Every finding on record at Golden Crest Nursing Centre

Based on clinical record review, and family and staff interview, the facility failed to ensure a resident received the necessary monitoring and assistance to maintain proper hydration for 1 of 3 residents reviewed, Resident ID #1.Findings are as follows:According to Fundamentals of Nursing 7th Edition (2011), .Fluid Balance.The desirable amount of fluid intake.in adult ranges from 1,500 to 3,500 milliliter (mL) each 24 hours, with most people averaging 2,500 to 2,600 mL per day.Parameters to be considered in clinical assessment for fluid, electrolyte, and acid-base balance.Records may be initiated by the nurse for any patient with a real or potential water or electrolyte problem.Intake should include all fluids taken into the body.If monitoring of a patient's intake.is required, the patient, family, and all caregivers must be alert to the need to measure all fluids entering.the body.Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/2/2026 alleged in part, that the facility is short staffed and has been letting Resident ID #1's health decline.During a surveyor interview on 4/15/2026 at 11:31 AM, with the complainant, s/he alleges that the facility has not been assisting the resident with his/her hydration consistently.Record review revealed Resident ID #1 was admitted to the facility in March of 2026 with diagnoses including, but not limited to, a left femur fracture and Alzheimer's disease.Record review of Resident ID #1's care plan revealed a problem of alteration in fluid maintenance due to diuretic (a medication prescribed to help the body eliminate excess sodium and water through increased urine production) use and poor insight into hydration needs. Further review revealed an intervention initiated on 3/19/2026 to monitor his/her fluid intake.Record review of the laboratory blood work results on 4/9/2026 revealed a creatinine level of 1.47 milligrams/deciliter (mg/dL) (a blood laboratory test prescribed to assess the kidney function; 0.8 - 1.40 mg/dL is the normal level and an elevation may be a sign of dehydration). This level was higher when compared to the creatinine level of 1.25 on the 4/2/2026 blood work results.During a surveyor interview on 4/15/2026 at approximately 1:00 PM with Licensed Practical Nurse, Staff A, she acknowledged that staff are expected to monitor the resident's fluid intake and document it in the electronic medical record (EMR) every shift.Review of the EMR fluid intake documentation from 3/21/2026 through 4/14/2026 failed to reveal record of fluid intake for 53 of 75 shifts reviewed. Additionally, the resident's fluid intake failed to reflect the minimum recommended daily intake of 1,500 mL for 24 of 25 days reviewed.During a surveyor interview on 4/15/2026 at approximately 2:00 PM with the Assistant Director of Nursing Services, she revealed that she would expect staff to document the resident's fluid intake in the EMR, as required.

Based on clinical record review, and family and staff interview, the facility failed to ensure that resident records are complete and accurately documented related to assistance with activities of daily living for 2 of 3 residents reviewed, Resident ID #s 1 and 2.Findings are as follows:According to Fundamentals of Nursing, Seventh Edition dated 2011, states in part, Documenting Nursing Care .Remembering the legal truth 'It wasn't done if it wasn't documented'.Documentation Guidelines.Aim: Complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/2/2026 alleged in part, that the facility is short staffed and has been letting Resident ID #1's health decline.During a surveyor interview on 4/15/2026 at 11:31 AM, with the complainant, s/he alleges that the facility did not have enough staff to assist Resident ID #1 during the day shift (7:00 AM to 3:00 PM) on 4/9/2026.1. Record review revealed Resident ID #1 was admitted to the facility in March of 2026 with diagnoses including, but not limited to, a left femur fracture and Alzheimer's disease.Record review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required maximal assistance with personal hygiene and toileting.Record review of the Nursing Assistant (NA) Point of Care History 4/9/2026, failed to reveal documentation assistance with care was provided for Resident ID #1 during the day shift.2. Record review revealed Resident ID #2 was admitted to the facility in November of 2022 with a diagnosis including, but not limited to, paraplegia (paralysis of lower body).Record review of the Quarterly MDS assessment dated [DATE] revealed the resident as staff-dependent for personal hygiene and toileting.Record review of the NA Point of Care History for 4/9/2026, failed to reveal documentation assistance with care was provided for Resident ID #2 during the day shift.During a surveyor interview on 4/15/2026 at approximately 2:00 PM, the Assistant Director of Nursing Services acknowledged that the NAs failed to document in the clinical record the care provided to Resident ID #s 1 and 2 during the day shift on 4/9/2026, as required.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to prevent a new pressure ulcer from developing for 1 of 1 resident reviewed (Resident ID #7) with a physician's order to off load heels. The physician-ordered intervention to offload the resident's heels was not consistently implemented for Resident ID #7, despite the resident's identified risk factors for pressure ulcer development, including impaired mobility, malnutrition, and a moderate risk score on the Norton Plus Pressure Ulcer Scale (a tool utilized to assess a resident's risk for developing a pressure ulcer). This failure resulted in the development of a deep tissue injury (DTI) to the resident's left heel, which was identified during a skin assessment requested by the surveyor. Findings are as follows:Review of the facility policy last revised in September of 2013 titled Prevention of Pressure Ulcers, states in part, .Pressure Ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue.once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident.Record review revealed Resident ID #7 was admitted to the facility in September of 2025 with diagnoses including, but not limited to, severe protein-calorie malnutrition, muscle weakness, and abnormalities of mobility.Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status Score of 9 out of 15, indicating the resident's cognition is moderately impaired. Further review revealed the resident requires moderate assistance with activities of daily living, including lower body dressing and applying footwear.Review of a care plan dated 9/25/2025, revealed the resident is at risk for pressure ulcers and impaired skin integrity related to impaired mobility and a history of skin breakdown. Further review revealed an intervention to offload heels with a pillow, as ordered.Record review of a Norton Plus Pressure Ulcer Scale dated 10/8/2025, revealed a score of 12, indicating the resident is at a moderate risk for developing a pressure ulcer.Review of the physician's orders revealed an order dated 10/20/2025, to off load heels with a pillow every shift, including special instructions indicating that the resident prefers one pillow.Review of a Weekly Skin assessment dated [DATE] revealed, the resident did not have any skin impairments noted. During surveyor observations on the following dates and times, the resident's heels were not offloaded and lying directly on the mattress while in bed:-12/10/2025 at 1:34 PM-12/11/2025 at 10:53 AM-12/11/2025 at approximately 11:40 AM-12/11/2025 at 1:10 PMDuring a surveyor observation and interview on 12/11/2025 at 1:20 PM, with Licensed Practical Nurse (LPN), Staff H, he indicated that he was unaware of the physician's order to offload the resident's heels and acknowledged that the resident's heels were not offloaded at that time. Additionally, Staff H and the surveyor observed the resident's heels. A non-blanchable, red and purple area was noted to his/her left heel. Staff H indicated that he would notify the provider of the new area identified on the resident's left heel during the observation.During a subsequent interview on 12/11/2025 at 1:39 PM, with LPN, Staff H, he indicated that the provider was notified and a new order was given to apply skin prep to the resident's heels twice a day, and to continue to offload his/her heels. During a surveyor interview on 12/11/2025 at 1:43 PM, and at approximately 2:00 PM, with the Director of Nursing Services (DNS), he indicated that he would expect the physician's order to be followed. He further indicated that a DTI was observed to the resident's left heel measuring 2.8 centimeters (cm) by 2.5 cm. Record review revealed a progress note dated 12/11/2025 at 1:53 PM, which noted a DTI was identified on the resident's left heel measuring 2.8 cm by 2.5 cm and the provider was notified. Further review revealed a new order was given for skin prep to the heel twice a day, and to continue to offload.Record review of the Wound Details revealed a new wound that was categorized as a DTI and was identified on 12/11/2025 at 1:50 PM, after it was brought to the facility's attention by the surveyor.The facility failed to ensure that physician-ordered interventions to offload the resident's heels were consistently implemented for Resident ID #7, despite the resident's identified risk factors for pressure ulcer development, including impaired mobility, malnutrition, and a moderate risk score on the Norton Plus Pressure Ulcer Scale. This failure resulted in the development of a DTI to the resident's left heel, which was identified during a skin assessment requested by the surveyor.

Based on surveyor observation, clinical record review, and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices relative to 2 of 6 residents reviewed with an identified skin impairment, Resident ID #s 21, and 67 and 1 of 3 residents reviewed who are dependent on staff for activities of daily living (ADLs), Resident ID #118.Findings are as follows:1. Record review revealed Resident ID #21 was readmitted to the facility in July of 2025 with diagnoses including, but not limited to, stage 4 pressure injury (full thickness skin loss, involving subcutaneous tissue, exposing muscle and possibly tendon or bone) of the right foot second toe.Record review of wound detail report dated 9/3/2025 at 11:09 AM revealed, Resident ID #21 has an ulcer to the right foot 2nd toe, measuring 0.1 centimeters by 0.1 centimeters.Record review revealed a physician's order dated 12/2/2025 to cleanse the right 2nd toe with wound cleanser, apply Iodosorb (a medication prescribed to treat pressure ulcers) to the base of the wound and secure with a Band-Aid. Apply lamb's wool between toes to off-load the wound.Record review of the weekly skin assessments completed on the following dates and times revealed the resident had no skin impairments to his/her right 2nd toe:11/9/202511/23/202511/30/202512/7/2025During a surveyor interview on 12/11/2025 at 10:11 AM Licensed Practical Nurse, Staff I, she acknowledged that the toe wound was not identified on the above-mentioned skin checks and should have been.2. Record review revealed Resident ID #67 was readmitted to the facility in July of 2025 with a diagnosis including, but not limited to, Alzheimer's disease.Record review of a facility reported incident report submitted to the Rhode Island Department of Health on 12/9/2025 at 9:35 AM revealed, Resident ID #67 was observed with a bruise to his/her left temporal area of his/her forehead.Record review of a weekly skin assessment completed on 12/9/2025 at 4:49 PM by Licensed Practical Nurse (LPN), Staff J, failed to reveal evidence of any skin impairment.During a surveyor interview on 12/11/2025 at approximately 1:30 PM, with the Director of Nursing Services, he revealed that he would expect the skin assessments to be reflected accurately.3. Record review revealed Resident ID #118 was readmitted to the facility in July of 2025 with diagnoses including, but not limited to, Alzheimer's disease and hemiplegia (paralysis or weakness of the face, arm or leg). Additional record review revealed s/he is totally dependent on staff for transfers with the use of a Hoyer lift (a mechanical device used to aid staff with transferring).Record review of the activities of daily living documentation revealed the resident was transferred via a Hoyer lift on the following dates and times:12/7/2025 at 2:52 PM12/7/2025 at 10:02 PM12/2/2025 at 11:20 PM12/1/2025 at 11:04 PM11/30/2025 at 11:05 PM11/28/2025 at 11:14 PM11/27/2025 at 10:59PM11/25/2025 at 10:39 PM11/24/2025 at 11:18 PM11/23/2025 at 10:38 PM11/21/2025 at 10:51 PM11/20/2025 at 10:38 PM11/18/2025 at 10:42 PM11/17/2025 at 10:49 PM11/16/2025 at 10:44 PM11/14/2025 at 11:16 PM11/13/2025 at 10:41 PM11/11/2025 at 10:31 PM11/10/2025 at 11:14 PM11/9/2025 at 10:52 PMDuring a surveyor interview on 12/11/2025 at 10:22 AM, with Nursing Assistant, Staff K, she acknowledged that although she signed off that she transferred the resident on the above-mentioned dates she did not because the resident is already in bed at the beginning of the 3:00 PM through 11:00 PM shift.During a surveyor interview on 12/11/2025, with the Director of Nursing Services at approximately 1:30 PM, he was unable to provide evidence that Resident ID #118's medical record was reflected accurately related to the above-mentioned transfers.

Based on surveyor observation, clinical record review, resident representative, and staff interview, the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs); for 1 of 1 resident reviewed with a delay in personal care, Resident ID #40, and for 1 of 3 residents reviewed relative to transfers, Resident ID #118.Findings are as follows: 1. Record review revealed Resident ID #40 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, dementia and diabetes.Record review of a Minimum Data Set assessment dated [DATE] revealed that the resident is rarely/never understood and has severe cognitive impairment. Additional record review revealed that s/he is always incontinent of bowel and bladder and is totally dependent on two staff members for Activities of Daily Living (ADLs), including, toileting, hygiene, and dressing.Record review of the ADL documentation dated 12/8/2025, failed to reveal evidence that the resident received incontinence care or personal hygiene care between 1:14 AM until 3:05 PM.Record review of a care plan dated 8/15/2025 revealed interventions including, but not limited to, provide incontinence care after each incontinent episode.A surveyor observation on 12/8/2025 at 11:05 AM revealed the resident was in his/her bed, wearing a hospital gown. A note was posted on the closet door to remind the Nursing Assistant's (NA's) to dress the resident with long sleeves and to ensure that the resident wears an undershirt at all times.During a surveyor interview on 12/8/2025 at 11:21 AM with NA, Staff B, she acknowledged that she was the assigned NA for the resident for the 7:00 AM to 3:00 PM shift and that AM care had not been provided on that shift. Additionally, she revealed that she was waiting for the resident to have a bowel movement before providing care.Additional observation of the resident on 12/8/2025 at 1:00 PM revealed the resident was lying in bed, still wearing a hospital gown, while s/he was being assisted with his/her meal by NA, Staff A.During a subsequent surveyor interview on 12/8/2025, at approximately 1:15 PM with Staff B, she acknowledged that she had not provided any ADL care to the residents including, incontinence care, hygiene, or dressing care. She further revealed that that she did not provide care because she has been busy and was helping other residents.During a surveyor interview on 12/8/2025 at 1:30 PM, with Registered Nurse, Staff C, she acknowledged she was aware that the resident has not received ADL care since prior to 7:00 AM. Additionally, she indicated that she would have expected ADL care to have already been provided. During a surveyor interview on 12/9/2025 at 1:47 PM, with the Director of Nursing Services, he revealed that he would expect ADL morning care to be completed by 11:00 AM.2. Record review revealed Resident ID #118 was readmitted to the facility in September of 2025 with diagnoses including, but not limited to, Alzheimer's disease and hemiplegia (paralysis or weakness of the face, arm or leg.)Record review of a Minimum Data Set assessment dated [DATE] revealed, s/he is rarely or never understood and totally dependent on staff for transfers.During a surveyor interview on 12/8/2025 at 2:20 PM with the resident's representative, s/he revealed the resident does not get out of bed. Additionally, s/he revealed s/he wished the resident would be assisted out of bed, so s/he could be stimulated. Record review of a care plan with a start date of 1/9/2025 revealed, the resident requires complete assistance for all ADLs related to decreased mobility and impaired cognition with interventions including, but not limited to, the use of a Hoyer lift (a mechanical device to assist caregivers in transferring) with the assistance of two staff members to transfer out of bed to the recliner chair.Surveyor observations of the resident revealed s/he was in bed on the following dates and times:12/8/2025 at approximately 10:00 AM12/8/2025 at approximately 1:00 PM12/9/2025 at approximately 8:45 AM12/10/2025 at approximately 9:00 AM12/10/2025 at approximately 12:00 PMRecord review revealed the resident's transfer status was documented as activity did not occur for the first, second, and third shifts on 12/8/2025 and 12/10/2025.During a surveyor interview on 12/10/2025 at 12:28 PM, with Nursing Assistant (NA), Staff E, she acknowledged that the resident was in bed while being assisted with his/her lunch meal. Additionally, when asked why the resident had not been assisted out of bed, she indicated that the resident gets out of bed every other day.During a surveyor interview on 12/11/2025 at 9:13 AM, with NA, Staff F, she revealed that the resident only gets out of bed every other day. Additionally, she revealed that the unit has a lot of residents who require a Hoyer lift transfer with two staff members, and it is hard to get everyone out of bed every day.During a surveyor interview on 12/11/2025 at 1:30 PM, with the Director of Nursing Services, he indicated that it would be his expectation that staff would attempt to get the resident out of bed every day.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide an ongoing activity program to support a resident in his/her choice of activities based on the comprehensive assessment, care plan, and preferences for 1 of 1 resident reviewed, Resident ID #118.Findings are as follows:Record review revealed Resident ID #118 was readmitted to the facility in September of 2025 with diagnoses including, but not limited to, Alzheimer's disease and hemiplegia (a paralysis or weakness of the face, arm or leg.)Review of an admission Minimum Data Set assessment, Section F, titled, Preferences for Customary Routine and Activities, dated 9/17/2025 revealed, it is very important for the resident to listen to music.Review of the resident's care plan last revised on 6/25/2024 revealed, the resident has Alzheimer's and is non-verbal with the intervention to ensure the TV or some type of music is available for the resident.Surveyor observations of the resident on the following dates and times failed to reveal evidence that the resident was offered or participated in any activities while in his/her room alone and awake.-12/8/2025- At approximately 10:00 AM-12/8/2025- At approximately 1:00 PM-12/9/2025- At approximately 8:45 AM-12/10/2025- At approximately 9:00 AM-12/10/2025- At approximately 12:00 PMReview of the resident's daily activity report sheet indicated that an X was documented to reflect participation in television or music with the resident on 12/8/2025, 12/9/2025, and 12/10/2025.During a surveyor interview on 12/11/2025 at 10:50 AM, with the assigned unit Activities Aide, Staff G, she indicated that in the morning she visits the resident to turn on his/her television. Additionally, she indicated she does not enter a resident room if the door is shut. Further she acknowledged that she failed to visit the resident on 12/9/2025, although she signed off that the visit was completed. She was unable to provide evidence the television was on when the resident was observed on 12/8/2025 and 12/10/2025.During a surveyor interview on 12/11/2025 at approximately 1:30 PM with the Director of Nursing Services, he indicated that he would expect the staff to put on the resident's television or music as indicated in his/her plan of care.

Based on record review and staff interview, it has been determined that the facility failed to develop and implement individualized care plans that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment relative to Activities of Daily Living (ADL's, e.g. eating, oral hygiene, toileting hygiene, showering and bathing, personal hygiene, dressing, rolling to the left and right, all transfers and mobility) for 5 of 5 residents reviewed, Resident ID #s 1, 4, 5, 6, and 7. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/5/2024 alleged that Resident ID #1 had fallen out of his/her bed a couple months ago resulting in bruising and a hospital evaluation. 1. Record review revealed Resident ID #1 was admitted to the facility in July of 2022 with diagnoses including, but not limited to, multiple sclerosis (chronic neurological disorder), spastic quadriplegia (a form of cerebral palsy that affects both arms and legs), and bilateral lower extremity contractures (a shortening of the muscles and tendons in both legs that limit ability of movement in joint). Review of a progress note dated 7/8/2024 at 12:03 PM revealed the resident had a witnessed fall. A Nursing Assistant (NA), was performing morning care, when the resident rolled off the bed and onto the floor. The resident was sent to the hospital for an evaluation. During a surveyor interview on 12/19/2024 at 9:08 AM with the resident, s/he indicated on the morning of 7/8/2024 a NA was getting him/her washed to get out of bed and s/he was laying on his/her bed, face down with his/her leg hanging off the bed. Additionally, the weight of his/her leg pulled him/her onto the floor. The resident revealed that s/he usually receives care with assistance from one staff person, sometimes two. Record review of the resident's Care Area Assessment (CAA's) dated 7/8/2024 indicates the resident is dependent for all ADL's and will proceed to plan of care (a written document that outlines the care required for an individual based on their individual health needs). Record review of the resident's comprehensive care plan failed to reveal evidence of a focused CAA for ADL's, including a person specific approach with, descriptive of the individual resident needs, that included person centered interventions the facility would implement to assist the resident, including the level of assistance needed to provide care. Additionally, the resident's care plan was revised on 12/18/2024 to include a focused CAA for ADLs, after it was brought to the attention of the facility by a surveyor. 2. Record review revealed Resident ID #4 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, muscle weakness and dementia. Record review of a CAA dated 9/11/2024 revealed the resident required set up assistance for eating, substantial assistance for bathing, showering, and dressing, and was dependent for toileting hygiene, transfers and mobility and will proceed to plan of care. Record review of a comprehensive care plan last revised on 12/16/2024 revealed a focus area for ADL's indicating the resident has a decline in function and mobility, and a goal to maximize independence with ADL self-care tasks and mobility. Interventions in place include to use an assistive device, to provide assistance with ADL's, and provide physical and occupational therapy, as needed. Review of the comprehensive care plan for Resident ID #4 failed to provide evidence of a person specific approach that was descriptive of the individual resident needs, including the level of staff assistance required to provide care. 3. Record review revealed Resident ID #5 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, Post Traumatic Stress Disorder (PTSD is a mental and behavioral disorder that can develop after someone experiences or witnesses a traumatic event), Parkinson's disease (movement disorder of the nervous system that worsens over time), and a fracture of the lower end of the right tibia (break in the shinbone that may include the inability to walk or bear weight on the leg). Record review of a CAA dated 11/5/2024 revealed that the resident required set up assistance for eating, substantial assistance for upper body dressing, personal hygiene, rolling left to right and transfers, and s/he was dependent for lower body dressing and mobility and indicated to proceed to plan of care. Record review of a comprehensive care plan dated on 7/9/2024 with a focus area for ADL's indicating the resident has a decline in function and mobility, related a right tibial plateau fracture (a break in the upper part of the shin bone, that affects the knee's stability and movement) as well as debridement (a medical procedure that removes damaged, dead, or infected tissue from a wound to help it heal) of the right lower leg with a goal to maximize the residents independence with ADL self-care tasks and mobility. Interventions in place include to use an assistive device, to provide assistance with ADL's, and provide physical and occupational therapy, as needed. Review of the comprehensive care plan for Resident ID #5 failed to provide evidence of a person specific approach that was descriptive of the individual resident needs, including the level of staff assistance required to provide care. Additionally, the care plan failed to reveal evidence of a focused care area for PTSD that is culturally competent, and trauma informed. 4. Record review revealed Resident ID #6 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, dementia and abnormal gait. Record review of a CAA dated 1/2/2024 indicated that s/he triggered by the MDS for ADL's due to impaired mobility and weakness and indicated to proceed to plan of care. Record review of a comprehensive care plan dated 1/3/2024 revealed a focus area for ADL's indicating the resident has a decline in function and mobility, and a goal to maximize independence with ADL self-care tasks and mobility. Interventions in place include to use an assistive device, to provide assistance with ADL's, and provide physical and occupational therapy, as needed. Review of the comprehensive care plan for Resident ID #6 failed to reveal evidence of a person specific approach that was descriptive of the individual resident needs, including the level of staff assistance required to provide care. 5. Record review revealed Resident ID #7 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, fracture of upper right humerus (a break at the top of the right upper arm bone, near the shoulder joint), and generalized muscle weakness. Record review of a CAA dated 11/19/2024 revealed the resident requires set up assistance for eating, and moderate assistance for oral and personal hygiene. Additionally, s/he is dependent for showering, bathing, dressing, mobility, and transfers and indicated to proceed to plan of care. Record review of a comprehensive care plan dated 11/26/2024 for ADL's revealed the resident had a deficit in function and mobility with a goal in place to maximize independence with ADL self-care and mobility. Interventions in place include to use an assistive device, to provide assistance with ADL's, and provide physical and occupational therapy, as needed. Review of the comprehensive care plan for Resident ID #7 failed to provide evidence of a person specific approach that was descriptive of the individual resident needs, including the level of staff assistance required to provide care. During a surveyor interview on 12/19/2024 at 8:56 AM with Licensed Practical Nurse, Staff A, she revealed that to learn the level of assistance needed to care for a resident she relies on verbal communication from the resident and the NA's that care for them. She further indicated that she could refer to the residents MDS Assessment, section GG of their electronic medical records. She further indicated that she was aware of the resident's care plans, however does not rely on them to direct resident care. Additionally, Staff A indicated that she was unaware of a binder used to communicate residents' individual functional status to the NA's proving care. During a surveyor interview on 12/19/2024 at 11:54 AM with NA Staff B, she revealed that NA's receive verbal reports from nursing staff on how much assistance is needed to provide care to the residents. During a surveyor interview on 12/19/2024 at 11:26 AM with Registered Nurse (RN) Staff C, she revealed that she refers to a binder kept on each unit which contain documents titled Nursing Aid Care Plans to learn a resident's level of dependency. Additionally, she acknowledged that the above-mentioned care documents for the residents on the unit were all undated, several residents on the unit lacked care information, and there were forms that contained only a resident's name. During a surveyor interview on 12/19/2024 at 12:15 PM with RN Staff D, he revealed that the level of care required for each resident can be found in the care plan binders located on the units. He indicated the information in the binders are to be updated for new admissions, when residents have a hospitalization , or there is a change in status. During a surveyor interview on 12/19/2024 at 12:55 PM with the Director of Nursing Services, he acknowledged that the resident's comprehensive care plan failed to contain a focused care area for ADL's to encompass specific approaches, the resident's individual needs, and specific interventions for each resident that s/he required pertaining to his/her level of dependency required when providing him/her with personal care.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles for 1 of 1 resident reviewed relative to storing lidocaine patches in his/her room without an assessment for self-application, Resident ID #2. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, arthritis and muscle weakness. Review of a physician's order dated 10/1/2024 revealed Lidocaine adhesive patch 4% (a medication prescribed for pain), apply 1 patch to the right shoulder every morning and to be removed at bedtime. Record review failed to reveal evidence of an assessment for the self administration of the medication, which indicated the resident is safe to store and administer his/her medications. During a surveyor observation on 11/4/2024 at approximately 12:00 PM, there was a total of 5 unopened lidocaine patches in the opened manufacturer's box observed in the resident's room. During a surveyor interview on 11/4/2024 at approximately 1:15 PM with Licensed Practical Nurse (LPN), Staff A, she acknowledged that the resident had the lidocaine patches in his/her room and s/he should not have. During a surveyor interview on 11/4/2024 at 3:10 PM with the Assistant Director of Nursing Services, she indicated the lidocaine patches should not be left in the resident's room by the nurses. Additionally, she stated she would have expected the lidocaine patches to be stored in the medication cart and not in the resident's room.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 5 medication carts reviewed and 1 of 2 medication rooms. Findings are as follows: Review of a facility policy titled, Storage of Medications last revised [DATE] states in part, The facility shall store all drugs and biological's in a safe, secure, and orderly manner . 1. During a surveyor observation of the 2 East Medication Cart on [DATE] at 8:25 AM, in the presence of Certified Medication Technician (CMT), Staff E, revealed the following: - 1 bottle of Latanoprost Solution (eye drops used to treat glaucoma) 0.005 % with an open date of [DATE]. Manufacturer's instructions indicate to discard the eye drops 6 weeks after opening, revealing the medication should have been discarded on [DATE]. - 1 bottle of Timolol Maleate Gel Forming Solution 0.5 % (eye drops used to treat high pressure inside the eye) dated as opened [DATE]. Manufacturer's instructions indicate to discard the eye drops 4 weeks after opening, revealing the medication should have been discarded on [DATE]. - 1 opened bottle of Artificial Tears Ophthalmic Solution (eye drops used to treat dry eyes) with a date of [DATE]. Manufacturer's instructions indicate to discard the eye drops 90 days after opening, revealing the medication should have been discarded on [DATE]. - 1 bottle of brimonidine-timolol drops; 0XXX,d+[DATE].5 % (eye drops used to treat high pressure inside the eye) dated as opened on [DATE]. Manufacturer's instructions indicate to discard the eye drops 4 weeks after opening, revealing the medication should have been discarded on [DATE]. During a surveyor interview with Staff E, at the time of the above observation, she acknowledged that the above-mentioned medications were expired and should have been discarded. During a surveyor interview immediately following the above observation with Registered Nurse, Staff D, he revealed that the staff should be writing the date when the medication is opened and then discarding when expired. 2. During a surveyor observation of the 2 [NAME] Medication Cart on [DATE] at approximately 9:00 AM, in the presence of CMT, Staff F, revealed the following: - 2 bottles of Cosopt (dorzolamide-timolol) drops (eye drops used to treat high pressure inside of the eye) opened and undated. Manufacturer's instructions indicate to discard the eye drops 15 days after opening. - 3 bottles of Artificial Tears Ophthalmic Solution opened and undated. Manufacturer's instructions indicate to discard the eye drops 90 days after opening. - 1 bottle of Systane Complete PF (propylene glycol) 0.6 % (eye drops prescribed to treat dry eyes) opened and undated. Manufacturer's instructions indicate to discard the eye drops 90 days after opening. - 1 bottle of brimonidine-timolol drops; 0XXX,d+[DATE].5 % opened and undated. Manufacturer's instructions indicate to discard the eye drops 4 weeks after opening. During a surveyor interview immediately following the above observation with Staff F, she acknowledged that all of the above-mentioned medications were opened and undated, and she was unsure when they expired. During a surveyor interview on [DATE] at 9:10 AM with Licensed Practical Nurse, Staff C, she revealed that the staff are supposed to date the eye drops once opened and discard when expired. 3. During a surveyor observation on [DATE] at 9:20 AM of the 2 East Medication Room in the presence of RN, Staff D, revealed one multidose vial of Aplisol, opened and undated. Manufacturer's instructions on the Aplisol box state, once entered vial should be discarded after 30 days. During a surveyor interview immediately following the above observation with RN, Staff D, he acknowledged that the vial was opened and undated. Additionally, he was unable to provide evidence when the vial had been opened. During a surveyor interview on [DATE] at 11:30 AM with the Director of Nursing Services, he revealed that he would expect the staff to date medications when opened and discard appropriately. 21613

Based on record review, staff and resident interviews, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development of infections for 1 of 1 resident reviewed relative to the use of a Bilevel positive airway pressure (BIPAP, a device that provides breathing support which is administered through a face mask or nasal mask) device, Resident ID #77. Findings are as follows: Review of the manufacturer's instructions titled RESVENT IBREESE Series user manual dated July 2017, states in part, .Clean the flexible tube and mask before first use and daily. Disconnect the flexible tube and mask from the device. Gently wash the tube and mask in a solution of warm water and a mild detergent. Rinse thoroughly. Air dry . Record review revealed that Resident ID #77 was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, sleep apnea (a sleep disorder where breathing is interrupted repeatedly) and acute respiratory failure. Record review of a quarterly Minimum Data Set assessment completed on 8/22/2024, revealed a Brief Interview of Mental Status score of 15 out of 15, indicating intact cognition. During a surveyor interview on 9/17/2024 at approximately 11:30 AM with the resident, s/he revealed that the facility does not clean his/her BIPAP machine. Review of the Treatment Administration Record for August and September of 2024 revealed, the resident has an order to use a BIPAP machine every night at bedtime. Additional review revealed that the order was signed off as in use every night while s/he was in the facility. Further record review failed to reveal evidence of an order to clean the mask and tubing of the BIPAP machine. Record review failed to reveal evidence that the BIPAP machine tubing and mask were cleaned per the manufacturer's instructions in August or September of 2024. During a surveyor interview on 9/19/2024 at 12:31 PM with the Director of Nursing Services (DNS), he revealed that it is the facility's policy to follow the manufacturer's instructions for cleaning the BIPAP equipment. He further acknowledged, the above-mentioned resident does not have an order to clean their BIPAP equipment and was unable to provide evidence that the machine was cleaned, as required.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 32 opportunities for errors observed during the medication administration task there were 2 errors resulting in an error rate of 6.25%, involving Resident ID #62. Findings are as follows: Review of a facility policy titled, Administering Medications last revised December 2012 which states in part, .Medications shall be administered in a safe and timely manner, and as prescribed . Record review revealed that Resident ID #62 had the following physician's orders: - Depakote (divalproex) tablet, delayed release 500 milligrams (MG), twice daily - MiraLAX (polyethylene glycol 3350) powder, 17 gram dose, once daily During a surveyor observation on 9/19/2024 at 8:08 AM during the medication administration task with Certified Medication Technician, Staff E, she failed to administer the Miralax and then crushed the Depakote tablet. Review of the Depakote blister package revealed a directions label that indicated, Do not crush/chew. During a surveyor interview immediately following the above observation with Staff E, she acknowledged that she crushed the Depakote although the medication packaging indicated to not crush or chew. During a surveyor interview on 9/19/2024 at 11:24 AM with Registered Nurse, Staff D, he acknowledged that the Miralax was signed off, in the medical record, as administered during the medication pass. Staff D indicated that he would expect medication to only be signed off when administered, and was unable to explain why Staff E would sign off the medication if it was not administered. Additionally, he acknowledged the Depakote tablet should not be crushed.

Based on record review, and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 2 residents reviewed with medication refusals, Resident ID #73. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 which states, 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 Resident ID #73 was readmitted to the facility in August of 2022 with a diagnosis including, but not limited to, gastro-esophageal reflux disease (GERD, a condition in which stomach acid repeatedly flows back up into the esophagus, causing irritation and discomfort). Record review revealed a physician's order with a start date of 9/12/2022 for Famotidine (a medication prescribed to treat GERD) 8 milligram (mg)/milliliter (ml), give 2.5 ml once daily. Review of the Medication Administration Record revealed the medication was not administered due to the residents refusal on the following dates: - 9/1/2024 - 9/10/2024 - 9/11/2024 - 9/15/2024 - 9/17/2024 - 9/19/2024 Record review failed to reveal evidence the provider was notified of the residents refusals of the Famotidine. During a surveyor interview on 9/19/2024 at 12:16 PM with Certified Medication Technician, Staff A, she revealed the resident refuses often because the medication is a liquid. During a surveyor interview on 9/19/2024 at 12:18 PM with Licensed Practical Nurse, Staff B, she acknowledged that the provider was not notified the resident was refusing the Famotidine. She further revealed that the resident will take pills, and that she will notify the provider that the resident is refusing the liquid form of the medication. During a surveyor interview on 9/19/2024 at 2:37 PM with the Director of Nursing Services, he revealed that if the patient is not taking a medication the physician should be notified. He was unable to provide evidence that the physician was notified of the Famotidine refusals.

Based on record review and staff interview, it has been determined the facility failed to ensure the residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight, relative to a weight gain for 1 of 2 residents reviewed, Resident ID #134. Findings are as follows: Review of a facility undated policy titled, Weight Policy which states in part, .Upon completion of weight, if a 3% discrepancy in one week or a 5% discrepancy in one month is noted, a reweight will be obtained in 48 hours .If a re-weight indicates a 3% discrepancy in one week or a 5% discrepancy in one month, the dietitian, physician, and resident and/or resident representative will be notified . Record review revealed Resident ID #134 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, Crohn's disease (a type of inflammatory bowel disease), rectal abscess, pressure ulcer of sacral region and chronic osteomyelitis, multiple sites (an infection in the bone). Record review of the physician's orders revealed the following: - 8/11/2024; Fluid intake not to exceed 1500 milliliters (ml) per day 1200 ml dietary 300 ml nursing - 8/14/2024; weekly weights once a week on Wednesday Review of the resident's weight record revealed the following weights: - 8/10/2024 117.4 lbs. (pounds) - 8/14/2024 122.6 lbs. - 8/21/2024 127.2 lbs. - 8/28/2024 125.4 lbs. - 9/4/2024 128.6 lbs. - 9/11/2024 131.8 lbs. - 9/18/2024 133.6 lbs. Record review revealed the resident gained a total of 14.4 lbs., a weight gain of 12.27% in one month, indicating a significant weight gain. Record review failed to reveal evidence that the physician was notified until 9/20/2024, after the surveyor brought the significant weight gain to the facility's attention. During a surveyor interview on 9/19/2024 at 9:39 AM with Registered Nurse, Staff D, he acknowledged the resident had a significant weight gain since his/her admission and that there was no evidence that reweights were obtained or that the physician was notified. Additionally, he acknowledged that the weight discrepancy would be alarming, as the resident was on a fluid restriction. During a surveyor interview on 9/20/2024 at 9:35 AM with the Dietitian, she revealed that she reviews the residents' weights weekly, but she was unaware of how much weight the resident had gained. Additionally, she was unable to provide evidence the residents weight gain had been reported to his/her physician, prior to being brought to the attention to the facility by the surveyor on 9/20/2024. During a surveyor interview with the Director of Nursing Services on 9/19/2024 at 9:52 AM, he revealed that he was unaware that Resident ID#134 had a significant weight gain until it was brought to his attention by a surveyor. Additionally, he was unable to provide evidence that the residents physician had been notified of the significant weight gain or that reweights had been obtained, per the facility policy.

Based on record review and staff interview, it has been determined that the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 2 residents reviewed for as needed antipsychotic medications, Resident ID #67. Findings are as follows: Record review of a facility policy titled Medication Regimen Review [MRR] and Reporting which states in part, .Medication 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 risks associated with medication .The consultant pharmacist 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 .In performing medication regimen review, the consultant pharmacist incorporates federally mandated standards of care .A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians and the care planning team within 48 hours of the MRR completion . Record review revealed Resident ID #67 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, major depressive disorder, anxiety disorder, post-traumatic stress disorder, and paranoid personality disorder. Record review revealed a physician's order with a start date of 8/22/2024 for Seroquel (an antipsychotic medication) 50 milligrams (mg) twice daily, as needed. This order had no stop date. Record review of the progress notes revealed, the pharmacy had reviewed the resident's medications with new recommendations made on 8/23/2024 and 9/10/2024. During a surveyor interview with the Director of Nursing Services (DNS) on 9/19/2024 at 1:22 PM, he could not provide the pharmacy reports for the above-mentioned recommendations, because they had not received them from the pharmacy. He further revealed that he would call the pharmacy and have them sent. Record review of a pharmacy document titled New Admission/ Re-Admission Review dated 8/23/2024, revealed in part, .Seroquel 50 mg .PRN [as needed] .PRN antipsychotic orders need a 14 day stop date . Record review of the Medication Administration Record from 8/23/2024 through 9/10/2024 revealed that the resident received the above ordered Seroquel 50 mg on 8/31/2024 and 9/12/2024. Review of the Pharmacist Consultation Recommendation Report dated 9/11/2024, failed to reveal evidence of a stop date as recommended in the previous pharmacy review dated 8/23/2024. During a surveyor interview on 9/19/2024 at approximately 2:30 PM with the DNS, he was unable to provide evidence that the pharmacist's recommendations from 8/23/2024 and 9/10/2024 were available to the facility, or acted upon until it was brought to his attention by the surveyor on 9/19/2024.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure 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 1 resident who was observed during a wound dressing change, Resident ID #102. Findings are as follows: Record review revealed Resident ID #102 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, Peripheral Artery Disease (PAD, a condition in which narrowed arteries reduce blood flow to the arms or legs), Peripheral Vascular Disease (PVD, a condition in which narrowed vessels reduces blood flow to the arms, legs, or other body parts), and status post-surgery for left and right below knee amputations. Record review of the resident's care plan dated 5/5/2023 revealed, the resident is at risk for impaired skin integrity related to status post bilateral knee amputations, coccyx wound, wounds to right lateral knee and right lower shin. Record review of a wound measurement sheet dated 9/17/2024 revealed the resident has pressure ulcers to the following areas: - coccyx; 4.5 centimeter (cm) in length x 2.9 cm in width x 0.1 cm in depth - right lower shin; 3.5 cm in length x 1.6 cm in width x 0.1 cm in depth - right knee (lateral); 2.9 cm in length x 3.2 cm in width x 0.2 cm in depth Record review revealed the resident has the following physician orders: - 8/21/2024 to irrigate coccyx wound with wound cleanser then soak w [with] Vashe [wound cleanser that contains pure hypochlorous acid, a molecule produced by the human immune system to fight bacteria and infection] for 10 minutes, skin prep [a liquid that when applied to the skin forms a protective film or barrier] to peri wound [skin around the wound that has been affected by the wound] . - 9/3/2024 to cleanse right lower shin wound with Vashe, skin prep to peri-wound . - 9/3/2024 to cleanse right lateral leg wound with Vashe, skin prep to peri-wound . During a surveyor observation of the dressing changes to the resident's wounds on 9/19/2024 at 10:47 AM with License Practical Nurse, Staff C, revealed she soaked the coccyx wound with Vashe for only 2 minutes, not for the 10 minutes specified in the order. Additionally, Staff C failed to apply the skin prep to the peri-wounds of the coccyx, right lower shin, and right lateral knee, as ordered. During surveyor interviews on 9/19/2024 at 11:45 AM and 12:32 PM, Staff C acknowledged she did not provide treatments to the above wounds as ordered and that she should have followed the physician orders. During a surveyor interview on 9/20/2024 at 10:30 AM with the Director of Nursing Services, he was unable to provide evidence that Staff C administered the treatments to the wounds, as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to provide person centered care in accordance with a resident's plan of care for 1 of 2 residents reviewed relative to his/her call light being within reach, Resident ID #67. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, adult failure to thrive, paroxysmal atrial fibrillation (a type of irregular heartbeat) and muscle weakness. Record review of a care plan dated 4/18/2024 revealed in part, .Potential for falls/injury r/t [related to]: impaired mobility, impaired cognition, impaired vision, incontinence, weakness and FTT [failure to thrive] . This care plan has interventions including, but not limited to, .Call light within reach & remind to call for assist as needed . During a surveyor observation on 7/15/2024 at 12:40 PM, the resident was observed to be seated in his/her wheelchair between the bed and wall, closest to the doorway, and more than halfway down the length of the bed. S/he had his/her rolling bedside table in front of him/her containing his/her meal tray, his/her bilateral lower extremities were slightly elevated on the wheelchair leg rest. Additionally, the resident's call light was tied to the bed rail on the opposite side of the bed, out of sight and reach of the resident. During a surveyor interview immediately following the above-mentioned observation with the resident, s/he revealed that s/he felt trapped, just trapped here, I have to yell for help and hope they hear me due to his/her inability to locate and utilize his/her call light for assistance. During a surveyor interview and observation on 7/15/2024 at 12:45 PM with Nursing Assistant, Staff A, she acknowledged the call bell for Resident ID #67 should be within his/her reach and it was not. Staff A, relocated the call bell so that it was within reach for the resident to use. During a surveyor interview on 7/15/2024 at 1:53 PM with the Director of Nursing Services, he acknowledged that the care plan regarding the call light being within reach had not been not followed for Resident ID #67. .

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remains as free from accident hazards as possible for 2 of 4 residents reviewed related to fall risk prevention, Resident ID #s 2 and 3. Findings are as follows: 1. Record review revealed Resident ID #3 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia and history of falls. Record review of the document titled Risk of Falls Assessment completed on 4/2/2024 revealed that the resident was at a moderate risk for falls. Record review of the care plan last revised on 4/9/2024 revealed a problem related to a history of falling with an intervention to keep the call light within reach. During a surveyor observation on 5/9/2024 at 9:46 AM, the resident was observed sitting in his/her wheelchair attempting to get up and calling out for help. The call light was noted to be hanging on his/her bedside rail, which was approximately 8 feet away from him/her. During a surveyor interview with the Registered Nurse, Staff A, following the above observation, he acknowledged that Resident ID #3's call light was not within his/her reach. 2. Record review revealed Resident ID #2 was readmitted to the facility in March of 2024 with diagnoses including, but not limited to, urinary tract infection and bipolar disorder (a mental illness characterized by extreme mood swings). Record review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12 of 15, indicating moderately impaired cognition. Record review of the document titled Risk of Falls Assessment completed on 5/9/2024 revealed that the resident was at a moderate risk for falls. During a surveyor observation and simultaneous interview with the resident on 5/9/2024 at 9:15 AM, s/he was observed to be lying in bed. The resident revealed that s/he was experiencing pain and wanted to call the nurse to ask for a pain medication. When asked if s/he had pressed his/her call light, s/he stated that s/he did not know where it was and asked the surveyor to get the nurse. During a surveyor interview with Licensed Practical Nurse, Staff B, immediately following the above observation, she acknowledged that the resident's call light was hanging off of the resident's bedside rail which was out of the resident's reach. During a surveyor interview with the Director of Nursing Services on 5/9/2024 at 1:15 PM, he revealed that he would expect the residents to have their call light within reach.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following a physician's order for nutritional supplements for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 5/8/2024 alleges in part, .In the course of over a month, [Resident ID #1] has lost 20 pounds. According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states, 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 October of 2023 with diagnoses including, but not limited to, acquired absence of the right leg below the knee and type II diabetes mellitus. Record review of a progress note authored by the Licensed Dietitian/Nutritionist on 4/23/2024 at 4:05 PM states in part, .has experienced weight loss, supplement initiated to report. Record review revealed a physician order with a start date of 4/23/2024 for 60 milliliters of med pass (oral nutritional supplement) twice daily. Record review of the May 2024 medication administration record revealed the resident failed to receive the supplement for 5 of 16 opportunities. During a surveyor interview with the Director of Nursing Services on 5/9/2024 at 2:00 PM, he acknowledged that the resident did not receive the supplement per the physician's order because it was not available in the facility and it was on back order at the time.

Based on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to protect the resident's right to be free from abuse for 1 of 3 residents reviewed, Resident ID #102. Findings are as follows: Review of the facility policy titled, Abuse Prohibition, states in part, .Resident abuse is defined as willful infliction of .unreasonable confinement, intimidation, or punishment resulting in .mental anguish; and included mental abuse. Examples of abuse include, but are not limited to the following .mental abuse .threats of punishment or deprivation . Review of the resident record revealed s/he was admitted to the facility in April of 2021 with diagnoses including, but not limited to, schizophrenia [characterized by delusions, hallucinations, unusually physical behaviors, and disorganized thinking and speech], obsessive-compulsive disorder, bipolar disorder, post-traumatic stress disorder, and anxiety. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 8/21/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of a care plan, updated on 4/28/2023, revealed that staff are to set and maintain firm limits regarding activities and extra caffeine beverages when exhibiting behaviors. Review of a geriatric psychiatry document, dated 10/5/2023, revealed an intervention to start with one cup of 50% caffeine coffee per day. Further review of this document failed to reveal any additional interventions relative to his/her daily coffee consumption. Surveyor observation on 10/10/2023 at approximately 11:00 AM of the bedside table in the room of the resident, revealed a copy of a handwritten note that states, Per [NAME] .Re: [Resident name redacted] .[S/He] can come out of [his/her] room on Saturday .No Coffee .No Activities . During an interview with the resident immediately following the above-mentioned observation s/he indicated that the note was given to him/her during the previous weekend, but was unsure of who gave it to him/her. S/he further stated that the administrator would not allow the resident to have coffee or attend activities. Surveyor observation during the lunch meal on 10/11/2023 at approximately 12:00 PM, revealed the resident was with other residents sitting in the hallway eating their meals. S/he was upset and arguing with staff because s/he did not receive a cup of coffee with his/her meal. During a surveyor interview with Nursing Assistant (NA), Staff A on 10/11/2023 at approximately 1:00 PM, she indicated that staff provide the resident with only decaffeinated coffee because her behaviors increase with caffeine consumption. Additionally, it was stated that s/he only receives one cup of coffee with his/her breakfast and dinner meals, not lunch. During a surveyor interview with Registered Nurses (RN), Staff B and Staff C on 10/11/2023 at approximately 1:30 PM, it was revealed that staff limit the resident's coffee intake due to psych recommendations and a behavioral contract s/he signed. Additionally, it was stated that when large amounts of coffee are consumed s/he becomes increasingly incontinent requiring staff assistance with toileting. Review of a 6/5/2023 document titled, [Resident's name redacted] Behavioral Plan, revealed that if at any time this contract is broken the resident will lose activities, his/her coffee privileges, and any further infractions will result in placement at another facility. Further review of this document revealed restrictions including, but not limited to, not asking for additional coffee and staying out of other resident's business. Additional review revealed this document was signed by the resident, Social Services Director, Activities Director, Clinical Nurse Manager, and the Administrator. Review of the April through October 2023 Social Services notes revealed the following: - 4/14/2023: Resident was requesting [his/her] incentive from the nurse who reported she needed to speak to the team to see if the resident earned the incentive. SW [Social Worker] informed the resident due to [his/her] behavior this week [s/he] was unable to get incentive . - 6/15/2023: SW and [Activities Director] spoke with resident regarding [his/her] behavior this morning. Resident lost one week of activities for swearing at staff members. Resident became frustrated with the conversation and reported why is everyone picking on me. SW and [Activities Director] reviewed resident's [contract] with [him/her] and [his/her] [contract] was posted in [his/her] room to review. - 10/4/2023: Resident was observed by Unit RN taking coffee off a tray .SW spoke to resident about [his/her] behaviors and resident became verbally aggressive towards staff. Resident would not return the coffee and began to swear and yell at staff .Resident was informed [s/he] would not be able to attend activities due to [his/her] behaviors. Review of the January through September 2023 nursing notes revealed the resident was both verbally and physically aggressive towards other residents and staff relative to his/her coffee and activity restrictions. Review of the October 2023 notes revealed his/her coffee seeking behaviors were increasing in frequency and the aggressive behaviors towards others were escalating. During an interview with the Administrator in the presence of another surveyor on 10/12/2023 at 2:56 PM, it was revealed that he authored the resident's behavioral contract, agrees with the restrictions imposed, and indicated that it is in collaboration with psych services. He denies writing the handwritten note found in the resident's room and is unaware of who gave the document to the resident. Additionally, he stated that staff are expected to restrict his/her coffee intake and activity participation if the resident does not follow the contract. During an interview with the psychiatric services physician on 10/13/2023 at 8:58 AM, she indicated that she did not agree with the contract. Additionally, it was indicated that she is aware of the contract but was not involved in its development, was not present when it was signed by the staff or resident and is unaware of the resident's mental status when s/he was signing the contract. During an interview with the resident's physician on 10/12/2023 at 3:11 PM, it was indicated that he is okay with the resident receiving more decaffeinated coffee to alleviate his/her escalating behaviors and approved an increase of up to three cups of coffee daily on 10/12/2023. It was further indicated that he did not agree with the contract.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 1 resident reviewed related to abdominal girth measurements, Resident ID #25. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, 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 readmitted to the facility in July of 2021 with diagnoses including, but not limited to, chronic systolic congestive heart failure (long-term condition that occurs when the heart muscle does not pump blood as well as it should), chronic kidney disease, and bladder cancer. Record review of the resident's Treatment Administration Record revealed an order dated 9/12/2023 to measure his/her abdominal girth once a day on Friday. Further review failed to reveal evidence of measurements for the resident's abdominal girth in the following dates: - 9/15/2023 - 9/22/2023 - 9/29/2023 - 10/6/2023 During a surveyor interview with the Licensed Practical Nurse, Staff E on 10/13/2023 at 11:47 AM, she was unable to provide evidence that any abdominal girth measurement was completed for the above-mentioned dates. Additionally, she acknowledged that she signed the order on 10/6/2023 without measuring the resident's abdominal girth. During a surveyor interview with the Director of Nursing Services on 10/13/2023 at approximately 1:00 PM, he was unable to provide evidence of the resident's abdominal girth measurements. Additionally, he acknowledged that he would expect the staff to follow the physician's orders and document their findings in the resident's record.

Based on record review, staff, and family representative interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 3 resident's reviewed for medication administration, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/13/2022 alleges in part, Pt. [patient] reported to not have received Prednisone [an immunosuppressant drug used to prevent the body from rejecting a transplanted organ] while at [facility] resulting in AKI [acute kidney injury] as [s/he] is a kidney transplant pt . Review of a facility policy titled Reconciliation of Medications on Admission states in part, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: a. Discharge summary from referring facility .c. All prescription and supplement information obtained from the resident/family during the medication history .General Guidelines .2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption .during the admission/readmission process .Steps in the Procedure 1. If a medication history has not been obtained from the resident or family, complete this first .3. Review the list carefully to determine if there are discrepancies/conflicts . Record review for the resident revealed that s/he was admitted to the facility in November of 2022 and has diagnoses including, but not limited to, end stage renal disease (the final, permanent stage of chronic kidney disease), urinary tract infection, hypertension, gastro-esophageal reflux disease, and status post kidney transplant on 6/2022. Review of the resident's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 indicating that the resident is cognitively intact. Review of a hospital document which the facility indicated they received at admission titled Case Management Discharge Communication Sheet dated 11/29/2022 revealed a section titled Changes to your medication list including Keflex (an antibiotic). Bactrim (an antibiotic), and Prograf (a medication used to help prevent organ rejection). The document further revealed a section titled STOP taking these medications including Tylenol, Melatonin, Simethicone, and Vitamin B-12. Additionally, this document listed no further medications. Review of the resident's progress note revealed the following: -11/29/2022- [AGE] year old .admitted .received a kidney transplant .All medications verified by [medical doctor] . - 12/05/2022 3:47 PM- .[family member] made aware resident not admitted with all meds ordered . - 12/05/2022 4:01 PM- .call received from resident's [family member] .she stated [resident] should be taking prednisone 5mg [milligram] daily indefinitely. Call transferred to case manager who will have [family member] email list of meds to her. - 12/05/2022 11:03 PM- .Has not been getting home meds, med list to be sent over tomorrow . - 12/06/2022 11:30 AM- medication list given to this writer by case manager this am . - 12/07/2022 11:47 PM- .skin color pale .ble [bilateral lower extremity] weakness . - 12/08/2022 9:53 AM- received call from .transplant clinic .stated md [medical doctor] there concerned regarding elevated bun/create [BUN (blood urea nitrogen) and creatinine are both filtered in the kidneys and excreted in urine. The two together are used to measure overall kidney function.] and would like resident directly admitted to hospital today . - 12/08/2022 6:27 PM- [hospital name] admitting dept [department] called that patient is being admitted . Additional review of the resident's progress notes failed to reveal evidence that the facility contacted the hospital to verify the resident's medication list upon his/her admission on 11/29/2022. Review of a hospital discharge summary dated 12/13/2022 revealed that the resident's principal problem was Acute Kidney Injury and the preliminary read on the resident's transplanted kidney biopsy was tubular injury suggestive of acute tubular necrosis (a kidney disorder involving damage to the tubule cells of the kidney which can lead to acute kidney failure. The tubules are tiny ducts in the kidneys that help filter the blood when it passes through the kidneys) which may be concerning for kidney transplant rejection. The summary further indicated that there was an abrupt rise in creatinine [an increased level may be a sign of poor kidney function] after sent from ED [emergency department] to rehab .apparently only on one immunosuppression agent. Additionally, the summary revealed a section titled CONTINUE these medications which have NOT CHANGED that included prednisone, amlodipine, aspirin, gabapentin, magnesium oxide, pantoprazole, Mirapex, rosuvastatin, and sodium bicarbonate. Indicating, the resident was receiving these medications prior to his/her 11/29/2022 admission to the facility and should have still been receiving them. Review of the resident's Medication Administration Record for November and December 2022 revealed that the resident did not receive the following medications: - Prednisone 5 mg daily on 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, and 12/7/2022 - Amlodipine (a medication used to treat hypertension) 5 mg daily on 11/30, 12/1, 12/2, 12/3, 12/4, and 12/5/2022 - Aspirin (a medication used to prevent heart attack or stroke) 81 mg daily on 11/30, 12/1, 12/2, 12/3, 12/4 and 12/5/2022 - Gabapentin (a medication used to assist with restless leg syndrome) 400 mg every night on 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, and 12/5/2022 - Magnesium Oxide (a supplement used to prevent low levels of magnesium in the blood) 800 mg twice a day on 11/30, 12/1, 12/2, 12/3, 12/4, and 12/5/2022 - Mirapex (a medication used to treat restless leg syndrome) 1.5 mg twice a day on 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, and 12/6/2022 - Pantoprazole (a medication used to treat gastro-esophageal disease) 40 mg daily on 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, and 12/6/2022 - Rosuvastatin (a medication used to treat high cholesterol) 5 mg every night on 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, and 12/5/2022 - Sodium Bicarbonate (a medication used to prevent metabolic acidosis in kidney transplant patients) 650 mg twice a day on 11/30, 12/1, 12/2, 12/3, 12/4, and 12/5 During a surveyor interview with the resident's family member on 12/13/2022 at 1:20 PM, s/he revealed that s/he did not speak with the facility until 12/5/2022 regarding the resident's medications and s/he was made aware that the resident was not receiving all of his/her medications as ordered. S/he further indicated that s/he had to provide the facility with a list of the resident's medications via email that day. Additionally, the family member revealed that the resident is still in the hospital and has had a biopsy on his/her transplanted kidney to see if his/her body is rejecting the organ. During a surveyor interview with the Clinical Manager, a Registered Nurse on 12/13/2022 at 1:50 PM, she revealed that she is responsible for reviewing admission documentation including medication orders to make sure they are transcribed accurately. She further indicated that she would expect the admitting nurse to contact the hospital immediately to obtain a complete medication list. Additionally, she acknowledged that the resident's medication was not complete when s/he was admitted to the facility on [DATE]. During a surveyor interview with the Director of Nursing Services on 12/13/2022 at 1:40 PM, he revealed that if a resident is admitted from the hospital with an incomplete medication list such as the list mentioned above, he would expect that the nurse would call the hospital to obtain an accurate medication list. Additionally, he was unable to provide evidence that the medications were reconciled until 12/06/2022 which is 7 days after the resident was admitted to the facility.

Based on record review and staff interview it has been determined that the facility failed to provide adequate supervision to prevent accidents for one of one resident reviewed, Resident ID# 1. Findings are as follows: According to the Lippincott Manual of Nursing Practice 10th Edition reveals in part, .pg.1233 Suicide Ideation .assess for risk factors .associated psychiatric illness .Determine whether patient has ever attempted suicide .the risk factor is much greater in these people . Review of the American Nursing Associations journal article, published January 4,2022, titled Suicide assessment and follow-up care, states in part: .Patients at risk .Risk factors include a history of suicide attempts .mental health or substance use disorder . Assessment .Educate the patient about suicide and validate their feelings, while also conveying hope for the future .A common myth persists that assessing for suicide will put the idea of suicide in the patient's head. However, the only way to detect suicide risk is by talking about it . Review of a community reported complaint sent to the Rhode Island Department of Health, dated 4/10/2022, indicated the resident had a witnessed fall out of the second story window of the facility. The patient indicated s/he decided to jump out. Record review revealed the resident was admitted to the facility in April of 2022 following an acute care hospitalization with diagnoses to include but not limited to [CONDITION(S)] and dementia. Review of the continuity of care form (COC; a form used to communicate health information and provide for the safe transition of residents who are transferred from one healthcare facility to another), dated 4/6/2022, provided to the facility upon the resident's admission states in part, .[Resident] .has a history of 3 years ago purposely jumping form [sic] a height and causing major injury. [S/he] was in [his/her] usual health and then recently .had a decompensation with worsened CAH [continuous auditory hallucinations] from The Devil insisting people .were out to hurt [him/her] and that [s/he would] have to hurt [him/herself] first . Additional review of the COC revealed a Problem List which includes, mental health problem and intentional self-harm by jumping from a high place. Review of the resident's Level II PASRR-MI (Preadmission Screening and Resident Review; the Level II PASRR is an evaluation that determines if the mental disability/illness or other related condition needs of the individual can be met in a Nursing Facility or if the individual requires Specialized Services), reveals the following: NF [nursing facility] to provide psychiatric services during skilled stay for the above treatment recommendations . The above referenced treatment recommendations were as follows; ongoing psychiatric evaluation, individual counseling, intensive monitoring of mental status, behavior therapy and/or management and health and mental health education. Record review of a document titled History and Physical dated 4/11/2022, revealed in part the following: .significant for dementia, [CONDITION(S)] .SI [[CONDITION(S)]] thought .and fractures associated with jumping from high places. [Resident] was previously at [another nursing facility]. Patient with prior fixation on self-harm and sent to hospital due to increased paranoia . Review of the resident's Baseline Care Plan dated 4/8/2022 revealed in part, .Behavioral concern Has had a history of paranoid behavior, coupled with self-harming event (jumped out of a third-floor window). PASARR Level II Recommendations Monitor mood and behavior . Further review of this baseline care plan failed to reveal evidence of interventions and strategies for staff to assess the resident's mood, behavior, or suicidal thoughts. During an interview with the Director of Nursing Services (DNS) on 4/12/2022 at 12:14 PM he indicated that he leaves it up to the psych team to act upon the recommendations found in the resident's Level II PASRR-MI. Additionally, he was unable to provide evidence that the resident was being assessed or monitored for suicidal thoughts. He further indicated that the resident was placed on 30-minute checks to monitor his/her behaviors in the facility. During an interview with the Psychiatric Nurse Practitioner (NP), on 4/12/2022 at 12:54 PM, she indicated she had been in to see the resident on 4/7/2022 and completed his/her initial Geriatric Psychiatry screening. Additionally, she revealed that no one had shown her the resident's Level II PASRR-MI preadmission screening tool and was unaware of its recommendations. She further indicated that she could not speak to what her expectations of intensive monitoring would be as indicated on the resident's Level II PASRR-MI. Review of the resident's initial Geriatric Psychiatry form dated 4/7/2022 failed to reveal a full assessment of the resident had been completed on that date, as the Thought Content section under MENTAL STATUS EXAM was left blank. During an interview with the NP on 4/11/2022 at 2:45 PM she revealed she did not ask the resident about any suicidal thoughts. During a surveyor interview with Registered Nurse (RN), Staff A on 4/11/2022 at 1:10 PM, she revealed that when she reported to work on 4/7/2022 she was informed by the nurse that the resident was walking the halls and wandering on his/her own, so they placed a wander guard on him/her. During an interview with RN, Staff B, on 4/12/2022 at 9:10 AM, she indicated that she assessed the resident as being an elopement risk on 4/7/2022, as s/he was walking about the unit independently and placed him/her on 30-minute checks for safety, because of the wandering. Review of the resident's 30-minute check list from 4/7/2022 through 4/10/2022 revealed the resident was positive for Behaviors on the following dates and times: -4/7/2022 12:30 PM [at] nursing station, questioning freedom of religion/anxious -4/7/2022 1:00 PM Walking back and fourth from room to nurses station -4/7/2022 1:30 PM anxious showed nurse hospital document about religion -4/8/2022 10:00 AM keeps asking about phone -4/8/2022 11:00 AM keeps asking about phone/sister not picking up -4/9/2022 4:00 AM wandering unit -4/9/2022 5:30 AM wandering unit -4/9/2022 11:00 AM concern about TV -4/9/2022 11:30 AM requesting lunch Additional review of this 30-minute check list failed to reveal evidence the resident was being monitored for suicidal thoughts, or that there were any interventions, such as an increase in monitoring, implemented when the resident was noted to exhibit the above behaviors. Review of the resident's Medication Administration Record (MAR) revealed an order with a start date of 4/7/2022, and a created date of 4/10/2022 to, Monitor behavior: hallucinations. Further review of the MAR failed to reveal evidence that the staff documented that they had monitored the resident for hallucinations. During an interview with the DNS on 4/12/2022 at 12:13 PM he acknowledged the above order on the resident's MAR was not signed off as completed. Additionally, he was unable to provide evidence the resident was being monitored for hallucinations by staff. Review of the resident's progress notes revealed a note dated 4/10/2022 and time stamped 8:35 AM, which states in part, [Resident] slept majority of the night .At approximately 6:30am [s/he] came to the nurse's station and asked me to help [him/her] with [his/her] TV .I told [him/her] I would be with [him/her] shortly. Resident went back to [his/her] room. At 6:45am patient approached desk and walked with me toward [his/her] room, stopped and said [s/he] was going to get the paper and [s/he] would be right back. When [s/he] didn't come back within 2 minutes I went to look for [him/her]. As I walked toward East 2 I witnessed [the resident] half out of one of the window's on East 2. I started to bang on the window overlooking the gazebo diagonally from the room [s/he] was in telling [him/her] to stop and [s/he] fell from the window to the ground in the gazebo area .[s/he] was transported .to [hospital] . Review, of the resident's hospital record following the above noted incident revealed s/he sustained a broken right hip and a subdural hematoma (bleeding in the brain). During an interview with the Administrator on 4/12/2022 at 12:50 PM, he was unable to provide evidence that the facility kept this resident free from accidents. Additionally, he indicated that this Skilled Nursing Facility is not a Psych facility.

Based on record review and staff interview it has been determined that the facility failed to provide each resident with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings are as follows: According to the Lippincott Manual of Nursing Practice 10th Edition reveals in part, .pg.1233 Suicide Ideation .assess for risk factors .associated psychiatric illness .Determine whether patient has ever attempted suicide .the risk factor is much greater in these people . Review of the American Nursing Associations journal article, published January 4,2022, titled Suicide assessment and follow-up care, states in part: .Patients at risk .Risk factors include a history of suicide attempts .mental health or substance use disorder . Assessment .Educate the patient about suicide and validate their feelings, while also conveying hope for the future .A common myth persists that assessing for suicide will put the idea of suicide in the patient's head. However, the only way to detect suicide risk is by talking about it . Review of a community reported complaint sent to the Rhode Island Department of Health, dated 4/10/2022, indicated the resident had a witnessed fall out of the second story window of the facility. The patient indicated s/he decided to jump out. Record review revealed the resident was admitted to the facility in April of 2022 following an acute care hospitalization with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the continuity of care form (COC; a form used to communicate health information and provide for the safe transition of residents who are transferred from one healthcare facility to another), dated 4/6/2022, provided to the facility upon the resident's admission states in part, .[Resident] .has a history of 3 years ago purposely jumping form [sic] a height and causing major injury. [S/he] was in [his/her] usual health and then recently .had a decompensation with worsened CAH [continuous auditory hallucinations] from The Devil insisting people .were out to hurt [him/her] and that [s/he would] have to hurt [him/herself] first . Additional review of the COC revealed a Problem List which includes, mental health problem and intentional self-harm by jumping from a high place. Review of the resident's Level II PASRR-MI (Preadmission Screening and Resident Review; the Level II PASRR is an evaluation that determines if the mental disability/illness or other related condition needs of the individual can be met in a Nursing Facility or if the individual requires Specialized Services), reveals the following: NF [nursing facility] to provide psychiatric services during skilled stay for the above treatment recommendations . The above referenced treatment recommendations were as follows; ongoing psychiatric evaluation, individual counseling, intensive monitoring of mental status, behavior therapy and/or management and health and mental health education. Record review of a document titled History and Physical dated 4/11/2022, revealed in part the following: .significant for dementia, [CONDITION(S)] .SI [[CONDITION(S)]] thought .and fractures associated with jumping from high places. [Resident] was previously at [another nursing facility]. Patient with prior fixation on self-harm and sent to hospital due to increased paranoia . Review of the resident's Baseline Care Plan dated 4/8/2022 revealed in part, .Behavioral concern Has had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . PASARR Level II Recommendations Monitor mood and behavior . Further review of this baseline care plan failed to reveal evidence of interventions and strategies for staff to assess the resident's mood, behavior, or suicidal thoughts. During an interview with the Director of Nursing Services (DNS) on 4/12/2022 at 12:14 PM he indicated that he leaves it up to the psych team to act upon the recommendations found in the resident's Level II PASRR-MI. Additionally, he was unable to provide evidence that the resident was being assessed or monitored for suicidal thoughts. He further indicated that the resident was placed on 30-minute checks to monitor his/her behaviors in the facility. During an interview with the Psychiatric Nurse Practitioner (NP), on 4/12/2022 at 12:54 PM, she indicated she had been in to see the resident on 4/7/2022 and completed his/her initial Geriatric Psychiatry screening. Additionally, she revealed that no one had shown her the resident's Level II PASRR-MI preadmission screening tool and was unaware of its recommendations. Review of the resident's initial Geriatric Psychiatry form dated 4/7/2022 failed to reveal evidence that s/he was screened for Thought Content in the mental status section of the form. During an interview with the NP on 4/11/2022 at 2:45 PM she revealed she did not ask the resident about any suicidal thoughts. During a surveyor interview with Registered Nurse (RN), Staff A on 4/11/2022 at 1:10 PM, she revealed that when reported to work on 4/7/2022 she was informed by the nurse that the resident was walking the halls and wandering on his/her own, so they placed a wander guard on him/her. During an interview with RN, Staff B, on 4/12/2022 at 9:10 AM, she indicated that she assessed the resident as being an elopement risk on 4/7/2022, as s/he was walking about the unit independently and placed him/her on 30-minute checks for safety, because of the wandering. Review of the resident's 30-minute check list from 4/7/2022 through 4/10/2022 revealed the resident was positive for Behaviors on the following dates and times: -4/7/2022 1:30 PM anxious showed nurse hospital document about religion -4/8/2022 10:00 AM keeps asking about phone -4/8/2022 11:00 AM keeps asking about phone/sister not picking up -4/9/2022 4:00 AM wandering unit -4/9/2022 5:30 AM wandering unit -4/9/2022 11:00 AM concern about TV -4/9/2022 11:30 AM requesting lunch Additional review of this 30-minute check list failed to reveal evidence the resident was being monitored for suicidal thoughts. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR failed to reveal evidence that the staff documented that they had monitored the resident for hallucinations. During an interview with the DNS on 4/12/2022 at 12:13 PM he acknowledged the above order on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes revealed a note dated 4/10/2022 and time stamped 8:35 AM, which states in part, [Resident] slept majority of the night .At approximately 6:30am [s/he] came to the nurse's station and asked me to help [him/her] with [his/her] TV .I told [him/her] I would be with [him/her] shortly. Resident went back to [his/her] room. At 6:45am patient approached desk and walked with me toward [his/her] room, stopped and said [s/he] was going to get the paper and [s/he] would be right back. When [s/he] didn't come back within 2 minutes I went to look for [him/her]. As I walked toward East 2 I witnessed [the resident] half out of one of the window's on East 2. I started to bang on the window overlooking the gazebo diagonally from the room [s/he] was in telling [him/her] to stop and [s/he] fell from the window to the ground in the gazebo area .[s/he] was transported .to [hospital] . Review, of the resident's hospital record following the above noted incident revealed s/he sustained a broken right hip and a subdural hematoma (bleeding in the brain), as a result of this fall. During an interview with the Administrator on 4/12/2022 at 12:50 PM, he was unable to provide evidence that the facility provided the resident with the necessary behavioral health care or services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care or PASRR II-MI recommendations. Additionally, he indicated that this Skilled Nursing Facility is not a Psych facility.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide services that meet professional standards of quality, relative to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing page 314 states The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed this resident was admitted to the facility in July of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission record from the hospital dated 7/27/2021 titled Discharge Summary states in part .Current Discharge Medication list: [MEDICATION(S)] 10 MG: Take 1 (one) table (10 mg total) by mouth once daily. Hold till PCP [primary care provider] follow up or BP [blood pressure] > [greater than] 160 systolic [first number that measures the pressure in your arteries when your heart beats]. Record review revealed the above-mentioned medication order was approved by the Nurse Practitioner upon admission to the facility on [DATE]. Record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7:00 AM-11:45 AM. Record review revealed the nurse failed to transcribe the above-mentioned order as approved by the Nurse Practitioner on 7/27/2021. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a progress note dated 7/29/2021 at 10:09 PM states in part resident is alert. VS [vital signs] 81/47, 78, 18, 98.1, 97% room air, notified the NP [Nurse Practitioner] to put parameters on meds. Record review revealed a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Parameters: bp less 100 HOLD, P [pulse] less 60 HOLD. 7:00 AM-11:45 AM. Further record review revealed the following blood pressure readings: - 7/27/2021 at 10:58 PM: BP was 138/72 - 7/29/2021 at 10:09 PM: BP was 81/47 - 7/30/2021 at 10:35 AM: BP was 100/60, at 11:47AM, BP was 79/45, at 8:32 PM, BP was 100/74. - 7/31/2021 at 12:20 PM: BP was 94/60 Further record review revealed the following progress notes: - 7/30/2021 at 12:13 PM which states in part .pt.[patient] c/o [complains of] dizziness, requesting to sit. Nursing obtained vitals with decrease BP [blood pressure] . - 7/30/2021 at 2:16 PM which states in part .Pt. became dizzy, nursing made aware, Pt BP low, pale in appearance stating [s/he] was fatigued and dizzy . - 7/31/2021 at 2:39 PM which states in part .c/o [complains of'] exhaustion from patient. Very weak, VS [vital signs] .94/60 .sent out to [NAME] . Record review failed to revealed that the above-mentioned medication was held and not administered as the approved order indicates in the discharge medication list from the hospital. Record review of the resident's hospital records for this transfer to the emergency room dated 7/31/2021 titled ER [emergency room ] visit notes states in part .EMS [emergency medical service] states BP [blood pressure] was 70/40 when the resident was assessed at the facility prior to transfer .This is likely a volume issue. Primary impression: [CONDITION(S)], Additional impression: Volume depletion . During a surveyor interview on 8/11/2021 at 10:49 AM with the Nurse, Staff A, she acknowledged that the resident had received the above-mentioned medication. She further revealed that she was not aware that this medication should have been on hold. During a surveyor interview on 8/11/2021 at 11:13 AM and 12:24 PM with the Nurse Practitioner, he acknowledged that he approved the discharge orders from the hospital when he assessed the resident on the date of his/her admission. He further indicated that the above-mentioned medication should have been put on hold and not administered. Additionally, he indicated that he would not have expected this medication to be administered since the resident's SBP was not greater than 160.

Based on record review and staff interview, it has been determined that the facility failed to provide each resident adequate supervision and assistance to prevent accidents for 1 of 2 sample residents reviewed for safe patient handling, Resident ID #2. Findings are as follows: Review of the facility policy titled Safe Lifting and Movement of Residents states in part, In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Record review revealed the resident was admitted to the facility in August of 2019 with diagnoses which include, but are not limited to: major depressive disorder, anxiety disorder, [CONDITION(S)], and [CONDITION(S)]. Review of an annual Minimum Data Set (MDS) assessment, dated 5/14/2021, revealed a brief interview for mental status score of 15 out of 15, indicating the resident is cognitively intact. Review of the Smooth Moves Patient Handling Assessment, dated 8/30/2020, reveals that the resident is dependent for all transfers. Furthermore, the resident requires a mechanical lift (used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) with two staff members to transfer. Review of the Facility-Reported Incident revealed that on 7/7/2021 the resident was transferred from his/her bed to a shower chair via a mechanical lift. The resident was later admitted to the hospital. Further review of the Nursing Facility 5 - Day Investigation Report, submitted to the Department of Health on 7/15/2021, states in part, Hoyer bar, hit resident in head. Resident sent to ER [emergency room ] for evaluation .Additionally, it states, During transfer, [the resident] was pumped [sic] on the head from the hoyer lift .Resident became dizzy the next morning and sent to ER . [S/he] had a subdermal hematoma [bleeding in the brain] from the incident. Record review revealed that the resident was admitted to the hospital on 7/8/2021 and discharged back to the nursing home on 7/10/2021. Review of the hospital discharge summary, dated 7/10/2021, states in part, presents from nursing home with headache after being hit in the head with a Hoyer lift the day prior to admission. [S/he] sustained a small laceration of [his/her] forehead .[S/he] currently rates the headache as a 7 out of 10 .[S/he] missed [his/her] [CONDITION(S)] session today as a result of being taken to the emergency room . Further review revealed that the computerized tomography (CT) scan of the brain revealed that the resident sustained a subdural hematoma. Review of the statement, dated 7/8/2021, by certified nursing assistant, CNA, Staff A (who transferred the resident during the incident on 7/7/2021), revealed that during the transfer, the hoyer tilt and bang [the resident] in the forehead and it's started bleeding. Review of the statement, dated 7/8/2021, by CNA, Staff B (who transferred the resident during the incident on 7/7/2021), revealed that during the transfer, The hoyer flip and hit [his/her] forehead. Review of Staff A's in-service training revealed a document titled Certified Nursing Assistant Core Competency List. This document reveals that on 12/20/2020 Staff A performed satisfactorily with both a transfer from bed to chair-two persons using appropriate device and transfer using a mechanical lift. Review of Staff B's in-service training revealed a document titled Certified Nursing Assistant Core Competency List. This document reveals that on 6/8/2021 Staff B performed satisfactorily with both a transfer from bed to chair-two persons using appropriate device and transfer using a mechanical lift. During a surveyor interview with the resident on 7/16/2021 at 10:15 AM, s/he stated, s/he felt the staff wiggling the mechanical lift when being lowered to the shower chair, when the bar swung and hit her/his forehead. During a surveyor interview with Staff A, on 7/16/2021 at 3:25 PM, she acknowledged that the resident was injured during the mechanical lift transfer. She further indicated that the bar of the lift hit the resident's forehead during the transfer. During a surveyor interview on 7/16/2021 at 3:40 PM with the Director of Nursing, he acknowledged that the resident was injured during the mechanical lift transfer on 7/7/2021.