Every finding on record at Evergreen House Health Center

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that the resident was treated with dignity and in a manner that maintained his/her quality of life. Specifically, the facility did not ensure the resident received a meal prior to departure for a scheduled medical appointment. The resident was transported without breakfast and had not received nourishment since dinner the previous evening, resulting in an excessive and avoidable period of approximately 20 hours without food for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Record review of a community-reported complaint received by the Rhode Island Department of Health on 4/20/2026 alleges, that on 4/15/2026, Resident ID #1 was sent out to an early morning appointment and was not provided with breakfast. It further alleges that following the resident's appointment at approximately 11:00 AM, no return transportation had been arranged or made available. Despite multiple calls placed to the facility requesting assistance, an ambulance was not arranged until much later. As a result, the resident did not return to the facility until after 1:00 PM.Record review revealed the resident was readmitted to the facility in November of 2025 with diagnoses including, but not limited to, contractures (a permanent tightening of muscles and surrounding tissues that causes joint stiffness and significantly reduced movement) of the right and left hip and contractures of the right and left knee.Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition.Record review of a care plan initiated on 4/8/2025 revealed the resident is at risk for malnutrition (a severe condition caused by the body not getting the nutrients it needs) with interventions including in part, to serve the ordered diet: regular with large portions.Record review of the electronic medical record documentation completed by the nursing assistants revealed the resident t did not receive breakfast or lunch on 4/15/2026.Record review of the progress notes dated 4/15/2026, authored by the Unit Manager, Staff B, revealed the resident was sent to a dermatology appointment during this shift and that at 11:50 AM, the dermatology provider called to report that his/her procedure was finished. During a surveyor interview on 4/21/2026 at approximately 2:00 PM, with the resident, s/he revealed that on the day of the appointment s/he was at the dermatology office for a long time and had not received any breakfast or bagged lunch and that s/he was hungry when they returned to the facility. During a surveyor interview on 4/21/2026 at 2:15 PM, with Staff A, she revealed that she was the NA assigned to provide care to the resident on 4/15/2026 and acknowledged that the resident was not provided with breakfast or lunch at the facility. During a surveyor interview on 4/22/2026 at approximately 11:05 AM, the Director of Nursing Services acknowledged that the resident was not provided breakfast or lunch by the facility while the resident was out at their appointment. Additionally, she acknowledged no meal was prepared for the resident to take along with them to the appointment.

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. Specifically, the facility did not ensure the resident received a meal prior to departure for a scheduled medical appointment. The resident was transported without breakfast and had not received a meal since dinner the previous evening, an approximate sixteen-hour time period for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Record review of a community-reported complaint received by the Rhode Island Department of Health on 4/20/2026 alleges, that on 4/15/2026, Resident ID #1 was sent out to an early morning appointment and was not provided with breakfast.Record review revealed the resident was readmitted to the facility in November of 2025 with diagnoses including, but not limited to, unspecified depression and Gastro-Esophageal Reflux Disease (GERD) without Esophagitis (a common form of acid reflux where symptoms occur without visible esophageal damage).Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 of 15, indicating intact cognition.Record review of a care plan initiated on 4/8/2025 revealed the resident is at risk for malnutrition (a severe condition caused by the body not getting the nutrients it needs) with interventions including in part, to serve the ordered diet: regular with large portions.Record review of the physician's orders revealed, Regular diet.Large .Portions/Fortified Food.Record review of the electronic medical record documentation completed by the nursing assistants revealed the resident did not receive breakfast on 4/15/2026 as Resident Not Available. The last documented nourishment was on 4/14/2026 prior to bed.Record review of the progress notes dated 4/15/2026, authored by the Unit Manager, Staff B, revealed that the resident was sent to a dermatology appointment during this shift and that at 11:50 AM, the dermatology provider called to report that his/her procedure was finished. During a surveyor interview on 4/21/2026 at approximately 2:00 PM, with the resident, s/he revealed that on the day of the appointment s/he was at the dermatology office for a long time and had not received any breakfast or a bagged lunch and that s/he was hungry when s/he returned to the facility. During a surveyor interview on 4/21/2026 at 2:15 PM, with Nursing Assistant, (NA) Staff A, she revealed that she was assigned to provide care to the resident on 4/15/2026 and acknowledged that the resident was not provided with breakfast at the facility, prior to leaving for their appointment. During a surveyor interview on 4/22/2026 at approximately 11:05 AM, the Director of Nursing Services acknowledged that the resident was not provided breakfast by the facility. Additionally, she acknowledged no meal was prepared for the resident to take along with them to the appointment.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with a percutaneous drainage catheter (a thin, flexible tube surgically placed into the abdomen used to drain fluid), Resident ID #2.Findings are as follows:Record review of a facility policy titled Percutaneous Drainage Catheter Management issued on 1/27/2026 revealed in part, .Policy: The facility will provide Percutaneous Drainage Catheter Management in accordance with professional standards of practice, as outlined by [NAME].Position the patient so that you can clearly see and access the percutaneous drainage catheter. Trace the drainage catheter from the patient to its point of origin to ensure that you're managing the correct catheter. Ensure that the drainage bag or system is below the level of the fluid collection to ensure optimal fluid removal .Completing the procedure Secure the drainage bag. to the patient's gown, as necessary, to prevent it from pulling, ensuring that it's below the level of the fluid collection. Perform securement with a safety pin or a tube holder through the plastic loop at the neck of the bulb or bag.Documentation.drainage catheter integrity and securement.Record review of a community-reported complaint received by the Rhode Island Department of Health on 4/20/2026 alleges, that Resident ID #2 was hospitalized for a severe gallbladder infection with an abscess, and was treated with the placement of a drain (an opening designed to remove fluid). Further review of the complaint revealed that on 4/11/2026, the drain bag (an external pouch connected to a tube that drains bile, pus, or infected fluid from the gallbladder) was secured to a call light using a safety pin. Record review revealed that the resident was admitted to the facility in January of 2026 with diagnoses including, but not limited to, perforation of the gallbladder (a medical emergency where a hole forms in the gallbladder), cholecystitis (inflammation of the gallbladder), and dementia.Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 11 out of 15, indicating moderate impaired cognition.Record review of a care plan initiated on 4/16/2026 revealed the resident has a surgical incision for a percutaneous cholecystostomy drain (a tube placed through the skin into the gallbladder to remove bile) with interventions including to empty and monitor drainage. Record review revealed a physician's order with a start date of 4/10/2026 to keep the bag secure, drain to gravity and monitor drainage every shift.During surveyor interviews on 4/22/2026 at 1:00 PM and 4/23/2026 at 12:30 PM with Licensed Practical Nurse (LPN), Staff C, he reported observing that on 4/12/2026 the resident was in bed with the percutaneous drainage bag improperly secured to the call light, which was in turn attached to an elevated bed rail, preventing the system from draining by gravity as intended.During a surveyor interview on 4/23/2026 at 12:10 PM with Nurse Practitioner, Staff D, she indicated that it is her expectation for the drain not to be attached to the call light.During a surveyor interview on 4/22/2026 at 12:47 PM with the Director of Nursing Services, she acknowledged the resident's drain was attached to the call light and stated that it is her expectation for the drain not to be pinned to the call light. Additionally, she was unable to provide evidence that the facility implemented their policy relative to Percutaneous Drainage Catheter Management.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the unscheduled implementation of the fire and evacuation plan was reported immediately to the local state agency (Rhode Island Department of Health). Findings are as follows:Review of a community-reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 10/20/2025 alleged that the fire department responded to the facility for a reported fire. The complaint also stated that smoke was observed coming from a heater that had experienced an electrical fire behind its control panel.During a surveyor interview on 10/21/2025 at 8:53 AM with the Director of Nursing Services, she acknowledged that the Fire Department responded to an unscheduled implementation of the fire and evacuation plan on 10/18/2025. She was unable to provide evidence that the facility reported the unscheduled implementation of the fire and evacuation plan immediately to the RIDOH.

Based on record review, and resident and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards as possible, related to heating devices for 2 of 3 resident rooms observed. Findings are as follows:Review of a community-reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 10/20/2025 alleged that the fire department responded to the facility for a reported fire. The complaint also stated that smoke was observed coming from a heater that had experienced an electrical fire behind its control panel.Record review of the fixed installed heater maintenance manual on 10/21/2025 at 1:00 PM revealed, a minimum of an eight-inch clearance is required from the unit to furniture, beds, or other objects for proper operation. In severe airflow restrictions, damage can occur to the unit components.A surveyor observation on 10/21/2025 at 9:55 AM, of room [ROOM NUMBER], a recliner was partially blocking the fixed installed heater and was approximately 2 inches from the unit.Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident ID #1, who resides in room [ROOM NUMBER], had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition.During a surveyor interview with Resident ID #1 following the above observation, s/he revealed that the recliner has been in the same location in his/her room for at least a year. A surveyor observation on 10/21/2025 at 10:12 AM, of room [ROOM NUMBER], revealed Resident ID #2's recliner was also blocking the fixed installed heating unit and failed to maintain a clearance of more than eight inches, as required.During subsequent surveyor observations in the presence of the Maintenance Director on 10/21/2025 at 2:00 PM, he acknowledged that the recliners for Resident ID #1 and 2 were closer than 8 inches from the fixed installed heating units.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is served utilizing professional standards for food service safety, relative to the main dining room. Record review of The Rhode Island Food Code 2022 edition 3-501.19 reads in part, .Time/Temperature Control For Safety Food shall have an initial temperature of .41 [degrees] F [Fahrenheit] or less when removed from cold holding temperature control .or 135 [degrees] F or greater when removed from hot holding temperature control . During a surveyor observation on 7/1/2025 at approximately 11:44 AM, whole milk had an internal temprature reading of 52 degrees F. During a surveyor observation on 7/2/2025 at 12:15 PM, a tossed salad with a grilled chicken breast had an internal temperature of 125 degrees F. During a surveyor interview on 7/2/2025 at 2:30 PM, with the Food Service Director, she was unable to provide evidence that the temperatures were within the established guidelines for food service safety.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication rooms and 2 of 5 medication carts observed. Findings are as follows: Review of a facility policy titled, Storage and Expiration Dating of Medications and Biologicals states in part. .Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container .when the medication has a shortened expiration date once opened .If a multidose vial of an injectable medication has been opened or accessed .the vial should be dated and discarded within 28 days unless the manufacturer specifies a different .date for that opened vial . According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised April 2025 indicates that although medication delivery and labeling systems may vary, the medication label at a minimum includes the medication name (generic and/or brand), prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration. 1) During a surveyor observation on 7/2/2025 at 10:10 AM, of the first-floor medication room, in the presence of Registered Nurse (RN), Staff A, one bottle of Lorazepam 2 milligrams/milliliter (mg/ml) opened and undated was revealed. The manufacturer's instructions on the box state to discard open bottle 90 days after opening. During a surveyor interview immediately following the observation, Staff A acknowledged that the Lorazepam was opened and undated. 2) During a surveyor observation on 7/2/2025 at 8:15 AM of the second-floor East side medication cart in the presence of RN, Staff B, two 20 ml vials of lidocaine 1% with no resident name, opened and undated were revealed. During a surveyor interview immediately following the observation, Staff B acknowledged that the two vials of lidocaine were opened and undated. She further acknowledged that the vials failed to be labeled with a resident's name. 3) During a surveyor observation on 7/2/2025 at 10:00 AM of the first-floor East side medication cart, in the presence of Staff A, two 20 ml vials of lidocaine 1%, opened and undated were revealed. During a surveyor interview immediately following the observation, Staff A acknowledged that the two vials of lidocaine were opened and undated. During a surveyor interview on 7/3/2025 at 8:51 AM with the Director of Nursing Services, she revealed that the lidocaine vials should have been labeled with a resident's name and all of the above medications should have been dated when opened.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a dietary menu that meets the nutritional needs of residents, in accordance with established national guidelines, as evidenced by a planned menu which failed to follow standardized recipes. Findings are as follows: According to the United States Department of Agriculture, a standardized recipe is defined as one that, . has been tried, adapted, and retried several times for use by a given food service operation and has been found to produce the same good results and yield every time when the exact procedures are used with the same type of equipment and the same quantity of ingredients . Additionally, .a consistent nutrient content ensures that the nutritional values per serving are valid and consistent, because the same products and quantities are being used every time the recipe is produced . Record review of the facility's recipes on file failed to ensure standardized recipes were utilized, as evidenced by handwritten recipes that did not include portion sizes and/or nutritional content of the items prepared. During a surveyor interview on 7/2/2025 at approximately 2:30 PM, with the Food Service Director, she was unable to provide evidence of standardized recipes on file and acknowledged that standardized recipes were not used when preparing menu items.

Based on record review, resident and staff interview, it has been determined that the facility failed to keep a resident free from abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/21/2025, revealed in part, Resident ID #2 was observed by Licensed Practical Nurse, Staff A, kissing and inappropriately touching Resident ID #1 on 4/19/2025. Further review revealed Resident ID #2 was alert and aware, whereas Resident ID #1 was not alert and aware. Resident ID #2 was sent to the hospital and the facility changed him/her to a different unit. Review of a facility policy titled, Abuse - Identification of Types reviewed 6/17/2024, states in part, .It is the policy of this facility to identify abuse, neglect, and exploitation of residents .This includes but is not limited to identifying and understanding the different types of abuse and possible indicators .The resident has the right to be free from abuse .Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at have the capacity to consent. Sexual abuse includes, but is not limited to .Unwanted intimate touching of any kind especially of breasts or perineal area .Generally, sexual contact is nonconsensual if the resident either .appears to want to contact to occur, but lacks the cognitive ability to consent; or .does not want the contact to occur . Record review revealed that Resident ID #1, the alleged victim, was admitted to the facility in October of 2023 with a diagnosis including, but not limited to, Alzheimer's disease. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating the resident has severely impaired cognition. Record review revealed that Resident ID #2, the alleged perpetrator, was readmitted to the facility in October of 2024 with a diagnosis including, but not limited to, unspecified intellectual disabilities. Record review of a care plan dated 3/28/2025 for Resident ID #2 reveals s/he is in an intimate relationship with a resident of the opposite sex (not Resident ID #1). Review of Resident ID #2's Annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, indicating the resident has moderately impaired cognition. Record review for Resident ID #2 revealed a progress note dated 4/19/2025 which revealed Resident ID #2 was observed by staff rubbing Resident ID #1's breast and kissing him/her on the lips. Further review revealed the resident stated, [S/he] asked me to do it. Review of a Continuity of Care form dated 4/19/2025 revealed Resident ID #2 was sent to the hospital for a psychiatric evaluation for touching [a] patient that cannot give consent. Record review of a progress note dated 4/21/2025 indicates that Social Services met with Resident ID #1 to see how s/he was doing after the incident that occurred with Resident ID #2 and Resident ID #1 asked if [s/he] was involved. During a surveyor interview on 4/22/2025 at 9:49 AM, with Resident ID #1's family member, s/he revealed that they do not consent to Resident ID #1 being intimate with Resident ID #2, as Resident ID #1 is married and is unable to consent for him/herself. During surveyor interviews on 4/22/2025 at 10:22 AM and 10:50 AM, with Resident ID #2, the alleged perpetrator, s/he revealed that s/he had moved to a new room because another resident was bothering him/her. S/he acknowledged touching and kissing Resident ID #1, and stated. It is not my fault. During a surveyor interview on 4/22/2025 at 11:02 AM with Resident ID #1 s/he was able to hold a conversation but asked the surveyor multiple times what her name was and that s/he liked her hair. S/he was unable to answer detailed questions. During a surveyor interview on 4/22/2025 at 10:56 AM, with Staff A, she revealed that on 4/19/2025, she observed Resident ID #2 approach Resident ID #1 in the day room, where Resident ID #2 touched Resident ID #1's breast and kissed Resident ID #1 on the lips. She further revealed that when she spoke with Resident ID #2, s/he revealed that Resident ID #1 asked him/her to do it. During surveyor interviews on 4/22/2025 at 8:31 AM and 11:09 AM, with the Assistant Director of Nursing Services (ADON), she acknowledged that Resident ID #2 inappropriately touched Resident ID #1 on 4/19/2025. She further revealed that Resident ID #1 is unable to consent for him/herself, due to his/her cognitive impairment, indicating that Resident ID #1's family makes decisions on his/her behalf. During a surveyor interview on 4/22/2025 at 1:28 PM, with the ADON, and the Director of Nursing Services via telephone, they were unable to provide evidence that the facility kept Resident ID #1 free from sexual abuse on 4/19/2025.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, prepared, distributed, and served in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1. Record review of a product label, Vital Cuisine Mightyshakes reads in part, .store frozen. Use thawed product within 14 days . During a surveyor observation on 6/18/2024 at approximately 8:30 AM, of the walk-in refrigerator unit of the main kitchen, 3 cases of Mightyshakes were observed without a date indicating when they were placed in the refrigerator unit for thawing. During a surveyor interview on 6/18/2024 at approximately 11:30 AM with the Food Service Director (FSD), she acknowledged that the dietary staff failed to date the product when placed in the refrigerator unit for thawing. 2. Record review of the RI Food Code 2018 Edition 8-201.14 Contents of a HACCP (Hazard Analysis and Critical Control Points) Plan reads in part, .TIME/TEMPERATURE CONTROL FOR SAFETY FOODS [food prepared from ingredients at room temperature must be cooled to 41 degrees Fahrenheit (F) or lower within 4 hours], such as salads .follow a flow diagram by specific FOOD identifying CRITICAL CONTROL POINTS [monitoring temperature for food safety over a period of time] . During a surveyor observation on 6/20/2024 at approximately 2:00 PM, revealed chicken salad in a steam table pan, that was sitting on a work table at room temperature in the main kitchen. During a surveyor observation and interview on 6/20/2024 at approximately 2:05 PM, when the FSD was asked for a temperature reading of the chicken salad, the reading was observed at 70 degrees F. During a surveyor interview on 6/20/2024 at approximately 3:00 PM, with the FSD, she revealed that the staff failed to follow policy regarding the taking and recording of the temperature of the chicken salad and following a HCAPP plan.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following a physician's order for 1 of 2 residents reviewed with diabetic ulcers and for the use of off-loading boots, Resident ID #87. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, type II diabetes mellitus and non-pressure chronic ulcer of the left foot. 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 a care plan focus area dated 6/14/2024 revealed s/he is at risk for skin breakdown related to a left foot diabetic ulcer with an intervention for heel off-loading boots to bilateral feet while in bed as tolerated. Review of the June 2024 Treatment Administration Record revealed an order for heel off-loading boots to bilateral feet while in bed as tolerated and to check placement. Further review revealed they were signed off as in place daily. During surveyor observations on the following dates and times the resident was observed in bed without heel off-loading boots in place: - 6/18/2024 at 9:38 AM - 6/20/2024 at 11:13 AM - 6/21/2024 at 1:12 PM During a surveyor interview on 6/21/2024 at 1:12 PM with the resident, s/he revealed that s/he would like to wear the heel off-loading boots. Additionally, s/he revealed that staff does not ask if s/he would like to wear the boots. During a surveyor interview on 6/21/2024 at 1:17 PM with Licensed Practical Nurse, Staff A, she acknowledged that the resident did not have the off-loading boots in place and was initially unable to locate the boots in the room. Additionally, she acknowledged that she documented that the boots were in place although they were not. During a surveyor interview on 6/21/2024 at 1:29 PM with the Assistant Director of Nursing Services, she revealed that she would expect the staff to apply the off-loading boots as ordered. Additionally, she was unable to provide evidence that the facility provided services that meet professional standards relative to following physician orders. Cross Reference F 842

46241 Based on record review, resident, and staff interview, it has been determined that the facility failed to follow their policy relative to weights. Additionally, the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 3 residents reviewed for weight loss, Resident ID #28. Findings are as follows: Review of a facility policy titled Weight measurement last revised 8/21/2023 states in part, .Notify the nurse if the weight obtained is significantly different from the prior weight [greater than or equal to] 3 lbs. [pounds] for a weekly weight; [greater than or equal to] 5 lbs. for a monthly weight .Reweigh as needed .The unit manager/designee should review and verify the weights on the day they are obtained to ensure there is no unexplained significant variance from the prior weight by utilizing the weight reports . Record review revealed the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, protein-calorie malnutrition and diabetes mellitus. Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of the resident's care plan revealed a focus area initiated on 6/7/2024 and last revised on 6/10/2024, which revealed the resident presents with signs and symptoms of malnutrition and has potential nutrition related issues due to his/her diagnoses of diabetes mellitus and gastroparesis (a delayed emptying of gastric contents into the intestine) with a goal that states, [Resident ID #28] will not sustain any significant, unintentional weight loss through next review. An intervention includes, but is not limited to, report significant weight changes to physician. Review of a Nutrition assessment dated [DATE], authored by the Registered Dietitian, states in part, Malnutrition [related to] physiologic causes as evidenced by decreased appetite PTA [prior to admission], [complaint of] difficulty swallowing, weakness, muscle and fat wasting . Further review of the Nutrition assessment dated [DATE], revealed a summary that indicated the resident appeared frail with temporal and clavicular muscle wasting. Review of a document titled weight summary revealed the resident had a documented weight of 153.8 lbs. on 6/5/2024 and had a documented weight of 143 lbs. on 6/20/2024, which is a weight loss of 10.8 lbs., indicating a 7% weight loss over a 2-week period. Record review failed to reveal evidence that the Physician or Registered Dietitian was notified of the resident's 10.8 lbs. weight loss in a 2-week period. During a surveyor interview on 6/20/2024 at 11:35 AM, with the resident, s/he revealed that s/he gets hungry at night. During a surveyor interview on 6/21/2024 at 10:15 AM, with the Registered Dietitian, she revealed that she was unaware of the resident's 10.8 lbs. weight loss in a two-week period and acknowledged she was not notified of the weight loss. Review of a progress note dated 6/21/2024 at 1:48 PM, authored by the Registered Dietitian, after the concern was brought to the facility's attention by the surveyor, states, Resident reports [s/he] would like larger portions of food at all meals. Recommend: Amend diet order to include 'double portions of protein'. During a surveyor interview on 6/24/2024 at 10:08 AM, with the Assistant Director of Nursing Services, she acknowledged the resident's 10.8 lbs. weight loss in a two-week period and indicated the facility's weight loss policy was not followed. Additionally, she failed to provide evidence that the resident maintained acceptable parameters of nutritional status, such as usual body weight.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 8 residents reviewed whose medications were reconciled following the medication administration task, Resident ID #40, and 1 of 2 residents reviewed with diabetic foot wounds requiring offloading boots, Resident ID #87. Findings are as follows: Review of a facility policy titled, Administration of Medications last reviewed on 8/24/2023, states in part, .Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration .6. Right Documentation. Make sure to write the time and any remarks on the chart correctly. Medication administrations should be documented timely following the administration to the resident . 1. Record review revealed Resident ID #40 was admitted to the facility in October of 2013 with a diagnosis including, but not limited to, heart failure. Record review revealed the resident has the following physician orders: - Bumex 1 milligram give 1 tablet daily between 8:00 AM - 11:00 AM for congestive heart failure - Fluticasone Propionate Nasal Suspension 50 micrograms per actuation give 2 sprays in both nostrils daily between 8:00 AM - 11:00 AM for allergies During a surveyor observation during the medication administration task on 6/21/2024 at 9:29 AM with Licensed Practical Nurse, Staff B, she provided the nasal spray to the resident to self-administer, however the resident indicated it was empty. Additionally, Staff B failed to administer the Bumex. Record review of the June 2024 Medication Administration Record revealed Staff B had signed off the above medications as administered on 6/21/2024. During a surveyor interview on 6/21/2024 at 12:08 PM with Staff B, she revealed that she had not administered Bumex to the resident and indicated that the resident did not receive his/her Fluticasone or Bumex as ordered. She further revealed that she should not have documented the medications as being administered if they were not administered as ordered to the resident. 2. Record review revealed Resident ID #87 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, type II diabetes mellitus and non-pressure chronic ulcer of the left foot. Review of a physician's order revealed to apply heel off-loading boots to his/her bilateral feet while in bed as tolerated and to check placement. During surveyor observations on the following dates and times the resident was observed in bed without heel off-loading boots in place: - 6/18/2024 at 9:38 AM - 6/20/2024 at 11:13 AM - 6/21/2024 at 1:12 PM Review of the June 2024 Treatment Administration Record revealed the order was documented as completed from 6/5 through 6/21/2024. Further review revealed the order was signed off as completed on 6/21/2024 by Licensed Practical Nurse, Staff A. During a surveyor interview on 6/21/2024 at 1:17 PM with Staff A, she acknowledged that the resident did not have the off-loading boots in place. Additionally, she acknowledged that she documented that the offloading-boots were in place although they were not. During a surveyor interview on 6/21/2024 at 1:29 PM with the Assistant Director of Nursing Services, she revealed that she would expect the staff to be following the physician orders and accurately documenting. Cross Reference F 658

50004 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program (IPCP) to help prevent the transmission of communicable diseases and infections for 2 of 2 residents reviewed for contact precautions, Resident ID #s 32 and 64. Additionally, the facility failed to conduct appropriate infection control practices relative to the storage of a nebulizer mask for 1 of 1 resident reviewed with a nebulizer machine (a device for producing a fine spray of liquid, used for inhaling a medicinal drug), Resident ID #12. Findings are as follows: Review of the Centers for Disease Control and Prevention's (CDC) document titled, Contact Precautions states in part, .Providers and staff must also .Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . Review of a facility policy titled Contact Precautions states in part, .Contact Precautions-Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or environment .requires the use of appropriate PPE [Personal Protective Equipment], including a gown and gloves before or upon entering the room .Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environment contamination and risk of transmission of a pathogen, even before specific organism has been identified . 1a) Record review revealed that Resident ID #32 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, Parkinson's Disease. Review of a Physician's order dated 6/17/2024 states in part, .Isolation: Contact Precautions Diagnosis: Vomit . During a surveyor observation on 6/18/2024 at 11:38 AM of the resident's room revealed a sign for contact precautions. The sign states in part, Everyone must put on gloves before room entry .put on a gown before room entry . During a surveyor observation on 6/18/2024 at 11:43 AM of Housekeeper, Staff C, she was observed in the resident's room washing the floor and speaking with the resident without wearing a gown. During a surveyor interview on 6/18/2024 at 11:46 AM with Staff C, she acknowledged that she should have worn a gown as required as the resident is on contact precautions. During a surveyor interview immediately following the above observation on 6/18/2024 at 11:48 AM with Licensed Practical Nurse, Staff D, she acknowledged that the housekeeper should have worn a gown to enter the resident's room as required. Additionally, she acknowledged the resident was on contact precautions for vomiting. During a surveyor interview on 6/20/2024 at 10:06 AM with the Assistant Director of Nursing Services (ADNS), she revealed that the resident was on contact precautions for vomiting and would expect staff to wear a gown when entering the resident's room. 1b) Record review revealed that Resident ID #64 was readmitted to the facility in June of 2024 with a diagnosis including, but not limited to, parainfluenza (a group of viruses that cause common respiratory infections. It is a very contagious type of viral respiratory infection caused by any of the 4 kinds of human parainfluenza viruses). Review of a hospital document dated 6/12/2024, titled Hospital Course, states in part, .+[positive] parainfluenza . Review of a progress note dated 6/17/2024 states in part, .patient continues on precautions for +flu .patient complaints of slight cough . During a surveyor observation on 6/18/2024 at 11:10 AM of the resident's room revealed a sign for contact precautions. The sign states in part, Everyone must put on gloves before room entry .put on a gown before room entry . During a surveyor observation on 6/18/2024 at 11:10 AM of Nursing Assistant, Staff E, in the presence of LPN, Staff F, she entered the resident's room without wearing a gown or gloves. During a surveyor interview immediately following the above observation on 6/18/2024 with Staff E, in the presence of Staff F, she acknowledged that she entered the resident's room to answer his/her call light and to deliver a drink without wearing a gown and gloves as required. Additionally, she revealed that she was unaware of why the resident was on contact precautions. Additionally, Staff F revealed that the resident was on contact precautions related to positive influenza. She further acknowledged that staff are to wear a gown and gloves when entering the room. During a surveyor interview on 6/20/2024 at 10:06 AM with the ADNS, she revealed that the resident was on contact precautions for parainfluenza and would expect staff to wear a gown and gloves when entering the resident's room. 2. Review of a document from the National Heart, Lung and Blood Institute, titled How to use a Nebulizer states in part, .Between uses: Store nebulizer parts in a dry, clean plastic storage bag . Record review revealed that Resident ID #12 was readmitted to the facility in June of 2024 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease. Review of a physician's order dated 6/18/2024 revealed the resident has an order for a nebulizer treatment as needed. During surveyor observations on the following dates and times the resident's nebulizer mask was observed on the resident's bed, and not in a plastic bag. - 6/18/2024 at 10:13 AM - 6/20/2024 at 2:00 PM - 6/21/2024 at 8:42 AM - 6/24/2024 at 11:38 AM During a surveyor interview following the above observation on 6/24/2024 at 11:38 AM with LPN, Staff G, she acknowledged that the mask was on the bed and was not in a bag. She further revealed that the nebulizer mask should be placed in a bag after the treatment is provided to the resident. During a surveyor interview on 6/24/2024 at 11:53 AM with the ADNS, she revealed that the nebulizer mask should be bagged following the treatment by staff. Additionally, she was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of communicable diseases and infections.

Based on record review and staff interview, it has been determined that the facility failed to ensure each resident receives the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 3 resident's reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/14/2023, alleges that the resident was transported to two hospitals due to suicidal ideations and safety concerns. According to the Resident Assessment Instrument (RAI) manual, last revised October 2019, SECTION:D .The items in this section address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable . Record review revealed the resident was admitted to the facility in May of 2023. S/he has diagnoses, including but not limited to, failure to thrive, cancer, anxiety, and depression. Record review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed a mood interview score of 0. Record review of a Significant Change MDS assessment dated [DATE], revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. Additionally, the Significant Change MDS revealed a mood interview score of 9, indicating mild depression, which is a noted change from the 5/15/2023 MDS score of 0, indicating the resident was not experiencing any signs or symptoms of depression. Further record review revealed a care plan dated 7/11/2023, indicating the resident is at risk for a change in his/her mood or behavior due to medical condition. An intervention includes, psychiatric consult as indicated. Record review revealed the following progress notes: - 7/11/2023 at 4:41 PM, The note indicates that the resident completed the mood interview scoring a 9 due to reporting poor sleep, energy, appetite, concentration, and feeling a little down. - 9/10/2023 at 10:56 AM, .patient reported .'I am not good today, I want to go home, I am going to lose my apartment. If I lose my apartment, I am going to kill myself . The note further indicates that the resident reported feeling depressed while at the facility and locked in his/her room all day. - 9/12/2023 at 3:26 PM, pt [patient] stated to this nurse that [s/he] was not happy and feeling very depressed lately . Additionally, the note indicates that the resident was experiencing visual hallucinations, reported that s/he would be better off dead, and reported previously harming him/herself. - 9/13/2023 at 12:00 PM, The note indicates that the resident was out of the facility at an appointment when s/he made the comment that if s/he were transferred back to the facility, s/he would kill him/herself. Further record review revealed that the resident was transferred to the hospital on 9/13/2023 at 2:46 PM, after making suicidal ideations on 9/10 and 9/12/2023. Additionally, the record revealed that the resident was not admitted to the hospital and returned to the facility the evening of 9/13/2023. Record review of a progress note dated 9/13/2023 at 10:54 PM, indicates the resident returned to the facility during the evening on 9/13/2023 and reported feeling anxious, depressed, and unsafe at the facility. Furthermore, s/he was transferred back to the hospital and remained at the hospital during the time of the investigation. Further record review failed to reveal evidence that the resident was provided with a psychiatric consult after scoring a 9 on the mood interview on 7/11/2023, which was an increase from his/her previous mood interview completed on 5/15/2023 and making suicidal ideations on 9/10/2023 and 9/12/2023. During a surveyor interview on 9/18/2023 at 3:31 PM with the Director of Nursing Services, she was unable to provide evidence that the resident was provided with a psychiatric consult after s/he was assessed as having an increase in his/her mood interview score. She indicated that a psychiatric consult would have been requested if the social worker who completed the mood interview on 7/11/2023 said the resident needed to be seen. She further indicated that the resident was placed on the psychiatric consult list on 9/12/2023, after making suicidal ideations on 9/10 and 9/12/2023. During a surveyor interview on 9/18/2023 at 12:28 PM, with the social worker, Staff A , she indicated that she was not the social worker who completed the mood interview on 7/11/2023. Additionally, she revealed that when a resident's mood interview score increases, she stops in and checks on the resident. She was unable to provide evidence that the resident was provided with a psychiatric consult as indicated on the residents care plan, or answer why the resident was not provided with one after s/he was assessed as having a change in mood score.

Based on record review and staff interview if has been determined that the facility failed to promptly identify and intervene for an acute change in a resident's condition related to a blood sugar and insulin administration for 2 of 3 residents reviewed for diabetes mellitus, Resident ID #s 5 and 7. The facility also failed to document the resident's condition in the medical record for Resident ID #5. 1. Review of the facility policy dated [DATE] titled Nursing Documentation revealed staff must document the resident's medical and non-medical status when any positive or negative condition change occurs, at a periodic reassessment. According to the facility's procedure, charting will be completed every shift for a minimum of 72 hours following an identified change in condition. The policy also indicates resident assessments should include vital signs and system reviews. Record review revealed Resident ID #5 was readmitted to the facility in September of 2022 with diagnoses of, but not limited to, diabetes mellitus type 2 and cellulitis of left lower limb (skin infection). Record review a physician's order dated [DATE] for Insulin NPH (intermediate-acting) 7 units in the morning and 7 units in the evening. Further review revealed this was an active order on [DATE], when the resident to transferred to the hospital and was admitted due to a left hip abscess. Record review of the hospital discharge summary dated [DATE] revealed an order for Insulin NPH- insulin regular ,d+[DATE] (a mix of rapid-acting and intermediate-acting) 60 units in the morning and 50 units in the evening. Additional review revealed the resident was alert, comfortable and in no acute distress upon discharge from the hospital and readmission to the facility. Record review revealed the above order was not approved by the physician at the facility prior to the first dose administration on [DATE] and was transcribed by the nurse upon admission without question, even though this dose was significantly larger than the 7 units of insulin the resident received twice daily prior to his/her transfer to the hospital. Record review revealed the resident was administered 50 units of NPH- insulin regular ,d+[DATE] on the evening of [DATE] and was was found to be lethargic with a blood sugar reading of 49 (according to the Center for Disease Control a normal blood sugar level for a diabetic is 80 - 130) at approximately 4:30 AM on [DATE]. Further review revealed the resident received Glucagon gel (a medication used to rapidly increase low blood sugar). Record review failed to reveal evidence that the resident's physician was successfully notified of the above mentioned low blood sugar or that the resident received glucagon, as the facility indicated they sent the physician a text message but did not receive a response from her. Further record review revealed that following the above incident, the resident then received 60 units of NPH- insulin regular ,d+[DATE] in the morning and 50 units of NPH- insulin regular ,d+[DATE] in the evening on [DATE]. Record review revealed that on [DATE], the resident only ate ,d+[DATE]% of his/her dinner. Additional record review revealed the resident expired on [DATE] at 5:51 AM. This death was not reported to the state agency, the medical examiner or investigated by the facility. Record review failed to reveal evidence of documentation or charting after the above incident per the facility's policy and procedure. Further review failed to reveal evidence of an assessment or vital signs obtained on the second shift on [DATE] and third shift on [DATE]. Record review revealed that the resident's blood pressure was last obtained at 9:59 AM, temperature at 1:10 AM, pulse at 9:59 AM, oxygen saturation at 9:59 AM on [DATE] and no record of respiration was obtained on [DATE]. During a surveyor interview on [DATE] at 2:35 PM with the resident's physician, she indicated that she was not notified or made aware of the resident's low blood sugar on [DATE] and if she had been made aware, she would have made adjustments to the resident's insulin orders. Additionally, she indicated that she believed the resident expired due to hypoglycemia (low blood sugar). During a surveyor interview on [DATE] at 9:39 AM with Licensed Practical Nurse, Staff C, she indicated that she was the nurse on the resident's unit on [DATE] from 7:00 PM until [DATE] at 7:00 AM. She further indicated that she failed to obtain vital signs or document a skilled nursing note prior to the resident's expiration on [DATE] at 5:51 AM. During a surveyor interview on [DATE] at approximately 3:00 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the physician was successfully notified and made aware of the resident's change of condition on [DATE] when s/he experienced a low blood sugar of 49, was found to be lethargic by staff and required glucagon administration to raise his/her blood sugar level. Additionally, she was unable to provide evidence that the nursing staff provided periodic reassessments of the resident following a change in his/her condition on [DATE], prior to the resident's expiration on [DATE]. 2. Record review revealed Resident ID #7 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, diabetes mellitus type 2 and long term use of insulin. Record review of physician orders revealed the following active orders: -Insulin Glargine-aglr (long-acting) 30 units in the morning -Humalog (short acting) per sliding scale (blood sugar checked before meals) Record review of the resident's meal intake revealed the resident ate less than 25% of breakfast, lunch and dinner on [DATE], [DATE] and for the breakfast meal on [DATE]. Record review revealed the resident's blood sugar was 61 on [DATE] at 8:55 AM. Record review of the [DATE] Medication Administration Record revealed the resident was administered his/her 30 units of insulin on [DATE] in the morning as ordered despite his/her blood sugar reading of 61 and not eating breakfast. During a surveyor observation on [DATE] at 10:24 AM of the resident and simultaneous interview with Nursing Assistant, Staff D she revealed that the resident was Spanish speaking only and was not responding to her translation of the surveyors question, How are you feeling. She further indicated this was not the resident's baseline and that the resident was confused. At that time, Staff D notified the unit nurse and the nurse entered the resident's room with a vital sign machine. During a surveyor interview on [DATE] at 10:27 AM with Physical Therapy Assistant, Staff E, he revealed that he had just attempted to assist the resident in sitting up to transfer however the resident was unable to sit up even with assistance and unable to participate in therapy that morning. He further indicated that this was not the resident's baseline as s/he was walking with his assistance in recent days. During a surveyor interview on [DATE] at 11:20 AM with Nurse Practitioner, Staff F, she revealed that she was unaware of the resident's poor intake or change in condition that morning and would expect to be notified of this due to his/her insulin orders. During a surveyor interview on [DATE] at 11:28 AM with Licensed Practical Nurse, Staff G, she indicated that the resident did not eat breakfast that morning and that she administered the resident's insulin as ordered after obtaining his/her blood sugar of 61. She further revealed that the resident was confused when she assessed him/her after Staff D brought the resident's change in condition to her attention. Additionally, she indicated that she failed to obtain the resident's blood sugar at the time of her last assessment and failed to notify the physician of the change in condition for the resident. During a surveyor observation on [DATE] at 11:40 AM in the presence of Staff G, the resident's breakfast tray was untouched on his/her bedside table. Further observations revealed the resident appeared confused with glossy eyes and labored breathing. At that time, Staff G obtained the resident's blood sugar which was 45. During a surveyor interview immediately following the above observation, Staff G revealed she noticed the resident was unable to sit up for breakfast earlier that morning. She further revealed that no interventions had been implemented related to the resident's change in condition because she did not recognize this as a change in the resident's condition or that it could have been related to a low blood sugar. Additionally, she indicated that she thought the resident's behavior was just [his/her] dementia. Additional review revealed a glucagon injection was needed to increase the resident's low blood sugar. During a surveyor interview on [DATE] at 12:38 PM with the DNS, she indicated that she would expect the nurse to identify a change in condition and follow the facility's policy and procedures. 46118

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 2 of 3 resident reviewed relative to diabetes mellitus and changes in condition, Resident ID#s 5 and 7. Findings are as follows: 1.Review of the facility's policy dated [DATE] titled Nursing Documentation revealed staff must document the resident's medical and non-medical status when any positive or negative condition change occurs, at a periodic reassessment. According to the facility's procedure, charting will be completed every shift for a minimum of 72 hours following an identified change in condition. The policy also indicates resident assessments should include vital signs and system reviews. Record review revealed Resident ID #5 was readmitted to the facility in September of 2022 with diagnoses including, but not limited to, diabetes mellitus type 2 and cellulitis of left lower limb (skin infection). Record review a physician's order dated [DATE] for Insulin NPH (intermediate-acting) 7 units in the morning and 7 units in the evening. Further review revealed this was an active order on [DATE], when the resident transferred to the hospital and was admitted due to a left hip abscess. Record review of the hospital discharge summary dated [DATE] revealed an order for Insulin NPH- insulin regular ,d+[DATE] (a mix of rapid-acting and intermediate-acting) 60 units in the morning and 50 units in the evening. Additional review revealed the resident was alert, comfortable and in no acute distress upon discharge from the hospital and upon readmission to the facility. Record review revealed the above order was not approved by the physician at the facility prior to the first dose administration on [DATE] and was transcribed by the nurse upon admission without question, even though this dose was significantly larger than the 7 units of insulin the resident received twice daily prior to his/her transfer to the hospital. Record review revealed the resident was administered 50 units of NPH- insulin regular ,d+[DATE] on the evening of [DATE] and was was found to be lethargic with a blood sugar reading of 49 (according to the Center for Disease Control a normal blood sugar level for a diabetic is 80 - 130) at approximately 4:30 AM on [DATE]. Further review revealed the resident received Glucagon gel (a medication used to rapidly increase low blood sugar). Record review failed to reveal evidence that the resident's physician was successfully notified of the above mentioned low blood sugar or that the resident received glucagon, as the facility indicated they sent the physician a text message but did not receive a response from her. Record review failed to reveal evidence that the resident's physician was successfully notified of the above mentioned low blood sugar or that the resident received glucagon, as the facility indicated they sent the physician a text message but did not receive a response from her. Further record review revealed that following the above mentioned incident, the resident then received 60 units of Insulin ,d+[DATE] on [DATE] in the morning and 50 units in the evening. Record review revealed on [DATE], the resident only at ,d+[DATE]% of his/her dinner. Additional record review revealed the resident expired on [DATE] at 5:51 AM. This death was not reported to the state agency, the medical examiner or investigated by the facility. Record review failed to reveal evidence of documentation or charting after the above incident per the facility's policy and procedure. Further review failed to reveal evidence of an assessment or vital signs being obtained on the second shift on [DATE] or the third shift on [DATE]. Record review revealed that the resident's blood pressure was last obtained at 9:59 AM, temperature at 1:10 AM, pulse at 9:59 AM, oxygen saturation at 9:59 AM on [DATE] and no record of respiration was obtained on [DATE]. During a surveyor interview on [DATE] at 2:35 PM with the resident's physician, she indicated that she was not notified or made aware of the resident's low blood sugar on [DATE] and if she had been made aware, she would have made adjustments to the resident's insulin orders. Additionally, she indicated that she believed the resident expired due to hypoglycemia (low blood sugar). During a surveyor interview on [DATE] at 1:49 PM with Licensed Practical Nurse (LPN), Staff I, she indicated that she was the resident's unit nurse on [DATE] from 7:00 AM until 7:00 PM. She further indicated that she was unaware of the resident's low blood sugar early that morning and gave the insulin as ordered without question. Additionally, she indicated that she was afraid to question the physician's orders and was unaware she could hold the insulin if the order was of concern. During a surveyor interview on [DATE] at 9:39 AM with LPN, Staff C, she indicated that she was the nurse on the resident's unit on [DATE] from 7:00 PM until 7:00 AM on [DATE] . She further indicated that she failed to obtain vital signs or document a skilled nursing note prior to the resident's expiration on [DATE] at 5:51 AM. During a surveyor interview on [DATE] at approximately 3:00 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the physician was successfully notified and made aware of the resident's change of condition on [DATE] when s/he experienced a low blood sugar of 49, was found to be lethargic by staff and required glucagon administration to raise his/her blood sugar level. Additionally, she was unable to provide evidence that the nursing staff provided periodic reassessments of the resident following a change in his/her condition on [DATE], prior to the resident's expiration on [DATE]. 2. Record review revealed resident ID #7 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, diabetes mellitus type 2 and long term use of insulin. Record review of physician orders revealed the following: -Insulin Glargine-aglr (long-acting) 30 units in the morning -Humalog (short acting) per sliding scale (blood sugar checked before meals) Record review of the resident's meal intake revealed the resident ate less than 25% of breakfast, lunch and dinner on [DATE], [DATE] and for breakfast on [DATE]. Record review revealed the resident's blood sugar was 61 on [DATE] at 8:55 AM. Record review of the [DATE] Medication Administration Record revealed the resident was administered his/her 30 units of insulin on [DATE] in the morning as ordered despite his/her blood sugar reading of 61 and not eating breakfast. During a surveyor observation on [DATE] at 10:24 AM of the resident and simultaneous interview with Nursing Assistant, Staff D, she revealed that the resident was Spanish speaking only and was not responding to her translation of the surveyors question, How are you feeling. She further indicated this was not the resident's baseline and that the resident was confused. At that time, Staff D notified the unit nurse and the nurse entered the resident's room with a vital sign machine. During a surveyor interview on [DATE] at 10:27 AM with Physical Therapy Assistant, Staff E, he revealed that he had just attempted to assist the resident in sitting up to transfer however the resident was unable to sit up even with assistance and unable to participate in therapy that morning. He further indicated that this was not the resident's baseline as s/he was walking with his assistance in recent days. During a surveyor interview on [DATE] at 11:20 AM with Nurse Practitioner, Staff F, she revealed that she was unaware of the resident's poor intake or change in condition that morning and would expect to be notified of this due to his/her insulin orders. During a surveyor interview on [DATE] at 11:28 AM with LPN, Staff G, she indicated that the resident did not eat breakfast that morning and that she administered the resident's insulin as ordered after obtaining his/her blood sugar of 61. She further revealed that the resident was confused when she assessed him/her, after Staff D brought the resident's change in condition to her attention. Additionally, she indicated that she failed to obtain the resident's blood sugar at the time of her last assessment and did not notify the physician of the change in condition for the resident. During a surveyor observation on [DATE] at 11:40 AM in the presence of Staff G, the resident's breakfast tray was untouched on his/her bedside table. Further observations revealed the resident appeared confused with glossy eyes and labored breathing. At that time, Staff G obtained the resident's blood sugar which was 45. During a surveyor interview immediately following the above observation, Staff G revealed she noticed the resident was unable to sit up for breakfast earlier that morning. She further revealed that no interventions had been implemented related to the resident's change in condition because she did not recognize this as a change in the resident's condition or that it could have been related to a low blood sugar. Additionally, she indicated that she thought the resident's behavior was just [his/her] dementia. Additional review revealed a glucagon injection was needed to increase the resident's low blood sugar. During an interview with the Staff Development Coordinator on [DATE] at approximately 3:30 PM, she revealed that an annual skills fair was conducted on [DATE] for all nurses. She further revealed that the skills fair included the following topics: -glucometer competency (a tool for checking blood sugar) -when to report critical labs -SBAR (communication tool) for glycemic (blood sugar) reaction -high risk medications (Insulin pen, Mixed Insulin, Administration Chart) Review of the facility's inservice Attendance Sheet dated [DATE] failed to reveal evidence that LPN, Staff C and I attended the skills fair. During an interview with the Staff Development Coordinator on [DATE] at 3:45 PM, she was unable to provide evidence that the above-mentioned staff attended the skills fair and indicated that her expectation is for all nurses to attend the skills fair. During a surveyor interview on [DATE] at 12:38 PM and at 4:30 PM with the DNS, she indicated that she would expect the nurse to identify a change in condition and follow facility policy and procedures. Additionally, she was unable to provide evidence that the facility ensured licensed nurses have the specific skill sets necessary to care for residents' needs. 46118

Based on record review and staff interview, it has been determined that the facility failed to provide training as outline in the Facility Assessment relative to identification of resident changes in condition, for 4 of 9 staff reviewed, Staff J, K, L, and M. Findings are as follows: The facility assessment updated on 1/17/2023 revealed the following trainings will be provided to all staff upon hire, annually, and quarterly: -Identification of resident changes in condition, including how to identify medical issues appropriately -how to determine if symptoms represent problems in need of intervention -how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life 1. Record review revealed Nursing Assistant Staff J was hired on 9/24/2019. Further record review failed to reveal evidence that Staff J had received the above mentioned training since she was hired. 2. Record review revealed Nursing Assistant Staff K, was hired on 11/23/2021. Further record review failed to reveal evidence that Staff K had received the above training since she was hired. 3. Record review revealed Nursing Assistant Staff L, was hired on 11/15/2022. Further record review failed to reveal evidence that Staff L had received the above training since she was hired. 4. Record review revealed Nursing Assistant Staff M, was hired on 2/11/2003. Further record review failed to reveal evidence that Staff M had received the above training since she was hired. During a surveyor interview with the Staff Development Coordinator on 6/15/2023 at 3:05 PM, she was unable to provide evidence that Staff J, K, L and M received the above training as outlined in the facility assessment. 46118

Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan, relative to behaviors, for 1 of 1 residents reviewed for behaviors, Resident ID #1. Findings are as follows: Record review revealed the resident was readmitted to the facility in May of 2023 with diagnoses of, but not limited to, dementia, bipolar disorder, major depressive disorder and anxiety disorder. Record review of a progress note dated 5/18/2023 authored by a Nurse Practitioner, Staff A, revealed the resident was expressing HI (homicidal ideation) and .was heard saying 'I am going to stab someone. I'm going to stab someone right in the back with a knife,' by another resident . Record review revealed the resident was sent to the hospital for a psychiatric evaluation on 5/18/2023 as ordered by the physician where s/he was admitted from 5/19/2023 until 5/31/2023. Record review of the hospital Psychiatric Initial Evaluation dated 5/19/2023 revealed the resident was brought to the emergency department .due to agitation, aggression, and threatening to stab others with a butter knife . Further review revealed the .Justification for Admission: Danger to self, Danger to others . Record review of the resident's care plan failed to reveal evidence that the threatening behaviors were addressed or that interventions were put into place upon return to the facility following the hospital admission. During a surveyor interview on 6/8/2023 at approximately 2:38 PM with Registered Nurse, Staff B, she revealed that she would expect the resident's care plan to reflect his/her threatening and aggressive behaviors. Additionally, she acknowledged the behaviors were not included in the resident's care plan. During a surveyor interview on 6/8/2023 at 2:48 PM with the Director of Nursing Services, she was unable to provide evidence that the care plan was reviewed and revised to address the aggressive and threatening behaviors that the resident was hospitalized for prior to his/her readmission to the facility.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a residents environment remains as free from accident hazards as possible for 1 of 3 residents reviewed for falls, Resident ID #4. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, history of falling, muscle weakness, and dementia. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed s/he was moderately cognitively impaired. Further review revealed the resident required assistance with transfers, ambulation, and activities of daily living. Record review of a care plan dated 2/23/2023 revealed the resident is at risk for falls including an intervention of Pt [physical therapy] evaluate and treat as ordered and PRN [as needed]. Record review revealed a physician's order dated 5/27/2023 for PT/OT [physical therapy/occupational therapy] evaluation related to fall risk. Record review failed to reveal evidence that a PT/OT evaluation was completed as ordered. Record review revealed the resident sustained a fall on 5/29/2023 resulting in pain to his/her right hip, a fall on 6/4/2023 resulting in pain to his/her right knee, and three falls on 6/6/2023. During a surveyor interview on 6/12/2023 at 10:00 AM with the Director of Rehab, she revealed that she was unaware of the above mentioned physician order dated 5/27/2023 for a PT/OT evaluation. She further revealed that she would have expected nursing to transcribe the order and therapy to be notified for an evaluation to be completed. During a surveyor interview on 6/12/2023 at 9:48 AM and 10:33 AM with the Director of Nursing Services, she acknowledged the resident has had multiple recent falls. Additionally, she was unable to provide evidence that a PT/OT evaluation was completed as ordered.

Based on record review and interview with professional staff, it was determined that the facility failed to provide services to ensure the physical well-being of one resident relative to bowel care, resulting in an injury to the resident that required hospitalization . Findings are as follows: Resident ID # 1 requested and received a Fleets enema on 4/13/12. The enema was administered while the resident was in a sitting position and leaning forward, as opposed to the standard left side-lying position. Immediately after the enema, the resident complained of dry mouth and weakness and was assisted back to bed by two staff members. Oxygen was then applied and 911 was called for transport to the hospital. Surveyor telephone interview with the RI Hospital surgeon, on 4/25/12 at 11:30 AM, revealed that the resident sustained [REDACTED]. Interview with the responsible nurse was conducted by telephone on 4/26/12 at 3:15 PM. The nurse told the surveyor that the resident was sitting, leaning forward at the time she administered the enema. She went on to say that although she was aware that the left side-lying position is standard practice, she did not insist on the proper position when the resident protested and wanted to remain sitting in the bathroom. The facility appropriately responded by re-educating the nurse regarding the facility bowel protocol and proper technique for the administration of cleansing enemas. Nursing administration will monitor to assure compliance with facility protocols. "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions."