the resident was discharged . He stated he was not aware the home care agency had requested that he sign the orders due to the PCP's refusal until 3/6/2026. He further indicated that although he does not usually sign home care orders, he would have signed the orders in this situation if he had been made aware that the new PCP would not sign them, and the resident was unable to receive services.

Based on surveyor observation, clinical record review, and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to the care of a central venous catheter (CVC, a long thin tube that is inserted through a vein and passed through to the larger veins into the heart), for 3 of 3 residents reviewed with a CVC, Resident ID #s 23, 161, and 206, and for 1 of 1 resident reviewed for mouth care, Resident ID #2. Findings are as follows:According to Lippincott Nursing Procedures, Ninth Edition page 657, states in part, .Performing a CVC dressing change .Use a sterile measuring tape or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated .Review of a facility policy titled, Central Venous Catheter Care and Dressing Changes dated October 2024 states in part, .Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion.Change the dressing if it becomes damp, loosened or visibly soiled and at least every 7 days.For PICCs [a PICC, a long, flexible catheter that is inserted into a vein in the upper arm. After insertion, the catheter is threaded to a central vein near the heart. The PICC line can be used to deliver fluids and medications], measure arm circumference and compare to baseline when clinically indicated to assess for edema and possible deep- vein thrombosis [DVT- a blood clot (thrombus) that forms in one or more of the deep veins in the body] .1a. Record review revealed that Resident ID #23 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, bacterial pneumonia.Record review of a hospital document titled PICC insertion Record dated 12/31/2025, revealed the resident had a PICC placed in his/her left arm. The baseline external length of the catheter was 0 centimeters (cm), and the baseline arm circumference was 36 cm.Record review revealed a physician's order dated 1/3/2026 to change the PICC dressing on admission and then every 7 days. Further record review failed to reveal evidence that the PICC dressing was changed on admission per the physician's order and the facility policy. Record review revealed a physician's order dated 1/4/2026 to document the baseline mid-upper arm circumference, check arm circumference (a measurement used to monitor for a deep vein thrombosis (DVT, a blood clot) as needed one time only on 1/4/2026.Review of the Medication Administration Record (MAR) for January 2026 revealed the above order to check the arm circumference was completed on 1/4/2026 with an arm circumference of 41 cm, indicating a 5 cm increase from the hospital's measurement. Record review revealed a physician's order dated 1/3/2026 to document the baseline external length of the intravenous (IV) catheter, check external length with each dressing change and as needed in the evening every 7-day(s) and document the external length.Review of the MAR for January 2026 revealed that the above order to check the external length was completed on 1/6/2026 with a documented external length of 7 cm, indicating a 7 cm increase from the hospital's measurement. Record review failed to reveal evidence that the provider was notified that the arm circumference measurement was 5 cm greater than the baseline arm circumference and that the PICC line was documented as migrating 7 cm on 1/6/2026 (displacement of the tip of the catheter from the intended position, increasing the risk for complications such as clot development, infection and vessel perforation) from the initial placement. Furthermore, the record revealed that the resident continued to receive his/her antibiotic 20 times without confirmation that the PICC tip was in the correct location or that the resident did not have a DVT relative to his/her enlarged arm circumstance.During a surveyor interview with the Nurse Practitioner, Staff E, on 1/14/2026 at 11:40 AM, she revealed that she would have expected to have been notified of the changes to the external length of the PICC line catheter as well as the change in arm circumference and acknowledged that she was not notified of either change for Resident ID #23. She further revealed that if she was aware she would have ordered a chest Xray to confirm that the PICC was correctly placed. 1b. Record review revealed that Resident ID #161 was admitted to the facility in December of 2025, with a diagnosis including, but not limited to, urinary tract infection.Record review revealed a physician order dated 1/7/2026 to document the baseline external length of the IV catheter, check external length with each dressing change and as needed one time a day every 7 days.Record review of the January 2026 MAR revealed a physician's order dated 1/7/2026 to change the central line dressing every 7 days and to measure the length. Further record review revealed that the order was signed off as completed on 1/7/2026 with the length documented as NA.Record review failed to reveal evidence that a baseline external length was documented on 1/7/2026.During a surveyor interview on 1/13/2026 at 1:42 PM with Registered Nurse, Staff D, she acknowledged that the external catheter length was not documented in the resident's record. She further revealed that she changed the resident's dressing and will document the external length that she observed.During a surveyor interview with the Nurse Practitioner, Staff E, on 1/14/2026 at 11:40 AM, she revealed that if the resident has an order to measure the external length of a PICC line catheter, she expects that to be completed.During a surveyor interview with the Director of Nursing Services (DNS) on 1/14/2026 at 12:10 PM, she revealed that she would expect staff to measure and document the external length as ordered and was unable to provide evidence that the external length was documented until it was brought to the facility's attention by the surveyor.1c. Record review revealed that the Resident ID #206 was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, end stage renal failure and protein calorie malnutrition. Record review of the hospital discharge summary titled, Patient lines/Drains/Airway Status revealed that the resident had a CVC double lumen internal jugular line (a CVC that is placed in the jugular vein) placed on 12/24/2025 with an initial external catheter length of 0 cm.Record review revealed a physician's order dated 1/7/2026 to change the central line dressing every 7 days and to measure the length of the external catheter. Record review of a nursing progress note dated 1/7/2026 revealed that the dressing to the left chest wall was changed. Further review failed to reveal evidence that a baseline external length was documented on 1/7/2026.Record review of a nursing progress note dated 1/10/2026 marked as a Late Enry for 1/8/2026 authored by the Chief Nursing Officer (CNO) states in part, .chest central line dressing change by nurse OS [On Shift], observed by this writer. Changed due to dressing becoming loose at the edges. Left chest CVC site is clean and dry with no signs of infection. External catheter length is 2 cm. Catheter is sutured in place.During a surveyor interview on 1/15/2026 at 9:34 AM with the CNO, she revealed that she observed the nurse on 1/8/2026 change the dressing and measure the external catheter length at 2 cm. Additionally, she revealed that the catheter was sutured and was not aware that the hospital discharge documents had a measurement of the length at 0 cm. She further acknowledged that a measurement of the external catheter length is to be completed with each dressing change, documented in the medical record, and a change from the hospital record should be reported to the physician. During surveyor interviews with the Physician on 1/15/2026 at 9:09 AM and 9:49 AM he revealed that the external length of the catheter should be completed with each dressing change and would expect to be notified if there is a change. Additionally, he revealed he was not aware of the change in the catheter length on 1/8/2026.2. Review of a facility policy titled, Mouth Care last revised in February 2018 states in part, The purposes [sic] of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection.moisten the applicators with the mouthwash solution.Thoroughly wipe the roof of the resident's mouth, inside the cheeks, the tongue, and the teeth with the applicator.Record review revealed Resident ID #2 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, cerebrovascular disease (a group of conditions that affect blood flow to the brain) and adult failure to thrive.Record review revealed a physician's order dated 10/10/2024 indicating s/he receives nothing by mouth. Additionally, s/he receives enteral nutrition (a method of delivering liquid nutrition directly into the stomach) via a gastrostomy tube (G-tube-a tube inserted through the abdominal wall directly into the stomach used to provide nutrition, hydration and medications for residents that are unable to take food or fluids by mouth).Review of a care plan focus area dated 6/26/2025 revealed s/he has self-care performance deficits and is dependent on staff for personal hygiene and requires assistance with oral care.Further review revealed the following physician's orders pertaining to oral hygiene:-11/10/2023: Mouth care two times each shift-12/4/2023: Biotene artificial saliva apply 2 swabs orally every 4 hours for mouth careReview of an annual oral exam assessment dated [DATE] revealed the resident's tongue appeared pink. Additionally, it revealed the tongue was documented as not coated.Surveyor observations revealed the resident's tongue had a thick brown, fuzzy coating that appeared hardened, blackish brown matter on his/her upper and lower teeth, and malodorous breath on the following dates and times:-1/12/2026 at 10:12 AM-1/13/2026 at 12:20 PM, 2:29 PM, 3:13 PM, and 3:48 PMDuring a surveyor interview immediately following the observation on 1/13/2026 at 3:48 PM with Licensed Practical Nurse, Staff F, she acknowledged the thick brown coating on the resident's tongue and the buildup of blackish brown matter on the resident's upper and lower teeth. She revealed that she has been working at the facility since July of 2025 and indicated the resident's tongue and oral cavity has always appeared that way. She further revealed that she feels mouth care should be completed more than what is ordered, however has not informed the provider. She revealed that she already completed mouth care for the resident earlier in the day at approximately 8:45 AM and 11:45 AM. When the surveyor inquired how she conducts mouth care, she revealed she only utilizes the Biotene solution and a mouth swab. Staff F failed to indicate that she utilizes mouthwash to clean the resident's oral cavity. Further, Staff F acknowledged the resident's malodorous breath that was noticeable to the surveyor despite wearing a surgical mask.During surveyor interviews on 1/14/2026 at approximately 11:10 AM and 12:00 PM with the Nurse Practitioner, Staff E, she revealed that she would expect staff to be providing mouth care according to the facility policy to cleanse the resident's mouth in addition to the applying the Biotene solution.During a surveyor interview on 1/14/2026 at approximately 3:00 PM with the DNS, she revealed that she expects proper mouth care to be completed as ordered.During a surveyor observation on 1/15/2026 at approximately 9:30 AM, the resident's teeth and oral cavity appeared clean, his/her tongue pink and without a coating, and his/her breath without a noticeable foul odor after the concern was brought to the facility's attention by the surveyor.

Based on clinical record review, resident and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 3 of 3 residents reviewed for not following physician's orders, Resident ID #s 2, 17 and 208. Findings are as follows:1) Record review revealed Resident ID #2 was admitted to the facility in November of 2023 with a diagnosis including, but not limited to, cerebrovascular disease (a group of conditions that affect blood flow to the brain). Further review revealed the resident has a gastrostomy tube (G-tube-a tube inserted through the abdominal wall directly into the stomach used to provide nutrition, hydration and medications for residents that are unable to take food or fluids by mouth). Record review revealed a physician's order dated 4/14/2025 to flush the g-tube with 50 milliliters (ml) of water after medications, and feedings.During a surveyor observation on 1/14/2026 at 9:45 AM, during the medication administration task, Licensed Practical Nurse (LPN), Staff A, flushed the resident's g-tube with 30 ml of water after administering the resident his/her medications, instead of 50 ml of water, per the physician's order.During a surveyor interview on 1/14/2026 at 1:45 PM, with Staff A, she acknowledged that she did not flush the g-tube with 50 ml of water and revealed that she should that per the physician's order. During a surveyor interview on 1/14/2026 at 3:00 PM, with the Director of Nursing Services (DNS), she revealed that it is her expectation that the physician's orders are followed. 2) Review of a policy dated 4/2019 titled, Administering Medications, states in part, .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered within one (1) hour of their prescribed time.Record review revealed that Resident ID #17 was readmitted to the facility in December of 2025, with a diagnosis including, but not limited to, Parkinsons disease.Record review revealed a care plan dated 11/11/2025, which revealed the resident is on antiparkinsonian therapy, with an intervention to administer medications as ordered.Record review revealed the following physician orders:- Rytary (a medications prescribed to treat Parkinson's disease) Oral Capsule Extended Release 36.25-145 milligrams (mg), with instructions to administer 2 capsules by mouth, two times a day, at 8:30 AM and 4:30 PM for Parkinsons disease.- Rytary Oral Capsule Extended Release 36.25-145 MG, with instructions to administer 3 capsules by mouth, two times a day, at 5:00 AM and 12:30 PM for Parkinsons disease.Review of the December 2025 Medication Administration Record (MAR), under the section titled, Administration Details revealed the following:- 12/29: 12:30 PM dose administered at 2:16 PM- 12/29: 4:30 PM dose administered at 5:39 PM, which is 3 hours and 23 minutes after the last dose was administered, as opposed to 4 hours apart-12/31: 5:00 AM dose administered at 7:59 AM- 12/31: 8:30 AM dose administered at 8:52 AM, 1 hour and 7 minutes after the last dose was administered, as opposed to 3 hours and 30 minutes apartReview of the MAR Administration Details for January 2026 revealed the following:- 1/1: 8:30 AM dose administered at 10:52 AM- 1/1: 12:30 PM dose administered at 12:41 PM, 1 hour and 49 minutes after the last dose was administered, as opposed to 4 hours apart- 1/1: 4:30 PM dose administered at 7:19 PM, 2 hours and 11 minutes after the scheduled time- 1/2: 5:00 AM dose administered at 7:02 AM, 2 hours late- 1/2: 8:30 AM dose administered at 11:03 AM, 2 hours and 33 minutes late- 1/2: 12:30 PM dose administered at 11:31 AM, 28 minutes after the last dose was administered, as opposed to 4 hours apart- 1/3: 5:00 AM dose administered at 9:14 AM, 4 hours and 14 minutes late- 1/3: 8:30 AM dose administered at 10:43 AM, 1 hour and 29 minutes after the last dose was administered, as opposed to 3 hours and 30 minutes apart- 1/3: 12:30 PM dose administered at 12:07 PM, 1 hour and 24 minutes after the last dose was administered, as opposed to 4 hours apart- 1/4: 8:30 AM dose administered at 10:48 AM, 2 hours and 18 minutes late- 1/4: 4:30 PM dose administered at 8:22 PM, 3 hours and 8 minutes late- 1/6: 12:30 PM dose administered at 2:16 PM, 1 hour and 46 minutes late- 1/7: 8:30 AM dose administered at 10:07 AM, 1 hour and 37 minutes late- 1/7: 12:30 PM dose administered at 2:27 PM, 1 hour and 53 minutes late- 1/7: 4:30 PM dose administered at 6:21 PM, 1 hour and 59 minutes late- 1/8: 4:30 PM dose administered at 8:04 PM, 3 hours and 34 minutes late- 1/10: 8:30 AM dose administered at 10:06 AM, 1 hour and 36 minutes late- 1/10: 12:30 PM dose administered at 11:31 AM, 1 hour and 25 minutes after the last dose was administered, as opposed to 4 hours apart- 1/10: 4:30 PM dose administered at 9:53 PM, 5 hours and 23 minutes late- 1/11: 8:30 AM dose administered at 10:44 AM, 2 hours and 14 minutes late- 1/11: 12:30 PM dose administered at 11:43 AM, 59 minutes after the last dose was administered, as opposed to 4 hours apart- 1/11: 4:30 PM dose administered at 7:43 PM, 3 hours and 13 minutes apartDuring a surveyor interview on 1/15/2026 at 9:55 AM, with the DNS, she acknowledged Resident ID #17's Rytary was not administered per the physician's order and indicated that it should have been.3) Record review revealed Resident ID #208 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, altered mental status.Review of a progress note dated 1/11/2026, authored by an on-call provider, revealed nursing called and reported the resident was experiencing increased agitation, a runny nose, and weakness. Further review states in part, .Nursing staff to discuss with family/POA [Power of Attorney] regarding whether or not they would like the patient to be tested for COVID and FLU and will notify this [Nurse Practitioner] of their decision. If so, then the staff may test for COVID and FLU.Record review revealed a physician order, scanned into the resident's electronic medical record (EMR), dated 1/11/2026, which states in part, Please discuss with family/POA regarding whether or not they would like the patient to be tested for COVID and FLU and notify clinician of their decision. -If family/POA want patient to be tested for COVID and FLU, then you may test patient for COVID and FLU and notify a clinician of the results.Record review failed to reveal evidence that Resident ID #208's family/POA was contacted to discuss testing the resident for COVID or FLU.During a surveyor interview on 1/14/2026 at 9:54 AM, with LPN, Staff B, she revealed that she was unaware if the resident's family was contacted to discuss testing him/her for COVID/FLU and revealed that if the family was contacted, it should be documented in a progress note. Further, she was unable to provide evidence that Resident ID #208's family was contacted, per the physician's order.During a surveyor interview on 1/14/2026 at 11:18 AM, with Resident ID #208's family member, s/he revealed that the facility had not called him/her about testing the resident for COIVD or the FLU and indicated that had s/he been called and the resident was symptomatic, s/he would have approved the testing.During a surveyor interview on 1/14/2026 at 11:28 AM, with the DNS, she revealed that the on-call providers write their physician's orders in a progress note and in a document that is scanned to the facility. She revealed that it is the nurse's responsibility to ensure the physician's order is entered into the residents EMR. Further, she revealed that she would have expected staff to call the resident's family to discuss testing him/her and revealed that the notification should be documented in a progress note.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 27 opportunities for errors observed during the medication administration task, there were 2 errors resulting in an error rate of 7.41%, involving Resident ID #s 56 and 161.Findings are as follows:Review of a facility policy titled, Administering Medications last revised in [DATE] states in part, Medications are administered in a safe and timely manner, and as prescribed.1.Record review for Resident ID #161 revealed a physician's order for ertapenem sodium (an antibiotic) and to infuse 500 milligrams every 24 hours intravenously at a rate of 105 milliliters per hour (ml/hr) for a urinary tract infection.During a surveyor observation of the medication administration task on [DATE] at approximately 1:10 PM with Registered Nurse, Staff D, she began infusing the resident's antibiotic but was asked by the surveyor to pause the infusion. An additional observation revealed the medication had expired on [DATE] and the flow rate was incorrectly set to 100 ml/hr instead of the prescribed flow rate of 105 ml/hr.During a surveyor interview immediately following the above observation with Staff D, she acknowledged the medication was expired and the flow rate was not set as prescribed.2.Record review for Resident ID #56 revealed a physician's order for Lactaid oral tablet and to administer one tablet before meals for lactose intolerance.During a surveyor observation of the medication administration task on [DATE] at approximately 8:55 AM with Certified Medication Technician, Staff G, she administered the Lactaid tablet to the resident.During a follow up surveyor interview on [DATE] at approximately 1:50 PM, she acknowledged administering the Lactaid tablet to the resident after s/he had already eaten his/her breakfast.During a surveyor interview on [DATE] at approximately 3:00 PM with the Director of Nursing Services, she revealed that medications are to be administered as prescribed. She was unable to provide evidence that the facility ensured each resident's medication regimen is free from a medication error rate of 5% or greater.

Based on surveyor observation, clinical record review, staff and resident interviews, the facility failed to treat a resident with respect and dignity, for 1 of 1 resident reviewed, Resident ID# 1.Findings are as follows:Record review of a facility reported incident received by the Rhode Island Department of Health on 12/11/2025 revealed that the resident reported that Nursing Assistants, Staff A and B had been rude during care. In addition, s/he reported that when s/he asked Staff B for his/her phone she responded, I do not care about your F [Explicit] phone. Record review revealed that the resident was admitted to the facility in November of 2025 with diagnoses including but not limited to, anxiety, depression and heart failure. Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition, is frequently incontinent of bowel and bladder, and requires substantial to maximum assistance of staff for toileting.Record review of a care plan initiated on 11/21/2025 revealed a focus area indicating that the resident has a deficit in performance of Activities of Daily Living (ADL) and requires assistance of two staff members for turning and repositioning. Record review of the progress notes dated 12/11/2025 at 3:09 AM authored by Licensed Practical Nurse, Staff C, revealed that a staff member overheard the resident on the phone speaking to someone stating that s/he feared for his/her life at this facility because s/he was being threatened.Record review of the facility incident investigation revealed the following:-An unsigned written statement provided by the resident's roommate, Resident ID #2, that revealed that s/he overheard a verbal dispute between Resident ID #1 and Staff A and B. In addition, s/he revealed that when the resident asked Staff B to please get his/her phone, Staff B responded, I do not give a F [Explicit] about your phone. S/he further revealed that s/he heard Staff A stating calm down to Staff B.-An unsigned written statement provided by Staff B that revealed she told the resident, I don't care about your phone and that s/he can look for the phone him/herself. -An employee performance improvement notification dated 12/12/2025 revealed that Staff B received a verbal notice for an employee conduct rule violation that included, unsatisfactory performance, insubordination, refusing or disrespectful conduct and violation of company policy. During a surveyor interview on 12/17/2025 at 12:50 PM with the resident, s/he revealed that is s/he is afraid of the staff that works on the night shift and gets nervous when they open the door as s/he thinks that s/he is going to see Staff A and B's faces. S/he further revealed that when staff comes into his/her room they should be more approachable and not threatening because if s/he is calling for help it is because s/he needs them as s/he is unable change his/her incontinence brief without their help.During a surveyor interview on 12/17/2025 at 3:51 PM with the Director of Social Work, she was unable to provide evidence that Staff A and B treated Resident ID #1 with dignity and respect.During a surveyor interview on 12/17/0252 at and 4:44 PM with the Administrator, she was unable to provide evidence that Staff A and B treated Resident ID #1 with dignity and respect.

Based on record review and staff interview, it has been determined that the facility failed to provide the necessary treatment and care in accordance with professional standards of practice relative to implementing a surgical wound treatment order for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/8/2025 alleges in part, that the facility did not .properly. care for the resident's wound. Record review revealed Resident ID #1 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, sepsis (an infection in the body) due to Serratia (a type of germ).Record review of a hospital continuity of care document dated 9/12/2025, provided to the facility upon the resident's admission revealed, General Discharge Instructions indicating to cleanse the resident's left hip incision site wound with Vashe cleanser (a special wound cleaning solution that removes germs, dirt, and dead tissue without stinging or damaging healthy tissue), pat dry, cover the wound with an antibacterial dressing and protective cover daily, and as needed.Record review revealed a physician's order dated 9/15/2025, indicating to cleanse the resident's left hip incision with Vashe cleanser, pat dry, apply a dressing and secure daily, and as needed.Further record review failed to reveal evidence that a physician's order for a treatment to the resident's left hip surgical wound was implemented prior to 9/15/2025. This indicates that the resident went approximately 3 days without surgical wound care orders on 9/12, 9/13, and 9/14/2025.During a surveyor interview on 11/13/2025 at 1:32 PM, with the Unit Manager, Licensed Practical Nurse, Staff A, she acknowledged that the surgical wound care instructions were noted on the hospital continuity of care document received by the facility on 9/12/2025 when the resident was admitted and was not implemented until 9/15/2025.During a surveyor telephone interview on 11/13/2025 at 2:10 PM, with Nurse Practitioner, Staff B, she stated that based on the information reviewed on the continuity of care document regarding the general discharge instructions for surgical wound care, she would have expected the order for the treatment to have been implemented on 9/12/2025, when the resident was admitted to the facility.During a surveyor interview with the Director of Nursing Services on 11/13/2025 at 2:14 PM, she was unable to provide evidence that a surgical wound treatment order was implemented upon the resident's admission to the facility on 9/12/2025.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows:1) Record review of the manufacturer's label for a Vital Cuisine Mighty Shake states in part, .use within 14 days of thawing.During a surveyor observation on 7/28/2025 at 8:53 AM, of the main kitchen, revealed thirty-four Vital Cuisine Mighty Shakes in the walk-in refrigerator, without a use-by date to identify when the product was thawed.During a surveyor interview immediately following the above observation with the Food Service Director (FSD), he acknowledged the Mighty Shakes were not dated and revealed that they are dated when they are delivered to the unit.2) Record review of The Rhode Island Food Code 2022 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight .During a surveyor observation on 7/28/2025 at 8:53 AM of the ice machine located in the main kitchen, revealed an accumulation of a pink wipeable substance located on the ice dispenser shield.During a surveyor interview immediately following the above observation with the Regional FSD, she acknowledged the pink wipeable substance in the ice machine and revealed it had been professionally cleaned three weeks prior.During a follow up surveyor observation of the main kitchen on 7/30/2025 at 9:42 AM, after the above concerns were identified by the surveyor, the ice machine was cleaned, and all of the Mighty Shakes were dated when thawed.

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 4 of 4 residents observed with their call lights out of reach who were requesting staff assistance, Resident ID #s 1, 105, 162, and 175.Findings are as follows:Review of a facility policy titled, Call System, Resident dated September 2022, states in part, .Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor.1) Record review revealed Resident ID #162 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, dementia and muscle weakness.Review of a care plan focus area dated 5/12/2025 revealed s/he has Activities of Daily Living (ADL) self-care performance deficits related to physical limitations and medical co-morbidities with an intervention to encourage him/her to use his/her call light for assistance.Surveyor observations revealed the resident's call light was placed out of the resident's reach on the following dates and times:-7/28/2025 at 11:37 AM: The resident was observed in a recliner in the center of his/her room while the call light was noted to be on his/her bed.-7/29/2025 at 12:03 PM: The resident was observed in a recliner in the center of his/her room while the call light was noted to be on the foot of his/her bed.-7/30/2025 at 10:03 AM: The resident was observed in a recliner in the center of his/her room while the call light was noted lying to be lying across the bed and resting on the floor.During a surveyor interview immediately following the above observation on 7/30/2025 with Activity Aide, Staff J, she acknowledged that the resident's call light was out of the resident's reach.During an additional surveyor observation on 7/30/2025 at 10:34 AM, the resident was observed in a recliner in the center of his/her room while the call light was noted lto be [NAME] across the bed and resting on the floor, out the resident's reach.During a surveyor interview immediately following the above observation with Licensed Practical Nurse, Staff B, she acknowledged that the resident's call light was out of the resident's reach.2) Record review revealed Resident ID #105 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, history of falling and muscle weakness.Review of the care plan revealed s/he has ADL self-care performance deficits and is at risk for falls with interventions that include to ensure his/her call light is within reach and to encourage him/her to use his/her call light for assistance.Surveyor observations revealed the resident's call light was placed out of the resident's reach on the following dates and times:-7/28/2025 at 11:08 AM: The resident was observed in his/her bed while the call light cord was noted to be tied to the bedrail with the call light dangling off the side of the bed.-7/29/2025 at 12:09 PM: The resident was observed in his/her bed while the call light cord was noted to be tied to the bedrail with the call light dangling off the side of the bed.-7/30/2025 at 10:00 AM: The resident was observed in his/her bed while the call light was resting on the floor.During a surveyor interview immediately following the above observation on 7/30/2025 with Nursing Assistant, Staff K, she acknowledged that the resident's call light was on the floor and was out of the resident's reach.3) Record review revealed Resident ID #175 was readmitted to the facility in November of 2022 with diagnoses including, but not limited to, repeated falls and unsteadiness on feet.Review of the care plan revealed s/he has ADL self-care performance deficits and is at risk for falls with interventions that include to ensure his/her call light is within reach and to encourage him/her to use his/her call light for assistance.During a surveyor observation on 7/28/2025 at 10:50 AM, the resident was observed in his/her bed while the call light was noted to be resting on the floor behind the headboard of his/her bed, out of the resident's reach.4) Record review revealed Resident ID #1 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, muscle weakness and history of falling.Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.Review of the care plan revealed s/he has ADL self-care performance deficits and is at risk for falls with interventions that include to ensure his/her call light is within reach and to encourage him/her to use his/her call light for assistance.During a surveyor observation and simultaneous interview on 7/31/2025 at 8:26 AM with Resident ID #1, s/he was observed in his/her bed eating breakfast. S/he revealed that s/he would like sugar packets for his/her cereal but cannot reach his/her call light. Additionally, his/her call light was noted to be resting on his/her nightstand by the foot of his/her bed, out of his/her reach. Further, s/he revealed that the call light is often on the nightstand, and s/he is unable to reach it.During a surveyor interview immediately following the above observation with Staff B, she acknowledged that the resident's call light was out of the resident's reach.During a surveyor interview on 7/30/2025 at 12:52 PM with the Director of Nursing Services, she revealed that she would expect the residents' call lights to be within reach and accessible to the resident.

Based on surveyor observation, record review, staff, and resident representative interview, it has been determined that the facility failed to treat each resident with respect and dignity for 1 of 1 resident reviewed relative to incontinence care prior to a leave of absence (LOA), Resident ID #18. Findings are as follows:Review of a facility policy titled, Resident Rights last revised February 2021 states in part, .Employees shall treat all residents with kindness, respect and dignity.Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to.a dignified existence .Record review revealed the resident was admitted to the facility in June of 2025 with a diagnosis including, but not limited to, Alzheimer's disease.Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed s/he had a Brief Interview for Mental Status score of 3 out of 15, indicating severely impaired cognition. Additional review of the MDS revealed the resident was incontinent of bowel and dependent on staff for toileting and hygiene.Review of his/her care plan revealed a focus area dated 6/21/2025 indicating that the resident is incontinent of bowel related to advanced dementia. During a surveyor observation on 7/29/2025 at 8:42 AM, Certified Medication Technician, Staff A, was seen escorting the resident from the elevator. A strong odor of fecal incontinence was immediately noticeable through a surgical mask. Further observation showed Staff A, continuing to lead the resident toward the lobby, ultimately escorting the resident out through the main entrance to a family member before promptly walking away. The resident's family member immediately returned to the door, urgently calling for staff assistance. When this surveyor approached the family member and resident, it was observed that the resident had loose stool running down the resident's pants, into his/her shoes and dripping onto the floor. At this time the receptionist was asked to call for staff to come assist.During a surveyor interview on 7/29/2025 immediately following the above observation with the resident representative, s/he revealed that s/he called the facility earlier to have the resident ready to go to the hospital to visit with his/her dying spouse. S/he was extremely upset, crying and stated, Why would they give [the resident] to me like that?During a surveyor interview on 7/29/2025 at approximately 9:30 AM with Staff A, she acknowledged that she transported the resident from the unit to the main lobby to go on a LOA with his/her family. She would not acknowledge that the resident was incontinent of bowels. During a surveyor interview with the Director of Nursing Services on 7/29/2025 at 11:57 AM, she revealed that the resident had two episodes of loose stool and may not be feeling well. She further revealed that it would be the expectation that a resident is clean, and that incontinence care would have been provided prior to leaving the facility. Additionally, she was unable to provide evidence that the resident was treated with respect and dignity.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 1 of 1 resident reviewed for a urology consult, Resident ID #1, and for 1 of 1 resident reviewed for dietary restrictions, Resident ID #103.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.1) Record review revealed Resident ID #1 was readmitted to the facility in May of 2025 with a diagnosis including, but not limited to, fibromyalgia (chronic pain syndrome).Review of a Continuity of Care (COC) form dated 7/25/2025 revealed the resident attended a urology consult and returned with a recommendation including, but not limited to, increase fluid intake.Record review failed to reveal evidence of a physician's order to encourage fluids.During a surveyor interview on 7/31/2025 at 8:43 AM, with Unit Manager, Licensed Practical Nurse, Staff B, she revealed that if a resident requires extra fluids, it should be documented on the Medication Administration Record as a task. She acknowledged that there was not a current physician's order in place to encourage fluids and indicated that there should be. Record review revealed a physician's order dated 7/31/2025 at 8:48 AM, entered by Staff B, to encourage an extra 240 milliliters (ml) of fluid, per shift. This order was entered after the surveyor interviewed Staff B. During a surveyor interview on 7/31/2025 at 10:47 AM, with Nurse Practitioner (NP), Staff C, she revealed that she was aware of the urology recommendation from 7/25/2025 and revealed that she would not approve the recommendation, due to the resident's current sodium levels. Additionally, when asked about the physician's order entered by Staff B, she revealed that she did not give the order to encourage 240 ml of fluid every shift.During a surveyor interview on 7/31/2025 at 11:05 AM, with Staff B, she acknowledged that she entered the above-mentioned physician's order without speaking to the resident's provider, Staff C.During a surveyor interview on 7/31/2025 at 11:41 AM, with the Director of Nursing Services (DNS) she revealed that she would expect staff to speak with the resident's provider prior to entering any orders. Further, she revealed the order has been discontinued, as it was not approved by Staff C.2) Record review revealed Resident ID #103 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing).Record review revealed a physician's order dated 8/3/2024 for a regular diet with special instructions that state, NO PAPER PRODUCTS ON TRAY-REMOVE MENU, TRAY MAT, NAPKIN.Record review revealed a progress note dated 8/20/2024 which states in part, Resident noticed to be biting into [his/her] paper ticket at breakfast this morning.Removed tray ticket and napkin from tray. Resident redirected back to food.Nursing, NP and Dietary Department notified. Tray ticket modified to include instructions for no paper products on tray. Care plan updated.During a surveyor observation on 7/28/2025 at 12:24 PM, Resident ID #103 was noted to be in his/her room eating lunch, with the tray ticket, tray mat, and napkin in front of him/her on the table.During a surveyor interview on 7/28/2025 at 1:10 PM, with Nursing Assistant, Staff D, she acknowledged the special instructions on the resident's meal ticket and acknowledged the resident still had the ticket, mat and napkin in front of him/her. Additionally, she revealed that she was unsure why the resident's meal ticket included removing the ticket, mat, and napkin.During a surveyor interview on 7/29/2025 at 8:19 AM, with Registered Nurse, Staff E, she acknowledged that the diet order instructions specified to remove paper products from the meal tray.During a surveyor interview on 7/29/2025 at 1:18 PM, with the DNS, she revealed that she would expect nursing to review a resident's meal ticket prior to distributing their meal. Further, she revealed that she would have expected Resident ID #103 to not have received any paper products, per the physician's order.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident reviewed for daily weights, Resident ID #192. Findings are as follows:Record review revealed that the resident was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, congestive heart failure (CHF, a condition where the heart struggles to pump blood effectively, leading to excess fluid in the body). Additionally, the record revealed that s/he was transferred to an acute care hospital on 6/3/2025 due to an exacerbation of CHF.Record review of a care plan that was initiated on 5/12/2025, revealed a focus area for CHF. Interventions included to monitor for signs and symptoms of CHF, such as weight gain unrelated to meal intake.Record review of the hospital Continuity of Care documents which were received upon admission to the facility on 5/11/2025, revealed the following physician's order:- Weigh daily, call the provider if weight is greater than 3 pounds (lbs.) in a day or 5 lbs. in a week.Further record review failed to reveal evidence that the above physician's order was accepted or declined by a facility provider.Record review of a progress note dated 5/23/2025, authored by Nurse Practitioner, Staff F, states in part, .Patient's weight has continued to increase. Patient should be receiving daily weights.Additional record review revealed that a physician's order for daily weights to be obtained, was implemented on 5/28/2025, 17 days after the resident was admitted to the facility.Additionally, the record failed to reveal evidence that the resident's weights were documented daily on the following dates:5/14, 5/16, 5/17, 5/18, 5/21, 5/22, 5/24, 5/25, 5/26, 5/27, and 5/31/2025 which indicates his/her weight was not obtained for 11 out of 24 opportunities. During a surveyor interview on 7/31/2025 at 2:12 PM, Nurse Practitioner, Staff F declined to confirm whether the order for daily weights should have been implemented on 5/11/2025, despite documentation in her previously noted progress note entry.During a surveyor interview on 7/31/2025 at 11:41 AM with the Director of Nursing Services, she was unable to provide evidence that the resident's weight was monitored daily since his/her admission to the facility on 5/11/2025.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from medication error rates of 5% or greater. Based on 28 opportunities for error observed during the medication administration task, there were 3 errors resulting in a 10.71% error rate involving Resident ID #s 24 and 135.Findings are as follows:Review of the facility's policy titled, Administering Medications states the following in part, .Medications are administered in accordance with prescriber orders.Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.1. Record review revealed Resident ID #24 had a physician's order with start date of 7/28/2025 for Keppra oral tablet give 1250 milligrams (mg) by mouth two times a day to treat epilepsy (seizure disorder).During a surveyor observation of the medication administration task on 7/30/2025 at 8:27 AM, with Licensed Practical Nurse (LPN), Staff H, she retrieved a bottle of liquid Keppra oral liquid solution 100 mg/milliliters (mL) from the medication cart and poured an unmeasured amount of the medication into a 30 mL medicine cup that lacked a 12.5 mL measurement mark. The liquid medication was observed to be between the 10 mL and 15 mL measurement marks.During a surveyor interview with Staff H, immediately following the above-mentioned observation, she acknowledged that she was ready to administer the medication to Resident ID #24. Additionally, she stated that she poured the medication above the 10 mL and below the 15 mL marks. She then acknowledged that the medication should be measured accurately. Additionally, Staff H confirmed that the order was for a tablet, but she was administering the medication in liquid form. 2. Record review revealed Resident ID #135 had the following physician's orders:A. An order dated 7/28/2025, for GlycoLax Powder give 17 grams by mouth two times a day for constipation, mix powder in 6 ounces (oz) of fluid of choice.During a surveyor observation of the medication administration task on 7/31/2025 at 8:28 AM, with LPN, Staff I, she was observed mixing the 17 grams of GlycoLax powder into a 120 mL cup (approximately 4 oz) of water. Additionally, Staff I did not measure or provide 6 oz of fluid as prescribed.During a surveyor interview with Staff I, immediately following the above observation, she stated she was ready to administer the medication to Resident ID #135. When the surveyor asked her how much water was in the cup, she stated it was about 6 oz. She then proceeded to calculate using her cellphone and showed the surveyor that 6 oz is approximately 177 mL but acknowledged that she did not measure 6 oz. She then proceeded to get a second 120 mL cup and poured and unmeasured amount of water into that cup. Staff I proceeded to transfer the fluids back and forth from the first cup into the second cup several times. The surveyor then asked again if she was ready to administer the medication which Staff I stated yes. The surveyor then asked if the facility had a different size cup to which Staff I indicated that she would get a larger cup and proceeded to start the preparation over.B. An order dated 7/23/2025, for Fluticasone Propionate Nasal Suspension 50 micrograms/activated one spray in both nostrils two times a day for allergies.During a surveyor observation on 7/31/2025 at approximately 8:52 AM, Staff I handed the Fluticasone nasal spray to Resident ID #135 without asking the resident if s/he wanted to self-administer. Additionally, the resident was observed to administer two sprays in each nostril instead of one, as ordered.During a surveyor interview with Resident ID #135 immediately following the above observation, s/he indicated that s/he always administers two sprays in each nostril.Further record review failed to reveal evidence of an order for the resident to self-administer medications.During a surveyor interview with Staff I, immediately following the above observation, she acknowledged that the resident self-administered two sprays and not one per the physician's order. Additionally, Staff I acknowledged that the order does not indicate self-administration and indicated she would notify the provider.During a surveyor interview with Director of Nursing Services (DNS) on 7/31/2025 at approximately 9:07 AM, the DNS indicated that she would expect the nurses to administer medications according to the physician's order and allow a resident to self-administer if the order and an assessment indicates such.

Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 3 residents reviewed, Resident ID #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 6/9/2025 revealed that staff over heard Resident ID #3, the perpetrator, yelling from his/her room. Resident ID #2, the victim, had wandered into Resident ID #3's room and was found lying on the floor next to Resident ID #3's bed. The report further revealed that when staff assisted Resident ID #2 off of the floor, Resident ID #3 struck Resident ID #2 in the face, causing a bloody nose. Review of a policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program last revised in April of 2021 states in part, .Residents have the right to be free from abuse .the resident abuse .prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse .by anyone including .other residents . Record review revealed Resident ID #2, the victim, was admitted to the facility in April of 2021 with diagnoses including, but not limited to, dementia, age-related physical debility, and fractures of the nasal bones. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating the resident has severely impaired cognition. Further review revealed the resident was able to ambulate independently. Record review revealed a progress note dated 6/8/2025 indicating that Resident ID #2 was found on the floor in Resident ID #3's room. Further review revealed while the nurse was helping the resident off of the floor, the other resident struck Resident ID #2 in the face causing a bloody nose. Record review of an MQS: Interim Pain Evaluation completed after the above incident revealed the resident exhibited pain non-verbally through facial expressions, sounds, actions or behaviors. Record review revealed that Resident ID #3, the perpetrator, was admitted to the facility in May of 2020 with a diagnosis including, but not limited to, traumatic brain injury and mood disorder. Review of a MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15, indicating the resident has severely impaired cognition. Further review revealed the resident is independent with transfers and mobility in his/her wheelchair. Record review of a care plan dated 5/7/2025 revealed that Resident ID #3 does not like people entering his/her room or personal space and can become combative and agitated when such instances occur. Record review revealed the following progress notes involving Resident ID #3 and altercations related to resident's wandering into his/her room. -5/13/2025- resident became verbally upset related to a resident entering his/her room and went into the hallway yelling and cursing. Another resident told Resident ID #3 not to speak that way, but Resident ID #3 continued to yell and move his/her hands around. The other resident touched Resident ID #3's wrist and staff intervened. No injuries were noted. -6/1/2025- Resident had an episode of yelling and cursing related to another resident entering his/her room. Record review failed to reveal evidence that new interventions had been put into place in an attempt to prevent a resident-to-resident altercation until after the third incident, which resulted in injuries to Resident ID #2. Record review revealed a stop sign was placed on Resident ID #3's door and then his/her room was moved to another unit on 6/10/2025. Further record review revealed a social service note dated 6/11/2025 indicating that the social worker spoke with the resident's mother regarding .looking into a group home or a facility that has a behavioral unit . Further review revealed the resident's mother was .in agreement to look into these options . During a surveyor observation on 6/11/2025 at approximately 1:40 PM, Resident ID #2 was observed with a bruise which was blue and yellow in color under the resident's left eye, and a dark bruise to the right side of his/her lower lip. During a surveyor interview following the above observation with Licensed Practical Nurse, Staff A, she acknowledged the bruising to the resident's face was a result of the resident-to-resident physical altercation between Resident ID #s 2 and 3. During a surveyor interview on 6/11/2025 at 1:54 PM with the Director of Nursing Services, she indicated that Resident ID #3 has behaviors related to his/her traumatic brain injury. She acknowledged that the resident had verbal altercations related to other residents entering his/her room on 5/13/2025 and 6/1/2025. She further acknowledged that no new interventions were put into place following those two incidents. Additionally, she acknowledged that Resident ID #3 hit Resident ID #2 in the face with his/her hand out of anger, resulting in Resident ID #2 sustaining a bloody nose. The facility's failure to implement interventions on 5/13 and 6/1/2025 after two witnessed incidences of Resident ID #3 becoming upset at other residents entering his/her room placed Resident ID #2 at risk for physical abuse. This abuse resulted in Resident ID #2 sustaining a bloody nose and facial bruising.

Based on record review and staff interview it has been determined that the facility failed to provide and document sufficient preparation and orientation to residents to ensure a safe and orderly discharge from the facility for 1 of 1 resident reviewed who left the facility, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/5/2025 alleged that a resident had gone missing from the facility the week prior, and the facility's management did not take appropriate action. The complaint further alleged that the resident said s/he wanted to go home, and it took hours for the facility to find him/her. Review of a facility policy titled, Discharging a Resident Without a Physician's Approval states in part, .Regardless of the resident or resident's representative's request to leave the facility against medical advice, the facility will provide a Notice of Discharge, discharge orientation, and a Discharge Summary .before the resident leaves the facility. Record review revealed Resident ID #1 was admitted to the facility in May of 2025 with diagnoses including, but not limited to, aftercare following a hip replacement, post-traumatic stress disorder, and osteoarthritis. Review of a Brief Interview for Mental Status evaluation dated 5/25/2025 revealed a score of 14 out of 15, indicating intact cognition. Review of a Nurse Practitioner's (NP) note with a service date of 5/29/2025 at 9:45 AM revealed the resident informed the NP that s/he is leaving the facility today and had discussed leaving against medical advice. Further review revealed the NP wrote that the resident is safe and medically cleared for discharge home. Record review failed to reveal evidence of a physician's order for the discharge from the facility, a discharge plan involving the interdisciplinary team, a notice of discharge, a discharge summary, or a medication reconciliation. During a surveyor interview via telephone on 6/11/2025 at 11:34 AM with the resident, s/he indicated that s/he told staff that s/he wanted to leave the facility and they had asked him/her to wait so s/he agreed to stay, but s/he left the facility around 11:00 AM on 5/29/2025 with his/her friend. Additionally, the resident indicated that s/he was not given any paperwork, medications, or a referral to home care services. During a surveyor interview on 6/11/2025 at 9:45 AM with Licensed Practical Nurse, Staff B, she indicated that she was the unit nurse on 5/29/2025 when the resident left the facility. She further acknowledged that she did not complete any discharge planning, complete a discharge summary, or conduct a medication reconciliation for the resident. During a surveyor interview on 6/11/2025 at approximately 10:04 AM with the Assistant Director of Nursing Services, she indicated that the unit nurse is responsible for starting the discharge summary and the discharge process. Additionally, she could not provide evidence that the resident received an appropriate discharge. Cross reference F-684

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive adequate supervision to ensure the safety of 1 of 1 resident reviewed who left the facility, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/5/2025 alleges that a resident had gone missing from the facility the week prior, and the facility's management did not take appropriate action. The complaint further alleged that the resident said s/he wanted to go home and it took hours for the facility to find him/her. Review of the facility policy titled, Wandering and Elopements states in part, .If a resident is missing, initiate the elopement/missing resident emergency procedure .If the resident is not located, notify .law enforcement officials . Record review revealed Resident ID #1 was admitted to the facility in May of 2025 with diagnoses including, but not limited to, aftercare following a hip replacement, post-traumatic stress disorder, and osteoarthritis. Review of a Brief Interview for Mental Status evaluation dated 5/25/2025 revealed a score of 14 out of 15, indicating intact cognition. Review of a Nurse Practitioner's (NP) note with a service date of 5/29/2025 at 9:45 AM revealed the resident informed the NP that s/he is leaving the facility today and had discussed leaving against medical advice. Further review revealed the NP wrote that the resident is safe and medically cleared for discharge home. Record review revealed the following progress notes: - 5/29/2025 at 10:21 AM- authored by the Minimum Data Set (MDS) assessment Nurse, Staff C, the resident is not available for quality of life rounds. - 5/29/2025 at 12:19 PM- social worker and case manager went to see the resident to discuss his/her wishes to discharge, resident was not in his/her room at the time of the visit today. Will follow up. - 5/29/2025 at 6:11 PM- Resident is alert oriented x3 and expressed desire to discharge to home today. Resident met with NP who stated she would sign off on discharge if resident insisted on going home. Resident encouraged by staff to speak to social services and wait for discharge plan to be put into place. Resident had a friend visiting at the time. Resident stated to nurse [s/he] would stay until discharge could be set up but that [s/he] was leaving. Activity aid went into room and resident told activity aid [s/he] was leaving today and was observed packing [his/her] room. Resident also stated to activities [s/he] had a ride arranged today to go home and [s/he] told [his/her] friend in the room to go get [him/her] a wheelchair. Resident stated to staff [s/he] was going to go outside with [his/her] friend for 'air' Social services went into see resident in [his/her] room but [s/he] was not in room. Resident's wheelchair found left outside rehab gym. All resident's belongings were not in room. Resident did not wait for discharge paperwork or sign AMA (against medical advice) form. Message left for resident to call facility to obtain paperwork and medications needed for discharge. MD (medical doctor) made aware. Record review failed to reveal a physician's order for the resident's discharge from the facility. Record review failed to reveal evidence of signed AMA paperwork, a discharge summary or a medication reconciliation. Record review failed to reveal evidence that the police were notified of an elopement. During a surveyor interview on 6/10/2025 at 12:43 PM with the MDS assessment Nurse, Staff C, she revealed that she entered the resident's room for a routine interview on 5/29/2025 at approximately 11:00 AM and the resident was not in his/her room at that time. She further indicated that she thought the resident was being discharged later that week and had planned to return later to complete the MDS interview. Additionally, she indicated that during the facility's end of day meeting, around 3:30 PM, it was realized that the resident hadn't been seen in the building for a while and an Elopement Code was announced over the intercom. Furthermore, she indicated that the staff searched the building for the resident and when s/he was not located, staff assumed s/he left AMA. During a surveyor interview on 6/10/2025 at 12:53 PM with the Social Worker, Staff D, she indicated that the resident had said that s/he wanted to go home and she went to speak with the resident about discharge on [DATE] around 12:00 PM. She indicated that the resident was not in his/her room at that time; however, she believed his/her belongings were still in the room, so she planned to follow up later that day. She further indicated that an Elopement Code was called at approximately 3:00 PM and a search of the facility was conducted. Additionally, she indicated that when the resident wasn't located, s/he was called multiple times with no return phone call received. Furthermore, she indicated that she spoke with the resident via telephone the following day, 5/30/2025 to offer to set up outside services; however, the resident indicated that s/he would do it him/herself. During a surveyor interview on 6/11/2025 at 10:04 AM with the Assistant Director of Nursing Services, she indicated that it was brought to her attention during her morning meeting that the resident wanted to leave so she went to speak with him/her around 8:00-9:00 AM. She further indicated that the resident told her that s/he wanted to leave; however, s/he would stay until s/he saw social services, physical therapy (PT), and the provider. Additionally, she indicated that during the afternoon meeting it was discussed that the resident hadn't been seen in his/her room and when they realized s/he was not with PT, an Elopement Code was called, and the facility was searched. Furthermore, she indicated that she called the resident, did not receive a response, and did not notify the police. During a surveyor interview on 6/10/2025 at approximately 1:15 PM with the Director of Nursing Services, she indicated that the resident had said that s/he wanted to go home on 5/29/2025 and was evaluated by the NP who indicated that she would sign off if s/he really wanted to go home. She further indicated that throughout the day some staff thought s/he was at an appointment however s/he was not. Additionally, she indicated that an unknown staff member called an Elopement Code during the afternoon meeting around 3:30 PM but when the resident was not located, the code was cleared, and it was assumed s/he had gone home with a friend. Furthermore, she could not identify when the resident left the facility or where s/he went until the resident returned her phone call on 5/30/2025, the day after s/he unknowingly left the facility. During a surveyor interview on 6/11/2025 at 10:41 AM with the Administrator, she indicated that she was told that the resident wanted to leave on 5/29/2025 and when she heard the Elopement Code over the facility's over head paging system, she cleared the code because she thought the resident had been discharged from the facility earlier that day. She further indicated that she called the resident a couple of times with no answer and had assumed that s/he went home with a friend. Additionally, she was unable to provide evidence that the resident had been discharged from the facility, left AMA, or that the police were notified of an elopement per the facility policy. During a surveyor interview on 6/11/2025 at 11:34 AM with Residnet ID #1, s/he stated that his/her stay at the facility was awful, s/he didn't feel safe, and that s/he had escaped. The resident indicated that s/he told staff that s/he wanted to leave the facility and they had asked him/her to wait so s/he agreed to stay. The resident indicated s/he left the facility around 11:00 AM on 5/29/2025 with his/her friend. Additionally, the resident indicated that s/he was not given any paperwork, medications, or a referal to homecare services. Cross reference F-627

Based on record review and staff interview it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to 1 of 1 resident reviewed who left the facility, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/5/2025 alleges that a resident had gone missing from the facility the week prior, and the facility's management did not take appropriate action. The complaint further alleged that the resident said s/he wanted to go home and it took hours for the facility to find him/her. Record review revealed Resident ID #1 left the facility at an unknown time on 5/29/2025. During a surveyor interview via telephone on 6/11/2025 at 11:34 AM with the resident, s/he stated that s/he left the facility around 11:00 AM on 5/29/2025 with his/her friend. Additionally, the resident indicated that s/he was not given any paperwork, medications, or had any homecare services set up. During a surveyor interview on 6/10/2025 at approximately 3:00 PM with the Director of Nursing Services, she indicated that an Elopement Code was called around 3:30 PM when staff realized the resident had not been seen for a while at the facility. She further indicated that because the resident had said that s/he wanted to go home that morning and because his/her belongings were not in the resident's room, staff assumed that s/he left the facility to go home and the Elopement Code was cleared. Additionally, she could not indicate when the resident left the facility and could not be sure where the resident went because the resident did not return the multiple phone calls from the facility until the next morning. During a surveyor interview on 6/11/2025 at 10:41 AM with the Administrator, she indicated that she was told that the resident was being discharged that day so when she heard the Elopement Code, she assumed that the resident had been discharged and cleared the code. Additionally, she could not indicate when the resident left and could not provide evidence that the resident was safely discharged from the facility on 5/29/2025. Cross reference F 684 & 627

Based on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to 1 of 1 resident reviewed for use of a baclofen pump (a small device that is placed under the skin on one side of the abdomen near the hip bone. It is used to deliver baclofen, a medication prescribed to treat muscle spasms, directly into the spinal canal), Resident ID #35, and for 2 of 2 residents reviewed for medications with parameters, Resident ID #s 71 and 137, and for 1 of 5 residents reviewed for antibiotic use, Resident ID #76. Findings are as follows: 1a. Record review revealed Resident ID #35 was readmitted to the facility in January of 2025 with diagnoses including, but not limited to, chronic pain syndrome and anoxic brain injury (a brain injury that occurs when the brain lacks a supply of oxygen). Review of hospital discharge paperwork dated 1/3/2025 revealed that the resident had his/her baclofen pump replaced and has a surgical incision to the left side of his/her abdomen that is covered with a dressing that is to remain in place until his/her surgical follow up appointment. Review of a progress note dated 1/10/2025 authored by Unit Manager, Staff A, revealed that the resident was seen for a surgical follow up appointment for his/her baclofen pump replacement and returned without any dressing orders for the surgical wound. Review of a progress note dated 1/14/2025 authored by Nurse Practitioner (NP), Staff B, states in part, .Patient seen for removal of surgical dressing on the abdomen following baclofen pump replacement. Incision with staples intact, no erythema [redness] or evidence of infection noted. Site is healing well. Plan: Nursing to change dressing daily with dry sterile dressing and apply bacitracin [a topical ointment that helps prevent infection] to the suture line. Will monitor the site closely . Record review failed to reveal evidence that the above-mentioned orders for close monitoring of the surgical site, bacitracin, and a daily dressing change had been transcribed as ordered by the NP, Staff B. Record review failed to reveal evidence that a dressing was applied to the surgical site or that the site had been closely monitored from 1/14/2025 until 2/5/2025, a total of 22 days. During a surveyor interview with the resident and simultaneous observation on 2/5/2025 at 12:26 PM, s/he revealed that s/he has a baclofen pump and lifted his/her shirt to show the surveyor the incision site. The incision site was noted to be red. Review of a progress note dated 2/5/2025 authored by Staff B, states in part, .Patient seen for possible surgical site infection following recent baclofen pump replacement in the left lower quadrant of the abdomen. Surgical site shows erythema [a common sign of inflammation] with scant amount of pus draining from lateral [the side of something] edge of incision .Physical exam reveals well-healed incision with 1 pinpoint opening on lateral edge, mild amount of pus draining actively, and blanching erythema surrounding lateral portion of incision .1) Wound culture sent. 2) Started on clindamycin [antibiotic] .4) Consulted with pain clinic regarding antibiotic therapy; they will determine if patient needs to be seen or requires longer duration of antibiotics given underlying hardware. Additionally, they state the patient's planned procedure for tomorrow will have to be rescheduled given active infection . During a surveyor interview on 2/5/2025 at 12:31 PM with Staff A, she acknowledged that the resident does not have an order for a dressing to the surgical wound to his/her left abdomen. Additionally, Staff A, revealed that the resident would be starting on an antibiotic due to a possible infection at the surgical site. During a surveyor interview on 2/5/2025 at 2:26 PM with the Interim Director of Nursing Services (DNS) she was unable to provide evidence that an order had been transcribed for wound care for the resident's surgical site. During a surveyor interview on 2/6/2025 at 10:36 AM with NP, Staff B, she revealed that she gave a verbal order for wound care to the nursing staff on 1/14/2025. Additionally, Staff B revealed that she would expect the staff to transcribe the order she provided, complete the wound care daily, and monitor the incision site for infection. 1b. According to SynchroMed II Drug Infusion Pump SELECT WARNINGS AND PRECAUTIONS, states in part, .It is mandatory that all patients, caregivers, and treating physicians receive adequate information regarding the risks of the mode of treatment. Instruction Abrupt discontinuation of intrathecal [route of medication administration by injection directly into the spinal canal] baclofen, regardless of the cause, has resulted in sequelae [consequence of a previous disease or injury] that include high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity, that in rare cases has advanced to multiple organ-system failure and death. Prevention of abrupt discontinuation of intrathecal baclofen requires careful attention to programming and monitoring of the infusion system, refill scheduling and procedures, and pump alarms. Patients and caregivers should be advised of the importance of keeping scheduled refill visits and should be educated on the early symptoms of baclofen withdrawal. Special attention should be given to patients at apparent risk (e.g. spinal cord injuries at T-6 or above, communication difficulties, history of withdrawal symptoms from oral or intrathecal baclofen) . Record review of the physician's orders failed to reveal documentation of the pump or what the facility does relative to the management of the pump. Review of the care plan failed to reveal evidence that the resident has a baclofen pump or what interventions the facility is providing to mitigate the risks such as symptoms of baclofen withdrawal, monitoring for alarms, or what to do if an alarm was to sound per the manufacturer's guidance. During a surveyor interview on 2/5/2025 at 12:31 PM with Unit Manager, Staff A, she acknowledged that the resident has a baclofen pump without a physician's order in place or a care plan. Additionally, Staff A, was unaware of what an alarm would mean if it was sounding. Furthermore, she indicated that she did not know the signs and symptoms of a baclofen overdose. During a surveyor interview on 2/5/2025 at 2:36 PM with the Interim DNS she acknowledged that the resident does not have orders or a care plan in place for his/her baclofen pump to include; symptoms of baclofen withdrawal, monitoring for alarms, or what to do if an alarm was to sound per the manufacturer's guidance. Additionally, the Interim DNS was unaware that the baclofen pump alarms to alert to a complication. 2a. Review of a facility policy titled, Administering Medication states in part, Medications are administered in a safe and timely manner and as prescribed .Medications are administered in accordance with prescriber orders .The following information is checked/verified for each resident prior to administering medications .vital signs if necessary . Record review revealed Resident ID #71 was readmitted to the facility with a diagnosis including, but not limited to, takotsubo cardiomyopathy (a sudden stress induced heart condition that weakens the left ventricle and can cause heart attack like symptoms). Review of a physician's order dated 1/22/2025 for Metoprolol Succinate Oral Tablet Extended Release 25 milligrams (mg). Give 12.5 mg by mouth, one time a day for takotsubo cardiomyopathy, hold if apical pulse (a pulse point on your chest at the bottom tip (apex) of your heart) is less than 60. Review of the January and February 2025 Medication Administration Records (MAR) revealed the Metoprolol Succinate was signed off as administered daily from 1/22/2025 through 2/4/2025. Additional review failed to reveal evidence that an apical pulse had been obtained to correspond with the medication administration. During a surveyor interview on 2/5/2025 at 8:27 AM with Certified Medication Technician, Staff C, she acknowledged that there was no documented heart rate for the medication administration. During a surveyor interview on 2/5/2025 at 8:30 AM with Licensed Practical Nurse, Staff D, she acknowledged that the medication parameters are not being followed and that there are no documented apical pulse readings for the resident. 2b. Record review revealed that Resident ID #137 was readmitted to the facility with diagnoses including, but not limited to, type II diabetes and Parkinson's. Review of a physician's order dated 1/30/2025 for Humalog (insulin) to administer 7 units for type II diabetes and to hold for a blood glucose reading below 100 milligrams per deciliter (mg/dL). Review of the February 2025 MAR revealed that the insulin was administered when the residents blood glucose reading was below 100mg/dL on the following dates: - 2/1/2025 - 98 mg/dL - 2/3/2025 - 71 mg/dL During a surveyor interview on 2/5/2025 at 3:40 PM with the Interim DNS in the presence of the Administrator and a second surveyor, she acknowledged that the insulin was administered on the above dates when it should have been held per the physician's order. 3. Review of a facility policy titled, Administering Medication states in part, Medications are administered in a safe and timely manner and as prescribed .Medications are administered in accordance with prescriber orders . Record review revealed Resident ID #76 was readmitted to the facility in January of 2025 with diagnoses including, but not limited to, muscle weakness and acute kidney injury. Review of a physician's order dated 1/9/2025 for Bactrim DS (antibiotic) tablet 800-160 mg, two times daily to treat a urinary tract infection for 7 days. Review of the January 2025 MAR revealed that two doses of the Bactrim DS were not administered on 1/13/2025. Record review failed to reveal evidence that the provider was made aware of the missed doses of antibiotics. During a surveyor interview on 2/5/2025 at 11:21 AM with NP, Staff B, she revealed that the facility staff did not report that Resident ID #76 missed two missed doses of Bactrim. During a surveyor interview on 2/5/2025 at 11:54 AM with the Interim DNS, she acknowledged the resident missed two doses of Bactrim. Additionally, she could not provide evidence the NP was notified of the missed doses of medication.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from unnecessary medications for 1 of 2 residents reviewed who have cancer diagnoses, Resident ID #1. Findings are as follows: Review of a community reported complaint dated 1/17/2025 alleged that a cancer medication was given to the wrong resident for 14 days. During a surveyor interview on 1/21/2025 at 9:35 AM with Registered Nurse, Staff A, she indicated that she mistakenly transcribed Resident ID #2's Abiraterone Acetate into Resident ID #1's medical record. Staff A acknowledged that Resident ID #1 received Abiraterone Acetate 1000 mg daily from 12/21/2024 through 1/2/2025 in error, for a total of 13 days. She further revealed that the prescription bottle for Abiraterone Acetate was delivered from the cancer center and labeled with Resident ID #2's name. According to the document released by the Food and Drug Administration, revised 8/2021, indicates Abiraterone Acetate in combination with prednisone is indicated for the treatment of patients with metastatic prostate cancer. For patients with baseline moderate hepatic (liver) impairment, reduce the recommended dose of Abiraterone Acetate to 250 mg once daily and to monitor liver function tests prior to the start of the medication and weekly for the first month. Patients with severe hepatic impairment, this medication is to be avoided. Abiraterone Acetate may cause high blood pressure, low potassium level and fluid retention. Additional review revealed adverse reactions of this medication includes, but are not limited to, fatigue, high blood pressure, nausea, vomiting, swelling, low potassium levels, diarrhea and upper respiratory infections. Review of the facility policy titled, Administering Medications revised 4/2019, revealed the individual administering medications verifies the resident's identity before giving his/her medications. Additionally, the facility's policy revealed that the individual administering the medication, is to check the label 3 times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before administering the medication. Additionally, the policy indicates medications ordered for a particular resident may not be administered to another resident. Record review revealed Resident ID #1 was admitted to the facility with a diagnosis including, but not limited to, liver cancer and Resident ID #2 was admitted to the facility with a diagnosis including, but not limited to, prostate cancer. Review of a Cancer Center document for Resident ID #2 dated 12/11/2024, revealed a recommendation to restart Abiraterone Acetate. Additional review of the Cancer Center document revealed the recommendation was approved by the Nurse Practitioner (NP), Staff G, on 12/20/2024 for Resident ID #2 to receive Abiraterone Acetate 1000 milligrams (mg) daily. Further record review revealed the order for Abiraterone Acetate was mistakenly transcribed into Resident ID #1's medical record, instead of Resident ID #2's record, for whom the medication was intended. Further record review of Resident ID #1's physician orders revealed that the same NP, Staff G, signed off approval for the order of Abiraterone Acetate on 12/21/2024 and failed to identify that Resident ID #1 was not the same resident that Staff G had approved the Abiraterone Acetate recommendation for on 12/11/2024. During a surveyor interview on 1/22/2025 at 11:40 AM with Staff G, she revealed that she did not recall being contacted by the facility regarding the resident's Abiraterone Acetate order or that she had any knowledge that Abiraterone Acetate was recommended by the Cancer Center for either resident until the medication error was identified. Record review of Resident ID #1's provider progress notes, revealed two notes authored by another NP, Staff H, with the dates of 12/23/2024 and 12/31/2024, revealed that she documented in each progress note that the resident has an order for Abiraterone Acetate 1000 mg daily and that she had completed her medication reconciliation (the process of comparing the medication orders to the medications that the resident has been taking in order to prevent and/or identify any errors or irregularities). Additional review of the progress notes by Staff H, failed to reveal evidence that she identified that this medication is prescribed to treat prostate cancer, and that Resident ID #1 did not have a diagnosis of prostate cancer. Furthermore, record review of the Consultant Pharmacist's progress note revealed a monthly medication regimen review was completed on 12/28/2024 for Resident ID #1 and with no recommendations noted. The pharmacist failed to identify that Abiraterone Acetate is prescribed to treat prostate cancer, and that Resident ID #1 did not have a diagnosis of prostate cancer. During a surveyor interview on 1/22/2025 at 10:13 AM with the Consultant Pharmacist, she revealed that she completed the MRR for Resident ID #1 on 12/28/2024. She further revealed that the Abiraterone Acetate is typically ordered for an individual with a diagnosis of prostate cancer. Additionally, she revealed that she should have verified if Resident ID #1 had a diagnosis of prostate cancer and she acknowledged that she failed to identify the irregularity when completing the MRR. Record review of the December 2024 and January 2025 Medication Administration Records (MARs) revealed Resident ID #1 received Abiraterone Acetate 1000 mg daily at 6:00 AM from 12/21/2024 through 1/2/2025, in error. Further review of the December 2024 and January 2025 MARs revealed the following staff members administered the medication to Resident ID #1 on the following dates: -Licensed Practical Nurse (LPN), Staff B, 12/21/2024 -LPN, Staff C, 12/24/2024, 12/27/2024, 12/28/2024 and 1/1/2025 -LPN, Staff D, 12/22/2024 -Registered Nurse, Staff E, 12/23/2024, 12/25/2024, 12/29/2024, 12/30/2024, 12/31/2024 and 1/2/2025 -Medication Technician, Staff F, 12/26/2024 During a surveyor interview on 1/21/2025 at 2:00 PM, with LPN, Staff B, she revealed that she had administered the Abiraterone Acetate to Resident ID #1 in error, and failed to verify the resident's name on the prescription bottle. During a surveyor interview on 1/21/2025 at 2:39 PM with LPN, Staff C, he revealed that he had administered the Abiraterone Acetate to Resident ID #1 in error, and failed to verify the resident's name on the prescription bottle. During a surveyor interview on 1/21/2025 at 2:50 PM with with LPN, Staff D, he revealed that he had administered the Abiraterone Acetate to Resident ID #1 in error, and failed to verify the resident's name on the prescription bottle. During surveyor interviews on 1/21/2025 at approximately 4:00 PM and 1/24/2025 at approximately 11:30 AM with the Administrator and the Acting Director of Nursing Services, they acknowledged that Staff A transcribed Resident ID #2's Abiraterone Acetate order into Resident ID #1's medical record, in error. Additionally, they acknowledged that the above-mentioned staff, who administered the medication, failed to follow the facility's policy for medication administration. Furthermore, they acknowledged that the two NPs failed to identify that Resident ID #1 had an order for a medication to treat prostate cancer when s/he did not have a diagnosis of prostate cancer. During a surveyor interview on 1/23/2025 at 2:06 PM with the Oncologist, he revealed that the Abiraterone Acetate is only prescribed for an individual with a diagnosis of prostate cancer. The failure of the facility to transcribe this medication into the correct resident's medical record resulted in Resident ID #1 receiving thirteen doses of a medication that s/he received unnecessarily. Additional failures included two NPs and a Consultant Pharmacist failing to identify that Resident ID #1 was being administered a drug without an adequate indication for its use. Furthermore, Staff B, C, D, E and F administered this medication to Resident ID #1 when the medication bottle had Resident ID #2's name on it. The above-mentioned facility failures placed Resident ID #1 at risk for serious injury, serious harm, serious impairment, or death. Cross reference F-756 and F-842

Based on record review and staff interview, it has been determined the facility failed to ensure that medication irregularities were identified by the pharmacist during the monthly drug regimen review for 2 of 4 residents reviewed, Resident ID #s 1 and 3. Findings are as follows: Review of the facility policy titled, Medication Regimen Review and Reporting revised 1/2023, revealed Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medications. The MRR includes a review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. Additional, review of the facility's policy revealed that the pharmacy consultant reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. According to the document released by the Food and Drug Administration, revised 8/2021, indicates Abiraterone Acetate in combination with prednisone is indicated for the treatment of patients with metastatic prostate cancer. For patients with baseline moderate hepatic (liver) impairment, reduce the recommended dose of Abiraterone Acetate to 250 mg once daily and to monitor liver function tests prior to the start of the medication and weekly for the first month. Patients with severe hepatic impairment, this medication is to be avoided. Abiraterone Acetate may cause high blood pressure, low potassium levels and fluid retention. Additional review revealed adverse reactions of this medication includes, but are not limited to, fatigue, high blood pressure, nausea, vomiting, swelling, low potassium levels, diarrhea and upper respiratory infections. 1. Record review revealed Resident ID #1 has a diagnosis including, but not limited to, liver cancer. Additionally, the record failed to reveal evidence that Resident ID #1 has a diagnosis of prostate cancer. Record review revealed a physician's order dated 12/20/2024 for Abiraterone Acetate (a medication prescribed to treat prostate cancer), 1000 milligrams (mg) daily. Further record review revealed that the Abiraterone Acetate was incorrectly transcribed into Resident ID #1's medical record, as it was intended for another resident. Review of the December 2024 and January 2025 Medication Administration Records revealed Resident ID #1 received Abiraterone Acetate from 12/21/2024 through 1/2/2025, for a total of 13 days. Further record review revealed that the pharmacy monthly medication review was completed for Resident ID #1 on 12/28/2024 and the pharmacist failed to identify any irregularities. During a surveyor interview on 1/22/2025 at 10:13 AM with the Pharmacy Consultant, she revealed that she completed the MRR for Resident ID #1 on 12/28/2024. She further revealed that the Abiraterone Acetate is typically ordered for a diagnosis of prostate cancer. Additionally, she revealed that she should have verified if Resident ID #1 had a diagnosis of prostate cancer and acknowledged that she failed to identify the irregularity when completing the MRR. During a surveyor interview on 1/23/2025 at 2:06 PM with the Oncologist, he revealed that the medication Abiraterone Acetate is only prescribed for an individual with a diagnosis of prostate cancer. The facility's failure to review Resident ID #1's medical chart to confirm that the medications s/he was receiving were appropriate when completing his/her MRR on 12/28/2024, resulted in him/her continuing to receive Abiraterone Acetate, a medication intended for another resident. This placed Resident ID #1 at risk for serious injury, serious harm, serious impairment, or death. 2. Record review revealed Resident ID #3 was readmitted to the facility with a diagnosis of clostridium difficile (C. diff; a type of bacterial infection effecting the colon causing diarrhea). Review of the hospital Continuity of Care document dated 1/16/2025 revealed a new order for Fidaxomicin (an antibiotic prescribed to treat C.diff infections) 200 mg twice daily for 5 days, for a total of 10 doses. Record review revealed the Fidaxomicin was transcribed to start on 1/17/2025 with an end date of 1/20/2025, indicating that the medication was to be administered for a duration of only 4 days, for a total of 8 doses. Further record review revealed Resident ID #3's MRR was completed by the Pharmacy Consultant on 1/20/2025 and the consultant failed to identify the Fidaxomicin transcription error, resulting in Resident ID #3 not receiving the full course of his/her medication. During a surveyor interview on 1/24/2025 at 9:07 AM with Registered Nurse, Staff A, she acknowledged that the Fidaxomicin was transcribed for a total of 4 days instead of the 5 days, as ordered. During a surveyor interview on 1/24/2025 at approximately 11:37 AM with the Administrator and the [NAME] President of Clinical Operations, they acknowledged that the Pharmacy Consultant failed to identify the irregularities during the MMR review for Resident ID #'s 1 and 3. Cross reference F-757 and F-842 37158

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident records are complete and accurately documented, relative to medication transcription errors, for 2 of 4 residents reviewed, Resident ID #s 1 and 3. Findings are as follows: 1. According to the document released by the Food and Drug Administration, revised 8/2021, Abiraterone Acetate in combination with prednisone is indicated for the treatment of patients with metastatic prostate cancer. Additionally, for patients with baseline moderate hepatic (liver) impairment, reduce the recommended dose of Abiraterone Acetate to 250 mg once daily and to monitor liver function tests prior to the start of the medication and weekly for the first month. In patients with severe hepatic impairment, this medication is to be avoided. Abiraterone Acetate may cause high blood pressure, low potassium level and fluid retention. Additional review of the document revealed an adverse reaction of this medication includes, but is not limited to fatigue, high blood pressure, nausea, vomiting, swelling, low potassium levels, diarrhea and upper respiratory infections. Record review revealed Resident ID #1 has a diagnosis including, but not limited to, liver cancer. Additional record review failed to reveal evidence that the resident has a diagnosis of prostate cancer. Record review revealed that Resident ID #2 was admitted to the facility with a diagnosis including, but not limited to, prostate cancer. Review of the Cancer Center document dated 12/11/2024 for Resident ID #2 revealed a recommendation to restart Abiraterone Acetate 250 milligrams (mg) to give four tablets (1000 mg) daily. Additional review of the Cancer Center document revealed the recommendation was approved by the Nurse Practitioner (NP), Staff G, on 12/20/2024 for Resident ID #2. However, record review revealed the order for Abiraterone Acetate was mistakenly transcribed into Resident ID #1's medical record, instead of Resident ID #2, for whom the medication was intended. Further record review of Resident ID #1's physician's orders revealed that the same NP, Staff G, signed off approval for the order for Abiraterone Acetate on 12/21/2024 and failed to identify that Resident ID #1 was not the same resident that the NP had approved the recommendation for. Review of a physician's order dated 12/20/2024 revealed Abiraterone Acetate 250 mg, give four tablets (1000 mg) daily, was incorrectly transcribed into Resident ID #1's medical record and not Resident ID #2. Record review of the December 2024 and January 2025 Medication Administration Records (MARs) revealed Resident ID #1 received Abiraterone Acetate 1000 mg daily at 6:00 AM from 12/21/2024 through 1/2/2025, in error for a total of 13 days. Further review of the MARs revealed the following staff members administered the medication to Resident ID #1 on the following dates: -Licensed Practical Nurse (LPN), Staff B, 12/21/2024 -LPN, Staff C, 12/24/2024, 12/27/2024, 12/28/2024 and 1/1/2025 -LPN, Staff D, 12/22/2024 -Registered Nurse, Staff E, 12/23/2024, 12/25/2024, 12/29/2024, 12/30/2024, 12/31/2024 and 1/2/2025 -Medication Technician, Staff F, 12/26/2024 During an interview on 1/21/2025 at 9:35 AM with Registered Nurse, Staff A, she revealed that she transcribed the Abiraterone Acetate intended for Resident ID #2, into Resident ID #1's medical record in error. During a surveyor interview on 1/21/2025 at approximately 4:00 PM with the Administrator and the Acting Director of Nursing Services, they acknowledged that Staff A transcribed Abiraterone Acetate into the wrong resident's record, resulting in Resident ID #1 receiving the medication in error. This transcription error resulted in a resident who has a diagnosis of liver cancer, Resident ID #1, receiving a hepatotoxic medication not intended for him/her, which put the resident at risk for serious injury, serious harm, serious impairment, and/or death. 2. Record review revealed Resident ID #3 was readmitted to the facility with a diagnosis of clostridium difficile (C. Diff; a type of bacterial infection affecting the colon causing diarrhea). Review of the hospital Continuity of Care document dated 1/16/2025 revealed a new order for Fidaxomicin (an antibiotic prescribed to treat C. Diff infections) 200 milligrams (mg) twice daily, for 5 days. Record review revealed Fidaxomicin was transcribed to start on 1/17/2025 with a stop date of 1/20/2025, indicating the medication was transcribed to be administered for only 4 days, instead of the 5 days, as ordered. Record review of the January 2025 Medication Administration Record (MAR) revealed the Fidaxomicin was documented as not administered to the resident on 1/17/2025, indicating s/he missed 2 doses of the antibiotic. During a surveyor interview on 1/24/2025 at 9:07 AM with Registered Nurse, Staff A, she acknowledged that the Fidaxomicin order was incorrectly transcribed by Licensed Practical Nurse, Staff B for a total of 4 days and not the 5 days, as ordered. Additionally, she acknowledged that the Fidaxomicin order was not administered to the resident twice on 1/17/2025. During a surveyor interview on 1/24/2025 at approximately 11:30 AM with the Administrator and the Acting Director of Nursing Services, they acknowledged that the Fidaxomicin order was transcribed inaccurately for Resident ID #3, resulting in him/her not receiving the full course of his/her antibiotic, as ordered. Cross reference F-756 and F-757 37158

46118 Based on record review and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for diabetic ulcers, Resident ID #94. Findings are as follows: According to the American Diabetes Association - 2017, Volume 35, Number 1, .Foot complications, specifically ulcers and amputations, are the number one reason for hospitalization in patients with diabetes .Thus, early recognition and proper management of patients at risk for developing foot ulcers and lower-extremity amputations are crucial. Performing regular foot exams on patients with diabetes in the primary care setting should be a high priority . Record review revealed Resident ID #94 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, diabetes mellitus, atopic dermatitis (a chronic skin condition that causes dry, itchy, and inflamed skin), and peripheral vascular disease (a condition that affects blood flow to the limbs). Additionally the record revealed that the resident previously had a right foot transmetatarsal amputation (TMA, a partial foot amputation). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Additionally, it revealed that the resident was at risk for developing pressure ulcers and did not have any infections to his/her feet, diabetic foot ulcers, or open lesions on his/her feet at that time. Further review of the MDS revealed that the resident required supervision or touching assistance with lower body dressing, putting on or taking off footwear, and personal hygiene. Lastly, the MDS revealed that the resident required substantial/maximum assistance with showers or bathing. Review of the care plan revealed a focus area dated 6/26/2024 which indicated the resident requires supervision with activities of daily living (ADLs) with an intervention for staff to provide skin inspections daily during care, and to observe for redness, open areas, scratches, cuts, bruises, and to report changes to the nurse. Additional review of the care plan revealed a focus area dated 7/1/2024, indicating an intervention for daily proper foot care and to promptly report any redness, blistering, and/or open areas to the provider. Record review failed to reveal evidence that daily foot care for the resident was being performed per the plan of care. Review of facility documents titled, Interim Skin Check with the dates of 7/25/2024, 7/27/2024, and 7/29/2024 revealed that the resident did not have any skin impairments noted during these comprehensive head to toe skin assessments. Record review revealed that the resident was followed by an offsite foot and ankle specialist (podiatrist) and had a routine appointment scheduled on 7/29/2024 at 9:45 AM. Record review revealed that the resident did not return to the facility from the above-mentioned appointment, as the podiatrist requested that the resident be transferred to an acute care hospital by rescue for an evaluation related to the appearance of cellulitis (a skin infection) and open ulcerations to both his/her feet and legs. Record review of a hospital admission physician's note electronically signed on 7/29/2024 at 8:21 PM, revealed that the resident arrived at the hospital via Emergency Medical Services from his/her podiatrist appointment after the resident was found to have infected foot ulcers to both feet. Further, the note indicates that the resident reported having foot problems over the past two weeks. Additionally, the physician noted that the resident's right foot TMA was covered with a dressing, his/her left toe was covered with a band-aid, s/he had mild swelling and warmth to his/her right foot and ankle, and multiple superficial excoriations (superficial wounds or scratches) and scales on both of his/her legs and feet. Lastly, the physician recommended that the resident be admitted to receive intravenous antibiotics for left and right foot cellulitis (a bacterial skin infection that can spread rapidly and cause serious complications if left untreated) with non-healing eschar (dry, thick, leathery, and dead tissue that forms over a wound as a result of tissue death). Further review of the hospital admission document revealed that the resident had a wound on his/her left foot measuring 1.5 centimeters (cm) by 1.5 cm and a wound on his/her right TMA site measuring 5 cm by 5 cm. Review of the podiatrist's visit note dated 7/29/2024 revealed that .at this point given the patient's weakness and inability to walk or transfer without assistance as well as the appearance of cellulitis and open ulcerations to both legs and feet, we did call the rescue service to transport the patient to the hospital for further evaluation and treatment of the feet and legs. I did perform a gentle gauze wrap to both feet and legs before [s/he] left . During a surveyor interview on 8/9/2024 at 10:09 AM with Registered Nurse (RN), Staff H, she revealed that the last time she remembered seeing the resident's feet was around the 3rd week of July. Review of the July Medication Administration Record revealed that on 7/29/2024 RN, Staff H, applied Aquaphor External Ointment (Emollient) to the resident's arms, legs, and back as ordered. Further review revealed that the order did not indicate to apply ointment to the resident's feet. During a surveyor interview on 8/9/2024 at 10:14 AM with Nursing Assistant, Staff I, she revealed that the resident can only assist with ADLs on the upper half of his/her body and requires staff assistance to complete ADLs for his/her lower half. During a surveyor interview on 8/9/2024 at 10:26 AM with Nurse Practitioner (NP), Staff D, she revealed that she was unaware of any ulcers on the resident's feet and would expect that the resident's skin assessments would accurately reflect his/her current condition. Further record review revealed that the resident was readmitted to the facility on [DATE] following his/her hospitalization related to foot cellulitis with ulcer. Record review of the hospital discharge document dated 8/2/2024 indicated the facility was to follow up with a vascular surgeon due to vessels in the resident's leg that were found to have partial blockages. Record review revealed evidence a follow up appointment with the vascular surgeon was scheduled on 8/19/2024, 17 days after the resident returned to the facility, when the vascular surgeon's office called to schedule the appointment for 8/26/2024. Record review revealed multiple documents titled, Skin and Wound Evaluation dated 8/7/2024, that revealed the resident had the following skin impairments: - Diabetic ulcer on the bottom of the left foot, measurements were not documented for this wound. - Diabetic ulcer on the top of the left foot, measuring 4.8 centimeters (cm) by 1.1 cm - Diabetic ulcer on the inner left foot, measuring 0.5 cm by 0.5 cm - Diabetic ulcer on the top of the right foot, measuring 3.8 cm by 2.4 cm - Diabetic ulcer on the bottom of the right foot, measurements were not documented for this wound. Review of a hospital document titled, Continuity of Care Form dated 8/2/2024, revealed that the resident was to start the following two antibiotics upon return to the facility: Augmentin 500 milligrams (mg)/125mg three times daily and Doxycycline 100mg twice daily. Record review of the August 2024 Medication Administration Record failed to reveal evidence that the resident received his/her Augmentin and Doxycycline per the hospital discharge instructions on 8/2, 8/3, 8/4, and 8/5; he/she received partial doses on 8/6/2024. Additional record review revealed that the above-mentioned antibiotics were not transcribed into the resident's record or initiated until 8/6/2024. During a surveyor interview on 8/9/2024 at 10:26 AM with NP, Staff D, she revealed that she would have expected the resident to have received the antibiotics, as ordered from the hospital discharge, and acknowledged she had ordered them after realizing that the antibiotics were never transcribed to be administered to the resident since 8/2/2024. Additionally, she acknowledged that the resident's white blood cell count (cells that fight infection; an elevated count may indicate an infection) had increased after s/he had not received the antibiotics as intended. Record review of an Integrated Wound Care initial progress note, dated 8/12/2024, revealed the following skin impairments and measurements: 1. Diabetic ulcer on the Left Great toe - 3 cm by 2 cm with 100% eschar 2. Unspecified wound on the Left foot, plantar- 1.5 cm by 1 cm with 100% eschar 3. Pressure ulcer on the Left heel, unstageable (a wound that is caused by prolonged pressure on a specific area of the skin, which can lead to a lack of blood flow and oxygen to the tissue. This type of wound is covered by a layer of dead tissue, that makes it difficult to determine its severity or stage as the depth of the wound cannot be observed to be measured) - 5 cm by 2 cm with 100% eschar 4. Surgical site- 1 cm by 1 cm by 0.2 cm 5. Unspecified wound on the Right foot, plantar- 4 cm by 4 cm with 100% eschar 6. Pressure ulcer on the Right heel, unstageable- 3 cm by 3 cm by 0.2 cm with 100% slough (tan, yellow, or white dead tissue) Record review revealed the resident was sent to the emergency department on 8/16/2024 related to a hypotensive (low blood pressure) event. Record review of the hospital documentation dated 8/16/2024 indicated that the hospital was going to admit the resident, have him/her evaluated by a vascular surgeon, and administer intravenous antibiotics. The resident decided to leave the hospital and return to the facility against medical advice. Record review of a provider noted dated 8/19/2024 indicated that necrosis was noted to the left toes and a risk was present for the resident to lose those toes secondary to the wounds. Record review of an Integrated Wound Care progress note, dated 8/20/2024, revealed the following skin impairments and measurements: 1. Diabetic ulcer on the Left Great toe - 3 cm by 2 cm with 100% eschar 2. Unspecified wound on the Left foot, plantar- 1.7 cm by 1.3 cm with 100% eschar 3. Pressure ulcer on the Left heel, unstageable- 3 cm by 5 cm with 100% eschar 4. Surgical site- 1 cm by 1 cm by 0.2 cm 5. Unspecified wound on the Right foot, plantar- 4 cm by 3 cm by 0.5 cm with 100% eschar 6. Pressure ulcer on the Right heel, unstageable- 3 cm by 3 cm by 0.1 cm Further review of the above document revealed additional wounds were identified including scattered areas of 50% eschar on toes 2-5 of the left foot without measurements and an unspecified wound on the left lateral foot measuring 1 cm by 1 cm with 100% eschar. During a surveyor observation on 8/20/2024 at 10:55 AM, NP, Staff L, was evaluating the resident's wounds and was picking and peeling thick pieces of skin off of the resident's feet and legs with her gloved hands and measuring the wounds. During a surveyor interview on 8/21/2024 at 10:03 AM with the resident's podiatrist, she indicated that she did not observe any wounds to the resident's heels or toes 2-5 on 7/29/2024. She further indicated that per her examination note, she observed a large escharized area on the right healed incision site, the plantar aspect of the right foot, and the distal aspect of the left great toe. Additionally, she indicated she was concerned that the resident's present condition is worsening and s/he should be evaluated by a vascular surgeon as soon as possible. Furthermore, she indicated that the resident is at risk for amputation related to the new wounds that have been identified on the resident's heels and toes, since the resident's podiatry evaluation on 7/29/2024. During a surveyor interview on 8/9/2024 at 10:43 AM and 8/21/2024 at 11:19 AM with the Director of Nursing Services, she indicated that she would have expected an appointment to be scheduled for the resident to be seen by a vascular surgeon. Additionally, she was unable to provide evidence that the facility provided treatment and care in accordance with professional standards of practice for a resident with diabetic ulcers. The facility's failure to accurately assess and monitor the skin of a resident's feet in order to identify impairments/wounds and implement antibiotics timely for a resident who had been hospitalized and was at risk for skin impairments as evidenced by the MDS Assessment, a diagnoses of diabetes mellitus, a diagnoses peripheral vascular disease, and a history of a right transmetatarsal amputation placed him/her at risk for serious harm, serious injury, impairment or death.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to honor a resident's right to refuse treatment, for 1 of 1 resident reviewed, Resident ID #39. Findings are as follows: Review of a community reported complaint received by the Rhode Island Department of Health on 8/19/2024 alleges that Resident ID #39 received a medication for 3 days, without his/her consent. Record review revealed the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, cervical disc degeneration, morbid obesity, and hypertensive kidney disease. Review of a Brief Interview for Mental Status Assessment completed on 6/5/2024 revealed a score of 15 out of 15, indicating s/he is cognitively intact. Record review revealed an order dated 8/15/2024 for Trazodone (an antidepressant medication) 50 milligrams (mg) with instructions to Give 0.5 tablet by mouth three times a day for Anger and Irritability until 8/28/2024 AS Needed Only for Anger and Irritability. Record review of the August 2024 Medication Administration Record (MAR) revealed the resident received Trazodone scheduled (routinely, not as needed) on the following dates and times: 8/15/2024 at 5:00 PM 8/16/2024 at 9:00 AM, 1:00 PM, and 5:00 PM 8/17/2024 at 9:00 AM, 1:00 PM, and 5:00 PM 8/18/2024 at 9:00 AM, 1:00 PM 8/19/2024 at 9:00 AM Further review of the August 2024 MAR revealed the resident was documented as refusing his/her dose of Trazodone on 8/18/2024 at 5:00 PM. Additionally, the Trazodone order was discontinued on 8/19/2024. During a surveyor interview on 8/22/2024 at approximately 12:40 PM, with Registered Nurse, Staff J, she revealed that the resident blew up because s/he received the wrong food and that a Nursing Assistant rolled their eyes at him/her, causing the resident to throw his/her food across his/her room. She further revealed that the psychiatric provider was contacted and came to the facility to assess the resident, which is when the Trazodone was ordered. During a surveyor interview on 8/22/2024 at approximately 12:45 PM, with the resident, s/he indicated that s/he recently became frustrated when s/he was served the incorrect meal while recovering from COVID and was kept in isolation in his/her room. The resident revealed that s/he had thrown a meal tray and a cell phone across the room on 8/12/2024. Following this incident, s/he revealed that a Nurse Practitioner (NP) came in to speak with him/her regarding his/her behaviors and indicated she was going to prescribe him/her Trazodone (a medication that is prescribed to treat depression and to help stabilize mood) to help with his/her anger. The resident revealed that s/he told the NP that s/he did not want to take Trazodone and the NP ordered Trazodone anyway. The resident further revealed that despite him/her stating that s/he did not want the medication, it was given to him/her for three days without his/her knowledge. Additionally, the resident revealed that it was on 8/18/2024 when s/he was noticed a pill that s/he did not recognize and asked the nurse what it was, that is when s/he found out that s/he had been receiving Trazodone for three times a day for three days, which made sense to him/her as s/he was unable to go outside and enjoy the sunshine due to being too sleepy and lethargic during that time. During a surveyor interview on 8/22/2024 at approximately 12:45 PM, with NP, Staff K, she revealed that when she saw the resident on 8/15/2024, the resident became angry when she discussed placing him/her on Trazodone, so she left the resident's room and did not return to further discuss prescribing him/her the medication. Additionally, she revealed that she prescribed the Trazodone to be administered as needed and not to be administered to the resident as a scheduled medication three times daily. Furthermore, she acknowledged that she had entered the order for Trazodone herself into the resident's electronic medical record. During a surveyor interview on 8/22/2024 at approximately 1:20 PM with the Director of Nursing Services, she revealed that the expectation is that the resident would have been educated and informed of the medication s/he was being prescribed and administered. She further revealed it is the resident's right to know and consent to treatment.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who is at risk for pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents reviewed with actual pressure ulcers, Resident ID #94. Findings are as follows: Record review revealed Resident ID #94 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, diabetes mellitus, atopic dermatitis (a chronic skin condition that causes dry, itchy, and inflamed skin), and peripheral vascular disease (a condition that affects blood flow to the limbs). Additionally the record revealed that the resident previously had a right foot transmetatarsal amputation (TMA, a partial foot amputation). Review of a Minimum Data Set (MDS) Assessment, dated 7/4/2024, revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Additionally, it revealed that the resident was at risk for developing pressure ulcers and did not have any pressure ulcers, or open lesions, on his/her feet at that time. Review of the care plan revealed a focus area dated 7/1/2024, indicating an intervention for daily proper foot care and to promptly report any redness, blistering, and/or open areas to the provider. Review of facility document titled, Interim Skin Check, dated 8/4/2024, revealed that the resident was noted to have bruises to the left side of his/her face and a small skin tear on the scalp. Further review revealed no other skin impairments were noted. Review of a Skin and Wound Evaluation, dated 8/7/2024, revealed a stage 1 pressure ulcer (Initial stage of skin damage due to prolonged pressure) to the resident's right foot that was .Non-blanchable erythema [a type of pressure ulcer that appears as a red or reddish-blue area of skin that does not turn white when pressed] of intact skin . was noted to the resident's right heel measuring 4.9 centimeters (cm) by 2.1 cm. Further review revealed this was an In-House Acquired wound. Record review failed to reveal evidence that an intervention was put into place when this pressure ulcer was identified on 8/7/2024. Additional record review revealed the resident's care plan was updated on 8/12/2024 to include off loading the feet related to an actual or risk of a pressure ulcer. Record review of a document titled, Integrated Wound Care, initial progress note dated 8/12/2024 included, but was not limited to, the following skin impairments and measurements: - Pressure ulcer on the Right heel, unstageable (a wound that is caused by prolonged pressure on a specific area of the skin, which can lead to a lack of blood flow and oxygen to the tissue. This type of wound is covered by a layer of dead tissue, that makes it difficult to determine its severity or stage as the depth of the wound cannot be observed to be measured)- 3 cm by 3 cm by 0.2 cm with 100% slough (dead tissue within the wound that can impede the healing process) Additional review of the above document revealed a new pressure ulcer was identified to the resident's left heel that was described as: - Pressure ulcer on the Left heel, unstageable - 5 cm by 2 cm with 100% eschar (dry, thick, leathery, and dead tissue that forms over a wound as a result of tissue death) Further review of the above document revealed wound care instructions to wash with mild soap and water, pat dry, then apply medihoney to eschar and cover with dry dressing daily and as needed. Additionally, the Plan to Address Factors Affecting Wound Healing included, but was not limited to, offloading pressure. Record review revealed the wound care orders for the left and right pressure wounds were not put into place and completed until 8/14/2024, two days after they were assessed by the wound care provider. Record review revealed an order dated 8/12/2024 for off loading booties to bilateral feet when in bed as tolerated every shift and to document if the resident refuses. During surveyor observations on the following date and times the resident's heels were not offloaded and were resting directly on the mattress: -8/20/2024 at 9:29 AM -8/20/2024 at 11:55 AM -8/20/2024 at 12:55 PM Further record review failed to reveal evidence that the resident refused the offloading booties during the above observations. During a surveyor interview on 8/20/2024 at 12:55 PM with the resident, s/he indicated that s/he would like his/her feet offloaded if it would help with wound healing. During a surveyor interview on 8/20/2024 at approximately 1:00 PM with Registered Nurse, Staff M, she acknowledged that the resident has an order for his/her feet to be offloaded and they were directly on the mattress at that time. She placed the resident's offloading booties on his/her feet. Record review revealed Staff M documented that the resident removed the offloading boots at 2:25 PM on 8/20/2024. During a surveyor interview on 8/20/2024 at approximately 3:00 PM with the resident, s/he indicated that s/he removed the boots to urinate. During a surveyor observation on 8/20/2024 at approximately 10:55 AM, Nurse Practitioner (NP), Staff L, was evaluating the resident's wounds and picking and peeling pieces of skin off of the resident's feet and legs with her gloved hands and measuring the wounds. Record review of an Integrated Wound Care progress note dated 8/20/2024 included, but was not limited to, the following skin impairments and measurements: -Pressure ulcer on the Left heel, unstageable- 3 cm by 5 cm with 100% eschar -Pressure ulcer on the Right heel, unstageable- 3 cm by 3 cm by 0.1 cm Additional surveyor observations on the following dates and times revealed the resident's heels were not offloaded and were resting directly on the mattress, after it was brought to the facility's attention: -8/21/2024 at approximately 9:20 AM -8/22/2024 at approximately 9:30 AM During a surveyor interview on 8/21/2024 at 11:19 AM with the Director of Nursing Services, she could not provide evidence that the resident received the necessary treatment and services to promote healing and prevent new pressure ulcers from developing.

Based on surveyor observation, record review, staff, and resident interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 residents reviewed for pain, Resident ID #539. Findings are as follows: Record review revealed the Resident was admitted to the facility in 8/2/2024 with a diagnosis including, but not limited to, left knee arthroplasty (a surgical procedure to resurface a knee damaged by arthritis). Review of a care plan focus area dated 8/2/2024 revealed the resident has an alteration in musculoskeletal status related to knee surgery with interventions to give pain medications as ordered by the physician. Record review of a physician's order dated 8/2/2024 revealed an order for 5 milligrams (mg) of oxycodone (an opioid medication used to treat moderate to severe pain) as needed for pain every 6 hours. Review of a progress note dated 8/6/2024 authored by Nurse Practitioner,Staff D, revealed that the resident reported experiencing a pain level of 7 out of 10 to his/her left knee and s/he is to continue using oxycodone for pain, and that the prescription had been sent to the pharmacy. Additionally, she indicated that staff is to obtain the oxycodone from the pyxis (computerized medication management system that provides immediate access to medications that have not been filled by the facility's pharmacy). During a surveyor interview on 8/7/2024 at 9:18 AM, with the resident s/he revealed that s/he was in pain related to having recent left knee surgery as well as burning pain when s/he urinates. S/he reported having increased pain when moving and when participating with therapy. Additionally, s/he revealed that s/he reported the pain to the nurse and was told that they do not have his/her oxycodone available, as the pharmacy has not delivered it to the facility. During a surveyor interview on 8/7/2024 at 10:43 AM, with Licensed Practical Nurse, Staff C, she revealed that on 8/6/2024 the resident informed her that the pain medication has not been available for him/her since his/her admission. Additionally, she revealed that she had contacted the physician to have the prescription sent to the pharmacy and was able to administer the oxycodone to the resident as ordered, at approximately 10:00 AM on 8/7/2024. Review of the August 2024 Medication Administration Record revealed that s/he was administered 5 mg of oxycodone for pain twice on 8/7 and twice on 8/8/2024. During a surveyor interview on 8/7/2024 at 10:53 AM, with the Director of Nursing Services, she indicated that she would expect the resident to be medicated for pain as ordered. She further revealed that she would have expected the nurse to utilize the pyxis to obtain the resident's oxycodone until it was delivered by the pharmacy.

Based on record review and staff and resident interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs, for 1 of 6 residents reviewed, Resident ID #39. Additionally, the facility failed to ensure that a resident receives a gradual dose reduction (GDR; a process of slowly tapering off a medication to determine if symptoms, conditions, or risks can be managed with a lower dose or if the medication can be discontinued altogether) unless clinically contraindicated for 1 of 3 residents reviewed, Resident ID #45. Findings are as follows: 1. Record review revealed Resident ID #39 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, cervical disc degeneration, morbid obesity, and hypertensive kidney disease. Record review of a Brief Interview for Mental Status Assessment was completed on 6/5/2024 with a score of 15 out of 15, which indicates that the resident's cognition is intact. Record review of a document titled, Order Details authored by Nurse Practitioner (NP), Staff K, dated 8/15/2024, revealed an order for Trazodone (an antidepressant medication) 50 milligrams (mg) with instructions to Give 0.5 tablet by mouth three times a day for Anger and Irritability until 8/28/2024 AS Needed Only for Anger and Irritability. Record review of the August 2024 Medication Administration Record (MAR) revealed the resident received Trazodone scheduled (routinely, not as needed) on the following dates and times: -8/15/2024 at 5:00 PM -8/16/2024 at 9:00 AM, 1:00 PM, and 5:00 PM -8/17/2024 at 9:00 AM, 1:00 PM, and 5:00 PM -8/18/2024 at 9:00 AM, 1:00 PM -8/19/2024 at 9:00 AM Further review of the August 2024 MAR revealed the resident was documented as refusing his/her dose of Trazodone on 8/18/2024 at 5:00 PM. Additionally, the Trazodone order was discontinued on 8/19/2024. During a surveyor interview on 8/22/2024 at approximately 12:40 PM, with Registered Nurse, Staff J, she revealed that the Trazodone order should have been administered as needed, but it was administered as a scheduled order. Additionally, she acknowledged that the Trazodone order was not transcribed or administered as it should have been. During a surveyor interview on 8/22/2024 at approximately 12:45 PM, with NP, Staff K, she revealed that when she saw the resident on 8/15/2024, the resident became angry when she discussed placing him/her on Trazodone, so she left the resident's room and did not return to further discuss prescribing him/her the medication. Additionally, she revealed that she prescribed the Trazodone to be administered as needed and not to be administered to the resident as a scheduled medication three times daily. Furthermore, she acknowledged that she had entered the order for Trazodone herself into the resident's electronic medical record. During a surveyor interview on 8/22/2024 at approximately 1:20 PM with the Director of Nursing Services (DNS), she revealed that the NP should have been contacted to verify the order and indicated that the Trazodone order should have been clarified, as the order read three times a day as needed only. 2. Record review revealed the resident was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, unspecified mood affective disorder and obsessive-compulsive disorder. Record review revealed a physician order dated 6/24/2024 for Risperidone (an antipsychotic medication), with instructions to administer 1 mg twice daily at 9:00 AM and 5:00 PM, related to unspecified mood affective disorder. Review of a psychiatric evaluation and consultation dated 7/12/2024 revealed a medication recommendation to consider a GDR of Risperidone from 1 mg twice daily to 0.5 MG in the morning and 1 mg in the evening. Review of the July and August 2024 MAR revealed, Risperidone 1 mg was administered twice daily from July 13th through August 6th, indicating the resident did not receive his/her reduced dose for 25 days. Record review failed to reveal evidence that the GDR recommendation for Risperidone from 7/12/2024 was implemented until another GDR recommendation for Risperidone was made on 8/5/2024. During a surveyor interview on 8/7/2024 at 11:59 AM with the DNS, she revealed that after psychiatric services makes a recommendation, the Nurse Practitioner or Physician will be notified to review the recommendation. Further, she was unable to provide evidence that the recommendation from 7/12/2024 to GDR the resident's Risperidone was addressed, approved, or denied by the Nurse Practitioner or Physician. During a surveyor interview on 8/9/2024 at 11:26 AM, the resident's physician revealed that he was unaware of the psychiatric evaluation and consultation recommendation made on 7/12/2024 for the resident's Risperidone to be reduced. Additionally, he revealed that he would have approved the GDR recommendation had he been made aware of it.

Based on record review, resident 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 who exhibited symptoms of an opioid overdose which required hospitalization in the critical care unit after being administered medication, methadone 60 mg, intended for another resident, Resident ID #1; and for 1 of 2 residents who missed a dose of medication and was not assessed for opiate withdrawal, Resident ID #2. Findings are as follows: According to the 2022 Ferri's Clinical Advisor, page 1090 states in part, Opioid Overdose .PHYSICAL FINDINGS & CLINICAL PRESENTATION Patients with opioid overdose classically present with the triad of altered mental status, pinpoint pupils, and respiratory depression .WORKUP .Obtain an ECG [electrocardiogram medical test that measures the hearts electrical activity] in the following scenarios: Use of methadone .to screen for QTc prolongation [an irregular heart rhythm] .The principal goals of treatment for opioid overdose are support of ventilation [breathing] and reversal of the drug .Administer naloxone [Narcan, a medication used in an emergency to treat an opioid overdose] . Review of the online January 2021 Davis Drug Guide for Nurses states in part, methadone .High Alert .Adverse Reactions .confusion, sedation .hypotension [low blood pressure] .QT interval prolongation .RESPIRATROY DEPRESSION .signs of overdose (difficult or shallow breathing, extreme tiredness or sleepiness, blurred vision, inability to think, talk, or walk normally, and feelings of faintness, dizziness, or confusion) .Methadone has a prolonged action causing increased risk of overdose . According to the article titled, Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families Updated 2021, found in the National Library of Medicine's National Center for Biotechnology Information: .Precautions and Warnings Respiratory depression Methadone can cause respiratory depression, particularly during initial dosing and dose titration .Patients who are older or .who have chronic obstructive pulmonary disease are more susceptible to respiratory depression and should be treated cautiously with lower doses . Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 11/8/2023 indicates Resident ID #1 was transferred to the hospital after sustaining an unwitnessed fall and was noted to have .potential opioid like sedation . Additional record review of a community reported complaint submitted to the RIDOH on 11/10/2023, alleges Resident ID #1 was inadvertently administered his/her roommate's dose of methadone. Record review of a facility policy revised April 2019 titled, Administering Mediations, states in part, .Medications are administered in a safe and timely manner, and as prescribed . 1. Record review revealed Resident ID #1 was readmitted to the facility in November of 2023 with diagnoses including, but not limited to, alcoholic liver cirrhosis (condition that affects how the liver functions, making it hard to filter medications or drugs), chronic obstructive pulmonary disease (COPD, a term used to describe a chronic lung disease), obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep), and hepatic encephalopathy (a nervous system disorder brought on by severe liver disease). Record review revealed a significant change Minimum Data Set (MDS) assessment dated [DATE] was completed after s/he was admitted to hospice services for end of life care. Additionally, the MDS revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. During a surveyor observation and interview with the resident on 11/10/2023 at 8:59 AM, s/he was observed lying in bed with his/her eyes closed. When the surveyor called his/her name, the resident opened his/her eyes briefly before closing them. S/he was unable to participate in the interview. During a surveyor interview on 11/10/2023 at 10:15 AM, with Resident ID #1's family member, revealed the following. S/he indicated that on 11/6/2023 some time after 11:00 AM, a facility staff member called to notify him/her that the resident was given narcan and being transported to the hospital due to a fall. Additionally, s/he asked the staff member why the resident was given narcan when s/he had not started taking morphine. The staff member told him/her a float nurse gave Resident ID #1 the wrong medication: his/her roommate's methadone. During a surveyor telephone interview on 11/10/2023 at 2:00 PM, with the hospice Registered Nurse, revealed she was notified that on 11/6/2023, Resident ID #1 was transferred to the hospital due to falling and possibly being administered his/her roommate's methadone. Additionally, she revealed that the resident was declining prior to the incident and was alert and oriented to him/herself only, therefore s/he would not question if someone gave him/her something to drink, s/he would just drink it. Record review of the resident's progress notes revealed the following entries: - 11/06/2023 11:40 AM, authored by Unit Manager, Registered Nurse (RN), Staff A - .This writer was informed by the floor nurse around 1030 that resident [ID #1] was on the floor at 1020. Upon entry to residents room it was noted that [s/he] was on the floor on the right side of the bed kneeling in front of [his/her] commode. This writer along with the floor nurse and CNA [nursing assistant] attempted to transfer resident back into the bed with a gait belt but [s/he] was unable to assist. Resident was placed on a hoyer [mechanical lift] bed then transferred back into bed. [S/he] was noticed with AMS [altered mental status]/ pinpoint pupils also with changes to respiratory rate/ breathing. [His/her] arms and hands were very rigid as well. Resident responded each time when [his/her] name was called but [s/he] was unable to remain alert. The floor nurse made this writer aware that the residents roommate [Resident ID #2] was adamant about not receiving [his/her] 0600 dose of Methadone 60mg [milligrams]. VS [vital signs] .spo2 [blood oxygen level]95%ra [room air] .[Resident ID #1] was placed on 2L [liters] of O2[oxygen] .for comfort due to [his/her] current breathing pattern .NP [Nurse Practitioner, Staff C] .was made aware of the resident possibly receiving the Methadone accidentally . The note further indicates that his/her vital signs were documented as heart rate 120 [normal resting heart rate should be between 60 to 100 beats per minute], respirations 15 breaths per minute and blood pressure was documented as 82/60 [normal blood pressure is 120/80]. Additionally, the note states in part, .NP [NP, Staff D] then walked in the room to see resident. Resident desated to 83% [normal oxygenation percentage is greater than 95%] on 2L O2, [his/her] HR [heart rate] decreased to 54, and respirations decreased to 11. NP ordered this writer to get the Narcan, a non rebreather mask [type of oxygen mask], and to call 911. The mask was placed on resident with 25L O2 .Narcan was administered to the left nostril at 1038 with minimal response so at 1043 [s/he] received Narcan to the right nostril. Resident became more alert and responsive but had some confusion. [His/her] pupils became 3mm [millimeters]. [S/he] was informed that rescue was called to transfer [him/her] to [the hospital] for further evaluation secondary to AMS . - 11/6/2023 3:28 PM, authored by Licensed Practical Nurse (LPN), Staff B - .Resident found on floor at 1015am on knees At bedside .Resident .eating breakfast 945am. Responses appeared slower than [his/her] baseline .Nurse practitioner in to assess PT [patient] .recommended to be sent to Acute care for evaluation . - 11/6/2023 8:08 PM, authored by the Administrator, This writer made the NP aware that the resident is going to be admitted to [the hospital name redacted] . - 11/7/2023 3:54 PM, authored by Nurse Practitioner, Staff D - .Chief Complaint: Fall and suspected OD [over dose] .Pt [patient] went to be evaluated after sustaining an unwitnessed fall. When pt returned to bed pt noted have a low snoring respiratory rate. Pt unable to follow commands, pupils pinpoint. Pt tachycardic [increased heart rate] and desaturating [low blood oxygen level]. Suspected pt with potential OD on narcotic .911 activated, and narcan x 2 administered. After 1 dose of narcan, pt saturations improved and pt more coherent but not to [his/her] baseline. After 2nd dose of narcan pt back to baseline MS [mental status] but remained slightly lethargic .HR [heart rate] normalized when EMS [emergency medical services] arrived. Pt sent to ED [emergency department] for further evaluation and management .Pharmacy called to ensure narcan was antidote for said narcotic . During a surveyor interview on 11/10/2023 at 9:26 AM, with Staff A, she revealed that on the morning of 11/6/2023 at approximately 10:00 AM she was notified by Staff B that the resident was found on the floor and upon her entry to the room she observed him/her with a change of condition. She indicated that the resident's blood oxygen level decreased to 83% on room air, his/her heart rate decreased and his/her pupils were pinpoint. She further indicated that at that time Staff B reported Resident ID #1's roommate, Resident ID #2, was adamant that s/he did not receive his/her morning dose of methadone. Staff A then indicated that she informed the NP, Staff D, who ordered Narcan to be administered and for the resident to be transferred to the emergency department. Additionally, Staff A indicated that Resident ID #1 received the first dose of Narcan at 10:38 AM with minimal effect, however after a second dose was administered s/he became alert. Staff A further indicated that the 11/5-11/6/2023 overnight shift was the first shift that the agency nurse, who administered the 6:00 AM medications on the morning of 11/6/2023, worked in the facility. She further indicated that the residents' beds are assigned as A and B beds and indicated that agency staff have had confusion with the bed setup in the past. During a surveyor telephone interview on 11/14/2023 at 3:42 PM, with Staff B, she revealed that she is an agency nurse who was the nurse assigned to Resident ID #'s 1 and 2 on 11/6/2023 during the 7:00 AM - 3:00 PM shift. She indicated that she saw Resident ID #1 during the breakfast meal as s/he was sitting on the edge of the bed. She further indicated that she had provided care to him/her once prior to 11/6/2023 and indicated that Resident ID #1 did not seem like him/herself. Staff B indicated that when she asked the resident questions s/he did not answer verbally but would nod his/her head in response. Furthermore, Staff B indicated that while she was exiting the room, Resident ID #2 reported that s/he did not receive his/her 11/6/2023 6:00 AM dose of methadone 60 mg. Staff B indicated that she left the resident's room to check on the administration record and upon return, Resident ID #1 was found on the floor with a change in mental status. Staff B indicated she reported the roommate's allegation to the unit manager at that time and indicated they felt that Resident ID #1 possibly received Resident ID #2's dose of methadone and s/he was subsequently transferred to the hospital. During a surveyor interview on 11/14/2023 at 11:50 AM, with NP, Staff C, she revealed that she assessed Resident ID #1 on the morning of 11/6/2023 after the nurse alerted her to his/her unwitnessed fall, change of condition, and possible opioid ingestion. She indicated that she went off of the information the nurse provided to her, that the resident may have been given his/her roommate's methadone and Resident ID #1's presentation and s/he was administered narcan at the facility with improvement in his/her status prior to transfer to the hospital. Record review revealed the following physician's orders for Resident ID #1: - 8/13/2023, Morphine Sulfate (opioid pain medication) .Solution 20 MG/ML [milliliters] .Give 5 mg by mouth every 4 hours as needed for Pain/SOB [shortness of breath] . - 9/6/2023, Citalopram (Selective serotonin reuptake inhibitors, SSRIs, medication to treat depression) 40 mg tablet one time a day at 10:00 AM for depression - 9/13/2023, Lorazepam (benzodiazepine medication used to treat anxiety) 0.5 milligrams tablet Give one tablet by mouth two times a day for anxiety at 9:00 AM and 5:00 PM - 11/4/2023, Morphine Sulfate .Oral Solution 20 MG/ML .Give 0.25 ml by mouth every 1 hours as needed for pain/discomfort/SOB . - 11/6/2023, Naloxone HCl Liquid 4 MG/0.1ML 0.4 mg Alternating nostrils as needed for Unresponsiveness Give 1 spray in nostril for unresponsiveness and/or respiratory depression related to opioid ingestion; May repeat every 2-3 minutes in alternating nostrils as needed until resident is responsive, or emergency medical assistance arrives. Record review of the November 2023 Medication Administration Record (MAR) and narcotic log book failed to reveal evidence that s/he was administered morphine. Additionally, the MAR revealed Resident ID #1 was administered his/her morning doses of medication on 11/6/2023 which included lorazepam and citalopram. Furthermore, the MAR revealed Naloxone was administered to the resident on 11/6/2023 at 10:38 AM and 10:43 AM. Additional record review revealed s/he received Lorazepam 0.5 mg as ordered on 11/1-11/5/2023 with no evidence of respiratory distress or altered mental status. Additional review of the article titled, Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families Updated 2021, found in the National Library of Medicine's National Center for Biotechnology Information reveals, methadone medication administered along with benzodiazepines may increase sedation and respiratory depression. Additionally, administration along with antidepressant medications (SSRIS) may increase methadone levels. Furthermore, the article indicates that methadone peaks (reaches its highest level in the blood stream) 2-3 hours after it is taken. Additional record review revealed the resident was transferred to an acute care hospital on 11/6/2023. Record review of the hospital document titled, HISTORY & PHYSICAL, dated 11/6/2023 at 4:09 PM, revealed the following in part, .Chief Complaint Methadone Overdose .Per EMS, patient had been given 60 mg of methadone by his nurse, which was meant for the patient's roommate, along with [his/her] scheduled morning medications .Emergency Department [ED] Course In the ED patient was noted to be lethargic .was noted to have pinpoint pupils .Patient was given an additional 2 mg of naloxone [narcan] IV [intravenous]. Patient was admitted .for further management and observation of unintentional opioid overdose .Etiology the patient's presentation is likely secondary to the methadone [s/he] received . Further record review of the hospital document dated 11/6/2023 4:19 PM titled, emergency room VISIT NOTES, revealed a head scan was completed which indicated there was no evidence of an acute stroke, brain bleed or mass. The document further indicates that the hospital provider was informed by the nursing facility that the resident was accidentally given methadone 60 mg. Furthermore, the document states in part, .Accidental opioid overdose methadone 60 mg in a patient from nursing home. Patient will be admitted to critical care unit to be monitored more closely .Patient was closely monitored EKGs . Furthermore, the document indicates the that the resident was noted to have a prolonged QT [measurement that represents the total time from ventricular depolarization to complete repolarization] interval upon initial assessment at the hospital. Additionally, the document indicates that due to his/her underlying liver disease, the methadone will take more time to be cleared from the resident's system. During a surveyor interview on 11/10/2023 at 1:53 PM, with the Medical Director, he indicated that he was informed of Resident ID #1's change in condition on 11/6/2023 which was thought to be related to him/her ingesting an opioid. He further indicated that the resident was administered Narcan and his/her status was improving. When asked, he indicated that Narcan would not change the resident's status if s/he had not ingested an opioid. 2. Record review revealed Resident ID #2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, opiate dependence and depression. Record review of an admission MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15, indicating intact cognition. Additional record review revealed the following physician's orders for a split daily dose (dividing the dose of methadone in two daily doses, taken 10-12 hours apart, rather than a single daily dose) of methadone for Resident ID #2: - 11/2/2023, Methadone 10 MG [milligrams]/ML [milliliters] give 60 mg by mouth one time a day at 6:00 AM related to opioid dependence - 11/2/2023, Methadone 10 MG/ML give 15 mg by mouth in the evening 6:00 PM related to opioid dependence Record review of the November 2023 Medication Administration Record revealed that the above-mentioned order for 60 mg of methadone was documented as administered on 11/6/2023 at 6:00 AM by an agency nurse, Staff E. Record review revealed a nursing progress note dated 11/6/2023 at 1:26 PM, authored by Staff A, which indicates a provider was notified that Resident ID #2 missed his/her morning dose of methadone 60 mg and indicated that s/he refused to work with therapy. Record review revealed a document dated 11/6/2023 at 1:52 PM, titled, Physical Therapy Treatment Encounter Note(s), which states in part, .pt [patient] approached for therapy and upon arrival pt .in bed, pt stated [s/he] wasn't going anywhere or doing anything today as [s/he] wasn't feeling well . During surveyor interviews on 11/10/2023 at 9:36 am and 4:02 PM, with Resident ID #2, s/he revealed that on the morning of 11/6/2023 an agency nurse, Staff E, entered his/her room at approximately 5:30 AM and obtained his/her blood pressure, however, did not return to administer his/her 6:00 AM dose of methadone 60 mg. Additionally, s/he indicated that after approximately two hours had passed and the nurse had not administered the methadone, s/he called for assistance. The resident indicated that the 7:00 AM - 3:00 PM nurse responded to his/her call and when s/he asked for his/her methadone, the nurse indicated that the medication was already administered. The resident indicated that s/he told the staff member that s/he did not receive his/her dose of methadone 60 mg. Additionally, Resident ID #2 indicated that s/he experienced methadone withdrawal symptoms because s/he had missed his/her 6:00 am dose of methadone on 11/6/2023. The resident further indicated that his/her symptoms included anxiety and indicated that s/he could not participate in therapy on 11/6/2023 because s/he did not feel well due to not receiving his/her 6:00 AM dose of methadone that day. Further record review failed to reveal evidence that Resident ID #2 was assessed for opiate withdrawal relative to him/her not being administered the 6:00 AM dose of methadone on 11/6/2023, such as pupil size, gastrointestinal upset, gooseflesh skin, sweating, yawning, tremors, runny nose or restlessness. During a surveyor interview on 11/10/2023 at 4:09 PM, with the Regional Clinical Director and the Director of Nursing Services (DNS) in the presence of the Administrator, they indicated that the facility's investigation finds the incident unsubstantiated because there is no evidence Resident ID #2 missed his/her dose. Additionally, the DNS indicated that the resident did not have signs or symptoms of pain therefore there was no evidence that s/he was not administered his/her 6:00 AM dose of methadone. Furthermore, the surveyor brought to their attention that Resident ID #2 complained of not feeling well and refused physical therapy on the afternoon of 11/6/2023 due to his/her missed dose of methadone at 6:00 AM. They were unable to answer or provide evidence that s/he was assessed for symptoms of methadone withdrawal. Further record review revealed a provider was notified of Resident ID #2's missed methadone administration; however, the record failed to reveal evidence that s/he was assessed for withdrawal symptoms. Additional record review failed to reveal evidence that Resident ID #2 exhibited any drug seeking behaviors. During a surveyor interview on 11/10/2023 at 9:41 AM and 2:21 PM with the Administrator, she indicated that she interviewed Resident ID #2 on 11/6/2023 sometime after the incident occurred with Resident ID #1. She indicated that Resident ID #2 reported s/he did not receive his/her morning dose of methadone 60 mg that day. Additionally, the Administrator indicated that the NP was the one who mentioned that this incident could possibly be an opioid overdose. However, she indicated the agency nurse, Sgtaff E, signed off that he administered the methadone to the correct resident and that this investigation was inconclusive as there was not any lab testing completed for Resident ID #1 to confirm that s/he actually received methadone. As a result of this survey, it has been determined that Resident ID #1 was placed at risk for serious harm or death; Resident ID #2, a cognitively intact individual, stated repeatedly to staff that s/he had not received his/her 6:00 AM dose of 60 mg of Methadone and experienced signs and symptoms of withdrawals causing him/her to refuse physical therapy on that day. Resident ID #1, the roommate of Resident ID #2, began exhibiting signs and symptoms of an opioid overdose, approximately four hours after it would have been inadvertently administered to him/her, which correlates with the peak onset of the effects of that medication. Additionally, it was noted that the symptoms Resident ID #1 was exhibiting when s/he was found on the floor such as, the inability to walk or speak normally, confusion, and respiratory depression, improved after s/he received two administrations of Narcan. It is more likely than not that s/he received his/her roommate's methadone on the morning of 11/6/2023. Furthermore, review of the hospital documentation indicates that they were informed by the facility staff that the resident received his/her roommate's methadone and reiterates that the resident presented with symptoms of an opioid overdose, such as a prolonged QT interval upon initial assessment, and was treated with an additional administration of Narcan to reverse the effects of an opioid overdose, which again improved the clinical condition of Resident ID #1.

46539 Based on record review and staff interview, it has been determined that the facility failed to ensure that licensed nurses have the specific skill sets necessary to care for residents' needs for 1 of 8 residents reviewed, Resident ID #1 relative to (1a) the failure to obtain a physician's order for Nitroglycerin (a medication that is used for the treatment of chest pain) prior to the administration, (1b) providing Nitroglycerin to a resident whose vital signs contraindicated its use and (2) improper positioning of a resident in the anticipation of providing Cardiopulmonary Resuscitation (CPR). Findings are as follows: 1a) According to Mosby's Fundamentals of Nursing, 4th Edition, 1997 page 804 states, the physician prescribes medications. Review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] reveals in part, on [DATE] the resident became diaphoretic (sweaty) while sitting in his/her wheelchair and had a loss of bowels. When assisting the resident back to bed with a sit to stand lift the resident had a syncopal (loss of consciousness) episode and was assisted by staff back to bed. S/he was then transported to the hospital. Record review revealed the resident was admitted to the facility in January of 2022 with diagnoses including, but not limited to, cerebral infarction (stroke) and atrial fibrillation (abnormal heartbeat). Record review of the Emergency Medical Services (EMS) Run Report indicates that the facility called 911 on [DATE] at 7:32 PM as Resident ID #1 was having an unresponsive incident. The rescue was in route at 7:37 PM and arrived to the resident at 7:44 PM. When EMS arrived, the resident was responsive and sitting up in bed and was complaining of arm pain. Record review of a progress note entered into the resident's record on [DATE] at 11:35 AM with an effective date of [DATE] at 7:34 PM (6 days after the incident occurred), authored by Licensed Practical Nurse (LPN), Staff A, states, Nitro given x 1 for c/o [complaint of] chest pain radiating to left arm. 911 called and EMS arrived to transport resident to hospital for evaluation. Resident transferred in stable condition. Additional record review revealed that Staff A entered an order for Nitroglycerin Tablet Sublingual- Give 1 tablet sublingually every 5 minutes as needed for chest pain X 3 doses. If no relief, call MD, on [DATE] at 7:58 PM. Additional review reveals this order was written without permission from a physician (see physician's interview and progress note). Record review of a progress note dated [DATE] at 7:50 PM (6:50 Central Time) authored by Third Eye Health [TEH], Telehealth Medical Doctor, Staff C, states in part, Exam findings per nurse and video observation Physical Exam-Notes: gen: somnolent and ill .CV [cardiovascular] [NAME] irreg. [slow irregular heartbeat] .Hypotension .near arrest .The patient's condition is critical .this is a new acute problem .transfer pt [patient] to ED via 911 EMS .notify TEH if pt returns with new orders . Record review of a progress note dated [DATE] at 7:56 PM authored by LPN, Staff G, states in part, .Chief Complaint unresponsive .c/o [complained of] left arm pain then got diaphoretic [sweaty] and nurse gave ntg. [Nitroglycerin] .then became unresponsive . Record review of a progress note dated [DATE] at 9:11 PM, authored by LPN, Staff B indicates that the resident was noted to be unresponsive during care, became very flaccid, diaphoretic, pale, unable to speak and non-responsive to stimuli. The resident was able to open his/her eyes, speaking in a very low voice stating, I have pain in my left arm is moving up and down. The resident then became unresponsive again. His/her legs were elevated, and s/he was place on oxygen via nasal cannula. Sternal rub Was done resident started moaning and holding left arm. TEH MD was contacted and ordered the resident to be sent out for an evaluation at the hospital. Review of the hospital inpatient paperwork dated [DATE] revealed the resident's left arm pain was due to a left humeral (left upper arm) fracture and not related to a cardiac event. During a surveyor interview on [DATE] at approximately 1:45 PM with Staff A in the presence of two surveyors, she acknowledged that she administered the Nitroglycerin to Resident ID #1. Additionally, she revealed that she did not directly receive the order to administer the Nitroglycerin, although she was the nurse that transcribed the Nitroglycerin into the record. She indicated that Staff B received the order from TEH to administer the Nitroglycerin. During a surveyor interview on [DATE] at 3:39 PM with Staff B, in the presence of 3 surveyors, she revealed that she was the nurse that administered the Nitroglycerin on [DATE]. She said that another nurse (she could not remember who) handed her the Nitroglycerin and she just administered it to the resident. She also indicated to the surveyors that she did not obtain the order for the Nitroglycerin from the physician. She could not recall what nurse indicated they obtained the order. Record review of the [DATE] Medication Administration Record reveals that an order for Nitroglycerin Tablet Sublingual- Give 1 tablet sublingually every 5 minutes as needed for chest pain X 3 doses. If no relief, call MD was transcribed on [DATE]. This medication was never signed off by Staff A or B. Therefore, record review failed to reveal evidence on who gave the Nitroglycerin or how many times the Nitroglycerin was administered as both Staff A and B indicated that they gave the resident Nitroglycerin on [DATE]. During a surveyor telephone interview on [DATE] at 10:08 AM with Staff C, in the presence of two surveyors, she revealed that the staff in the facility called her and reported that the resident had a low blood pressure, was unresponsive, and complained of left arm pain on [DATE] and they already given him/her Nitroglycerin. She indicated she absolutely did not give an order for them to administer the Nitroglycerin. The only order she provided to the facility was to send the resident out via 911 and to call TEH if the resident returns. 1b) Review of the Nitroglycerin Sublingual Tablet Prescribing Information Package insert reveals in part, Warnings and Precautions Severe hypotension (low Blood Pressure less than ,d+[DATE]) may occur with small doses of nitroglycerin particularly in patients who may be volume-depleted or are already have a low blood pressure. Hypotension induced by nitroglycerin may be accompanied by paradoxical bradycardia (Low heart rate less than 60). Symptoms of severe hypotension (nausea, vomiting, weakness, pallor, perspiration, and collapse/syncope). Review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] reveals in part, on [DATE] the resident became diaphoretic (sweaty) while sitting in his/her wheelchair and had a loss of bowels. When assisting the resident back to bed with a sit to stand lift the resident had a syncopal (loss of consciousness) episode and was assisted by staff back to bed. S/he was then transported to the hospital. Record review of the Emergency Medical Services (EMS) Run Report indicates that the facility called 911 on [DATE] at 7:32 PM as Resident ID #1 was having an unresponsive incident. The rescue was in route at 7:37 PM and arrived at the resident at 7:44 PM. When EMS arrived, the resident was responsive and sitting up in bed and was complaining of arm pain. Record review of a progress note entered into the resident's record on [DATE] at 11:35 AM with an effective date of [DATE] at 7:34 PM (6 days after the incident occurred), authored by Licensed Practical Nurse (LPN), Staff A, states, Nitro given x 1 for c/o [complaint of] chest pain radiating to left arm. 911 called and EMS arrived to transport resident to hospital for evaluation. Resident transferred in stable condition. Additional record review revealed that Staff A entered an order for Nitroglycerin Tablet Sublingual- Give 1 tablet sublingually every 5 minutes as needed for chest pain X 3 doses. If no relief, call MD, on [DATE] at 7:58 PM. Record review of a progress note dated [DATE] at 7:50 PM (6:50 Central Time) authored by Third Eye Health [TEH], Telehealth Medical Doctor, Staff C, states in part, Exam findings per nurse and video observation Physical Exam-Notes: gen: somnolent and ill .CV [cardiovascular] [NAME] irreg. [slow irregular heartbeat] .Hypotension .near arrest .The patient's condition is critical .this is a new acute problem .SBP [systolic blood pressure] 60s HR 30s [normal adult blood pressure ,d+[DATE] and normal adult heart rate is ,d+[DATE] beats per minute]. pulse ox [measurement of oxygen circulation in the blood] 70s [normal oxygen saturation is above 95%] .transfer pt [patient] to ED via 911 EMS .notify TEH if pt returns with new orders . Record review of a progress note dated [DATE] at 7:56 PM authored by LPN, Staff G, states in part, .Chief Complaint unresponsive .c/o [complained of] left arm pain then got diaphoretic [sweaty] and nurse gave ntg. [Nitroglycerin] .then became unresponsive . Record review of a progress note dated [DATE] at 9:11 PM, authored by LPN, Staff B indicates that the resident was noted to be unresponsive during care, became very flaccid, diaphoretic, pale, unable to speak and non-responsive to stimuli. The resident was able to open his/her eyes, speaking in a very low voice stating, I have pain in my left arm is moving up and down. The resident then became unresponsive again. His/her legs were elevated, and s/he was place on oxygen via nasal cannula. Sternal rub Was done resident started moaning and holding left arm. TEH MD was contacted and ordered the resident to be sent out for an evaluation at the hospital. Record review of the resident's blood pressure summary document for [DATE] revealed his/her blood pressure was ,d+[DATE] at 7:46 and 7:47 PM. This blood pressure was recorded in the resident's record by the Director of Nursing Services (DNS) when s/he was not present for the incident (see DNS interview). Review of the hospital inpatient paperwork dated [DATE] revealed the resident's left arm pain was due to a left humeral (left upper arm) fracture and not related to a cardiac event. During a surveyor interview on [DATE] at approximately 1:45 PM with Staff A, in the presence of two surveyors, she acknowledged that she administered the Nitroglycerin to Resident ID #1. During a surveyor interview on [DATE] at 3:39 PM with Staff B, in the presence of 3 surveyors, she revealed that she was the nurse that administered the Nitroglycerin on [DATE]. During a subsequent surveyor interview on [DATE] at approximately 1:45 PM with Staff A, in the presence of two surveyors, she indicated that she did not take the resident's vital signs on [DATE] and she was unable to recall which staff member obtained the resident's vital signs or when they were obtained. Additionally, she was unable to provide evidence if the vital signs,specifically the blood pressure, was taken before or after the Nitroglycerin was administered. During a subsequent interview with Staff B on [DATE] at 3:39 PM in the presence of three surveyors, she revealed that she had no idea who obtained the resident's blood pressure but did state she remembered it was all over the place. Additionally, she was unable to provide evidence if the blood pressure was taken before or after the Nitroglycerin was administered. During an interview on [DATE] at approximately 1:25 PM with the Director of Nursing Services in the presence of three surveyors, she revealed that she was not present at the time of the incident. Additionally, she revealed that she had entered the resident's blood pressure into his/her electronic medical record and that Staff B had provided her with the reading. Although, Staff B indicated to the surveyors on [DATE] that she had no idea who obtained the resident's blood pressure or what the blood pressure readings were. 2) According to the American Red Cross Adult First Aid/CPR/AED reveals in part that chest compressions to be effective should be performed at a depth of ,d+[DATE] centimeters. Additionally, it reveals that CPR is unlikely to be effective if performed in a bed. Furthermore, a first aider should move the victim to the floor to perform chest compressions. Review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] reveals in part, on [DATE] the resident became diaphoretic (sweaty) while sitting in his/her wheelchair and had a loss of bowels. When assisting the resident back to bed with a sit to stand lift the resident had a syncopal (loss of consciousness) episode and was assisted by staff back to bed. S/he was then transported to the hospital. Record review of the facility 5-day Investigation dated [DATE] revealed that the resident was slouched down in his/her wheelchair with vital signs but not responding to the staff. The document further reveals that staff transferred the resident back to bed anticipating having to perform CPR. Further record review reveals that Licensed Practical Nurses, Staff A, B, G were present for the above incident. During a surveyor interview on [DATE] at 8:29 AM with Staff B, she revealed that the staff anticipated that they would need to perform CPR and the resident was then transferred back to bed. During a surveyor interview on [DATE] at 9:29 AM with LPN Staff G, she was unable to explain why the staff transferred the resident to the bed and not to the floor to provide CPR as anticipated. During a surveyor interview on [DATE] at approximately 1:40 PM with the Director of Nursing Services, she was unable to provide evidence that the staff transferred the resident to a location that would be conducive for the performance of effective CPR for Resident ID #1. The following facility failures placed Resident ID #1 at risk for serious harm, impairment or death: -Administering Nitroglycerin without a physician's order -Administering Nitroglycerin a medication that lowers one's blood pressure, to a resident who as the physician documented, was already presenting bradycardic, hypotensive, and near arrest. -Failing to properly assess the root cause of the resident's pain -Failing to document in-real time as evidenced by the progress note that was written on [DATE] and back dated as a late entry for [DATE] and staff entering crucial information into the resident's record when they were not present for the incident, such as his/her blood pressures. -Failing to document who was responsible for what, and at what times the events of the incident occurred, such as; when the resident's blood pressure was taken, when or who administered the Nitroglycerin to the resident. -Failing to properly position the resident when staff were anticipating the need to perform CPR Please refer to F 757 39495

Based on record review and staff interview it has been determined that the facility failed to ensure each resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed who received Nitroglycerin (a medication used to relieve chest pain) (1a) without a physician's order and (1b) without an adequate indication for its use for, Resident ID #1. Findings are as follows: 1(a) Review of a facility policy titled Administering Medication states in part, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders .the following information is checked/verified for each resident prior to administering medications .b. vital signs if necessary . Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/30/2023 reveals in part, on 5/28/2023 the resident became diaphoretic (sweaty) while sitting in his/her wheelchair and had a loss of bowels. When assisting the resident back to bed with a sit to stand lift the resident had a syncopal (loss of consciousness) episode and was assisted by staff back to bed. S/he was then transported to the hospital. Record review revealed that the resident was admitted to the facility in January of 2022 with diagnoses including, but not limited to, type II diabetes mellitus and atrial fibrillation (abnormal heart rhythm). Record review of the Emergency Medical Services (EMS) Run Report indicates that the facility called 911 on 5/28/2023 at 7:32 PM as Resident ID #1 was having an unresponsive incident. The rescue was in route at 7:37 PM and arrived to the resident at 7:44 PM. When EMS arrived, the resident was responsive and sitting up in bed and was complaining of arm pain. Record review of a progress note entered into the resident's record on 6/5/2023 at 11:35 AM with an effective date of 5/28/2023 at 7:34 PM (6 days after the incident occurred), authored by Licensed Practical Nurse (LPN), Staff A, which states Nitro given x 1 for c/o [complaint of] chest pain radiating to left arm. 911 called and EMS arrived to transport resident to hospital for evaluation. Resident transferred in stable condition. Additional record review revealed that Staff A entered an order for Nitroglycerin Tablet Sublingual- Give 1 tablet sublingually every 5 minutes as needed for chest pain X 3 doses. If no relief, call MD, on 5/28/2023 at 7:58 PM. Additional review reveals this order was written without permission from a physician (see physician's interview and progress note). Record review of a progress note dated 5/28/2023 at 7:50 PM (6:50 Central Time) authored by Third Eye Health [TEH], Telehealth Medical Doctor, Staff C, states in part, Exam findings per nurse and video observation Physical Exam-Notes: gen: somnolent and ill .CV [cardiovascular] [NAME] irreg. [slow irregular heartbeat] .Hypotension .near arrest .The patient's condition is critical .this is a new acute problem .transfer pt [patient] to ED via 911 EMS .notify TEH if pt returns with new orders . Record review of a progress note dated 05/28/2023 at 7:56 PM authored by LPN, Staff G, states in part, .Chief Complaint unresponsive .c/o [complained of] left arm pain then got diaphoretic [sweaty] and nurse gave ntg. [Nitroglycerin] .then became unresponsive Record review of a progress note dated 05/28/2023 at 9:11 PM, authored by LPN, Staff B indicates that the resident was noted to be unresponsive during care, became very flaccid, diaphoretic, pale, unable to speak and non-responsive to stimuli. The resident was able to open his/her eyes, speaking in a very low voice stating, I have pain in my left arm is moving up and down. The resident then became unresponsive again. His/her legs were elevated, and s/he was place on oxygen via nasal cannula. Sternal rub Was done resident started moaning and holding left arm. Third Eye MD was contacted and ordered the resident to be sent out for an evaluation at the hospital. Review of the hospital inpatient paperwork dated 5/30/2023 revealed the resident's left arm pain was due to a left humeral (left upper arm) fracture and not related to a cardiac event. During a surveyor interview on 6/7/2023 at approximately 1:45 PM with Staff A, in the presence of two surveyors, she acknowledged that she administered the Nitroglycerin to Resident ID #1. Additionally, she revealed that she did not directly receive the order to administer the Nitroglycerin, although she was the nurse that transcribed the Nitroglycerin into the record. She indicated that Staff B received the order from TEH to administer the Nitroglycerin. During a surveyor interview on 6/14/2023 at 3:39 PM with Staff B, in the presence of 3 surveyors, she revealed that she was the nurse that administered the Nitroglycerin on 5/28/2023. She said that another nurse (she could not remember who) handed her the Nitroglycerin and she just administered it to the resident. She also indicated to the surveyors that she did not obtain the order for the Nitroglycerin from the physician. She could not recall what nurse indicated they obtained the order. Record review of the Medication Administration Record reveals that an order for Nitroglycerin Tablet Sublingual- Give 1 tablet sublingually every 5 minutes as needed for chest pain X 3 doses. If no relief, call MD was transcribed on 5/28/2023 but was never signed off by Staff A or B. Therefore, record review failed to reveal evidence on who administered the Nitroglycerin or how many times the Nitroglycerin was administered as both Staff A and B indicated that they gave the Nitroglycerin. During a surveyor telephone interview on 6/8/2023 at 10:08 AM with Staff C, in the presence of two surveyors, she revealed that the staff in the facility called her and reported that the resident had a low blood pressure, was unresponsive, and complained of left arm pain on 5/28/2023 and they already given him/her Nitroglycerin. She indicated she absolutely did not give an order for them to administer the Nitroglycerin. The only order she provided to the facility was to send the resident out via 911 and to call TEH if the resident returns. 1(b) Review of the Nitroglycerin Sublingual Tablet Prescribing Information Package insert reveals in part, Warnings and Precautions Severe hypotension (low Blood Pressure less than 90/60) may occur with small doses of nitroglycerin particularly in patients who may be volume-depleted or are already have a low blood pressure. Hypotension induced by nitroglycerin may be accompanied by paradoxical bradycardia (Low heart rate less than 60). Symptoms of severe hypotension (nausea, vomiting, weakness, pallor, perspiration, and collapse/syncope). Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/30/2023 reveals in part, on 5/28/2023 the resident became diaphoretic (sweaty) while sitting in his/her wheelchair and had a loss of bowels. When assisting the resident back to bed with a sit to stand lift the resident had a syncopal (loss of consciousness) episode and was assisted by staff back to bed. S/he was then transported to the hospital. Record review of the Emergency Medical Services (EMS) Run Report indicates that the facility called 911 on 5/28/2023 at 7:32 PM as Resident ID #1 was having an unresponsive incident. The rescue was in route at 7:37 PM and arrived at the resident at 7:44 PM. When EMS arrived, the resident was responsive and sitting up in bed and was complaining of arm pain. Record review of a progress note entered into the resident's record on 6/5/2023 at 11:35 AM with an effective date of 5/28/2023 at 7:34 PM (6 days after the incident occurred), authored by Licensed Practical Nurse (LPN), Staff A, that states Nitro given x 1 for c/o [complaint of] chest pain radiating to left arm. 911 called and EMS arrived to transport resident to hospital for evaluation. Resident transferred in stable condition. Additional record review revealed that Staff A entered an order for Nitroglycerin Tablet Sublingual- Give 1 tablet sublingually every 5 minutes as needed for chest pain X 3 doses. If no relief, call MD, on 5/28/2023 at 7:58 PM. Record review of a progress note dated 5/28/2023 at 7:50 PM (6:50 Central Time) authored by Third Eye Health [TEH], Telehealth Medical Doctor, Staff C, states in part, Exam findings per nurse and video observation Physical Exam-Notes: gen: somnolent and ill .CV [cardiovascular] [NAME] irreg. [slow irregular heartbeat] .Hypotension .near arrest .The patient's condition is critical .this is a new acute problem . SBP [systolic blood pressure] 60s HR 30s [normal adult blood pressure 120/80 and normal adult heart rate is 60-100 beats per minute]. pulse ox [measurement of oxygen circulation in the blood] 70s [normal oxygen saturation is above 95%] .transfer pt [patient] to ED via 911 EMS .notify TEH if pt returns with new orders . Record review of a progress note dated 05/28/2023 at 7:56 PM authored by LPN, Staff G, states in part, .Chief Complaint unresponsive .c/o [complained of] left arm pain then got diaphoretic [sweaty] and nurse gave ntg. [Nitroglycerin] .then became unresponsive . Record review of a progress note dated 05/28/2023 at 9:11 PM, authored by LPN, Staff B indicates that the resident was noted to be unresponsive during care, became very flaccid, diaphoretic, pale, unable to speak and non-responsive to stimuli. The resident was able to open his/her eyes, speaking in a very low voice stating, I have pain in my left arm is moving up and down. The resident then became unresponsive again. His/her legs were elevated, and s/he was place on oxygen via nasal cannula. Sternal rub Was done resident started moaning and holding left arm. TEH MD was contacted and ordered the resident to be sent out for an evaluation at the hospital. Record review of the resident's blood pressure summary document for 5/28/2023 revealed his/her blood pressure was 60/30 at 7:46 and 7:47 PM. This blood pressure was recorded in the resident's record by the Director of Nursing Services (DNS) when s/he was not present for the incident (see DNS interview). Review of the hospital inpatient paperwork dated 5/30/2023 revealed the resident's left arm pain was due to a left humeral (left upper arm) fracture and not related to a cardiac event. During a surveyor interview on 6/7/2023 at approximately 1:45 PM with Staff A, in the presence of two surveyors, she acknowledged that she administered the Nitroglycerin to Resident ID #1. During a surveyor interview on 6/14/2023 at 3:39 PM with Staff B, in the presence of 3 surveyors, she revealed that she was the nurse that administered the Nitroglycerin on 5/28/2023. During a subsequent surveyor interview on 6/7/2023 at approximately 1:45 PM with Staff A, in the presence of two surveyors, she indicated that she did not take the resident's vital signs on 5/28/2023 and she was unable to recall which staff member obtained the resident's vital signs or when they were obtained. Additionally, she was unable to provide evidence if the vital signs,specifically the blood pressure, was taken before or after the Nitroglycerin was administered. During a subsequent interview with Staff B on 6/14/2023 at 3:39 PM in the presence of three surveyors, she revealed that she had no idea who obtained the resident's blood pressure but did state she remembered it was all over the place. Additionally, she was unable to provide evidence if the blood pressure was taken before or after the Nitroglycerin was administered. During an interview on 6/15/2023 at approximately 1:25 PM with the DNS in the presence of three surveyors, she revealed that she was not present at the time of the incident. Additionally, she revealed that she had entered the resident's blood pressure into his/her electronic medical record and that Staff B had provided her with the reading. Although, Staff B indicated to the surveyors on 6/14/2023 that she had no idea who obtained the resident's blood pressure or what the blood pressure readings were. The following facility failures placed Resident ID #1 at risk for serious harm, impairment or death: -Administering Nitroglycerin without a physician's order -Administering Nitroglycerin a medication that lowers one's blood pressure, to a resident who as the physician documented, was already presenting bradycardic, hypotensive, and near arrest. -Failing to properly assess the root cause of the resident's pain -Failing to document in-real time as evidenced by the progress note that was written on 6/5/2023 and back dated as a late entry for 5/28/2023 and staff entering crucial information into the resident's record when they were not present for the incident, such as his/her blood pressures. -Failing to document who was responsible for what, and at what times the events of the incident occurred, such as; when the resident's blood pressure was taken, when or who administered the Nitroglycerin to the resident. Please refer to F 726 39495

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for 2 of 6 residents reviewed for dialysis, Resident ID #s 291 and 147. Findings are as follows: 1) Record review revealed that the resident ID #291 was admitted to the facility in March of 2023 and has diagnoses including, but not limited to, acute respiratory failure with hypoxia (when your lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning) and end stage renal disease (when your kidneys can no longer support your body's needs). Additional record review reveals this resident receives hemodialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) three times a week. Review of a hospital discharge summary dated [DATE] revealed that the resident was diagnosed with flash pulmonary edema (a condition in which fluid fills the lungs) and was started on dialysis. The summary also indicated that the resident has a physician's order for a 1000 milliliter (ml) fluid restriction. Record review of the Admission Report Sheet dated [DATE] at the facility revealed that the resident was on 1000 ml fluid restriction. Review of a Nutritional Risk assessment dated [DATE] revealed that a 1-liter fluid restriction was recommended, and that the 3rd floor unit manager was made aware. Additional record review revealed the fluid restriction was not initiated until the 3:00 to 11:00 PM shift on [DATE], indicating the resident's fluid intake was not monitored on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] or during the 7:00 AM to 3:00 PM shift on [DATE]. Record review of a physician's order dated [DATE] revealed Fluid Restriction: Breakdown over 24 hour 1000 ml: Nursing/meal time (500 ml ,d+[DATE], 350 ml ,d+[DATE], 150 ml ,d+[DATE]) every shift Further record review revealed a physician's order for Nepro one time a day 240 ml x 1 with a start date of [DATE]. Review of the [DATE] Medication Administration Record (MAR) revealed that the resident received 1160 ml on [DATE], 160 ml over the ordered fluid restriction. Record review of a progress note dated [DATE] at 9:01 AM states .Approx. [approximately] at 8 am Resident with Dyspnea [shortness of breath] VS [vital signs]: [blood pressure] ,d+[DATE], [Heart Rate- normal heart rate ,d+[DATE]] ,d+[DATE], [Respirations- normal respirations ,d+[DATE]] 30s. SPO2 [oxygen level- normal level 95%-100%] 69% on 4 L [liters] O2 [oxygen] via N/C [nasal cannula] Spo2. Emergency response initiated. 911 called. Resident Spo2 Remained at 40% Non rebreather[mask is a special medical device that helps provide you with oxygen in emergencies] applied pulse sluggish [abnormal pulse] .[ Emergency medical technician] Arrived at approx. 8:20 Am. Resident with loss of VS Resident is a Full Code. EMT initiated CPR. Family Notified. [DNS] and Administrator made aware at time of incident. Family Arrived at facility. EMT transported Resident to [hospital] . Further review of the progress notes revealed a note dated [DATE] at 3:44 PM stating, Called Hospital to determine status, resident deceased asystole/cardiac arrest, questioning flash pulmonary edema with hypoxic respiratory failure. During a surveyor interview in the presence of an additional surveyor on [DATE] at 10:32 AM with Unit Manager, Registered Nurse, Staff E, she acknowledged that the fluid restriction was not implemented until 6 days after the resident was admitted to the facility. She was unable to provide evidence that the provider was notified of the resident exceeding the fluid restriction on [DATE]. During a surveyor interview on [DATE] at approximately 2:00 PM with the Director of Nursing Services (DNS) and the Regional Nurse, they were unable to explain why the resident's order for a 1000 ml fluid restriction was not implemented upon his/her admittance to the facility. Additionally, they were unable to provide evidence that the provider was notified of the resident exceeding his/her fluid restriction on [DATE]. During a surveyor interview on [DATE] at 2:43 PM with the Nurse Practitioner, Staff F, she revealed that she would expect the facility to notify her of a resident exceeding his/her fluid restriction. 2) Record review revealed that Resident ID #147 was readmitted to the facility in February of 2023 and has diagnoses including, but not limited to, chronic kidney disease stage 4 (when your kidneys can no longer support your body's needs), dependence on renal dialysis, and acute on chronic diastolic (congestive) heart failure. Review of an order by a covering Physician (from a contracted provider) dated [DATE] at 8:56 PM, revealed in part, .orders and medications approved until patient is evaluated by primary team. Obtain and review all acute care documentation/orders with primary team when available .Daily weights. Low sodium diet. 2 Liter Fluid Restriction .Recommend that primary team review medication and eliminate unnecessary medications . The order was signed by the Physician on [DATE] at 9:04 PM. Record review of the resident's physician orders failed to reveal evidence that the 2 Liter fluid restriction, or the daily weights were implemented as per the order on [DATE]. Review of the February and [DATE], Medication and Treatment Administration records (MAR/TAR) failed to reveal evidence that the resident's fluid intake was documented, or that the fluid restriction was implemented. Record review of the physician order summary report for the period of [DATE] through [DATE], (including all active, completed, discontinued or on hold orders) failed to reveal evidence that the 2 Liter fluid restriction, or the daily weights were implemented as per the order on [DATE]. Record review of the physician's orders revealed an order dated [DATE] for Post Dialysis weights Monday, Wednesday, and Friday. Review of a History & Physical note dated [DATE] at 2:03 PM by the resident's attending physician revealed in part, .Pt is seen today for an initial visit and management of medical conditions .Assessment and Plan .ESRD [end stage renal disease] on HD [hemodialysis] .Chronic HF [heart failure] .Cont [continue] diuretics .on non HD days. Fluid restriction. Follow daily wts. [weights] . Review of progress notes signed on [DATE] at 9:17 PM, and [DATE] at 10:02 PM and 12:02 AM by Nurse Practitioner Staff F revealed in part, .Assessment and Plan .continue present diuretics. Follow daily weights . Record review of progress notes from [DATE] through [DATE] failed to reveal evidence that the order for fluid restriction was discussed or discontinued by the physician or the Nurse practitioner. Record review of the Weights and Vitals summary failed to reveal that daily weights were obtained. During a surveyor interview on [DATE] at 12:18 PM with Staff F, she revealed that when things are ordered by the covering physician the expectation is that the orders are put in by the nurse. If it was discontinued, she would expect to see documentation. During a surveyor telephone interview on [DATE] at approximately 10:30 AM with the attending physician, he could not explain why the covering physician's order for fluid restriction was not transcribed or why his note indicated a fluid restriction and daily weights were in place when they were not. During a surveyor interview on [DATE] at approximately 2:00 PM, with the DNS she was unable to provide evidence that a fluid restriction was in place after the order was received on [DATE] or that there was documentation to discontinue the fluid restriction. When asked by surveyor if she would expect physician's notes to accurately reflect the current plan of care for the resident, she acknowledged that she would. During surveyor telephone interview on [DATE] at 1:30 PM with the Director of Quality Assurance of the contracted company for the on call physicians, she revealed that the providers have been educated to include all orders given verbally to the nurse via Zoom (they are a telehealth provider) on the order form. She further revealed that the information contained on the form titled Physician order that is signed by the physician are in fact orders. She revealed the verbal orders are given to the nurse during an unrecorded zoom call and then the written orders are signed and put into the electronic health record. 46539 39496 47939

Based on record review and staff interview it has been determined that the facility failed to ensure that its residents are kept free from significant medication errors for 1 of 1 residents reviewed for ear drops, Resident ID #150, 1 of 4 residents reviewed for antibiotic use, Resident ID #176 and 1 of 8 residents reviewed for hospitalization and medication reconciliation, Resident ID #291. Findings are as follows: 1. Review of a facility policy titled, Administering Medication states in part, Medications are administered in a safe and timely manner, and as prescribed . Record review revealed Resident ID #150 was admitted to the facility in May of 2022 with diagnoses including, but not limited to, Alzheimer's disease and hearing loss. Review of a complaint received by the Rhode Island Department of Health on 3/10/2023 alleges in part, On 3/7/23 while visiting .a nurse came in to give nightly meds [medication] and ear drops. The nurse put the ear drops in [his/her] eyes. [The resident] immediately began to scream that it hurt .I yelled stop, are those [his/her] ear drops, she stopped and looked at me .I put a cold face cloth on [the resident's] eye and waited for help . Record review revealed the resident had an order for Debrox Solution 6.5% (Carbamide Peroxide, a medication used to treat earwax buildup) Instill 5 drops in both ears two times a day for hearing loss. Record review of the Medication Administration Record (MAR) for March 2023 indicated the medication was signed off as administered on 3/7/2023 by Registered Nurse (RN), Staff J. Review of a progress note dated 3/7/2023 at 8:24 PM revealed a telehealth note that stated in part, .complaining of left eye irritation after accidental administration of carbide peroxide otic gtt [ear drops] was instilled in eye. Eye is irritated. Review of a progress note dated 3/7/2023 at 11:43 PM revealed that a nurse had made a medication error and administered ear drops in the left eye instead of the left ear. The progress note further revealed that the resident was in pain following the administration of the ear drops into the left eye and it was flushed with sterile water and a syringe. Review of a progress note dated 3/8/2023 at 8:00 AM revealed the resident's left eye remained red. During a surveyor interview on 3/13/2023 at 12:14 PM with the resident's family member she revealed that she was visiting the resident on 3/7/2023 and witnessed a nurse administer ear drops into the resident's left eye. Additionally, she revealed the resident was screaming in pain and shaking following the medication administration. The resident's family revealed that she applied a cold compress to the resident's left eye and it took the staff greater than 10 minutes to return to the room. During a surveyor interview on 3/13/2023 at 1:47 PM with Staff J she acknowledged that she administered the medication prescribed for the ears into the resident's left eye. Additionally, she revealed the resident was yelling, stop that hurts. She further revealed that she immediately left the room and did not return. During a surveyor interview on 3/13/2023 at 1:57 PM with Licensed Practical Nurse (LPN), Staff K he revealed that he was the nurse working with Staff J and that they prepared the medication outside of the room and that he was not present when she administered the medication incorrectly but that she reported it to him. Additionally, he revealed the resident was in pain when he entered the room and was complaining there is something in his/her eye. Record review revealed an order dated 3/7/2023 for prednisoLONE Acetate Ophthalmic Suspension 1% (a medication used to treat certain eye conditions due to inflammation or injury) Instill 1 drop in left eye two times a day for Irritation. During a surveyor interview with two surveyors on 3/14/2023 at 1:54 PM with the Director of Nursing Services in the presence of the Administrator they acknowledged that the medication error had occurred. 2. Record review revealed Resident ID #176 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, bacteremia (the presence of bacteria in the blood) and osteomyelitis (an infection of the bone) of the spine. Record review revealed a Continuity of Care Consultation and Referral Form dated 3/7/2023 from the Infectious Disease Nurse Practitioner [specialist that treats infections disease] that states in part, continue levofloxacin [antibiotic] 750 daily .call regarding end date of antibiotics . Review of the MAR for February 2023 revealed an order for Levofloxacin 750 mg (milligrams) with the last administration dated 2/21/2023. Review of the MAR for March 2023 failed to reveal evidence that the resident was administered Levofloxacin. During a surveyor interview on 3/8/2023 at 11:02 AM with the Infectious Disease Nurse Practitioner he revealed that the resident was last seen at his office on 2/21/2023 and the resident was to continue taking the Levofloxacin 750 mg from 2/21/2023 until 3/8/2023. Additionally, he revealed that he was unaware the resident had not received the antibiotic as ordered from 2/22/2023 until 3/8/2023 which was brought to his attention by the surveyor. During a surveyor interview on 3/9/2023 at 8:47 AM with Unit Manager, Registered Nurse, Staff E she acknowledged that the resident was not on the antibiotic from 2/22/2023 until 3/8/2023 as ordered by Infectious Disease Nurse Practitioner. During a surveyor interview with two surveyors present on 3/10/2023 at 11:39 AM with the Director of Nursing Services she was unable to provide evidence that the resident received the Levofloxacin as ordered. 3. Record review revealed that Resident ID #291 was admitted to the facility in March of 2023 and has diagnoses including, but not limited to, acute respiratory failure with hypoxia (when your lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning) and end stage renal disease (when your kidneys can no longer support your body's needs). Additional record review reveals this resident receives hemodialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) three times a week. Review of a hospital discharge summary dated 3/1/2023 revealed Further review of the hospital Discharge Summary states in part, Discharge Medication Current Discharge Medication List .CONTINUE these medications which have NOT CHANGED .albuterol [is used to treat wheezing and shortness of breath caused by breathing problems] .90 mcg [micrograms] .inhaler inhale 2 (two) puffs by mouth every 6 (six) hours. Record review of the March 2023 MAR revealed an order dated 3/1/2023 which states in part, .(Albuterol Sulfate) 2 puff inhale orally every 12 hours as needed for SOB [shortness of breath] separate puffs by at least 1 minute. Further record review failed to reveal evidence that the resident's albuterol was transcribed as ordered per the Discharge Summary or that the physician at the facility modified the order. This indicates the resident did not receive his/her ordered inhaler for approximately 20 out of 22 opportunities, as s/he received two as needed doses on 3/6/2023 at 5:32 AM and 3/8/2023 at 6:10 AM. Additional record review of the March 2023 MAR revealed that on 3/3/2023 the resident was not administered the following medications: 1. Alogliptin Benzoate tablet 6.25 MG (Milligram), medication for diabetes 2. amlodipine Besylate tablet 10 MG, medication for hypertension 3. Aspirin tablet 81 MG, medication used as a preventive for blood clots 4. Bactrim DS tablet 800-160 MG, antibiotic medication 5. Calcitriol capsule 0.25 MG, calcium supplement 6. Ferrous Sulfate tablet 325 MG, iron supplement 7. GlycoLax Powder 17 Gram, Medication used for constipation 8. Isosorbide Mononitrate ER tablet 60 MG, medication used to prevent chest pain 9. Omperazole DR 20 MG Capsule, medication used heartburn 10. PrediSONE tablet 20 MG used for respiratory failure 11. Semglee (insulin) 26 Units medication for diabetes 12. Sertraline Tablet 100 MG medication used for depression 13. Toprol XL Oral Tablet 60 Mg medication used to treat chest pain, heart failure, and high blood pressure 14. Icosapent Ethyl Capsule 1 gram, medication used for cholesterol 15. hydrALAZINE HCl Oral Tablet 50 MG used to treat hypertension 16. NovoLOG Injection Solution medication to help with high blood sugar During a surveyor interview in the presence of an additional surveyor on 3/15/2023 at 10:41 AM with Unit Manager, Registered Nurse, Staff E, she was unable to provide evidence the Albuterol was administered to the resident every six hours as ordered. Additionally, she was unable to provide evidence that the Nurse Practitioner (NP), Staff F, was notified of the missed doses of the above-mentioned medications on 3/3/2023. During a surveyor interview in the presence of an additional surveyor on 3/14/2023 at 2:43 PM with Staff F she revealed that she would have implemented the discharge orders from the hospital including the orders for standing albuterol. Additionally, she revealed she would expect to be notified when a resident misses their scheduled medication. During a surveyor interview in the presence of an additional surveyor on 3/14/2023 at approximately 2:00 PM with the Director of Nursing Services and the Regional Nurse, they were unable to provide evidence that the resident's albuterol inhaler was implemented per the discharge summary. Additionally, she was unable to provide evidence the NP or physician were notified the resident missed the previously mentioned medications on 3/3/2023. 46539

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to continuity of care and emergency procedures, for 1 of 1 residents reviewed, Resident ID #291. Findings are as follows: 1. Record review revealed that the resident was admitted to the facility in March of 2023 and has diagnoses including, but not limited to, acute respiratory failure with hypoxia (when your lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning) and end stage renal disease (when your kidneys can no longer support your body's needs). Additional record review reveals this resident receives hemodialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) three times a week. Review of a hospital discharge summary dated [DATE] revealed that the resident was diagnosed with flash pulmonary edema (a condition in which fluid fills the lungs) and was started on dialysis. The summary also indicated that the resident has a physicians order for a 1000 milliliter (mL) fluid restriction. Record review of the Admission Report Sheet dated [DATE] at the facility revealed that the resident was on 1000 mL fluid restriction . Additional record review revealed the fluid restriction was not initiated until [DATE], 6 days after his/her admission to the facility. Review of the resident's [DATE] Medication Administration Record (MAR) revealed that the resident received 1160 ml on [DATE], 160 ml over the ordered fluid restriction. Further record review failed to reveal evidence that the resident's provider was notified that the resident exceeded his/her fluid restriction on [DATE] or a rationale as to why the fluid restriction was not implemented upon the resident's admission to the facility. During a surveyor interview in the presence of an additional surveyor on [DATE] at 10:32 AM with Unit Manager, Registered Nurse, Staff E, she acknowledged that the fluid restriction was not implemented until 6 days after the resident was admitted to the facility. She was unable to provide evidence that the provider was notified of the resident exceeding the fluid restriction on [DATE]. Further review of the hospital Discharge Summary states in part, Discharge Medication Current Discharge Medication List .CONTINUE these medications which have NOT CHANGED .albuterol [is used to treat wheezing and shortness of breath caused by breathing problems] .90 mcg [micrograms] .inhaler inhale 2 (two) puffs by mouth every 6 (six) hours. Record review of the [DATE] MAR revealed an order dated [DATE] which states in part, .(Albuterol Sulfate) 2 puff inhale orally every 12 hours as needed for SOB [shortness of breath] separate puffs by at least 1 minute. Further record review failed to reveal evidence that the resident's albuterol was transcribed as ordered per the Discharge Summary or that the physician at the facility modified the order. This indicates the resident did not receive his/her ordered inhaler for approximately 20 out of 22 opportunities, as s/he received two as needed doses on [DATE] at 5:32 AM and [DATE] at 6:10 AM. Additional record review of the [DATE] MAR revealed that on [DATE] the resident was not administered the following medications: 1. Alogliptin Benzoate tablet 6.25 MG (Milligram), medication for diabetes 2. amlodipine Besylate tablet 10 MG, medication for hypertension 3. Aspirin tablet 81 MG, medication used as a preventive for blood clots 4. Bactrim DS tablet ,d+[DATE] MG, antibiotic medication 5. Calcitriol capsule 0.25 MG, calcium supplement 6. Ferrous Sulfate tablet 325 MG, iron supplement 7. GlycoLax Powder 17 Gram, Medication used for constipation 8. Isosorbide Mononitrate ER tablet 60 MG, medication used to prevent chest pain 9. Omperazole DR 20 MG Capsule, medication used heartburn 10. PrediSONE tablet 20 MG used for respiratory failure 11. Semglee (insulin) 26 Units medication for diabetes 12. Sertraline Tablet 100 MG medication used for depression 13. Toprol XL Oral Tablet 60 Mg medication used to treat chest pain, heart failure, and high blood pressure 14. Icosapent Ethyl Capsule 1 gram, medication used for cholesterol 15. hydrALAZINE HCl Oral Tablet 50 MG used to treat hypertension 16. NovoLOG Injection Solution medication to help with high blood sugar During a surveyor interview in the presence of an additional surveyor on [DATE] at 10:41 AM with Staff E, she was unable to provide evidence the Albuterol was administered to the resident every six hours as ordered. Additionally, she was unable to provide evidence that the Nurse Practitioner (NP), Staff F was notified of the missed doses of the above mentioned medications on [DATE]. During a surveyor interview in the presence of an additional surveyor on [DATE] at 2:43 PM with Staff Fshe revealed that she would have implemented the discharge orders from the hospital including the orders for standing albuterol and the fluid restriction. Additionally, she revealed she would expect to be notified when a resident misses their scheduled medication or exceeds their fluid restriction. During a surveyor interview in the presence of an additional surveyor on [DATE] at approximately 2:00 PM with the Director of Nursing Services and the Regional Nurse, they were unable to provide evidence that the resident's albuterol inhaler and fluid restriction were implemented per the discharge summary. Additionally, she was unable to provide evidence the NP or physician were notified the resident missed the previously mentioned medications on [DATE] and that the resident exceeded the ordered fluid restriction on [DATE]. 2. Record review of a facility provided policy titled Emergency Procedure- Cardiopulmonary Resuscitation[CPR] states in part, .Sudden cardiac arrest is a loss of heart function due to abnormal heart rhythms .Cardiac arrest occurs soon after symptoms appear .Victims of cardiac arrest may initially have gasping respirations .Training in BLS [Basic Life Support] includes recognizing presentations of SCA [Sudden Cardiac Arrest] .Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes .can further increase chances of survival . Further review of the facility policy states in part, .Emergency Procedure- Cardiopulmonary Resuscitation .a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator [AED]. c. Verify or instruct a staff member to verify the .code status of the individual . During surveyor observation on [DATE] at approximately 8:10 AM, Resident ID #291 was observed rocking back and forth in his/her bedside chair pulling at his/her shirt and his/her oxygen tubing gasping for breath. Immediately following the above observation, the surveyor notified a staff member of the resident's condition, resident yelled hurry and staff entered Resident ID #291's room and closed the door. During a surveyor observation in the presence of an additional surveyor at approximately 8:30 AM revealed the facility crash cart (a cart that holds medical equipment needed if someone was in distress) located outside of the resident's room. Further observation revealed the AED remained on the wall down the hall at the nursing station. Record review revealed the resident was a Full Code indicating the resident wanted life sustaining measures to be performed. Record review of a document titled RI [Rhode Island] EMS [Emergency Medical Services] Patient Care Report dated [DATE] stated in part, Cardiac Arrest: Yes, Prior to EMS Arrival .having difficulty breathing. Engine 12 was on scene first and called a code 99 [cardiac arrest]. According to the medical staff at the rehabilitation facility the pt [patient] woke up this morning, refused [his/her] medication and breakfast, then started complaining of difficulties with [his/her] breathing. Pt was .found slumped over a chair, pulseless, with agonal breathing .Pt was immediately placed on the ground, CPR was resumed immediately .[NAME] Device [machine to provide compression] applied to [his/her] chest .Epi[epinepherine-medication used during a cardiac arrest]1:1000 through IO [Intraosseous, access into a bone to infuse fluids or hydration], patient was worked on scene for 30 minutes .[s/he] then changed to Asystole [type of cardiac arrest, which is when your heart stops beating entirely]. Pt was transported to [hospital]. Record review of the resident progress notes revealed the following. -[DATE] at 9:01 AM This writer ambulated Resident Back from bathroom around 715 am Resident talking able to ambulate with assist and use of RW [rolling walker]. Placed resident in recliner where [s/he] started to Color in [his/her] Coloring Book. Aprox [approximately] at 8 am Resident with Dyspnea [shortness of breath] VS [vital signs]: [blood pressure] ,d+[DATE], [Heart Rate- normal heart rate ,d+[DATE]] ,d+[DATE], [Respirations- normal respirations ,d+[DATE]] 30s. SPO2 [oxygen level- normal level 95%-100%] 69% on 4 L [liters] O2 [oxygen] via N/C [nasal cannula] Spo2. Emergency response initiated. 911 called. Resident Spo2 Remained at 40% Non rebreather[mask is a special medical device that helps provide you with oxygen in emergencies] applied pulse sluggish [abnormal pulse] .[ Emergency medical technician] Arrived at approx. 8:20 Am. Resident with loss of VS Resident is a Full Code. EMT initiated CPR. Family Notified. [DNS] and Administrator made aware at time of incident. Family Arrived at facility. EMT transported Resident to [hospital] . -[DATE] at 3:44 PM Called hospital to determine status, resident deceased asystole/cardiac arrest, questioning flash pulmonary edema [a condition in which fluid fills the lungs] with hypoxic respiratory failure. During a surveyor interview in the presence of an additional surveyor on [DATE] at 10:22 AM with Licensed Practical Nurse, Staff G, who was involved in the emergency situation, revealed that the the AED was not retrieved per the facility policy. During a surveyor interview in the presence of an additional surveyor on [DATE] at 10:26 AM with Unit Manager, Staff E, who was also involved in the emergency situation, revealed that the the AED was not retrieved per the facility policy. During a surveyor interview in the presence of an additional surveyor on [DATE] at 2:07 PM with the Director of Nursing and the Regional Nurse they revealed that the the AED was not retrieved per the facility policy. Furthermore, they were unable to provide evidence the facility followed their policy related to emergency procedures and that the resident ultimately expired after sustaining cardiac arrest in the facility. 46539

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide care consistent with professional standards of practice to promote wound healing and prevent new pressure ulcers from developing for 4 out of 14 residents reviewed who are at risk for pressure ulcers or who have actual pressure ulcers, Resident ID #'s 169, 17, 114 and 132. Findings are as follows: 1. Record review for Resident ID #169 revealed s/he was admitted to the facility in April of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed that s/he required a two-person physical assist for bed mobility including turning side to side. Record review of a weekly skin assessment completed on 3/7/2022 indicated the resident had a new pressure injury. Further review of the document failed to reveal any further documentation of a description or measurements of the wound until 3/9/2022. Further review of the resident's care plan failed to reveal evidence that a care plan for pressure ulcers was developed until 3/9/2022. Additionally, this care plan failed to reveal an intervention for repositioning of the resident while in bed. Record review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a progress note dated 3/9/2022 states in part, .This writer called to resident bedside, open areas noted to bilateral hips, L [left] 1 x 1.2 x 0.1 cm [Centimeters] R [right] 1.5 x 1.2 x 0.2 cm . Further record review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the Wound Care Progress Notes authored by the Wound Physician dated 3/11/2022 revealed the following: -Left hip pressure ulcer, unstageable (base of ulcer is covered by slough (yellow, tan, gray, green, or brown) which measured, 1.9 cm (centimeters) in length (L) x 1.5 cm in width (W) x 0 cm in depth (D). Further description revealed the wound has moderate serous (clear/yellow) drainage and the wound bed was covered in 100% eschar (dead tissue .usually black, brown, or tan in color, and may appear scab-like). -Right hip pressure ulcer, Stage 3 (full thickness tissue loss where subcutaneous fat may be exposed, and slough may be present but does not obscure the depth of tissue loss) which measures, 0.7 cm in L x 0.6 cm in W x 0.1 cm in D. Further description revealed the wound has a moderate amount of serous drainage, the peri wound was moist, and the wound bed was noted as 80% slough and 20% granulation (red tissue with cobblestone or bumpy appearance) tissue. -Left lateral knee unstageable pressure ulcer which measures, 1.2 cm in L x 1.2 cm in W x 0.2 cm in D. Further description revealed the wound bed is 100% scabbed. Surveyor observation of the resident's wound care on 3/23/2022 at 9:03 AM, revealed a wound to the left hip in which the wound bed was observed covered in slough. Further observation revealed two open areas to the right hip and an open area to the left knee. During a surveyor interview on 3/24/2022 at 12:03 PM with the Hospice Nurse, she revealed that she had recommended an air mattress for the resident on 3/1/2022. She further revealed that the wounds developed on 3/7/2022 and that the air mattress was not put in place until 3/10/2022. Additionally, she revealed the resident is at great risk for pressure ulcers and that his/her wounds are new. 2. Record review for Resident ID #17 revealed s/he was admitted to the facility in December of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a weekly skin check dated 3/15/2022 revealed the resident's right heel was boggy and blanchable. Record review of an Interim Skin Check dated 3/21/2022 revealed the resident had bilateral boggy heels and they were blanchable. Record review of an Interim Skin Check dated 3/23/2022 revealed a DTI (Deep tissue injury-purple or maroon area of discolored intact skin due to damage of underlying soft tissue) documented to the resident's right lateral foot. Further review of the document failed to reveal any measurements of the pressure injury. During a surveyor observation on 3/23/2022 from 1:01 PM until 1:25 PM revealed the resident sitting up in his/her wheelchair with the lateral (outer) side of his/her right foot resting directly on the foot buddy (wheelchair footrest) and his/her back left ankle resting directly on the edge of the wheelchair foot buddy without his/her booties in place. Further observation revealed the booties were on a chair on the opposite side of the bed. Surveyor observation on 3/23/2022 at 1:50 PM revealed the resident resting in bed with his/her feet resting directly on the mattress. Further observation revealed the booties were on a chair by the bed. During a surveyor interview on 3/23/2022 at 2:01 PM with staff nurse, Staff I, she acknowledged that the resident did not have his/her booties on his/her feet. During the interview with Staff I, an observation was made of the resident's feet which revealed a deep purple, non-blanchable area to the resident's right lateral foot near his/her heel. 3. Record review for Resident ID #114 revealed s/he was admitted to the facility in February of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor observation on 3/21/2022 at 1:30 PM, 3/22/2022 at approximately 10:00 AM, and 3/23/2022 at 2:32 PM of the resident revealed that the resident was lying in bed without bilateral boots on his/her feet. During a surveyor interview on 3/23/2022 at 2:32 PM with the unit manager, Staff A, she acknowledged that the resident was not wearing the boots to his/her feet. Additionally, she was unable to locate the resident's boots. 4) Record review for Resident ID #132 revealed s/he was admitted to the facility in February of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Continuity of Care Consultation and Referral Form dated 2/9/2022 from the resident's podiatrist revealed .pt [patient] has ulcer R [right] great toe daily dressing . Record review of the resident's care plan dated 2/10/2022 relative to pressure ulcers revealed documentation that the resident has an ulcer to his/her right great toe with an intervention to Monitor/document/report to MD [medical doctor] PRN [as needed] changes in skin status: appearance, color, wound healing, s/sx [signs and symptoms] of infection, wound size (length X width X depth), stage. Record review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review failed to reveal measurements of the wound to the right great toe since it was identified on 2/9/2022. During a surveyor interview on 3/24/2022 at 1:06 PM with the Unit Manager, Staff F, she was unable to provide evidence of weekly wound measurements and a description. Additionally, she revealed the wound is healed; it is a callous now. When the surveyor asked when the wound had healed, Staff F was unable to provide the date of when the wound had healed. During a surveyor interview on 3/24/2022 at 1:30 PM with the Wound Nurse, Staff C, she revealed ulcers need to be measured once a week and they are tracked by the Unit Manager. Additionally, if a wound is healed, it should be documented on the weekly wound skin check. Lastly, she was unable to provide evidence of weekly wound measurements and a description of the wound. During a surveyor interview with the resident's podiatrist on 3/24/2022 at 2:39 PM, he revealed when the resident came to see him on 2/9/2022 the resident was noted with an ulcer, further stating the area had progressed to a grade 1 ulceration with penetration to the dermis.

Based on record review, surveyor observation, staff and resident representative interview, it has been determined the facility failed to provide adequate supervision and assistance devices to prevent accidents for 5 of 6 residents reviewed for elopement behaviors, Resident ID #'s 1, 6, 7, 8 and 10. Findings are as follows: Review of the facility policy titled, Wandering and Elopements states in part, Policy heading .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation . 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises . 4. When the resident returns to the facility, the director of nursing services or charge nurse shall: . e. complete and file an incident report; and f. document relevant information in the resident's medical record. 1. Review of a community reported complaint submitted to the state agency, dated 10/25/2021, revealed Resident ID# 1 who was residing on the locked dementia unit had eloped on 10/23/2021 and was brought back to the facility by the police. Record review for Resident ID #1 revealed the resident was admitted to the facility in October of 2021 with diagnoses including, but are not limited to, Alzheimer's disease, [CONDITION(S)], and dementia with behavioral disturbance. Further record review revealed a document dated 10/15/2021 from the resident's most recent acute care hospital visit titled, Referral Information which stated in part, Referral Comments .Patient ready for discharge needs secured dementia unit ELOPEMENT RISK . Review of the resident's progress notes revealed a note dated 10/18/2021 written by the Director of Rehabilitation Services which states in part, [representative] reports primary barrier to dc [discharge] has been paranoid delusions in which [s/he] wanders away from home .has had recent stays at [psychiatric hospital] trialed [assisted living facility] (tried to break window with chair) . During an interview on 10/26/2021 at 10:30 AM with the resident representative, she revealed the resident has made prior elopement attempts at their private residence and at a previous community assisted living residence. She stated she communicated this to the facility staff at a planning meeting conducted at the facility on 10/18/2021. Review of an initial elopement assessment dated [DATE] revealed the resident did not have a history of eloping and was not at risk for elopement. Review of a baseline care plan initiated on 10/15/2021, failed to reveal evidence of a care plan related to the resident's prior elopement attempts. Review of a Quality Assurance Performance Improvement Plan dated 10/25/2021 revealed the following: Resident was observed leaving facility with a family member, returned to facility 20 minutes later by police. During an interview with the Director of Nursing Services (DNS) on 10/26/2021 at 10:35 AM, she revealed the resident eloped from the facility with a visitor after following her on to the elevator in the secured dementia unit. She further stated a staff member, Staff G, was present in the parking lot and witnessed the resident leave the facility with whom Staff G assumed was a family member. She further stated Staff G watched the resident walk to the main road (Smith Street), he then left his vehicle to assist the resident when he realized the resident was no longer with the family member. The DNS stated Staff G then witnessed a police car approach the resident. She stated Staff G did not approach the resident and the resident was escorted back into the building by the police officer. She stated she did not report the event to the state agency because the resident did not leave the sight of Staff G the entire time s/he was out of the building. During an interview on 10/26/2021 at 3:35 PM with Staff G, he revealed he had arrived at the facility between 3:00 PM and 4:00 PM to retrieve an item he had left at the facility. He was in the parking lot sitting in his car. He further stated he watched the resident leave the building with a visitor. He then stated he observed the visitor walk to the bus stop on the main road (Smith Street) and watched the resident proceed down a side street. He then stated he exited his vehicle to approach the resident but by that time a police officer had arrived and was assisting the resident. He stated he did not continue to approach the resident because he assumed the police would assist the resident back to the building. He then stated he entered the building and called the DNS. Review of a police incident report dated 10/23/2021 and timed 3:51 PM revealed the city police were called for a wellbeing check by a caller who was standing by with a person saying s/he was lost approximately 0.3-0.4 miles or approximately 7-9 minutes away from the facility on [NAME] Ave/Pasteur Street. During an interview with the resident representative on 10/26/2021 at 10:30 AM it was revealed that the police officer used a phone that the resident had on him/her that the representative had placed in his/her pocket earlier that day (10/23/2021). The police officer told the representative that they were taking the resident to the representative's residence. The representative then told the officer the resident resided at the facility and not his/her private home. The officer then told the representative they would return the resident back to the facility. During an interview on 10/27/2021 at 12:23 PM with Staff H, he stated at approximately 4:15 PM on 10/23/2021 he was in the rehabilitation room when he was approached by a police officer. The police officer stated they found a resident wandering down the street and that they were returning him/her back to the facility. Staff H met the resident in the lobby with another officer identified him/her as a resident who resided on the dementia unit. Staff H stated the resident had a steady gait, was wearing a beige jacket and a mask under his/her chin. Staff H stated the resident was well appearing. During an interview on 10/27/2021 at 12:30 PM with Staff I, the nurse who was working on the dementia unit when the resident was returned to the unit, she revealed she was unaware the resident had left the facility until s/he was brought back to the unit by Staff H. Staff I was unable to provide an accurate timeline of the events. During an interview on 10/27/2021 at 4:00 PM with the person identified to have called the police to report a lost individual, she revealed she was visiting a friend at the facility on 10/23/2021. Review of a visitor log revealed she entered the facility at 2:15 PM. She could not recall the time she left the facility. She stated she was exiting through the elevator on the dementia unit when an individual followed her on to the elevator. She stated she asked if this individual was a resident and the individual stated no. She stated the individual appeared to be well dressed and s/he had a mask under his/her chin, and she was unsure if s/he was a resident. She further stated she walked to the reception desk after exiting the elevator and approached the receptionist with her concerns. She stated the receptionist then asked the individual if s/he was a resident and s/he stated no. The visitor then left the building and went to sit in her car. She proceeded to watch the individual leave the facility and walk up towards the highly traveled main road. She observed him/her cross a highly traveled main road and continue into the neighborhood. She stated she followed him/her down the street in her vehicle. She then stated she noticed the individual appeared to be lost. She approached him/her and then called the police. The individual was identified as a resident of the facility. An attempt was made to interview the receptionist, but he was not available for interview. The above information of the actual account of events was presented to the facility. They were unable to explain the discrepancy of the events that occurred on 10/23/2021 on the day the resident eloped from the facility. Additionally, during a surveyor observation on 10/26/2021 at 2:00 PM the resident and the resident's representative were observed entering the elevator on the secure dementia unit. The resident representative entered a code that enabled the elevator door to open and then entered the elevator. The resident was observed with a wander guard (a device worn by a resident that triggers alarms and can lock monitored doors to prevent the resident leaving unattended) on the right ankle. There was an additional wander guard alarm inside the elevator which failed to alarm, it was not triggered by the resident's wander guard as the alarm inside the elevator is intended to, and the resident left the secure unit with the resident representative. During an interview with the DNS immediately following the observations, she stated she was unaware the wander guard alarm system had not been alarming when residents entered the elevator. There were various discrepancies noted in the facility's account of the elopement such as the actual location of where the resident was found and the resident being in sight of staff the entire time. From the parking lot at the facility to the location where the resident was found is 0.3-0.4 miles away and not in eyesight from the parking lot. This facility failed to provide adequate supervision to a cognitively impaired resident resulting in the resident eloping from the facility on 10/24/2021 and crossing a highly traveled road and being brought back by the police. This delay and lack of supervision placed the resident in immediate jeopardy for serious harm, injury, or death due to his/her diagnoses, cognitive impairment, and decreased functional abilities. 2. Record review Resident ID #6 was admitted to the facility in August of 2021 with diagnoses that include, but are not limited to, [CONDITION(S)] and infection of the bone of the left foot and ankle. Record review of a wander/elopement risk evaluation dated 8/24/2021 revealed the resident was not at risk for elopement. Review of the progress notes revealed the following: -progress note dated 9/15/2021 at 15:22 which reads After several attempts to get on elevator. Wander guard applied to RLE [right lower extremity] . -progress note dated 9/15/2021 at 22:11 which reads in part, Wander guard in place to ankle. No attempts made to elope off of unit. -progress note dated 9/20/2021 at 21:32 which reads in part, Wander guard in place to lower ext. [extremity]. -progress note dated 9/21/2021 at 15:22 which reads in part, Continues to wander on unit. Right LE [lower extremity] wander guard in place. -progress note dated 9/22/2021 at 16:17 which reads in part, Continues to wander in hallways. Wander guard in place to RLE. -progress note dated 9/23/2021 at 22:38 which reads in part, .Wander guard in place to Right ankle, no attempts made to elope off of unit . -progress note dated 9/24/2021 at 8:19 which reads in part, Spoke with daughter to provide update and discuss possible discharge as she requested. Daughter asking if [resident name redacted] anxiety and hallucination have resolved; made aware of pacing, occasional refusal of care. Daughter concerned of ability to care for [resident] due to past leaving the home to preach to others in the street. -progress note dated 9/26/2021 at 22:06 which reads in part, .Wander guard in place to RLE . -progress note dated 9/27/2021 at 22:06 which reads in part, .pt [patient] packing up all personal belongings, looking to be d/c [discharged ] home Redirected several times with + results. Stood by elevator, verbalized daughter was picking [him/her] up. Wander guard in place to RLE. -progress note dated 9/29/2021 at 22:04 which reads in part, .Elder noted very agitated this afternoon, exit seeking stating [s/he] needed to go home to take care of business and [s/he] needed to get out of [him/her]. Redirection attempted with no success. -progress note dated 10/7/2021 at 16:14 which reads in part, .Resident packed all [his/her] clothes in a suitcase. Patient states My doctor discharged me, and my daughter is here to take me home please open the door for me . -progress note dated 10/11/2021 at 13:53 which reads in part, .Resident increasing behavior, starting crying and states' I want to go home . -progress note dated 10/12/2021 at 8:47 which reads in part, .Resident lay down in front on the nursing station in the floor, and states I am going to be in the floor until I get discharge, I want to go home . Review of a quarterly minimum data set assessment dated [DATE] revealed the resident did not exhibit wandering behaviors. Further record review failed to reveal evidence of a wander/elopement risk assessment following the above noted elopement attempts, consistent monitoring of wander guard function, placement or a care plan initiated for wandering/elopement until 10/24/2021. During an interview on 10/27/2021 at 2:00 PM with the Regional DNS, he was unable to explain why the resident was not accurately assessed for wandering/elopement behaviors and why a risk assessment, monitoring of the wander guard, or a care plan was not completed until 10/24/2021. 3. Resident ID #7 was admitted to the facility in January of 2019 with diagnoses that include, but are not limited to, Alzheimer's disease, dementia with behavioral disturbance, and [CONDITION(S)] with delusions. Record review of the October 2021 electronic treatment administration record (TAR) revealed a treatment order dated 5/1/2020 which read, check placement of Wander Bracelet on every shift. Further review of the TAR revealed on 10/4/2021 day shift, 10/12/2021 evening shift, 10/14/2021 day shift and 10/18/2021 day and evening shift, no evidence the wander bracelet was checked for placement. During a surveyor observation on 10/26/2021 at approximately 3:00 PM of Resident ID #7, it was revealed the resident had a wander bracelet on the left ankle. The nurse, Staff J, was asked to enter the code to open the elevator door. The resident then walked into the elevator, in the presence of the surveyor. No alarm was triggered, and the resident was able to leave the secure dementia unit. During an interview with the DNS on 10/26/2021 immediately following the observation, she was unable to explain why the wander bracelet on the resident's ankle did not trigger the alarm inside the elevator. 4. Resident ID #8 was admitted to the facility in February 2021 with diagnoses that include, but are not limited to, dementia without behavioral disturbance and anxiety. Surveyor observation on 10/28/2021 at 10:00 AM revealed the resident in the common area with a wander guard on the right ankle. Record review of a quarterly MDS assessment dated [DATE] indicated the resident exhibited occasional wandering behaviors. Additionally, record review revealed a quarterly MDS assessment dated [DATE] that indicated the resident did not exhibit wandering behaviors. Further review of the physician's orders revealed an order dated 3/22/2021 which was discontinued on 7/21/2021 for wander bracelet check placement every shift. During an interview on 10/29/2021 at 2:00 PM with the Regional DNS, he was unaware that the resident had a wander guard bracelet on the ankle and could not explain why the bracelet was not removed upon discontinuation of the physician's order. 5. Resident ID #10 was admitted to the facility in May of 2020 with diagnoses that include, but are not limited to, [CONDITION(S)] disease and history of falling. Record review of the progress notes revealed the following: -progress note dated 8/23/2021 at 1:04 reads in part, Approx [approximately] 830pm Elder noted to be agitated and combative with staff. Elder set off alarm on door and was attempting to elope . -progress note dated 10/13/2021 at 8:29 reads in part.attempt to elope out of back elevator .waits until staff busy, then attempts to go to room 300, or out elevator . Review of the care plan failed to reveal evidence of a care plan for elopement behaviors. Further review of a wander/elopement risk evaluation dated 10/26/2021 revealed the resident did not have a history of eloping and was not at risk for elopement. During an interview with the resident on 10/29/2021 at 9:30 AM s/he stated s/he wished to leave the facility and go home to live with a relative. During an interview on 10/29/2021 at 2:00 PM with the DNS, she was unaware of the resident's prior elopement attempts and could not provide evidence of a care plan for elopement behaviors.

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, that meet each resident's physical, mental, and psychosocial needs for 1 of 1 resident reviewed for abnormal laboratory values and 1 of 1 resident reviewed for non-pressure related wound care, Resident ID #'s 2 and 9. Findings are as follows: 1. Record review for Resident ID #2 revealed s/he was admitted to the facility in August of 2021 with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's liver function test (LFTs-blood tests used to help diagnose and monitor liver disease or damage) dated 9/20/2021, revealed the following baseline LFT laboratory values: -Alkaline Phosphatase (ALK) 95 normal range (42-121 U/L (units per liter) -[MEDICATION(S)] Aminotransferase (AST) 9 normal range (10-42 U/L) -[MEDICATION(S)] Transaminase (ALT) 4 normal range (10-60 U/L) Further record review of the resident's subsequent LFTs obtained on the dates listed below revealed the following values which indicated that the LFT levels were progressively increasing: 10/4/2021 ALK 101 AST 13 ALT 9 10/11/2021 ALK 128 AST 65 ALT 54 10/14/2021 ALK 168 AST 176 ALT 143 10/18/2021 ALK 219 AST 351 ALT 224 Record review of the resident's order summary revealed the following current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (a medication that can cause an increase in liver enzyme levels) 20 milligrams (mg) by mouth at bedtime for [CONDITION(S)] - Acetaminophen (a medication which is metabolized in the liver) 975 mg by mouth every 8 hours for pain/discomfort Record review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a progress note dated 10/4/2021 at 3:07 PM, authored by the Nurse Practitioner (NP), Staff D, revealed he examined the resident's status, reviewed medications, and labs. Additionally, he indicated the resident was on [MEDICATION(S)] for [CONDITION(S)] and stated, will monitor lfts . Record review of a progress note dated 10/11/2021 at 3:09 PM, authored by Staff D, revealed he examined the resident's status and reviewed his/her medications. Additionally, he indicated that lab values were also reviewed that day, and that the resident was on [MEDICATION(S)] for [CONDITION(S)] and stated, will monitor lfts . Record review of a progress note dated 10/18/2021 at 4:05 PM, authored by Staff D, he revealed he examined the resident's status, reviewed the resident's medications and labs. Additionally, he indicated the resident was on [MEDICATION(S)] for [CONDITION(S)] and stated, will monitor lfts . Further record review failed to reveal that any new orders for interventions were implemented to address the increasingly elevated LFT levels. Additionally, review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's laboratory report results dated 9/27/2021 revealed handwritten documentation at the bottom of the report which read, Repeat BMP [Basic Metabolic Panel-laboratory test that provides information on body's metabolism including kidney function and the balance of electrolytes] 9/30. Record review failed to reveal evidence that these laboratory results were ordered and/or obtained on 9/30/2021. Subsequent record review of the resident's laboratory report results from 10/14/2021 revealed handwritten documentation at the bottom of the report, which read, [check mark] CBC, CMP tomorrow. Record review failed to reveal evidence that these laboratory results were ordered and/or obtained on 10/15/2021. During an interview with the Director of Nursing Services on 10/29/2021 at approximately 4:40 PM, she was unable to provide evidence that the laboratory tests for 9/30/2021 and 10/15/2021 were obtained. Record review of a nursing progress note dated 10/20/2021 revealed the resident's BMP values, which were ordered and obtained that day, were reviewed by the physician. The note further revealed that based on the elevated creatinine levels, the physician ordered for the resident to be further evaluated at the hospital. Record review of the hospital continuity of care documentation dated 10/20/2021, revealed the resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The LFT values were obtained at the hospital on 10/20/2021 and revealed the following: ALK 321 AST 464 ALT 277 During a surveyor interview on 10/28/2021 at 1:30 PM with Staff D, he revealed when he assesses a patient, he reviews the entire medication profile. Further stating that he was not aware the resident was on standing Acetaminophen, and he would have held this medication with the elevated LFT levels. Additionally, during a subsequent interview on 10/29/2021 at 2:07 PM with Staff D, he revealed that after reviewing the LFT values on 10/18/2021, he intended to give an order to hold the [MEDICATION(S)] but failed to do so. During a surveyor interview with the resident's physician on 10/29/2021 at 1:52 PM, during which the LFT values were reviewed with him. The physician revealed that he was unaware of the resident's elevated LFT values over the last month and if he was aware, he would have discontinued both the Acetaminophen and [MEDICATION(S)] medications. 2. Record review revealed Resident ID #9 was admitted to the facility in July of 2021 with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was coded as having a surgical wound upon admission. Record review revealed the resident is seen routinely by an outside podiatrist for management to his/her right foot surgical wound. Record review of the podiatry consults revealed a consult recommendation dated 9/2/2021 which states in part, .Iodosorb [an antimicrobial gel which includes iodine], 2x2 gauze to proximal wound . Record review of the podiatry consults revealed a consult recommendation dated 9/10/2021 which states in part, .leave dressing intact R [right] foot; only change if strike through noted . Record review of the September and October 2021 Treatment Administration Record revealed a treatment order to the right foot wound dated 7/28/2021 to apply [MEDICATION(S)] followed by dry protective dressing and wrap with kling. Further review of the TAR failed to reveal evidence that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the [MEDICATION(S)] treatment order continued to be signed off as completed on 9/11, 9/12, 9/13, 9/14, and 9/15, despite having a recommendation on 9/10/2021 to leave the dressing intact. Lastly, the [MEDICATION(S)] order was discontinued on 9/17/2021 and the record failed to reveal a treatment order to change the dressing to the right foot wound, as needed, if strike through noted, per the podiatrist recommendations on 9/10/2021. During a surveyor interview on 10/29/2021 at 3:05 PM with the Wound Nurse, she acknowledged that the recommendation for Iodosorb was not implemented per the podiatrist recommendations. Additionally, she was unable to provide evidence that a treatment order was implemented, as needed, in the event of a strike through to the right foot dressing.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a physician, physician assistant, nurse practitioner, or clinical nurse specialist provide orders for the resident's immediate care needs and that the medical care of each resident is supervised by a physician for 1 of 12 residents reviewed for physician services, Resident ID # 2. Findings are as follows: 1. Record review for Resident ID #2 revealed s/he was admitted to the facility in August of 2021 with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's liver function test (LFTs-blood tests used to help diagnose and monitor liver disease or damage) dated 9/20/2021, revealed the following baseline LFT laboratory values: -Alkaline Phosphatase (ALK) 95 normal range (42-121 U/L (units per liter) -[MEDICATION(S)] Aminotransferase (AST) 9 normal range (10-42 U/L) -[MEDICATION(S)] Transaminase (ALT) 4 normal range (10-60 U/L) Further record review of the resident's subsequent LFTs obtained on the dates listed below revealed the following values which indicated that the LFT levels were progressively increasing: 10/4/2021 ALK 101 AST 13 ALT 9 10/11/2021 ALK 128 AST 65 ALT 54 10/14/2021 ALK 168 AST 176 ALT 143 10/18/2021 ALK 219 AST 351 ALT 224 Record review of the resident's order summary revealed the following current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (a medication that can cause an increase in liver enzyme levels) 20 milligrams (mg) by mouth at bedtime for [CONDITION(S)] - Acetaminophen (a medication which is metabolized in the liver) 975 mg by mouth every 8 hours for pain/discomfort Record review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a progress note dated 10/4/2021 at 3:07 PM, authored by the Nurse Practitioner (NP), Staff D, revealed he examined the resident's status, reviewed medications, and labs. Additionally, he indicated the resident was on [MEDICATION(S)] for [CONDITION(S)] and stated, will monitor lfts . Record review of a progress note dated 10/11/2021 at 3:09 PM, authored by Staff D, revealed he examined the resident's status and reviewed his/her medications. Additionally, he indicated that lab values were also reviewed that day, and that the resident was on [MEDICATION(S)] for [CONDITION(S)] and stated, will monitor lfts . Record review of a progress note dated 10/18/2021 at 4:05 PM, authored by Staff D, he revealed he examined the resident's status, reviewed the resident's medications and labs. Additionally, he indicated the resident was on [MEDICATION(S)] for [CONDITION(S)] and stated, will monitor lfts . Further record review failed to reveal that any new orders for interventions were implemented to address the increasingly elevated LFT levels. Additionally, review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's laboratory report results dated 9/27/2021 revealed handwritten documentation at the bottom of the report which read, Repeat BMP [Basic Metabolic Panel-laboratory test that provides information on body's metabolism including kidney function and the balance of electrolytes] 9/30. Record review failed to reveal evidence that these laboratory results were ordered and/or obtained on 9/30/2021. Subsequent record review of the resident's laboratory report results from 10/14/2021 revealed handwritten documentation at the bottom of the report, which read, [check mark] CBC, CMP tomorrow. Record review failed to reveal evidence that these laboratory results were ordered and/or obtained on 10/15/2021. During an interview with the Director of Nursing Services on 10/29/2021 at approximately 4:40 PM, she was unable to provide evidence that the laboratory tests for 9/30/2021 and 10/15/2021 were obtained. Record review of a nursing progress note dated 10/20/2021 revealed the resident's BMP values, which were ordered and obtained that day, were reviewed by the physician. The note further revealed that based on the elevated creatinine levels, the physician ordered for the resident to be further evaluated at the hospital. Record review of the hospital continuity of care documentation dated 10/20/2021, revealed the resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The LFT values were obtained at the hospital on 10/20/2021 and revealed the following: ALK 321 AST 464 ALT 277 During a surveyor interview on 10/28/2021 at 1:30 PM with Staff D, he revealed when he assesses a patient, he reviews the entire medication profile. Further stating that he was not aware the resident was on standing Acetaminophen, and he would have held this medication with the elevated LFT levels. Additionally, during a subsequent interview on 10/29/2021 at 2:07 PM with Staff D, he revealed that after reviewing the LFT values on 10/18/2021, he intended to give an order to hold the [MEDICATION(S)] but failed to do so. During a surveyor interview with the resident's physician on 10/29/2021 at 1:52 PM, during which the LFT values were reviewed with him. The physician revealed that he was unaware of the resident's elevated LFT values over the last month and if he was aware, he would have discontinued both the Acetaminophen and [MEDICATION(S)] medications.

Based on surveyor observations, record reviews and staff interviews, it has been determined the facility failed to provide the necessary treatment and services for residents with pressure sores to promote healing and to prevent new pressure sores from developing for 3 of 9 sample residents with pressure sores or who are at risk for pressure sores, ID #(s) 1, 3 and 7. Findings are as follows: A review of the revised facility's "Skin and Wound Care Policy" of 4/22/2013 states under : VI. Procedure: A. Prevention of pressure ulcers: 5. Measures to prevent deterioration of skin are initiated with a Braden score less than 18: j. Use pressure reduction mattress and cushion with limited mobility... k. Use low air-loss mattress or air fluidized bed with stage III or IV ulcers... l. Keep pressure off heels by floating the heels. 1. A review of the 11/11/2013 Admission Minimum Data Set (MDS) for resident ID # 7 indicates the resident has no pressure sores and is at risk for pressure sores due to dementia, impaired mobility and bowel and bladder incontinence. A review of the resident's 11/1/2013 Admission Braden Assessment score revealed the resident was assessed as a 17 (at risk) indicating the above facility protocol should be followed. A review of the 11/15/2013 care plan to present relative to skin integrity specifies the resident is to have a pressure relieving device to the bed and chair, skin prep to heels and elbows as needed to maintain skin integrity and to follow the facility skin protocol which specifies to keep pressure off heels by floating heels. The April 2014 Treatment Administration Record (TAR) also indicates the resident is to receive weekly skin checks. There is no evidence of a skin check from 4/6/2014 until 4/18/2014 when a new facility acquired stage II pressure ulcer was found on the coccyx measuring 2.0 cm in length by 1 cm in width with no drainage. Review of the 4/6/2014 Braden Scale indicates the resident was assessed as 9 indicating very high risk. A review of a 4/18/2014 physician order [REDACTED]. On 4/19/2014 the wound is now staged as a stage II and stage III, measuring 2.6 cm in length by 0.9 cm in width and 0.2 cm in depth indicating scant clear drainage with surrounding macerated tissue to coccyx per E-Z Graph Wound Assessment. A 4/19/2014 physician order [REDACTED]. Surveyor observation on 4/22/2014 at 4:30 PM revealed the resident in a wheelchair in the common area on Unit 3. There was no evidence the resident's wheelchair was equipped with a seat cushion. Surveyor observation on 4/23/2014 at 11:30 AM revealed the resident sitting in a wheelchair at a table in the common area of Unit 3 without evidence the resident's wheelchair was equipped with a seat cushion. The resident was observed later that day at 4:30 PM in a wheelchair without evidence of a seat cushion. Observation on 4/24/2014 at 10:00 AM, in the resident's room revealed a pressure relief cushion on the resident's wheelchair. During a subsequent interview with the nursing assistant caring for this resident, she stated "The resident did not have a cushion prior to today, I think Hospice brought in the chair cushion". Additionally, when interviewed on 4/24/2014 at approximately 10:10 AM, the charge nurse indicated she was unaware of any prior use of a seat cushion for this resident. Review of the 4/26/2014 E-Z Graph Wound Assessment revealed the resident's wound measures 3 cm in length by 1.5 cm in width and 0.5 cm in depth with scant bloody drainage with surrounding red tissue. The area is not staged. On 4/27/2014 another E-Z Graph Wound Assessment of the coccyx wound was done which indicates stage II, measuring 1.5 cm in length by 0.75 cm in width, no depth identified. Further review of the resident's clinical record revealed a 4/6/2014 physician order [REDACTED]. Additionally, a review of the April 2014 TAR revealed no evidence that either the waffle boots were on the resident's heels or that the resident's heels were off-loaded on 4/7/2014, 4/13/2014 and 4/16/2014 on the 7:00 AM to 3:00 PM shift. On the 3:00 PM to 11:00 PM shift there was no evidence of waffle boots on 4/12/2014. When interviewed on 4/25/2014 at 4:30 PM, the Assistant Director of Nursing was unable to provide evidence that the waffle boots were applied, the resident's heels were offloaded or that the weekly skin checks were done on the above mentioned dates. 2. Record review for resident ID # 3 revealed an annual 12/13/2013 MDS indicating no pressure areas present. A review of resident ID #3's Care Area Assessment Summary (CAAS) dated 12/16/2013, assessed the resident at risk for skin breakdown secondary to frequent incontinence and decreased mobility. Additionally, the 12/16/2013 Braden Scale Assessment, score equals 10 indicating the resident is high risk for skin breakdown. There is no evidence that a care plan was developed for this resident relative to skin integrity. During record review the 2/3/2014 E-Z Graph Wound Assessment Worksheet indicates a Stage III pressure sore of the right heel with measurements as follows: On 2/3/2014 - 2.25 centimeters (cm) in length by 2 cm in width with no depth. On 2/12/2014 - 1.5 cm in length by 1.3 cm in width with no depth On 2/18/2014 - 0.6 cm in length by 0.7 cm in width with no depth. A physician order [REDACTED]. A review of the March 2014 TAR revealed no evidence that the above dressing change was done on 3/8/2014, 3/11/2014, 3/14/2014 and 3/20/2014. Although, the MDS Assessment of 12/16/2013 identified the resident as high risk for pressure ulcers, there is no evidence of offloading the resident's heels per the facility protocol until 2/3/2014, when a stage III pressure sore was found on the right heel. Review of the February 2014 TAR revealed no evidence on 2/19/2014 and 2/28/2014 of offloading of the right heel on the 7:00 AM - 3:00 PM shift and on 2/23/2014 on the 3:00 PM to 11:00 PM shift. A review of the March 2014 TAR revealed no evidence that offloading with waffle boots was done on 3/22/2014 and on 3/30/2014 on the 7:00 AM - 3:00 PM shift and on 3/21/2014, 3/25/2014 and 3/28/2014 on the 3:00 PM to 11:00 PM shift. A review of the April 2014 TAR revealed no evidence of offloading the right heel with a waffle boot on 4/4/2014 and on 4/13/2014 on the 7:00 AM to 3:00 PM shift. A review of the E-Z Graph of 1/16/2014 revealed a stage II coccyx pressure ulcer measuring 0.5 cm length by 1.0 cm width. A physician order [REDACTED]. A review of the February 2014 TAR revealed no evidence that this treatment was done on 2/28/2014 on the 11:00 PM to 7:00 AM shift. Review of the March 2014 TAR revealed no evidence of treatment on 3/9/2014 and 3/21/2014 and 3/25/2014 on the 3:00 PM to 11:00 PM shift and on 3/22/2014 on the 7:00 AM to 3:00 PM shift. Review of the April 2014 TAR revealed no evidence of the treatment to the coccyx on 4/13/2014 on the 7:00 AM - 3:00 PM shift and on 4/15/2014 on the 3:00 PM - 11:00 PM shift. On 2/12/2014 the resident developed a stage II blister (left lower buttock skin blister). The TAR specifies to monitor left lower buttock blister area cover with an Allevyn every 72 hours and as needed. A 2/12/2014 E-Z Graph indicated a non opened blister area measuring 0.5 centimeters (cm) length by 0.5 cm width with no indication of the wound location. There is no evidence on the February 2014 TAR of any Allevyn to the buttock until 2/15/2014. On 2/19/2014 a new physician order [REDACTED]. Review of the February 2014 TAR revealed no evidence of the treatment being done from 2/19/2014 through 2/28/2014. Review of the March 2014 TAR revealed no evidence of the treatment to the stage II done on 3/21/2014 and 3/25/2014 on the 3:00 PM to 11:00 PM shift and on 3/22/2014 on the 7:00 AM to 3:00 PM shift. Review of a 4/22/2014 E-Z- Graph revealed a newly acquired pressure sore, Stage III coccyx. Measurements on 4/22/2014 are 1 cm length by 1 cm width by 0.5 cm depth. On 4/28/2014 the E-Z Graph measurements were 1.3 cm length by 1 cm width by 0.5 cm depth. 3. Resident ID # 1 was admitted on [DATE] with a stage II pressure ulcer to the coccyx which resolved on 3/21/2013. On 4/17/2013 the above area reopened and measured 1.5 cm length by 1 cm width. No staging was identified. Review of the April 2013 TAR revealed treatment orders on 4/17/2013 which indicate apply [MEDICATION NAME] Cream to coccyx every shift until healed. There is no evidence of treatment to this area on 5/3/2013, 5/5/2013 on the 11:00 PM to 7:00 AM shift and 5/20/2013 on the 7:00 AM to 3:00 PM shift. Further review revealed a 3/19/2014 Occurrence Report indicates new facility acquired pressure areas on the resident's left hip and coccyx measuring approximately 3 centimeters (cm) in length by 3 cm in width. E-Z Graph of 3/19/2014 identified coccyx and left buttocks as a Stage II measuring 4.7 cm length by 1.2 width cm. Treatment orders on this date indicated cleanse coccyx with normal saline, pat dry, skin prep wound edges, Solosite and cover with Allevyn, change every 3 days. On 3/28/2014 a new physician order [REDACTED]. Review of the resident's April 2014 TAR revealed no evidence that this treatment was performed on 4/8/2014 and 4/13/2014, post breakfast, and on 4/1/2014, 4/2/2014, 4/3/2014, 4/8/2014, 4/9/2014, 4/12/2014, 4/13/2014, 4/14/2014, 4/16/2014 and 4/22/2014, post lunch. An April 2014 to present physician order [REDACTED]. Review of the April 2014 TAR revealed no evidence that this treatment was provided on 4/8/2014, 4/11/2014, 4/13/2014, 4/16/2014 and 4/24/2014 on the 7:00 AM to 3:00 PM shift and on 4/22/2014 on the 3:00 PM to 11:00 PM shift. On 3/28/2014 a new physician order [REDACTED]. Review of the April 2014 TAR revealed no evidence that this treatment was done on 4/13/2014. When interviewed on 5/16/2014 at 2:00 PM, the Director of Nurses, Assistant Director of Nurses and the Staff Educator were unable to provide evidence that the above treatments were done.