Every finding on record at Greenville Operations RI LLC DBA Greenville Skille

Based on clinical record review and staff interviews, the facility failed to ensure that the drug regimen of 1 of 2 residents reviewed, Resident #1, was free from unnecessary drugs. Specifically, Resident ID #1 was prescribed Lovenox (an anticoagulant medication prescribed to prevent and treat harmful blood clots) and was administered more than twice the intended dose due to the facility's failure to ensure the medication dosage was accurately ordered, verified, and administered. As a result of this medication error, Resident ID #1 sustained actual harm, including bruising, pain, and swelling of the left arm, which required hospitalization. Findings are as follows:The facility-reported incident submitted to the Rhode Island Department of Health on 8/26/2026 revealed that a resident received double the dose of Lovenox due to miscommunication between the nurse and the provider about the unit of weight reported, as the provider assumed the weight reported was in kilograms (kg) but the nurse reported the weight in pounds (lbs.).Record review of the facility policy titled MEDICATION ADMINISTRATION, last revised in November of 2025, states in part, .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss concerns.Review of the manufacturer's prescribing information for Lovenox dated 2025 states in part, .The recommended dose of Lovenox is 1 milligrams/kilograms (mg/kg) every 12 hours administered subcutaneously in patients with acute deep vein thrombosis (DVT, a medical condition where a fresh blood clot forms inside a deep vein and can break free to block blood flow in the lungs).1 mg/kg every 12 hours administered subcutaneously or 1.5 mg/kg once a day administered subcutaneously at the same time every day for inpatient [hospital] treatment of patients with acute deep vein thrombosis.Record review revealed that Resident ID #1 was re-admitted to the facility in June of 2026 with diagnoses including, but not limited to, paroxysmal atrial fibrillation (an irregular heart rhythm that starts suddenly and stops on its own), lymphedema (a chronic medical condition causing swelling usually in an arm or a leg, when lymph fluids build up in tissues because of blockage or damage), and left lower extremity (LLE) acute embolism, and DVT.Record review of a progress note dated 8/10/2026 authored by Registered Nurse (RN), Staff A, revealed the resident had an LLE DVT, and this was reported to the Medical Doctor (MD), Staff B, who ordered the following: hold Eliquis (a medication prescribed to treat and prevent blood clots); start Lovenox 173 mg subcutaneously twice daily for 14 days; and administer Motrin (a medication prescribed to treat minor aches and inflammation) 800 mg one time. Further review of the progress notes dated 8/10/2026 revealed the Lovenox order was changed to 175 mg two times daily due to the availability of dosing calibration.Record review revealed that the resident's weight was 173 lbs. on 8/10/2026, which is equal to 78.47 kg. According to the Lovenox manufacturer's prescribing information, the resident should have been prescribed approximately 78 mg to 80 mg of Lovenox every 12 hours, not 173 mg or 175 mg.Record review of the resident's August 2026 Medication Administration Record (MAR) revealed the resident received an excessive dose of Lovenox on 13 occasions prior to hospitalization on 8/18/2026. Specifically, the resident received 173 mg of Lovenox on two occasions and 175 mg on eleven occasions. The resident experienced actual clinical harm associated with the medication overdose and was admitted to the hospital on [DATE] with left arm bruising, pain, and swelling, as well as pneumonia (an infection that causes inflammation of the air sacs in one or both lungs). Record review of a hospital progress note, dated 8/20/2026, authored by a hematologist (a medical doctor who specializes in the study, diagnosis, treatment, and prevention of diseases related to blood, bone marrow, and lymphatic system) stating in part, .Patient was on Lovenox 175 mg.every 12 hours as per facility paperwork and reported by the patient, which is very high based on [his/her] weight.Recommendations: Hold Lovenox for another 2 weeks given recent bleed and no evidence of clots on recent ultrasound. When safe to resume anticoagulation with no additional bleeding and stable hemoglobin, patient should start on Lovenox 1 mg/kg twice daily dose, current dose appears too high based on [his/her] weight. Even after resuming Lovenox, would recommend checking hemoglobin to document stability.During a surveyor interview on 8/28/2026 at 10:31 AM, RN, Staff A, revealed that she reported the resident's LLE DVT to the physician, Staff B. Staff B requested the resident's weight, and Staff A reported the resident's weight as 173 without specifying whether the weight was in pounds or kilograms. Staff A acknowledged that she initially questioned the Lovenox order because the dose appeared excessive; however, she failed to clarify with Staff B that the resident's weight of 173 was in pounds, not kilograms.Staff A further revealed that she processed the pharmacy's recommendation to change the Lovenox dose from 173 mg to 175 mg due to calibration availability. However, she acknowledged that she failed to verify with the pharmacist whether the revised 175 mg dose was medically appropriate and safe for the resident.During a surveyor interview on 8/28/2026 at 11:27 AM, MD, Staff B, revealed that when Staff A reported the resident's LLE DVT, he intended to initiate Lovenox at a dose of 1 mg/kg twice daily. Staff B requested the resident's weight, and Staff A reported the weight as 173. Staff B acknowledged that he failed to clarify whether the weight was reported in pounds or kilograms and assumed the resident weighed 173 kg. Staff B acknowledged that, based on the resident's actual weight of approximately 80 kg, the resident should have received approximately 80 mg of Lovenox twice daily rather than 175 mg twice daily. During a surveyor interview on 8/28/2026 at 11:34 AM, the Medical Director acknowledged that the resident received an inappropriate dose of Lovenox. The Medical Director further acknowledged that RN, Staff A, and MD, Staff B, should have communicated and clarified the proper unit of measurement for the resident's weight to ensure the Lovenox dose was accurately calculated. The facility's failure to ensure the resident's weight was accurately communicated and verified resulted in Resident ID #1 receiving more than twice the intended dose of Lovenox on 13 occasions. The resident received 173 mg twice and 175 mg eleven times, when the appropriate dose based on the resident's actual weight was approximately 78-80 mg twice daily. As a result, Resident ID #1 sustained actual clinical harm, including left arm bruising, pain, and swelling, requiring acute hospitalization on 8/18/2026. During hospitalization, the hematologist identified the 175 mg dose as very high for the resident's weight, documented a recent bleed, and directed that Lovenox be held for two weeks before resuming at the weight-based dose. The resident's excessive Lovenox administration therefore resulted in actual harm requiring acute medical intervention.Cross reference F 658 and F 842.

Based on clinical record review and staff interviews, the facility failed to ensure that care and services provided to 1 of 2 residents related to anticoagulation therapy, Resident ID #1, were in accordance with accepted professional standards of practice. Specifically, multiple staff members failed to appropriately question, clarify, verify, and communicate concerns regarding Resident ID #1's unusually high Lovenox (an anticoagulant medication prescribed to prevent and treat harmful blood clots) dose despite multiple opportunities to identify and prevent the medication error. These failures resulted in Resident ID #1 receiving more than twice the appropriate dose of Lovenox on 13 occasions. Findings are as follows:The facility-reported incident submitted to the Rhode Island Department of Health revealed that a resident received double the dose of Lovenox due to a miscommunication between the nurse and the provider regarding the unit of weight reported, as the provider assumed the weight reported was in kilograms (kg) but the nurse reported the weight in pounds (lbs.).Record review of the facility policy titled MEDICATION ADMINISTRATION, last revised in November of 2025, states in part, .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss concerns.Review of the manufacturer's prescribing information for Lovenox dated 2025 stated in part, .The recommended dose of Lovenox is 1 milligrams/kilograms (mg/kg) every 12 hours administered subcutaneously in patients with acute deep vein thrombosis (DVT, a medical condition where a fresh blood clot forms inside a deep vein and can break free to block blood flow in the lungs).1 mg/kg every 12 hours administered subcutaneously or 1.5 mg/kg once a day administered subcutaneously at the same time every day for inpatient [hospital] treatment of patients with acute deep vein thrombosis .1. Review of the [NAME] Nursing Procedures Ninth Edition (2023), states in part, SAFE MEDICATION ADMINISTRATION PRACTICES.An adverse drug event (ADE) is defined as harm to the patient, including.physical harm.that results from a medication error. A medication error is a mistake that occurs during medication administration process.A preventable ADE occurs as a result of a clinician error or a systematic error and thus could have been prevented.Verifying the medication order.Verify the essential elements of the medication order are present, including the patient's name, the date and time the order was written, the name of the drug to be administered, the drug dosage, the route of administration, the frequency of administration.specific instructions for use (when applicable).Record review revealed that Resident ID #1 was re-admitted to the facility in June of 2026 with diagnoses including, but not limited to, paroxysmal atrial fibrillation (an irregular heart rhythm that starts suddenly and stops on its own), lymphedema (a chronic medical condition causing swelling usually in an arm or a leg, when lymph fluids build up in tissues because of blockage or damage), and left lower extremity (LLE) acute embolism and DVT.Record review of a progress note dated 8/10/2026 authored by Registered Nurse (RN), Staff A, revealed the resident had an LLE DVT, and this was reported to the Medical Doctor (MD), Staff B, who ordered the following: hold Eliquis (a medication prescribed to treat and prevent blood clots); start Lovenox 173 mg subcutaneously twice daily for 14 days; and administer Motrin (a medication prescribed to treat minor aches and inflammation) 800 mg one time. Further review of the progress notes dated 8/10/2026 revealed the Lovenox order was changed to 175 mg two times daily due to the availability of dosing calibration.Record review revealed that the resident's weight was 173 lbs. on 8/10/2026, which is equal to 78.47 kg. According to the Lovenox manufacturer's prescribing information, the resident should have been prescribed approximately 78 mg to 80 mg of Lovenox every 12 hours, not 173 mg or 175 mg.Record review of the resident's August 2026 Medication Administration Record (MAR) revealed the resident received an excessive dose of Lovenox on 13 occasions prior to hospitalization on 8/18/2026. Specifically, the resident received 173 mg of Lovenox on two occasions and 175 mg on eleven occasions. The resident experienced actual clinical harm associated with the medication overdose and was admitted to the hospital on [DATE] with left arm bruising, pain, and swelling, as well as pneumonia (an infection that causes inflammation of the air sacs in one or both lungs). Record review of a hospital progress note, dated 8/20/2026, authored by a hematologist (a medical doctor who specializes in the study, diagnosis, treatment, and prevention of diseases related to blood, bone marrow, and lymphatic system) stating in part, .Patient was on Lovenox 175 mg.every 12 hours as per facility paperwork and reported by the patient, which is very high based on [his/her] weight.Recommendations: Hold Lovenox for another 2 weeks given recent bleed and no evidence of clots on recent ultrasound. When safe to resume anticoagulation with no additional bleeding and stable hemoglobin, patient should start on Lovenox 1 mg/kg twice daily dose, current dose appears too high based on [his/her] weight. Even after resuming Lovenox, would recommend checking hemoglobin to document stability.1a. During a surveyor interview on 8/28/2026 at 11:27 AM, MD, Staff B, revealed that when Staff A reported the resident's LLE DVT, he intended to initiate Lovenox at a dose of 1 mg/kg twice daily. Staff B requested the resident's weight, and Staff A reported the weight as 173. Staff B acknowledged that he failed to clarify whether the weight was reported in pounds or kilograms and assumed the resident weighed 173 kg. Staff B acknowledged that, based on the resident's actual weight of approximately 80 kg, the resident should have received approximately 80 mg of Lovenox twice daily rather than 175 mg twice daily. 1b. Record review revealed the resident was evaluated by the Nurse Practitioner, Staff C on 8/11 and 8/14/2026. Staff C conducted a medication review and noted that the resident was on Lovenox 175 mg twice daily.During a surveyor interview on 8/28/2026 at 10:25 AM, Staff C acknowledged that she saw the resident and reviewed his/her medications on 8/11 and 8/14/2026. Staff C conducted a medication review and noted that the Lovenox dose was higher than usual and acknowledged that she should have talked to the provider directly to clarify the Lovenox dosage as it was more than twice the recommended dose.2. According to Fundamentals of Nursing 7th Edition by [NAME], Lillis, Lemone, and [NAME] (2011), nurses are legally responsible for carrying out the orders of the physician in charge of a patient unless an order would lead a reasonable person to anticipate injury if carried out. Nurses should question any physician order that is contraindicated by normal practice and/or contraindicated by the patient's present condition.During a surveyor interview on 8/28/2026 at 10:31 AM, RN, Staff A, revealed that she reported the resident's LLE DVT to the physician, Staff B. Staff B requested the resident's weight, and Staff A reported the resident's weight as 173 without specifying whether the weight was in pounds or kilograms. Staff A acknowledged that she initially questioned the Lovenox order because the dose appeared excessive; however, she failed to clarify with Staff B that the resident's weight of 173 was in pounds, not kilograms.Staff A further revealed that she spoke to a pharmacist and processed the pharmacy's recommendation to change the Lovenox dose from 173 mg to 175 mg due to calibration availability. However, she acknowledged that she failed to consult with the pharmacist when she had them on the phone on whether the revised 175 mg dose was medically appropriate and safe for the resident.3. Record review of the Fundamentals of Nursing 7th Edition by [NAME], Lillis, Lemone, and [NAME] (2011), states in part, .Questioning the Medication Order. Nurses are legally responsible for the drugs they administer. Any drug order suspected to be in error should be questioned. The suspected error may be in any part of the order. When preparing to administer a medication, ask: Do the patient's condition, symptoms, health status warrant receiving this medication? Does it make sense for the patient to have this medication? On occasion, the nurse may not think that there is an error in the order but may not understand why the medication has been prescribed. In such instances, ask the prescriber how the order relates to the patient's plan of care. This may prevent a medication error if the wrong medication has been ordered.The nurse is also responsible for double checking the dosage and appropriateness of the medication.Record review of the August 2026 MAR revealed multiple nursing staff members signed for and administered the excessive Lovenox dose on the following dates and times:-RN, Staff A: August 11, 12, 16, and 17, 2026 at 10:00 AM; August 13, 2026, at 10:00 PM-RN, Staff D: August 10, 2026, at 10:00 PM-RN, Staff E: August 12, 2026, at 10:00 PM-RN, Staff F: August 13, 2026, at 10:00 AM; August 15, 2026, at 10:00 PM-Licensed Practical Nurse (LPN), Staff G: August 14, 2026, at 10:00 AM-LPN, Staff H: August 14 and 16, 2026 at 10:00 PM-LPN, Staff I: August 17, 2026, at 10:00 PMDuring a surveyor interview on 8/28/2026 at 10:15 AM, RN, Staff F stated he recognized the Lovenox dosage was higher than usual but acknowledged that he failed to clarify or reconcile the dose with the provider prior to administration.During a surveyor interview on 8/28/2026 at 1:30 PM RN, Staff E, stated he recognized the Lovenox dosage was higher than usual but acknowledged that he failed to clarify or reconcile the dose with the provider prior to administration.Record review failed to reveal evidence that Staff D, G, H, and I, took steps to clarify or validate the resident's excessive Lovenox dosage prior to administration.During a surveyor interview on 8/28/2026 at 11:34 AM, the Medical Director acknowledged that the resident received an inappropriate dose of Lovenox. The Medical Director further acknowledged that RN, Staff A, and MD, Staff B, should have communicated and clarified the proper unit of measurement for the resident's weight to ensure the Lovenox dose was accurately calculated. Additionally, the Medical Director denied receiving a notification from the nursing staff regarding the Lovenox order prior to the resident's hospitalization on 8/18/2026. He stated that he would have expected the nursing staff to exercise clinical judgment, question the unusually high medication dose, and report it directly to him for clinical review prior to administration.The facility's failure of staff to exercise clinical judgment, question and clarify an unusually high medication order, and communicate concerns to the prescribing provider resulted in repeated administration of an excessive Lovenox dose that could have been prevented. Multiple staff members had opportunities to identify the unsafe dose, including the prescribing physician, the nurse who initiated the order, the nurse practitioner who reviewed the medication twice, and nurses who recognized the dose was higher than usual, yet the concern was not effectively communicated or resolved. As a result, Resident #1 received 13 excessive doses of Lovenox, sustained actual clinical harm including left arm bruising, pain, and swelling, and required hospitalization. The Medical Director confirmed that staff should have exercised clinical judgment and reported the unusually high dose for review prior to administration; therefore, the facility failed to provide care and services in accordance with accepted professional standards of practice. Cross reference with F 757 and F 842.

Based on clinical record review and staff interview, the facility failed to maintain medical records that are accurately documented, in accordance with professional standards and practices, for 1 of 2 residents reviewed related to anticoagulation therapy, Resident ID #1.Findings are as follows:A facility-reported incident submitted to the Rhode Island Department of Health on 8/26/2026 revealed that a resident received double the dose of Lovenox due to a miscommunication between the nurse and the provider.Record review revealed that Resident ID #1 was re-admitted to the facility in June of 2026 with a diagnosis including, but not limited to, paroxysmal atrial fibrillation (an irregular heart rhythm that starts suddenly and stops on its own).Review of the August 2026 Medication Administration Record revealed a physician's order dated 8/11/2026 to administer Lovenox (a medication prescribed to prevent and treat harmful blood clots) 175 milligrams twice daily.Further record review revealed that the Lovenox was administered on 8/15/2026 at 10:00 AM by Licensed Practical Nurse, Staff J.During a surveyor interview on 8/28/2026 at 1:40 PM, Staff J indicated that she did not administer the Lovenox to the resident on 8/15/2026. She stated that she must have signed it in error as she does not remember giving the resident the medication.During a surveyor interview on 8/28/2026 at 3:00 PM with the Administrator, she was unable to provide evidence that medical records are accurately documented and maintained.Cross reference F 658 and F 757.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure a system was in place to prepare and serve food and fluids in a form designed to meet residents' prescribed dietary needs. Specifically, the facility failed to ensure nectar thick liquids (mildly thick fluid consistency required to promote safe swallowing) were prepared according to physician orders for 3 of 4 residents reviewed who were prescribed nectar thick liquids ,Resident ID #s 30, 17, and 39. This failure reflects a breakdown in the facility's system for implementing and monitoring prescribed diet modifications and placed residents at risk for choking, aspiration, and other serious complications related to swallowing impairment.Findings are as follows:Review of the undated facility policy titled Thickened Liquids Preparation and Administration states in part, .Residents requiring thickened liquids will receive beverages prepared to the correct consistency as recommended by the Speech Language Pathologist (SPL) or provider. Thickened liquids will be prepared using the facility-approved thickening agent according to the manufacturer's instructions to ensure safe swallowing and reduce the risk of aspiration.1.Record review revealed that Resident ID #30 was initially admitted to the facility in April of 2024 with diagnoses including, but not limited to, Cerebral Palsy and dysphagia (difficulty swallowing).Record review revealed the resident had a gastrostomy tube (GT- a tube surgically placed through the abdomen, directly into the stomach).Record review revealed an order dated 10/3/2025, for a regular diet with pureed texture and nectar thick liquids.Record review of a progress note dated 2/19/2026 at 2:33 PM, revealed that Resident ID #30 was sent to the hospital for an evaluation due to having a distended abdomen accompanied by pain.Review of an additional progress note dated 2/19/2026 at 10:59 PM, revealed the resident was admitted with a diagnosis including, but not limited to, pneumonia.Review of the hospital discharge document dated 2/24/2026 revealed the resident was discharged back to the facility with a diagnosis including, but not limited to, possible aspiration pneumonia (a bacterial infection in the lungs caused by inhaling something other than air, like food or liquid).Review of an After Hours Telehealth Consult authored by a provider dated 2/24/2026, revealed the resident was readmitted to the facility requiring temporary enteral feeding (GT feeding that delivers nutrition directly into the stomach), while awaiting a speech and dietary consultation.Record review revealed the resident was evaluated by the Speech Language Pathologist (SLP) on 2/25/2026. Further review revealed the SLP recommended mildly thick drinks and pureed foods.Record review revealed a physician's order dated 3/2/2026 for a regular diet with pureed texture and nectar thick liquids.During a surveyor observation on 3/4/2026 at 9:14 AM, Nursing Assistant (NA), Staff A, mixed one packet of Honey Consistency [liquids as thick as honey, thicker than nectar consistency] thickening powder into a small plastic cup of milk on Resident ID #30's tray.During a surveyor interview immediately following the above observation, Staff A indicated that he was unaware of Resident ID #30's liquid consistency order and acknowledged that the packet of thickener was for honey consistency and not nectar as ordered. Additionally, he stated, that's just what they gave me.Review of the Honey Consistency thickener packet failed to reveal evidence of instructions for use to obtain a nectar thick consistency. During a surveyor interview on 3/4/2026 at approximately 9:15 AM with Licensed Practical Nurse (LPN), Staff B, she acknowledged that Resident ID #30 should receive nectar thick liquids as ordered. Additionally, she revealed honey thick packets were the only packets available in the facility. Additionally, she revealed thickener is delivered to the unit from the kitchen when packets are unavailable.2a. Record review revealed Resident ID #39 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and dysphagia.Record review of a care plan dated 6/8/2025 revealed the resident is at risk for impaired swallowing with an intervention to provide liquids at the consistency as ordered.Record review revealed a physician's order dated 10/1/2025 for nectar thick liquids. During a surveyor observation of the preparation of Resident ID #39's meal tray on 3/3/2026 at 12:10 PM revealed NA, Staff A, mixing two heaping spoonfuls of a white powder from an unlabeled container into a small plastic cup of juice.During an interview immediately following the above observation, Staff A, revealed he was unaware of the fluid consistency that was ordered for the resident. After the surveyor informed Staff A that the resident required nectar thick liquids, he was unable to determine the appropriate amount of thickener to add to the fluid to achieve nectar thick consistency.During a surveyor interview on 3/3/2026 at 2:22 PM with Dietary Aide, Staff M, he indicated that the kitchen sends up thickener in an unlabeled plastic container without the manufacture's label or thickening instructions.During a surveyor observation at the time of the above interview, the thickener was stored in the kitchen, in a container without the manufactures label or instructions for its use.2b. During a surveyor observation of the preparation of Resident ID #39's meal tray on 3/4/2026 at 8:19 AM revealed NA, Staff A, mixing two heaping spoonful's of a white powder from an unlabeled container into a small plastic cup of juice and two heaping spoonfuls into a larger cup of coffee.During a surveyor interview immediately following the above observation, Staff A, acknowledged that he does not measure the amount of thickener that he adds to liquids. During a surveyor interview on 3/4/2026 at 8:33 AM, the Unit Manager, Staff E, was interviewed in the presence of the LPN, Staff B. Staff E acknowledged that the thickening agent currently being used on the unit was not labeled and did not contain instructions for proper use. She further stated that staff should be utilizing pre-measured thickener packets when preparing thickened liquids. At that time, Staff E brought packets labeled Honey Consistency thickener to the unit, although no residents were prescribed honey consistency liquids.3. Record review revealed Resident ID #17 was admitted to the facility in January of 2021 with diagnoses including, but not limited to, dementia and cognitive communication deficit.Record review revealed a physician's order dated 10/1/2025 for nectar thick liquids.During a surveyor observation of the preparation of Resident ID #17's tray on 3/4/2026 at 8:10 AM, NA, Staff F, mixed one heaping spoonful of white powder into a small 5-ounce plastic cup of milk and one spoonful of white powder into a larger 8-ounce coffee cup.During a surveyor interview immediately following the above observation with Staff F, when asked what was in the container of the white powder, she revealed that it was thickener that is brought from the kitchen. She acknowledged that the container was not labeled and without instructions for use. Additionally, she revealed that she was unaware of how much thickener to add to the liquid, or what the resident's liquid consistency order was.During a surveyor interview on 3/4/2026 at 8:13 AM with Registered Nurse, Staff C, she indicated that two to three scoops should be added to each drink for any resident that requires thickened liquids. Additionally, she acknowledged that there was not a label or instructions for use available for the thickener. During surveyor interviews on 3/4/2026 at 9:33 AM and at 11:25 AM with the Director of Nursing Services, she was unaware of how to achieve the appropriate consistency for nectar thick liquids. Additionally, she acknowledged that the staff had not been educated on how to properly thicken liquids.The facility's failure to ensure a safe and consistent system for the preparation of prescribed thickened liquids, including the use of labeled thickening agents, manufacturer instructions, and staff competency, resulted in staff preparing liquids without knowledge of the required consistency. This systemic breakdown placed residents with dysphagia at risk for aspiration, choking, aspiration pneumonia, and other serious complications that could result in serious injury, serious harm, serious impairment, or death.

Based on clinical record review and staff interview, the facility failed to implement all required components of the facility-wide assessment and failed to annually review the facility's policies and procedures. Findings are as follows:Review of the Facility Assessment dated 1/5/2026 states in part, .Policies and Procedures: Review existing policies and procedures to ensure they meet current professional standards of practice and regulatory requirements. Identify any gaps or areas requiring updates based on evaluation findings.Record review failed to reveal evidence of annual reviews of the policies and procedures.Record review failed to reveal evidence that the facility assessment addressed the following:-any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities, and food and nutrition services.-contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during normal operations and emergencies.-health information technology resources such as systems for electronically managing patient records and electronically sharing information with other organizations.-maintain a plan to maximize recruitment and retention of direct care staff.During a surveyor interview on 3/5/2026 at 12:02 PM with the Administrator she was unable to provide evidence that the facility reviews all of their policies and procedures annually.

Based on surveyor observation, clinical record review, and staff and resident interviews, the facility failed to provide an ongoing activity program on the weekends to support residents in their choice of activities based on the comprehensive assessment, care plan, and preferences. This affected all residents in the facility specifically for 5 of 9 residents reviewed, Resident ID #s 7, 42, 49, 70, and 71. Findings are as follows:Review of a facility policy titled, Resident's/Patient's Choice dated 8/7/2023 states in part, Resident's/Patients have the right to participate or not participate in leisure and recreation of their choosing. To provide opportunities for leisure, recreation, and social involvement.Residents/Patients will be invited and encouraged to assist in the planning and development of recreation programming.Residents/Patients will be invited to attend activities of preference and interest and will be provided the opportunity to participate in structured and individual programs.During a surveyor interview on 3/4/2026 at approximately 1:00 PM with the members of Resident Council, the residents revealed that there are no activities offered on Saturdays and Sundays.Review of the Activities schedules for February and March 2026 revealed no activity staff were scheduled to work on Saturdays and Sundays.1. Record review revealed that Resident ID #7 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, anxiety.Review of a Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Further review of the MDS revealed that doing his/her favorite activities is very important.Review of a care plan dated 10/9/2024 revealed that Resident ID #7 states that it is important to have the opportunity to engage in daily routines that are meaningful relative to their preferences.2. Record review revealed that Resident ID #42 was admitted to the facility in July of 2023 with diagnoses including, but not limited to, anxiety and depression.Review of a Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. Further review of the MDS revealed that doing his/her favorite activities is somewhat important.Review of a care plan dated 7/20/2023 revealed that Resident ID #42 states that it is important to have the opportunity to engage in daily routines that are meaningful relative to their preferences.3. Record review revealed that Resident ID #49 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, anxiety and depression.Review of a Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. Further review of the MDS revealed that doing his/her favorite activities is somewhat important.Review of a care plan dated 8/7/2025 revealed that Resident ID #49 states that it is important to have the opportunity to engage in daily routines that are meaningful relative to their preferences.4. Record review revealed that Resident ID #70 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, depression and anxiety.Review of a Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. Further review of the MDS revealed that doing his/her favorite activities is very important.Review of a care plan dated 7/29/2025 revealed that Resident ID #70 states that it is important to have the opportunity to engage in daily routines that are meaningful relative to their preferences.5. Record review revealed that Resident ID #71 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, adjustment disorder and dementia.Review of a Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 indicating moderately impaired cognition. Further review of the MDS revealed that doing his/her favorite activities is somewhat important.Review of a care plan dated 7/29/2025 revealed that Resident ID #70 states that s/he enjoys leisure activities including coffee social, card playing, games of chance and bingo.During a surveyor interview on 3/5/2026 at 10:14 AM with the Administrator she acknowledged that they do not have activities staff scheduled and that none of the residents are offered structured activities on the weekends.

Based on clinical record review and staff interview, the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments, and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment as required for 5 of 5 nursing staff reviewed related to appropriately thickening liquids, Staff A, B, C and F, and the Director of Nursing Services (DNS). Additionally, 3 of 5 staff members failed to follow and explain the difference between contact and enhanced barrier precautions (EBP), Staff E, G, and H; and the facility failed to provide competencies for 3 of 10 staff reviewed related to EBP and contact precautions, Staff H, I, and J.Findings are as follows:Record review of the Facility Assessment Template dated 1/5/2026 revealed that staff training and competencies are necessary to provide the level and types of support and care needed for the resident population.1a. Record review revealed a physician's order for Resident ID #30 dated 10/3/2025 for a regular diet with pureed texture and nectar thick liquids (mildly thick liquid consistency to assist with safe swallowing).During a surveyor observation on 3/4/2026 at 9:14 AM, Nursing Assistant (NA), Staff A, mixed one packet of Honey Consistency [liquids as thick as honey, thicker than nectar consistency] thickening powder into a small plastic cup of milk on Resident ID #30's tray.During a surveyor interview immediately following the above observation, Staff A indicated that he was unaware of Resident ID #30's liquid consistency order and acknowledged that the packet of thickener was for honey consistency and not nectar as ordered. Additionally, he stated, that's just what they gave me.During a surveyor interview on 3/4/2026 at approximately 9:15 AM with Licensed Practical Nurse (LPN), Staff B, she acknowledged that Resident ID #30 should receive nectar thick liquids as ordered. Additionally, she revealed honey thick packets were the only packets available. 1b. Record review revealed Resident ID #39 has a physician's order dated 10/1/2025 for nectar thick liquids. During a surveyor observation of the preparation of Resident ID #39's meal tray on 3/3/2026 at 12:10 PM revealed NA, Staff A, mixing two heaping spoonfuls of a white powder from an unlabeled container into a small plastic cup of juice.During an interview immediately following the above observation, Staff A, revealed he was unaware of the fluid consistency that was ordered for the resident. After the surveyor informed Staff A that the resident required nectar thick liquids, he was unable to determine the appropriate amount of thickener to add to the fluid to achieve nectar thick consistency.1c. Record review revealed Resident ID #17 had a physician's order dated 10/1/2025 for nectar thick liquids.During a surveyor observation of the preparation of Resident ID #17's tray on 3/4/2026 at 8:10 AM, NA, Staff F, mixed one heaping spoonful of white powder into a small 5-ounce plastic cup of milk and one spoonful of white powder into a larger 8-ounce coffee cup.During a surveyor interview immediately following the above observation with Staff F, when asked what was in the container of the white powder, she revealed that it was thickener that was sent up from the kitchen. She acknowledged that the container was not labeled and without instructions for use. Additionally, she revealed that she was unaware of how much thickener to add to the liquid, or what the resident's liquid consistency order was.During a surveyor interview on 3/4/2026 at 8:13 AM with Registered Nurse, Staff C, she indicated that two to three scoops should be added to each drink for any resident that requires thickened liquids. Additionally, she acknowledged that there was not a label or instructions for use available for the thickener. During surveyor interviews on 3/4/2026 at 9:33 AM and at 11:25 AM with the DNS, she was unaware of how to achieve the appropriate consistency for nectar thick liquids. Additionally, she acknowledged that the staff had not been educated on how to properly thicken liquids. Furthermore, she could not provide evidence of staff education or competencies related to appropriately thickening liquids.2. Record review of the facility provided document titled Infection Control Nursing Principles and Practices, dated 2016 states in part, .Contact precautions for organisms that are transmitted by direct or indirect contact with the patient or patient's environment. Requires gown & gloves before entering patient's room.Record review of the Centers for Disease Control and Prevention sign related to EBP stating, Providers and staff must also: Wear gloves and a gown [PPE - Personal Protective Equipment] for the following High-Contact Resident Care Activities.During a surveyor observation on 3/2/2026 at 9:35 AM, Resident ID #79 was noted to have a contact precaution sign posted outside his/her room. NA Staff G was observed going in the room and assisted the resident with his/her meal without wearing a gown and gloves before entering the room, as required.During a surveyor interview with Staff G following the above observation, she revealed that she was only told to wear PPE when providing care and not for anything else. Additionally, she acknowledged that the sign stated that Resident ID #79 was on contact precautions and was unable to explain the difference between contact precautions and EBP.During a surveyor observation on 3/3/2026 at 12:27 PM revealed NA, Staff H, entering Resident ID #79's room without a gown and gloves.During a surveyor interview with Staff H following the above observation, she acknowledged that she did not wear a gown or gloves prior to entering Resident ID #79's room and revealed that she was unaware of the difference between EBP and contact precautions.During a surveyor interview on 3/3/2026 at 12:31 PM with the Unit Manager, Staff E, she was unable to accurately describe the difference between contact precautions and EBP. She stated that universal precautions (standard precautions) were the same as EBP. Additionally, she added that a resident on contact precaution only requires wearing PPE when providing care, changing a wound dressing, or administering an intravenous medication.During a surveyor interview on 3/3/2026 at 2:28 PM with the DNS, she revealed that she would expect all staff to follow the precaution signs for each resident and to know the difference between EBP, contact, and standard precautions.3. Record review of the Facility Assessment Template dated 1/5/2026 revealed that staff competencies must be completed upon hire and annually.Record review failed to reveal evidence that Staff H, I, and J, received their annual trainings for EBP and contact precaution practices, as required.During a surveyor interview on 3/5/2026 at 12:50 PM with the DNS, she was unable to provide evidence that the Staff H, I, and J, received their annual trainings related to EBP and contact precautions within the last year, as required.

Based on surveyor observation, clinical record review, resident and staff interview, the facility failed to accommodate the residents' food preferences for 4 of 4 residents reviewed who verbalized concerns regarding their food preferences, Resident ID #s 11, 13, 31, and 65.Findings are as follows:Record review of the facility policy titled, Resident Rights Under Federal Law last reviewed on 6/12/2025 states in part, .The resident has the right to make choices about aspects of his/her life in the facility that are significant to the resident. 1. Record review revealed Resident ID #11 was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, anemia.Record review of Resident ID #11's Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderately impaired cognition.During a surveyor interview on 3/2/2026 at 12:42 PM with Resident ID #11, s/he revealed that the facility does not follow his/her diet preferences indicating that the diet slips do not match the food being served.During a surveyor observation following the above interview revealed the resident was served a pork chop, mashed potatoes, and cake.Record review of his/her diet slip revealed that s/he was supposed to receive parslied noodles and pudding. 2. Record review revealed Resident ID #13 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, heart failure.Record review of Resident ID #13's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition.During a surveyor interview on 3/2/2026 at 12:40 PM with Resident ID #13, s/he revealed that the facility serves incorrect meals all the time. S/he revealed that despite selecting his/her preferences and reporting the discrepancies to dietary staff, s/he consistently receives items that do not match his/her meal ticket.During a surveyor observation following the above interview revealed that the resident was served mashed potatoes and vanilla cake.Record review of his/her diet slip revealed that s/he was supposed to receive mashed sweet potato and chocolate covered pumpkin cake.Further observation of breakfast on 3/5/2026 at approximately 8:30 AM revealed that the resident received scrambled eggs and toast.Record review of his/her diet slip revealed that s/he was supposed to receive sliced bread, egg whites, and an egg sandwich. 3. Record review revealed Resident ID #31 was admitted to the facility in October of 2023 with a diagnosis including, but not limited to, type 2 diabetes mellitus.Record review of Resident ID #31's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition.During a surveyor interview on 3/2/2026 at 12:40 PM with Resident ID #31, s/he revealed that the facility serves incorrect meals all the time. S/he revealed that despite selecting his/her preferences and reporting the discrepancies to dietary staff, s/he consistently receives items that do not match his/her meal ticket.Surveyor observation of the resident's meal following the above interview s/he received chicken, french fries, and cakeRecord review of his/her diet slip revealed that s/he was supposed to receive a baked pork chop, baked sweet potato wedges, and pumpkin pie.Further observation of breakfast on 3/5/2026 at 9:00 AM revealed that s/he received french toast and failed to have egg whites.Record review of his/her diet slip revealed that s/he was supposed to receive regular toast and egg whites.During a surveyor interview with the Nursing Assistant, Staff H, following the above observation, she acknowledged that Resident ID #31 was not served the menu items listed on the diet slip that s/he had requested to receive for breakfast. 4. Record review revealed Resident ID #65 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, anemia.Record review of Resident ID #65's Quarterly MDS assessment dated [DATE] revealed s/he has a BIMS score of 15 out of 15, indicating intact cognition.During a surveyor interview with Resident ID #65 on 3/3/2026 at 12:34 PM, s/he revealed that the facility serves incorrect meals and at times, not enough nutrition. S/he revealed that despite selecting his/her preferences and reporting the discrepancies to dietary staff, s/he consistently receives items that do not match his/her diet slip.During a surveyor observation of Resident ID #65's meal following the above interview revealed s/he received vanilla puddingRecord review of his/her diet slip revealed that s/he was supposed to receive chocolate pudding.During a surveyor interview on 3/5/2026 at 10:11 AM with the Regional Food Service Manager, he acknowledged that the diet slip should match what is being served for all meals. Additionally, he would expect the staff to notify the residents when there are changes prior to the meals being served.

Based on surveyor observation, clinical record review, staff and resident interview, the facility failed to ensure residents are free from neglect relative to providing meals for 1 of 1 resident reviewed who had a recent diet order change, Resident ID #30.Findings are as follows:Review of the facility policy titled Abuse Prohibition last revised on 10/24/2022 states in part, .prohibit.neglect.for all patients.Neglect is defined as the failure.or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information.Review of the undated facility policy titled Transmission of Diet Orders states in part, .Nursing staff will send the diet order to the food and nutrition services department as soon as possible after admission or diet change (preferably within 1 to 2 hours) .Record review revealed that Resident ID #30 was initially admitted to the facility in April of 2024 with diagnoses including, but not limited to, Cerebral Palsy and dysphagia (difficulty swallowing).Record review of a progress note dated 2/19/2026 revealed the resident was sent to the hospital for an evaluation and admitted with a diagnosis including, but not limited to, pneumonia.Review of an After Hours Telehealth Consult authored by a provider dated 2/24/2026 revealed the resident was readmitted to the facility requiring temporary enteral feeding (gastrostomy tube- a feeding that delivers nutrition directly into the stomach) while awaiting a speech and dietary consultation.Record review revealed the resident was evaluated by the Speech Language Pathologist (SLP) on 2/25/2026. Further review revealed the SLP recommended mildly thick drinks and pureed foods.Record review revealed a physician's order dated 3/2/2026 for a regular diet with pureed texture and nectar thick liquids (mildly thick liquids).During a surveyor observation on 3/3/2026 at approximately 12:30 PM, Resident ID #30 did not have a lunch tray brought to the unit.During a surveyor interview on 3/3/2026 at 12:34 PM with the resident, s/he indicated that s/he hadn't eaten dinner yesterday or breakfast or lunch that day. The resident further indicated that s/he was hungry.During a surveyor interview on 3/3/2026 at 12:43 PM with Nursing Assistant, Staff A, he revealed that the resident did not get a breakfast tray that morning and was not fed breakfast or lunch that day.During surveyor interviews on 3/3/2026 at 12:38 PM and at 12:47 PM with Licensed Practical Nurse (LPN), Staff B, she indicated that the resident was upgraded from a tube feeding to a pureed texture diet yesterday afternoon, on 3/2/2026. She further indicated that a diet order communication form had not been sent down to the kitchen, so kitchen staff were unaware that the resident needed a tray. Review of the Diet Order & Communication Form revealed it wasn't completed until 3/3/2026 at 12:30 PM by LPN, Staff B, after it was brought to her attention by the surveyor. Further review revealed the slip was for a Diet Order Change to pureed texture and nectar thick liquids.During a surveyor interview on 3/3/2026 at 2:12 PM with the Food Service Director, he revealed that diet orders are not changed with the kitchen until the kitchen receives the Diet Order & Communication Form from nursing. Additionally, he revealed that Resident ID #30 did not receive meals from the kitchen prior to receiving the communication form on 3/3/2026 at approximately 12:30 PM, after lunch had been delivered to the unit. He further revealed that the first tray that had been delivered from the kitchen recently was the late lunch tray on 3/3/2026.During a surveyor interview on 3/3/2026 at 2:43 PM with the Director of Nursing Services, she revealed that she had confirmed the new diet order with the provider on 3/2/2026 and did not complete the communication form for the new diet order to be sent to the kitchen. She further revealed that the dietitian usually gives the diet slips to the kitchen, however the dietitian did not complete the form for Resident ID #30 on 3/2/2026.

Based on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to physician's orders for 1 of 2 resident's reviewed for pressure ulcers, Resident ID #10.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.Record review revealed that the resident was admitted to the facility in April of 2020 with diagnoses including, but not limited to, dementia and multiple sclerosis (a disease that causes breakdown of the protective covering of nerves. causing numbness, weakness, trouble walking, vision changes and other symptoms).Record review revealed a physician's order for weekly skin assessments to be completed every Monday.Review of care plan dated 9/22/2024 revealed that the resident is at risk for pressure injury and skin breakdown related to incontinence and decreased mobility with interventions including, but not limited to, complete a weekly skin assessment by a licensed nurse.Record review failed to reveal evidence of completed skin assessments for 2/9, 2/16, 2/23, and 3/2/2026. Additionally, a skin assessment was not completed until 3/4/2026, after it was brought to the facility's attention by the surveyor.During a surveyor interview on 3/4/2026 at 11:16 AM with Registered Nurse, Staff C, she acknowledged that the last skin assessment was completed on 2/2/2026.During a surveyor interview on 3/4/2026 at 11:40 AM with the Director of Nursing Services she was unable to provide evidence that the facility completed the skin assessments as ordered.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure the residents receive treatment and care in accordance with professional standards of practice related to a wound vacuum device system (wound vac - a medical-grade suction system used for negative pressure wound therapy to accelerate the healing of chronic or acute, complex wounds) for 1 of 1 resident reviewed, Resident ID #79.Findings are as follows:Record review of the policy last reviewed on 5/1/2025 titled Skin Integrity and Wound Management states in part, .For surgical wounds.incisions.follow specific orders from surgeon.Record review revealed the resident was admitted in February of 2026 with a diagnosis including, but not limited, open wound of right back wall of thorax (area between the neck and the abdomen) with penetration into the thoracic cavity.Record review of the document titled Continuity of Care dated 2/27/2026 revealed an orthopedic spine surgery discharge instruction to continue with wound vac therapy. Further review revealed a setting recommendation of 125 mmHg (millimeters of mercury) negative pressure.Record review of a progress note dated 2/27/2026 revealed that the wound vac was discontinued and was changed to a daily dressing.Record review of a progress note dated 3/1/2026 at 6:50 PM revealed that the surgeon was notified of the change and gave a new recommendation to apply the wound vac to resident's back incision with 75 mmHg negative pressure continuously.Record review failed to reveal evidence that this new surgeon's recommendation to place the resident back on a wound vac at 75 mmHg negative pressure was reported to the physician.Record review of the Integrated Wound Care note dated 3/2/2026 revealed the resident has a mid/lower back surgical site with instructions to apply the wound vac per the surgeon's recommendations which was 75 mmHg.Surveyor observations revealed the resident's wound vac setting was at 125 mmHg instead of the surgeon's recommendation of 75 mmHg on the following dates and times:-3/3/2026 at 12:25 PM and 1:22 PM-3/4/2026 at approximately 9:00 AMDuring a surveyor interview on 3/3/2026 at 2:16 PM with Unit Manager, Staff E, she revealed that she was unaware that the resident's wound vac is supposed to be set at 75 mmHg negative pressure and acknowledged that it was set at 125 mmHg negative pressure.During a surveyor interview on 3/4/2026 at 3:04 PM with the Wound Nurse, she revealed that she was unaware of the surgeon's change of recommendation for the wound vac's negative pressure from 125 mmHg to 75 mmHg.During a surveyor interview on 3/4/2026 at 9:45 AM with the surgeon's office secretary, she acknowledged that the surgeon recommended applying the wound vac to his/her back incision with 75 mmHg negative pressure continuously.Record review of a nursing progress note dated 3/4/2026 at 8:37 PM revealed that the wound vac's setting was changed to 75 mmHg per the surgeon's recommendation, after it was brought to their attention to the surveyor.During a surveyor interview on 3/5/2026 at 9:59 AM with the Director of Nursing Services, she was unable to provide evidence that the surgeon's recommendation for the wound vac setting was reported to the provider and was followed per the facility policy.During a surveyor interview on 3/5/2026 at 11:48 AM with the Medical Director, he revealed that he would expect the staff to notify him of the surgeon's recommendations timely and to follow the surgeon's recommendations of applying the wound vac continuously at 75 mmHg.

Based on clinical record review and staff interview, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing relative to weekly wound documentation and having a wound treatment in place for 1 of 1 resident observed with a stage 3 pressure ulcer (deep, open wound exposing the subcutaneous tissue caused by pressure on the skin for an extended period time), Resident ID #10. Findings are as follows:Review of a facility policy titled, Skin Integrity and Wound Management dated 5/1/2025 states in part, .provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing.perform daily monitoring of wounds or dressings for presence of complications or declines. Document daily monitoring of ulcer/wound site with or without dressing. Monitor: Status of dressing.Status of the tissue surrounding the dressing.Signs of decline in the wound status.According to Pearson's Nursing A Concept-Based Approach to Learning, third edition 2019, which states in part, .Pressure injuries with full-thickness tissue loss (stages 3 and 4 .) .Clinical Therapies .dressings that maintain moisture are typically used .these dressings protect the wound from friction and bacterial colonization .Record review revealed that the resident was admitted to the facility in April of 2020 with diagnoses including, but not limited to, dementia and multiple sclerosis (a disease that causes breakdown of the protective covering of nerves. causing numbness, weakness, trouble walking, vision changes and other symptoms).A. Review of a care plan dated 9/22/2024, revealed the resident is at risk for skin breakdown due to incontinence and decreased mobility with an intervention including, but not limited to, provide wound treatment as ordered.Review of a Skin and Wound Evaluation dated 2/4/2026 revealed the resident has a new facility acquired, Stage III pressure ulcer (a serious skin injury characterized by full-thickness skin loss, exposing subcutaneous fat) to his/her left buttock, measuring 3.2 centimeters (cm) by 1.9 cm.Record review revealed the following physician's orders:-apply medi-honey (a wound treatment) and cover with a dry clean dressing daily with a start date of 2/5/2026 and an end date of 2/10/2026.-apply calcium alginate (a wound treatment) and cover with a bordered gauze with a start date of 2/17/2026.Record review failed to reveal evidence of a treatment order from 2/10/2026 until 2/17/2026.Record review failed to reveal evidence that wound care and daily monitoring of the wound were completed from 2/10/2026 until 2/17/2026.During a surveyor interview on 3/4/2026 at 11:16 AM with Registered Nurse (RN), Staff C acknowledged that there was not a wound treatment in place for Resident ID #10 from 2/10/2026 through 2/17/2026. During a surveyor interview on 3/12/2026 at 12:49 PM with the Medical Director, he revealed that he would expect a resident with a Stage III pressure ulcer to have a treatment in place. Additionally, he revealed that he was unaware that the resident did not have a treatment order in place for 7 days. B. Review of the care plan revealed an intervention dated 11/3/2025 to complete a weekly wound assessment including measurements and a description of the wound status.Record review failed to reveal evidence of wound measurements and a description of the wound for the following weeks:-2/8-2/14/2026-2/22-2/28/2026During a surveyor interview on 3/4/2026 at 11:16 AM with Staff C, she acknowledged that there were no wound measurements or a description of the wound for the above noted dates per the facility policy and the care plan.During a surveyor interview on 3/4/2026 at 11:40 AM with the Director of Nursing Services, she was unable to provide evidence that the facility provided wound care consistent with professional standards for Resident ID #10.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 4 residents reviewed for oxygen use, Resident ID #s 9 and 80.Findings are as follows:According to Lippincott Nursing Procedure Ninth Edition 2023, page 621, states in part, .Verify the practitioner's order for oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed .1. Record review revealed Resident ID #9 was admitted to the facility in July 2023 with diagnoses including, but not limited to, congestive heart failure (when the heart muscle is too weak or stiff to pump blood efficiently, causing blood and fluids to back up into the lungs, liver, or legs), and dementia.During surveyor observations on the following dates and times, Resident ID #9 was observed receiving 2 liters (L) of oxygen via nasal cannula: -3/3/2026 at 8:45 AM -3/4/2026 at 8:00 AM -3/5/2026 at 8:15 AMRecord review failed to reveal evidence of a physician's order for the use of oxygen, as required. During a surveyor observation on 3/5/2026 at approximately 10:30 AM, in the presence of Licensed Practical Nurse (LPN), Staff D, Resident ID #9 was observed in bed receiving oxygen via nasal cannula.During a surveyor interview on 3/5/2026 at 10:42 AM with the LPN, Staff D, she acknowledged that the resident was receiving oxygen and did not have a physician's order. 2. Record review revealed Resident ID #80 was admitted to the facility in January of 2026 with diagnoses including, but not limited to, respiratory failure, and anxiety.During surveyor observations on the following dates and times, Resident ID #80 was observed receiving 2 L of oxygen via nasal cannula: -3/2/2026 at 9:14 AM -3/2/2026 at 12:30 PM -3/3/2026 at 7:55 AM-3/3/2026 at11:20 AM Record review failed to reveal evidence of a physician's order for the use of oxygen, as required. Additionally, Resident ID #80 did not have cautionary, or safety signage posted on the room door indicating the use of oxygen. During a surveyor interview on 3/3/2026 at 2:16 PM with the Unit Manager, Staff E, she acknowledged that Resident ID #80 was receiving oxygen and did not have a physician's order. During a surveyor interview on 3/3/2026 at 2:28 PM with the DNS, she acknowledged that the resident was being receiving oxygen and did not have a physician's order.

Based on clinical record review and staff interview, the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents reviewed for fluid management related to dialysis, Resident ID #11.Findings are as follows:Review of a facility policy titled Nutrition/Hydration Care and Services last reviewed 2/1/2023 states in part, .When a physician.orders a fluid restriction due to a specific clinical condition.dietary will calculate the amount of fluids to be provided on the meal trays.nursing will calculate the remaining amounts of fluids allotted for each shift.monitor intake and output.a. Record review revealed the resident was admitted to the facility in July of 2025, with a diagnosis including, but not limited to, end stage renal disease (ESRD).Record review revealed Resident ID #11 receives dialysis three times a week.Record review revealed a physician's order with a start date of 1/12/2026 for a 1200 milliliter (mL) fluid restriction per day to monitor each shift and for 11 PM to 7 AM shift to total the amount for 24 hours.Review of a care plan dated 8/2/2025 revealed Resident ID #11 is at nutritional risk related to ESRD and is dependent on dialysis with a fluid restriction of 1200 mL with an intervention to monitor intake.Review of the February and March 2026 Medication Administration Record (MAR) revealed the intake was not being totaled every 24 hours as ordered.Record review of written documents titled Dialysis Fluid Restriction revealed they dd not equal the amount documented on the MAR for 28 of 28 opportunities in the month of February.Record review failed to reveal evidence that Resident ID #11's fluid intake was being consistently and accurately monitored.b. Record review of the February 2026 MAR revealed the intake amounts documented were over the 1,200 fluid restriction on the following dates:-2/3- 1,320 mL-2/17- 1,320 mL-2/20- 2,080 mL-2/21- 2,160 mL -2/22- 1,320 mL -2/26- 1,320 mL-2/27- 1,240 mLRecord review failed to reveal evidence that a provider was notified that the resident's intake was over the ordered fluid restriction on the above dates.During a surveyor interview on 3/3/2026 at 12:47 PM with Licensed Practical Nurse, Staff B, she acknowledged that the written intake documentation and the documentation on the MAR were inconsistent and should not be. Additionally, she could not explain the amount of fluids that the resident actually drank and indicated that she writes what the intake is supposed to be. During a surveyor interview on 3/5/2026 at 10:54 AM with the Director of Nursing Services, she indicated that she would expect fluid intakes to be accurately documented and the written fluid intake documentation to match the documentation in the MAR.During a surveyor interview on 3/5/2026 at 11:48 AM with the Medical Director, he indicated that he would expect a resident's fluid intake to be accurately documented and monitored if there is a physician's order for a fluid restriction. Additionally, he revealed that he would expect that a provider would be notified if the resident's intake is over the ordered fluid restriction.

Based on clinical record review and staff interview, the facility failed to address pharmacy recommendations in a timely manner for 2 of 5 residents reviewed for the January pharmacy recommendations, Resident ID #s 11 and 52. Findings are as follows:Review of a facility policy titled, Medication Regimen Review and Reporting dated 1/2024 states in part, .The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly.The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols.1. Record review revealed that Resident ID #11 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, post-traumatic stress disorder and anxiety.Review of a Note to Attending Physician/Prescriber dated 1/27/2026, authored by the facility's contracted pharmacy, revealed a recommendation for Resident ID #30 to, .Please consider a trial dose reduction: trazadone 75 mg [milligram] HS [hour of sleep], Quetiapine 75 mg QAM [every morning], Sertraline 150 mg QD [every day].Further review failed to reveal evidence that the facility addressed the above pharmacy recommendation within 30 days per the policy.Review of a Note to Attending Physician/Prescriber dated 2/25/2026, authored by the facility's contracted pharmacy, revealed a recommendation for Resident ID #30 to, Please consider a trial dose reduction: trazadone 75 mg HS, Quetiapine 75 mg QAM, Sertraline 150 mg QD.Further review revealed documentation indicating that the Medical Director agreed with a dose reduction for Trazadone 75 mg and no change for the other medications. This document was undated and the dose reduction for the trazadone was started on 3/5/2026, after the surveyor brought this to the facility's attention. 2. Record review revealed that Resident ID #52 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, Parkinson's and schizophrenia.Review of a Nursing Recommendations/Nurse Manager Report dated 1/30/2026 states in part, .Please update Lasix 100mg QD order to reflect how pharmacy is sending. Please change to 80 mg + 20 mg tablet to be given together to equal 100 mg dose.Record review failed to reveal evidence that the above recommendation was acted on within 30 days per the policy.During a surveyor interview on 3/5/2026 at 2:25 PM with the Director of Nursing Services she was unable to provide evidence that the pharmacy recommendations for January 2026 were acted on within 30 days per the facility policy.

Based on clinical record review and staff interview, the facility failed to ensure that residents are free from any significant medication error, for 1 of 1 resident reviewed related to warfarin therapy (a medication prescribed to reduce the blood's ability to clot, preventing or treating blood clots), Resident ID #13.Findings are as follows:Review of a document titled, A Guide to Taking Warfarin created by the American Heart Association, states in part, .It's important to monitor the INR [International Normalized Ratio, a standardized way to measure the prothrombin time [PT] of a blood sample. The INR is used to monitor the effectiveness of Warfarin] at least once a month and sometimes as often as twice weekly to make sure the level of warfarin remains effective. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding .Record review revealed the resident was admitted to the facility in December of 2025 with diagnoses including, but not limited to, atrial fibrillation (an irregular heartbeat) and heart failure (a chronic, progressive condition where the heart muscle cannot pump enough blood to meet the body's needs, often causing fluid buildup in the heart, lungs and legs).Record review revealed a physician's order to obtain a PT/INR laboratory test on 2/25/2026.The PT/INR was completed on 2/25/2026 but the results were not communicated to the physician until 2/26/2026. This delay in reporting the Pt/INR resulted in the resident missing one dose of Warfarin on 2/25/2026.Further record review of a progress note dated 2/26/2026 revealed a physician's order to obtain the PT/INR on Monday, 3/2/2026.Record review failed to reveal evidence that the PT/INR was obtained on 3/2/2026 as ordered.During a surveyor interview on 3/3/2026 at 2:16 PM with the Unit Manager, Staff E, she acknowledged that the resident missed his/her warfarin dose on 2/25/2026 and that the PT/INR result was not reported to the physician until 2/26/2026. Additionally, she acknowledged that the PT/INR should've been obtained on 3/2/2026 per the physician's order.During a surveyor interview with the Medical Director on 3/5/2026 at 11:48 AM, he indicated that he would expect the PT/INR to be obtained and reported to him in a timely manner, as he needs to review the results to determine the appropriate dose of warfarin to prescribe.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication rooms and 1 of 3 medication carts observed. Findings are as follows:Review of a facility policy titled, Storage of Medication dated 1/2026 states in part, Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration.1. During a surveyor observation on 3/4/2026 at 8:07 AM, of the medication room on the Lilly Unit, in the presence of Registered Nurse (RN), Staff C and Licensed Practical Nurse, Staff K, revealed two bottles of Lorazepam 2 milligrams/milliliter (mg/ml) opened and undated. The manufacturer's instructions on the box state to discard the bottle 90 days after opening.During a surveyor interview immediately following the observation, Staff C and K acknowledged that the Lorazepam was opened and undated.2. During a surveyor observation on 3/4/2026 at 9:05 AM in the presence of Certified Medication Technician, Staff L of the medication cart on the Sun Unit, revealed one bottle of biotene mouth wash in a pump spray bottle without resident identifiers and without a cover for the mouth nozzle. Additionally, the nozzle was noted to have debris and hair on it.During a surveyor interview immediately following the observation, Staff L acknowledged that the bottle of biotene did not have any resident identifiers and the mouth nozzle was dirty.During a surveyor interview on 3/4/2026 at 11:39 AM with the Director of Nursing Services, she was unable to provide evidence that the facility stored drugs and biologicals in accordance with currently acceptable professional standards.

Based on record review, and staff and resident's family interview, the facility failed to provide dental services for 1 of 1 resident with dentures, Resident ID #1. Additionally, the facility failed to have a policy that addressed instances when a resident's dentures were lost or damaged.Findings are as follows:Record review of a community reported complaint submitted to Rhode Island Department of Health on 12/1/2025 by Resident ID #1's family member alleges, the resident's upper dentures were missing, and the facility did not know that s/he was supposed to have upper dentures. Record review of the policy titled, .Oral Health last reviewed on 9/15/2025, states in part, .A patient's oral health will be evaluated as part of the nursing assessment upon admission, annually, and with a change in oral health.1. Record review revealed the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, dementia and mild protein calorie malnutrition.During a surveyor interview on 12/2/2025 at approximately 11:00 AM with the resident's family member, s/he indicated that the resident utilizes upper dentures and did not have the upper dentures when s/he last visited the resident on 12/28/2025. Record review of the document titled Oral Health Evaluation completed by Registered Nurse, Staff A, on 2/28/2025, revealed that the resident has a full upper denture.Record review of Staff A's nursing progress notes dated 2/28/2025 revealed that the resident's dentures appear healthy.Record review of the resident's plan of care and November 2025 Treatment Administration Record (TAR) failed to reveal evidence that the resident has been receiving assistance or care related to his/her dentures. During a surveyor interview on 12/2/2025 at 11:55 AM with Nursing Assistant (NA), Staff B, she revealed that she was unsure if the resident utilizes dentures. Additionally, she revealed that the NAs receive report from the nurse if a resident needs to have their dentures for meals.During a surveyor interview on 12/2/2025 at 12:00 PM with Licensed Practical Nurse, Staff C, she revealed that she was unaware if the resident utilizes dentures. She stated that she would expect a physician's order in the TAR to make sure that the nursing staff takes care of the dentures for the resident.2. Record review of a policy titled .Oral Health last reviewed on 9/15/2025, failed to reveal that the policy included language for circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures, as required. During a surveyor interview on 12/2/2025 at 2:20 PM with the Director of Nursing Services (DNS), in the presence of the Administrator and the Regional Director, she was unable to provide evidence that the resident received assistance with care related to his/her dentures, and acknowledged that the policy failed to include language for circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures, as required.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/5/2025 alleges in part that the kitchen is a mess: the walk-in refrigerator has mold on the walls, dirty racks where food is stored, and the food in the fridge has mold on it which goes unnoticed for weeks.Review of the 2022 Food and Drug Administration (FDA) Food Code, Section 3-202.15 Package Integrity states in part, Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.Review of the 2022 FDA Food Code, Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking states in part, .refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees C (41 degrees F [Fahrenheit]) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.During a tour of the main kitchen on 11/13/2025 at 9:05 AM in the presence of the Regional Food Service Director, the following was observed in the walk-in refrigerator: - A small pan of red beans, with a discard date of 11/5 - A small pan of fried rice, prepared on 11/6 - A quarter sized hotel pan of roasted potato wedges, with a discard date of 11/12 - A half-sized hotel pan of tomato soup prepared on 11/4, with a discard date of 11/11 - A quarter sized hotel pan of a red liquid with an illegible label - Approximately one dozen 4-ounce orange juice containers in a box that were sticky and wet with one container open and leaking through the box - Three broken eggs with the contents covering the inside of a box containing approximately 4 dozen whole, raw eggsDuring a surveyor interview immediately following the above observations, the Regional Food Service Director acknowledged that the above items in the walk-in refrigerator should have been discarded after 7 days and should have a legible label with the contents and date prepared. Additionally, he acknowledged that the orange juice container was leaking, the eggs were broken, and should be discarded.During a surveyor interview with the Administrator on 11/13/2025 at 10:31 AM, she acknowledged the above findings in the main kitchen.

Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that each resident receives adequate care to prevent an accident for 1 of 1 resident reviewed with an injury of unknown origin, Resident ID #2, and for 1 of 1 resident reviewed who experienced an actual fall, Resident ID #3. Findings are as follows: 1. Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/10/2025 revealed Resident ID #2 sustained an injury of unknown origin to his/her left lower leg during care and was sent to the hospital for an evaluation .large, deep half circle with moderate bleeding . The report further indicated that the resident returned to the facility with sutures to the wound. Review of a facility policy titled, Safe Resident Handling/Transfer Equipment states in part, Safe Resident Handling involves the use of assistive devices to ensure that patients can be transferred safely .A Gait Belt [a safety device that wraps around a resident's waist to assist with safe transfers] is used with patients who can .perform stand pivot transfer with limited/minimal assistance with one staff member . Record review revealed Resident ID #2 was originally admitted to the facility in July of 2024 with a diagnosis including, but not limited to, Alzheimer's Disease, dementia, difficulty in walking, and unsteadiness on feet. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is usually understood, experiences difficulty communicating some words or finishing thoughts, but is able if prompted or given time. Additionally, it reveals that s/he sometimes understands and can respond adequately to simple, direct communication only. Further review revealed the resident requires supervision or touching assistance (a helper to do less than half of the effort. Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for chair/bed-to-chair transfers and to go from sitting to standing. Record review of the resident's Kardex (a documentation system that enables nurses to write, organize, and easily reference key resident information that shapes their nursing care plan) reveals the resident requires a partial assist, substantial assist to safely transfer to and from a bed to a chair/wheelchair. Record review failed to reveal evidence of a physician's order with indications on how the resident transfers. Review of the [unit name redacted] Unit Ambulation/Transfer log, states in part, [Resident ID #2] assist of 1 for transfers w[with] walker. Record review of a progress note dated 4/9/2025 revealed the nurse was called to the resident's room by a Nursing Assistant (NA) when a large, deep, half circle wound was noted with moderate bleeding. The on-call provider was notified, and the resident was transferred to the hospital for sutures. Record review of the hospital documentation dated 4/9/2025 revealed the resident was evaluated for a large wound on his/her left leg. Further review revealed 13 sutures were placed to close the wound. During a surveyor interview on 4/15/2025 at 1:21 PM with NA, Staff D, she indicated that on the evening of 4/9/2025, she completed upper body care for the resident but was asked by the nurse to assist with another resident who was getting an x-ray. Staff D then revealed that she asked NA, Staff E to assist the resident with a transfer to bed because he had previously offered to help. Additionally, she revealed that when she returned to the resident's room, 10 minutes later, the resident was in bed with his/her pants and shoes still on, she noticed blood seeping through the resident's pants and onto the bed and then the new wound to the resident's left lower leg was identified. Furthermore, Staff D revealed that had the resident been bleeding prior to being transferred to bed she would have noticed it while providing him/her with upper body care. Record review of an undated written statement authored by NA, Staff E, revealed in part, that he was watching the dining room, when Staff D asked him to help transfer Resident ID #3. Staff E revealed that Staff D then went to help another resident and he was relieved from watching the dining room, so he went to Resident ID #3's room and transferred him/her to bed. The statement further reveals that the resident was combative, and he left him/her in bed with his/her clothes on so Staff D could take care of him/her. During a surveyor interview on 4/15/2025 at 1:30 PM with NA, Staff E, he indicated that on 4/9/2025 around 6:45 PM, he transferred the resident from his/her wheelchair into his/her bed by holding the resident's upper arm as the resident was holding onto the bedrail. He further indicated that he did not use a walker or a gait belt for the transfer. Additionally, he indicated that he did not notice any bleeding during the transfer and did not remove any of the resident's clothes, as s/he was not on his assignment, and he was only helping to transfer him/her into bed and then left the room. During a surveyor interview on 4/15/2025 at approximately 3:00 PM with the Director of Nursing Services, she indicated that she would expected a walker and a gait belt to have been utilized when Staff E transferred Resident ID #2 on the evening of 4/9/2025. The result of the facility's failure to utilize a walker and to implement their safe resident handling policy by applying a gait belt to the resident resulted in Resident ID #2 being transferred to the hospital for an evaluation of a new wound to his/her left lower leg and receiving 13 sutures. 2. Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/14/2025 revealed Resident ID #3 had a new onset of hip pain, and the resident reported that s/he had an unwitnessed fall. The resident was admitted to the hospital with a left hip fracture. Review of a facility policy titled, Falls Management states in part, .Patients experiencing a fall will receive the appropriate care and post-fall interventions will be implemented .Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care . Record review revealed Resident ID #3 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, dementia, muscle weakness, and a history of falls. Record review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident was independent with transfers and ambulation. Record review of a progress note dated 4/7/2025 revealed a bruise was noted to the resident's left bicep measuring 4 centimeters (cm) by 3.75 cm. Record review revealed a Change in Condition [CIC] Evaluation dated 4/8/2025 was completed due to an unwitnessed fall resulting in a bruise that was noted to be purple and blue in color. Further review revealed no other injuries were noted. Record review of a care plan dated 2/15/2025 revealed the resident is at risk for falls. Further review failed to reveal evidence that an intervention had been put into place to prevent falls following the resident's unwitnessed fall on 4/7/2025. Record review of an After Hours Telehealth Consult dated 4/12/2025, revealed the resident had an unwitnessed fall, complained of left hip pain and is unable to raise the left leg. Further review revealed the resident would not allow the nurse to touch his/her leg, however, the supervisor noted the left leg to be shorter than the right with the left hip externally rotated. Additional review revealed an order was given to transfer the resident to the hospital for an evaluation. Record review revealed a CIC Evaluation was completed on 4/12/2025 for a fall resulting in left hip pain and outward rotation. Further review revealed the resident stated that s/he had fallen. Record review of the hospital documentation dated 4/15/2025 revealed the resident was admitted to the hospital following a fall and was found to have a left hip fracture and a urinary tract infection. Further review revealed surgery was completed to repair the hip. Additionally, the resident was discharged back to the facility on [DATE]. During a surveyor interview on 4/16/2025 at approximately 10:00 AM with the Nursing Educator, she indicated that she was working the floor on 4/7/2025 when the bruise was noted to the resident's bicep and that the resident had reported that s/he fell . She further indicated that an unwitnessed fall was assumed to be the cause of the bruise, and a CIC evaluation was completed. She further acknowledged that no new fall interventions were put into place following the unwitnessed fall on 4/7/2025. During a surveyor interview on 4/16/2025 at 10:50 AM with the Director of Nursing Services, she indicated that she would expect new interventions to be put into place following an unwitnessed fall. During a surveyor interview on 4/16/2025 at 11:30 AM with the Administrator, she indicated that Physical Therapy (PT) was going to evaluate the resident that day and that the care plan was updated late. She further indicated that the resident had not been evaluated by PT after the resident's unwitnessed fall on 4/7/2025 and acknowledged that no new interventions were put into place for further fall prevention. Record review of a revised care plan that was given to the surveyor by the Administrator upon exit, revealed the fall care plan was revised on 4/16/2025 to include a new intervention for a PT evaluation with an initiation date of 4/7/2025.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents have the right to be free from any physical restraint, not required to treat the resident's medical symptoms, for 2 of 3 residents reviewed, Resident ID #s 2 and 7. Findings are as follows: Review of a facility policy titled, .Restraints: Use of states in part, .Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms .Convenience is defined as the result of any action that has the effect of altering a patient's behavior such that the patient requires a lesser amount of effort or care, and is not in the patient's best interest .Physical Restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the patient's body, Cannot be removed easily by the patient, and Restricts the patient's freedom of movement or normal access to their body .Patients will be evaluated for the use of restraints or protective devices during the nursing assessment process .If the device cannot be easily removed by the patient and/or restricts freedom of movement or normal access to their body, the Restraint Evaluation/Reduction will be completed .There must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint .Consent must be obtained prior to the application of the restraint. The patient, or patient representative if applicable, has the right to refuse the use of a restraint and may withdraw consent to use the restraint at anytime. Refusal must be documented in the medical record . Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed that Nursing Assistant (NA), Staff B reported an allegation of abuse that occurred on 4/24/2024 between Resident ID #2 and two staff members, NA, Staff D and Certified Medication Technician (CMT), Staff E. Staff B indicated that she overheard a resident yelling out loudly followed by a bang noise around 9:30 PM. A surveyor observation on 5/2/2024 at 1:51 PM, of video footage from 4/24/2024 at 9:49 PM, in the presence of the Administrator and the Human Resource Director, Staff L, revealed Resident ID #2 was seated upright in a recliner chair, with the wall on his/her left side and a table on his/her right side. Additionally, a chair was placed in front of Resident ID #2's elevated footrest, preventing the footrest of the recliner from releasing. Resident ID #7 was noted to be lying in a recliner, up against the back of Resident ID #2's recliner chair. Therefore, Resident ID #2 could not safely get out of the recliner if s/he wanted to, as there was a wall on his/her left side, a table on his/her right side, a chair under his/her footrest, and another resident, Resident ID #7, directly behind him/her, sitting in a recliner. Additionally, Resident ID #7 could not safely get out of the recliner if s/he wanted to, as the resident was reclined back and would be unable to reach the foot lever, as it is located behind the recliner. Additional surveyor observation of the video footage from 4/24/2024 at 9:51 PM, revealed that NA, Staff D was observed pushing the resident out of the room in his/her recliner chair. At 9:58 PM Staff D pushes Resident ID #2 back into the dayroom, in a wheelchair. Resident ID #2 is holding his/her chest area as s/he reenters the room and Staff D places the resident with his/her back against the wall. Staff D aggressively grabs both of Resident ID #2's arms and holds them up so that CMT, Staff E can push a table against Resident ID #2's chest. At this time, Staff D was noted to push the table again, causing the table to be wedged between the resident and a support column. Staff D then pulled Resident ID #7's recliner, towards Resident ID #2's wheelchair, so the footrest of Resident ID #7's recliner was propped up on Resident ID #2's wheelchair, preventing the recliner from returning to an upright position, not allowing Resident ID #7 to get up independently. 1. Record review revealed Resident ID #2 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of a Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, an assessment used to determine cognition) was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. Further review revealed the resident utilizes a wheelchair for mobility and requires extensive assistance for transfers by staff members. Record review failed to reveal evidence of any restraint assessments, consent form, physician orders, or care plan interventions, prior the incident on 4/24/2024, per the Restraints: Use of policy. During a surveyor interview with Licensed Practical Nurse (LPN), Staff J, on 5/2/2024 at 2:20 PM, she revealed the resident can stand up and walk but his/her gait is not steady. She further revealed that the resident can self-propel while in his/her wheelchair by moving his/her legs and feet. During a surveyor interview with LPN, Staff F, on 5/6/2024 at 9:30 AM, she revealed that Resident ID #2 can get up from his/her bed or his/her wheelchair if s/he wants to. Staff F further revealed that the resident can walk but only few steps without staff assistance and the resident will fall without staff assistance. Additionally, Staff F revealed that if the resident is in a recliner chair, s/he will try to get out of it. A surveyor observation of Resident ID #2, in the presence of Staff F on 5/6/2024 at 9:54 AM, revealed the resident was sitting in his/her wheelchair in the day room, with the left wheel in the locked position. It was noted at this time that the resident was trying to self-propel the wheelchair by using his/her feet. Staff F acknowledged that the resident's wheelchair was locked and revealed that the resident can self-propel by moving her/his feet while in his/her wheelchair if the wheelchair was not locked. During a surveyor interview with a NA, Staff H, on 5/6/2024 at 9:58 AM, she revealed that she has been providing care to Resident ID #2 since s/he was admitted to the facility. Staff H then revealed the resident can get up from his/her bed, his/her wheelchair, and his/her recliner chair. Staff H further revealed that the resident can walk but his/her gait is not steady, indicating that s/he can walk approximately 50 feet with assistance from staff. 2. Record review revealed Resident ID #7 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, dementia and cerebral infarction (stroke). Review of a MDS assessment dated [DATE] revealed a BIMS Assessment was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. Further review revealed the resident requires partial/moderate assistance with transfers. During a surveyor interview on 5/6/2024 at 9:40 AM, with LPN, Staff F, she revealed that Resident ID #7 can ambulate a few steps and indicated that at times, the resident tries to get up independently from the wheelchair or recliner chair. During a surveyor interview on 5/6/2024 at 10:06 AM, with NA, Staff G, she revealed that the resident can stand up on his/her own and can ambulate a few steps. Record review failed to reveal evidence of any restraint assessments, consent forms, physician orders, or care plan interventions prior to the incident on 4/24/2024, per the Restraints: Use of policy. During a surveyor interview on 5/2/2024 at 12:37 PM, with the Administrator and Director of Nursing Services (DNS), they acknowledged that Resident ID #2 was being physically restrained on 4/24/2024, by NA, Staff D and CMT, E. They acknowledged that s/he was unable to get up from the recliner chair. They further revealed that during the investigation of this incident, numerous staff have revealed that Resident ID #2 and #7 are often restrained in this manner, due to the residents being at risk for falls. They indicated that LPN, Staff A, told administration that she did, at times, have Nursing Assistants restrain residents in the day room by placing the resident in a recliner chair sideways against the wall, with a table adjacent to the resident on the other side, a chair at the foot of the recliner, as well as another resident behind them. During a surveyor interview on 5/2/2024 at 2:15 PM, with NA, Staff D, she revealed that Resident ID #2 is usually kept in the dining room, restrained in his/her recliner chair, due to resident being at risk for falls, because s/he tries to stand up and ambulate independently. She indicated that Staff A and other nurses have told staff to restrain the residents in this manner due to safety concerns. During a surveyor interview on 5/3/2024 at 9:22 AM with CMT, Staff E, he revealed that on 4/24/2024, Staff D called him over to assist her, after she brought Resident ID #2 back to the dayroom. He acknowledged that he pulled the table close to the resident, restraining him/her in the wheelchair, indicating that Staff A has previously told staff to place the resident in this position, due to him/her being at risk for falls. During a surveyor interview on 5/3/2024 at 9:46 AM, with LPN, Staff A, she indicated that she has never facilitated staff to restrain the resident in the dayroom but acknowledged that she has allowed it to happen in the past, because of a safety concern, indicating that staff do not properly monitor the residents especially when they are on their phones. Further, she revealed that she was unaware that restraining residents in this manner was a concern. During a surveyor interview on 5/2/2024 at 11:58 AM and 5/3/2024 at 2:00 PM, with the Administrator, and the DNS, they revealed that NA, Staff D was terminated following this incident and CMT, Staff E was suspended due to this incident. Additionally, they were unable to provide evidence that Resident ID #2 and #7 were kept free from physical restraints. 21613

Based on surveyor observation, record review and staff interview it has been determined that the facility failed to provide evidence that all alleged violations of abuse are thoroughly investigated and reported to the State Survey Agency (Department of Health) for Resident ID #1 and failed to prevent further potential abuse while an investigation was in progress for Resident ID #2. Findings are as follows: Review of a facility policy and procedure revised on 10/24/2022 titled Abuse Prohibition states in part, .6. Staff will identify events .patterns, and trends that may constitute abuse . 6.1 Anyone who witnesses an incident of suspected abuse, neglect .is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. 6.1.1. The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. 6.1.2. The employee alleged to have committed the act of abuse will be immediately remove from duty, pending investigation. 6.1.3. All reports of suspected abuse must also be reported to the patient's family and attending physician . 6.2. Anyone who witnesses an incident of suspected abuse, neglect .must also report to outside agencies, if required. 6.2.1 Staff are obligated to report reasonable suspicion of crime against the elderly to the state agency and local law enforcement . 1. Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/2/2024 revealed an allegation of abuse that occurred on 4/24/2024 during the second shift (3:00 PM-11:00 PM), before dinner, involving Resident ID #1, Nursing Assistant (NA), Staff D and Certified Medicaiton Technician (CMT), Staff E. The resident was overheard screaming help me, don't hit me, stop hitting me, you're not my mom. Record review revealed Resident ID #1 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, dementia and anxiety disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS, an assessment used to determine cognition) score of 4 out of 15, indicating s/he is severely cognitively impaired. During a surveyor interview on 5/2/2024 at 1:25 PM, with NA, Staff B and NA, Staff C, translated by the Director of Human Resources, Staff L, they revealed that on 4/24/2024, before dinner time, Staff B overheard Resident ID #1 screaming out loud in his/her room stating, help me, don't hit me, stop hitting me, you're not my mom, while Staff D and Staff E were present in the resident's room. Both Staff B and Staff C revealed that they immediately informed Licensed Practical Nurse (LPN), Staff A, of the abuse concerns with Resident ID #1. Record review failed to reveal evidence that this allegation of abuse involving Resident ID #1 was acted upon immediately. This failure allowed the two perpetrators, NA, Staff D and CMT, Staff E, to continue working the evening of 4/24/2024. Further record review failed to reveal evidence that this allegation of abuse was reported to the Administrator by LPN, Staff A, as required. Additionally, record review failed to reveal evidence of an investigation for this abuse allegation, until 5/1/2024, 7 days after the allegation occurred. This facility failure allowed NA, Staff D and CMT, Staff E, to continue working the evening of 4/24/2024 resulting in another abuse allegation approximately 5 hours later with Resident ID #2. This allegation of abuse was later corroborated by via footage. 2. Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed an allegation of abuse that occurred on 4/24/2024 with Resident ID #2 and two staff members, NA, Staff D and CMT, Staff E. Record review revealed Resident ID #2 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of a MDS assessment dated [DATE] revealed a BIMS Assessment was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. During a surveyor interview on 5/2/2024 at 12:37 PM, with the Administrator and Director of Nursing Services (DNS), they revealed that they were made aware of the allegation of abuse on 4/26/2024, when NA, Staff B asked another staff member about the incident. They indicated that they watched the video footage from 4/24/2024 around 9:30 PM and observed NA, Staff D and CMT, Staff E, physically abuse and restrain Resident ID #2, while the resident was sitting in a recliner and then wheelchair, located in the day room of the unit. Additionally, the Administrator revealed that they were not aware of the allegation of abuse relative to Resident ID #1 with Staff D and E, that occurred on 4/24/2024 until 5/1/2024, 7 days after the allegation was made. During a surveyor interview on 5/2/2024 at 1:25 PM, with NA, Staff B and NA, Staff C, translated by the Director Human Resources, Staff L, they revealed that on 4/24/2024 at approximately 9:30 PM, they were assisting other residents in their rooms when they both heard a female resident yelling followed by a loud bang noise coming from the day room. Staff B revealed that she immediately went to the day room and saw NA, Staff D and CMT, Staff E standing next to Resident ID #2, while s/he was sitting in his/her recliner chair. They revealed that Staff D then took Resident ID #2 out of the day room and assisted him/her in the bathroom and then returned the resident to the day room in a wheelchair. They indicated that when Staff D brought the resident back to the day room, they observed Staff D holding the resident's hands, while Staff E pushed a table up against the resident, while s/he was sitting in a wheelchair, with his/her back against the wall. Further, both NA's, Staff B and C revealed that they did not report this incident with Resident ID #2 to LPN, Staff A, because they had already reported an allegation of abuse earlier in the shift concerning Resident ID #1. After they informed Staff A of the alleged incident with Resident ID #1, Staff A threw her hands in the air and shrugged her shoulders. During a surveyor interview on 5/3/2024 at 9:46 AM, with LPN, Staff A, she revealed that nothing out of the ordinary occurred on 4/24/2024 and indicated that she did not witness any incidents of abuse. She further revealed that no one reported any allegations of abuse to her throughout the shift on 4/24/2024. She denied that NA's, Staff B and C reported an allegation of abuse to her concerning Resident ID #1. During a surveyor interview on 5/2/2024 at 11:58 AM and 5/3/2024 at 2:00 PM, with the Administrator and the DNS, they were unable to provide evidence that the allegation of abuse for Resident ID #1 was investigated immediately after the allegation was reported to LPN, Staff A, which could have prevented the incident of abuse from occurring with Resident ID #2, if Na, Staff D and CMT, Staff E were removed from duty immediately. 46241

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to protect the resident's right to be free from abuse for 1 of 1 resident observed for abuse, Resident ID #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed that Nursing Assistant (NA), Staff B, reported an allegation of abuse that occurred on 4/24/2024 between Resident ID #2 and two staff members, NA, Staff D and Certified Medication Technician (CMT), Staff E. Staff B indicated that she overheard a resident yelling out loudly followed by a bang noise around 9:30 PM. Review of a facility policy titled Abuse Prohibition Policy and Procedure states in part, .prohibits abuse, mistreatment, neglect .for all residents. This includes, but is not limited to, freedom from corporal punishment .any physical or chemical restraint not required to treat the patient's medical symptoms. Centers also strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obligated to immediately report any suspicion of a crime against a resident .Physical Abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment . Record review revealed Resident ID #2 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (an assessment used to determine cognition) was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. During a surveyor interview on 5/2/2024 at 12:37 PM, with the Administrator and Director of Nursing Services (DNS), they revealed that they were made aware of the allegation of abuse on 4/26/2024, when NA, Staff B asked another staff member about the incident. They indicated that they watched the video footage from 4/24/2024 around 9:30 PM, and observed NA, Staff D and CMT, Staff E physically abuse and restrain Resident ID #2, while the resident was sitting in a recliner and then a wheelchair, located in the day room of the unit. During a surveyor interview on 5/2/2024 at 1:25 PM, with NA, Staff B and NA, Staff C, translated by the Director Human Resources, Staff L, they revealed that on 4/24/2024 at approximately 9:30 PM, they were assisting other residents in their rooms when they both heard a female resident yelling followed by a loud bang noise coming from the day room. Staff B, revealed that she immediately went to the day room and saw NA, Staff D and CMT, Staff E standing next to Resident ID #2, while s/he was sitting in his/her recliner chair. They revealed that Staff D then took Resident ID #2 out of the day room and assisted him/her in the bathroom and then returned the resident to the day room in a wheelchair. They indicated that when Staff D brought the resident back to the day room, they observed Staff D and E push a table up against the resident, while s/he was sitting in a wheelchair, with his/her back against the wall. A surveyor observation on 5/2/2024 at 1:51 PM, of video footage from 4/24/2024 at 9:49 PM, in the presence of the Administrator and the Human Resource Director, Staff L, revealed Resident ID #2 was seated upright in a recliner chair and was observed attempting to get out of the recliner by placing his/her legs on a table, which was located directly next to the resident. Without notice, NA, Staff D, aggressively stands up and steps towards Resident ID #2 and without hesitation, Staff D uses her right arm to forcefully shove Resident ID #2 on his/her right shoulder, sending him/her backwards abruptly. Staff D then grabbed Resident ID #2's legs and yanked them to the left, continuing to push his/her legs down in an aggressive manner. Staff D was then assisted by CMT, Staff E, who was observed grabbing Resident ID #2 under his/her armpits and lifting his/her body upwards in the chair. At 9:51 PM Staff D was observed pushing the resident out of the dayroom in his/her recliner chair. At 9:58 PM Staff D pushes Resident ID #2 back into the dayroom, in a wheelchair. Resident ID #2 is holding his/her chest area as s/he reenters the room and Staff D places the resident with his/her back against the wall. Staff D aggressively grabs both of Resident ID #2's arms and holds them up so that Staff E can push a table against Resident ID #2's chest. At this time, Staff D was noted to push the table again, causing the table to be wedged between the resident and a support column. During a surveyor interview on 5/2/2024 at approximately 2:15 PM, with NA, Staff D, she revealed that she made a mistake and acknowledged pushing Resident ID #2 on 4/24/2024 and stated that it was not her intention to harm the resident. She further indicated that Licensed Practical Nurse, Staff A, tells staff to keep Resident ID #2 in the day room, restrained in his/her recliner, because the resident is a fall risk due to him/her attempting to get up and walk independently. A surveyor observation of Resident ID #2 on 5/2/2024 at approximately 2:20 PM, in the presence of LPN, Staff J, revealed s/he had scattered bruising noted to both arms. During a surveyor interview on 5/3/2024 at 9:22 AM with CMT, Staff E, he revealed that on 4/24/2024, Staff D called him over to assist her, after she brought the resident back to the dayroom. He acknowledged that he pulled the table close to the resident, indicating that Staff A has previously told staff to place the resident in this position, due to him/her being at risk for falls. During a surveyor interview on 5/3/2024 at 9:46 AM, with LPN, Staff A, she revealed that nothing out of the ordinary occurred on 4/24/2024 and indicated that she did not witness any incidents of abuse. She indicated that she has never facilitated staff to restrain the resident in the dayroom but acknowledged that she has allowed it to happen before due to a safety concern as staff do not properly monitor the residents especially when they are on their phones. Record review revealed a skin assessment dated [DATE] at 10:56 PM, which revealed the resident had bruises because arms restlessness, and legs throws them over recliner. Record review revealed a skin assessment dated [DATE] which revealed the resident was noted to have several pea size to pinpoint bruises on his/her right and left lower arms, nickel size bruises on his/her forearms, pea size bruises on his/her wrists and hands, two small bruises on his/her right upper arm, and a bruise noted to the lower front of his/her leg. During a surveyor interview on 5/2/2024 at 11:58 AM and 5/3/2024 at 2:00 PM, with the Administrator and DNS, they revealed that NA, Staff D was terminated following this incident and CMT, Staff E was suspended due to the incident. Additionally, they were unable to provide evidence that Resident ID #2 was kept free from physical abuse. 21613

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 assessing for injury after a fall, for 1 of 1 resident reviewed, Resident ID #2. Findings are as follows: Record review of a facility policy dated 8/7/2023 titled, Falls Management, revealed the following in part, .Post-Fall Management .Evaluate the patient for injury .Notify the physician/advanced practice provider (APP) of the fall, report physical findings and extent of injuries, and obtain orders if indicated . According to the August 2021, American Association of Post-Acute Care Nursing, online publication titled, POST-FALL ASSESSMENTS, which states in part, .Fall-related injuries are common, so it is important that nurses be able to conduct a post-fall assessment to determine if injuries are present and treat accordingly .it is an assessment of the resident to determine if an injury has occurred and whether action is needed to stabilize the resident medically .The most common fall-related injuries sustained by a .resident include .Musculoskeletal injuries, such as hip fracture or muscle tear .Skin and deeper-tissue trauma, such as bruises, abrasions, skin tears .When assessing the resident for post-fall injuries .always be aware of the resident's verbal and non-verbal expression of pain. The following changes post-fall indicate an injury has occurred .Vital signs .changes from the resident's normal baseline could also indicate an injury .Range of motion to a joint - The resident's ability to move a joint freely has been compromised, or the joint is hyperextended .Skin integrity - The resident's skin is bruised, discolored, swollen, or open from a fracture .Assess for a hip fracture by comparing the lower extremities to each other. If there is a hip fracture, the involved extremity will be shorter than the extremity and externally rotated . Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 1/10/2024, alleges that while the Licensed Practical Nurse (LPN), Staff A, was escorting the resident in the hallway in a wheelchair, his/her foot dropped, causing him/her to lean forward. Additionally, the report alleges that Staff A held the resident by his/her jacket, lowered him/her to the floor then assisted him/her back into the wheelchair. Furthermore, the report states in part, .Resident has baseline pain in left leg. Oxycodone [narcotic pain medication] .was already given prior to incident for transport. Resident doesn't use foot rests as [s/he] self propels ad lib [as desired]. Resident denied any increase pain or tenderness . Review of a community reported complaint submitted to RIDOH on 1/10/2024 alleges that the resident arrived at the Emergency Department on 1/9/2024 after falling from his/her wheelchair earlier in the morning. The report further indicates that the resident is wheelchair bound and was sitting in the wheelchair with his/her legs crossed when the staff member moved the wheelchair, resident's left leg got stuck in the wheels causing him/her to fall out of the wheelchair. Lastly, the report indicates s/he was admitted to the hospital due to a fracture of his/her left leg. Record review revealed that the resident was readmitted to the facility in December of 2023, with diagnoses including, but not limited to, dementia, left knee effusion (water on the knee that causes pain), and end stage renal (kidney) disease, on hemodialysis HD- a treatment to filter wastes and water from blood when the kidneys are unhealthy. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 11 out of 15, indicating moderately impaired cognition. Additionally, the MDS revealed that s/he has impaired range of motion on one side of his/her lower extremity and requires the use of a wheelchair. Review of a progress note dated 1/9/2024 revealed documentation of a change in condition evaluation due to the resident's fall. The note indicates pain was the outcome of the physical assessment. Review of a written statement authored by Staff A dated 1/15/2024 indicated that he assessed the resident for increased pain and assisted him/her to put back on his/her slipper. The note failed to reveal evidence the resident was assessed for injury including range of motion, physical injury and vital signs. During a surveyor observation of the facility's surveillance camera footage dated 1/9/2024 at approximately 5:26 AM, in the presence of the Director of Nursing Services, on 1/16/2024 at 10:54 AM, revealed the following. The footage revealed Staff A, assisting Resident ID #2 with transport while in his/her wheelchair in the corridor outside of the resident's room without the use of foot pedals. Staff A was observed to hold on to the resident's coat as s/he was leaning forward in the wheelchair. Staff A was observed to turn the wheelchair around and transported the resident down the remainder of the corridor with the wheelchair in reverse. Additionally, the observation failed to reveal evidence that Staff A assessed Resident ID #2 for injury including range of motion, physical injury and vital signs after s/he fell from his/her wheelchair. Record review of the 1/9/2024 dialysis encounter nursing progress note revealed that Resident ID #2 complained of pain upon arrival to the clinic when staff attempted to assist with raising his/her legs. The dialysis nurse assessed him/her and noted a small bruise on the resident's right foot along with a superficial skin tear to his/her right ankle. The note further indicates that the resident was moaning and groaning .Patient stated 'the transporter rolled over my foot' .'this morning at the nursing home.' The note further indicates that Resident ID #2 was restless and once the blanket on his/her lap was removed, staff noted large bruising .about 8 inches in diameter and was elevated about 5 inches on the patient's Left upper thigh approximately 5 inches below the hip bone .the patients left knee was facing medially [toward the center of the body] .The left leg was also shorter than the right leg . Furthermore, the note indicates that the dialysis nurse contacted the facility and spoke with the nurse in charge.[Resident ID #2] came into the unit and is complaining of foot pain .The LPN stated '[S/he] is talking about me. [Resident ID#2] usually self propels in [his/her] wheelchair so [s/he] did not have foot petals [SIC] on the wheelchair while I was transporting [him/her] to meet [his/her] driver to be transported to dialysis. At first all I noticed was [s/he] was falling forward so I grabbed [his/her] coat and pulled [him/her] back. Then the patient said 'oww that hurt' .when I assessed the patient it turns out [s/he] had not held [his/her] feet up during transport like usual and [his/her] foot got caught under the front wheel of the wheelchair. I took off [his/her] slipper and sock and [s/he] didn't appear to have sustained any injuries so I continued to transport [him/her] to the transportation provider . Additional record review revealed that the resident was transferred from the dialysis center to the hospital due to complaints of severe pain and was subsequently admitted to an acute care hospital with the diagnosis of left femur (thigh bone) fracture. Further record review failed to reveal evidence that Staff A thoroughly assessed Resident ID #2 for injuries, which would include, but not limited to, assessing his/her vital signs, extremities for range of motion, and skin for injuries, after s/he fell from his/her wheelchair on the morning of 1/9/2024. Additionally, the record failed to reveal evidence that the physician or APP were notified of the fall prior to the resident being transported to his/her routine dialysis appointment. During a surveyor interview with the Director of Nursing Services (DNS) on 1/16/2024 at 2:32 PM, she revealed that she would have expected the nurse to have assessed the resident for injury and document the findings in his/her medical record. During a surveyor interview on 1/17/2024 at 10:57 AM, with the Regional Clinical Nurse in the presence of the DNS, he acknowledged that Staff A failed to thoroughly assess Resident ID #2 after he transported him/her in his/her wheelchair without the use of foot pedals. The resident was then transported to his/her routine dialysis appointment, where his/her injuries were assessed upon arrival, and s/he was subsequently admitted to the hospital due to a left femur fracture.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure a resident's environment remains as free of accident hazards and provide assistive devices to prevent an avoidable accident for 1 of 1 resident reviewed who sustained major injuries after falling from his/her wheelchair, while being assisted by a staff member without the use of foot pedals, Resident ID #2. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 1/10/2024, alleges that while the Licensed Practical Nurse (LPN) Staff A, was escorting the resident in the hallway in a wheelchair, his/her foot dropped, causing him/her to lean forward. Additionally, the report alleges that Staff A held the resident by his/her jacket, lowered him/her to the floor then assisted him/her back into the wheelchair. Furthermore, the report states in part, .Resident has baseline pain in left leg. Oxycodone [narcotic pain medication] .was already given prior to incident for transport. Resident doesn't use foot rests as [s/he] self propels ad lib [as desired]. Resident denied any increase pain or tenderness . Review of a community reported complaint submitted to RIDOH on 1/10/2024 alleges that the resident arrived at the Emergency Department on 1/9/2024 after falling from his/her wheelchair earlier in the morning. The report further indicates that the resident is wheelchair bound and was sitting in the wheelchair with his/her legs crossed when the staff member moved the wheelchair, resident's left leg got stuck in the wheels causing him/her to fall out of the wheelchair. Lastly, the report indicates s/he was admitted to the hospital due to a fracture of his/her left leg. Record review of a facility policy dated 8/7/2023 titled, Falls Management, revealed the following in part, .Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented .PURPOSE .To evaluate the patient for injury post-fall and provide appropriate and timely care .5. Post-Fall Management .Evaluate the patient for injury .Notify the physician/advanced practice provider (APP) of the fall, report physical findings and extent of injuries, and obtain orders if indicated .Document circumstances of the fall, post-fall assessment, and patient outcome . Record review revealed that the resident was readmitted to the facility in December of 2023, with diagnoses including, but not limited to, dementia, left knee effusion (water on the knee that causes pain), and end stage renal (kidney) disease, on hemodialysis (HD- a treatment to filter wastes and water from blood when the kidneys are unhealthy). Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 11 out of 15, indicating moderately impaired cognition. Additionally, the MDS revealed that s/he has impaired range of motion on one side of his/her lower extremity and requires the use of a wheelchair. Record review revealed a physician's order dated 10/24/2023 for non-weight bearing to the left leg every shift. Additional record review revealed a physician's order dated 11/10/2023 indicating the resident is transported out of the facility for Dialysis every Tuesday, Thursday, and Saturday at 5:45 AM. Review of a progress note dated 1/9/2024 revealed documentation of a change in condition evaluation due to the resident's fall. The note indicates pain was the outcome of the physical assessment. Review of a written statement authored by Staff A dated 1/15/2024 indicated that he assessed the resident for increased pain and assisted him/her to put back on his/her slipper. The note failed to reveal evidence the resident was assessed for injury including range of motion, physical injury and vital signs. During a surveyor observation of the facility's surveillance camera footage dated 1/9/2024 at approximately 5:26 AM, in the presence of the Director of Nursing Services, on 1/16/2024 at 10:54 AM, revealed the following. The footage revealed Staff A, assisting Resident ID #2 with transport while in his/her wheelchair in the corridor outside of the resident's room without the use of foot pedals. Staff A was observed to hold on to the resident's coat as s/he was leaning forward in the wheelchair. Staff A was observed to turn the wheelchair around and transported the resident down the remainder of the corridor with the wheelchair in reverse. Additionally, the observation failed to reveal evidence that Staff A assessed Resident ID #2 for injury including range of motion, physical injury and vital signs after s/he fell from his/her wheelchair. During a surveyor interview on 1/12/2024 at 2:27 PM, with LPN, Staff A, he revealed that on 1/9/2024 at 5:30 AM he was taking the resident to the front door to leave for his/her appointment because s/he was running late. Staff A further indicated that he brought the resident down the hallway while s/he was sitting in his/her wheelchair. He indicated that the resident self-propels usually and does not use foot pedals on the wheelchair. While transporting the resident s/he put his/her foot down and fell forward. Staff A indicated he grabbed the resident by his/her coat and lowered him/her to the floor. He further indicated that he assumed that the resident had his/her feet up. Furthermore, Staff A indicated that the resident complained of left leg pain and indicated that s/he always has pain. S/he was able to get back up with staff assistance and was transported to his/her appointment. The dialysis center called the facility to report Resident ID #2 had complaints of increased pain upon his/her arrival to the clinic, and was transferred to an acute care hospital for an evaluation via rescue. A surveyor interview on 1/12/2024 at 2:46 PM was attempted with the nurse from the dialysis center, which was unsuccessful. Record review of the 1/9/2024 dialysis encounter nursing progress note revealed that Resident ID #2 complained of pain upon arrival to the clinic when staff attempted to assist with raising his/her legs. The dialysis nurse assessed him/her and noted a small bruise on the resident's right foot along with a superficial skin tear to his/her right ankle. The note further indicates that the resident was moaning and groaning .Patient stated 'the transporter rolled over my foot' .'this morning at the nursing home.' The note further indicates that Resident ID #2 was restless and once the blanket on his/her lap was removed, staff noted large bruising .about 8 inches in diameter and was elevated about 5 inches on the patient's Left upper thigh approximately 5 inches below the hip bone .the patients left knee was facing medially [toward the center of the body] .The left leg was also shorter than the right leg . Furthermore, the note indicates that the dialysis nurse contacted the facility and spoke with the nurse in charge.[Resident ID #2] came into the unit and is complaining of foot pain .The LPN stated '[S/he] is talking about me. [Resident ID#2] usually self propels in [his/her] wheelchair so [s/he] did not have foot petals [SIC] on the wheelchair while I was transporting [him/her] to meet [his/her] driver to be transported to dialysis. At first all I noticed was [s/he] was falling forward so I grabbed [his/her] coat and pulled [him/her] back. Then the patient said 'oww that hurt' .when I assessed the patient it turns out [s/he] had not held [his/her] feet up during transport like usual and [his/her] foot got caught under the front wheel of the wheelchair. I took off [his/her] slipper and sock and [s/he] didn't appear to have sustained any injuries so I continued to transport [him/her] to the transportation provider . Further record review revealed the resident was transferred from the dialysis center to an acute care hospital and admitted with a diagnosis of left femur (thigh bone) fracture. Record review of the hospital documents revealed the following entries: 1/9/2024 at 7:11 AM, which states in part, .Pt [patient] was being pushed in wheelchair, leg got stuck underneath wheelchair and wheelchair kept going. Pt still brought to dialysis, dialysis was not done d/t [due to] injury to leg. 1/9/2024 at 10:17 AM titled, ED [Emergency Department] Provider Note, revealed in part, .comes in due to left leg pain. Patient reports that earlier this morning [s/he] had his legs crossed in [his/her] wheelchair, and [his/her] left leg got stuck on the wheels when they started pushing [him/her]. [S/he] reports falling over and possibly hitting [his/her] head .was brought in by EMS [Emergency Medical Services] due to left leg pain. [S/he] currently has associated neck pain . 1/9/2024 at 7:26 PM, titled ED Provider Note which states in part, .PMH [past medical history] of .prior left knee replacement, presents with left thigh pain and swelling s/p [status post] trauma while in a wheelchair .Left thigh swelling and left lower extremity deformity significantly internally rotated .Imaging reveals a periprosthetic mid femur fracture [a broken bone around or close to an implant] with significant angulation .Plan pain control, orthopedic consult .Patient requires admission orthopedics .recommending above knee amputation . During a surveyor interview on 1/16/2024 at approximately 12:15 PM, with the Registered Occupational Therapist (OTR), Staff B and Physical Therapist Assistant (PTA), Staff C, they revealed that foot pedals should be placed on a wheelchair if a resident is unable to keep his/her feet up when sitting in the wheelchair and receiving locomotion assistance from a staff member. They also indicated that Resident ID #2 did not have foot pedals for his/her wheelchair because s/he can independently propel him/herself. During a surveyor interview on 1/16/2024, at 10:54 AM with the Director of Nursing Services (DNS), she acknowledged that the resident does not have foot pedals for his/her wheelchair because s/he is independent with self-propelling. She indicated that Staff A was unable to locate foot pedals after the incident, so he continued to transport the resident to the lobby for transport with the wheelchair in reverse. Additionally, she indicated that upon his/her return from the hospital, foot pedals will be provided for use when s/he goes to dialysis. Furthermore, the DNS was unable to provide evidence that Staff A kept Resident ID #2 free from accident hazards which resulted in him/her falling from the wheelchair, experiencing pain, was unable to complete dialysis treatment, and being admitted to the hospital due to significant injuries.

Based on record review and staff and resident interview, it has been determined that the facility failed to use a two-person transfer, as determined by the plan of care, during a transfer from the resident's bed to a commode, resulting in the resident sustaining fractures, for 1 of 3 residents reviewed for falls, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 12/20/2022 states in part, .resident had fall transferring to commode on 12/16/2022 with CNA [Certified Nursing Assistant] Xrays ordered, completed and received on 12/17/22 [negative] for FX [fracture]. Resident with lower Rt [right] leg pain. Additional xrays of knee, Tib/ Fib [tibia/fibula] and ankle done on 12/18/22 neg [negative] for FX. Seen 12/19/2022 by NP [Nurse practitioner], on physical exam felt should be evaluated in hospital setting . CT [CT scan- Uses several X-ray images and computer processing to create cross sectional images] and xrays repeated. Impression: 1: Impacted lateral femoral condyle fx and possible nondisplaced fx of medial condyle [ A femoral condyle is the ball-shape located at the end of the femur (thigh bone). There are two condyles on each leg known as the medial and lateral femoral condyles]. 2: Nondisplaced fx of the proximal medial tibial metaphysis [when the tibia, the long bone of the lower leg sustains a break or crack without a fragment of the bone becoming separated]. Record review revealed the resident was admitted to the facility in February of 2021 and has diagnoses including, but not limited to, difficulty in walking, osteoarthritis, presence of unspecified artificial hip joint, unsteadiness on feet and arthritis due to other bacteria of the right hip. Review of the quarterly Minimum Data Set (MDS) Assessment (entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 9/16/2022 revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident is cognitively intact. Record review of the resident's care plan revealed the focus area initiated on 2/15/2021, .requires assistance/is dependent for ADL [activities of daily living] care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to .weakness, arthritis, presence of vascular implants [long -term implantation of a patented medical device used in the treatment of an abnormality in the vein or an artery] . Interventions on the care plan at the time of the fall were as follows: Provide resident /patient with extensive assist of 2 or if able limited with slide board [equipment that is used to bridge the gap between two surfaces allowing for assistance with transfers] if resident wants to use date initiated 11/28/2022. Provide resident /patient with total assist of 2 for transfers using a mechanical lift full body sling, large date initiated 11/28/2022. Record review of nursing progress notes revealed the following: -12/16/2022 at 8:50 PM revealed Resident was transferring from bed to commode with staff then fell and is complaining of upper right leg pain. Pt does have hx [history] arthritis of [his/her] right hip .Patient is at risk for falls due to the following Recent Generalized weakness .Orders: Stat right femur and right hip xrays . - 12/17/2022 at 1:28 PM revealed .Radiology in and did xrays of right upper leg. At time of exam resident reported [his/her] pain being in the lower leg; anterior aspect of leg tender to palpation. Some swelling present in upper leg and lower leg .STAT xray (2 views) of Knee, Tib/Fib, and ankle ordered . Review of an encounter note dated 12/19/2022 by the Nurse Practitioner revealed in part, .Per review of right leg xray pt is noted to have old fracture involving right interochanteric femur [between the points where the muscles of the thigh and hip attach] with complete absence of right femoral head and neck, with moderate displacement of femoral shaft. Pt [patient] will be sent to .ER for further evaluation . Review of an encounter note dated 12/20/2022 by the Nurse Practitioner revealed in part, .Pt was sent to the hospital for further evaluation. While at the hospital pt was noted on xray of the right tibia fibula right knee and right femur noted to have impacted lateral femoral condyle fracture and possible nondisplaced fracture of the medial condyle. Nondisplaced fracture of the proximal medial tibial metaphysis. CT [cat scan] of the right knee noted Fracture of the tibial tuberosity [is caused by injury from violent tension forces on the tibial tuberosity] with associated soft tissue swelling . During a surveyor interview on 12/21/2022 at approximately 3:30 PM with CNA, Staff A, she revealed that the resident called her in to the room to help [him/her] to the commode from the bed. She acknowledged that she transferred the resident independently without the use a mechanical lift or a slide board. She was unable to explaint to the surveyor where she could find information relative to a resident's transfer requirements. During a surveyor interview on 12/21/2022 at 2:21 PM with the resident, s/he revealed that s/he really had to go to the bathroom so s/he was calling for staff assistance. A CNA came into the room by herself and had me grab her arm to when I fell . I now have two fractures. During a surveyor interview on 12/21/2022 at approximately 4:00 PM with the Director of Nursing Services, she acknowledged that the resident required two staff for transfers. She further acknowledged that on 12/16/2022 the resident was transferred by one CNA, which lead to a fall resulting in fractures.

Based on record review, and staff interview, it has been determined that the facility failed to ensure nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety as identified in the plan of care for 1 of 3 residents reviewed for falls, Resident ID #1. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2021 and has diagnoses including, but not limited to, difficulty in walking, osteoarthritis (inflammation of one or more joints), presence of unspecified artificial hip joint, unsteadiness on feet and arthritis due to other bacteria of the right hip. Review of the quarterly Minimum Data Set (MDS) Assessment (entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 9/16/2022 revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident is cognitively intact. Record review of a nursing note dated 12/16/2022 at 8:50 PM revealed Resident was transferring from bed to commode with staff then fell and is complaining of upper right leg pain . Record review of the resident's care plan revealed the focus area initiated on 2/15/2021, .requires assistance/is dependent for ADL [activities of daily living] care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to .weakness, arthritis, presence of vascular implants [long -term implantation of a patented medical device used in the treatment of an abnormality in the vein or an artery] . Interventions on the care plan at the time of the fall were as follows: Provide resident /patient [Pt] with extensive assist of 2 or if able limited with slide board [equipment that is used to bridge the gap between two surfaces allowing for assistance with transfers] if resident wants to use date initiated 11/28/2022. Provide resident /patient with total assist of 2 for transfers using a mechanical lift full body sling, large date initiated 11/28/2022. Review of an encounter note dated 12/19/2022 by the Nurse Practitioner revealed in part, Per nursing pt has fell over the weekend .Per review of right leg xray pt is noted to have old fracture involving right interochanteric femur [between the points where the muscles of the thigh and hip attach] with complete absence of right femoral head and neck, with moderate displacement of femoral shaft. Pt [patient] will be sent to .ER for further evaluation . Review of an encounter note dated 12/20/2022 by the Nurse Practitioner revealed in part, .Pt was sent to the hospital for further evaluation. While at the hospital pt was noted on xray of the right tibia fibula [bones in the lower legs] right knee and right femur noted to have impacted lateral femoral condyle fracture and possible nondisplaced fracture of the medial condyle. Nondisplaced fracture of the proximal medial tibial metaphysis [when the tibia, the long bone of the lower leg sustains a break or crack without a fragment of the bone becoming separated]. CT [cat scan] of the right knee noted Fracture of the tibial tuberosity [is caused by injury from violent tensile forces on the tibial tuberosity] with associated soft tissue swelling . During a surveyor interview on 12/21/2022 at approximately 3:30 PM with CNA, Staff A, she revealed that the resident called her in to the room to help [him/her] to the commode from the bed. She acknowledged that she transferred the resident independently without the use a mechanical lift or a slide board. She was unable to explain to the surveyor where she could find information relative to a resident's transfer requirements. Record review of a policy provided by the facility titled, .Performance Appraisal revealed in part, .Managers of [ company name redacted] .will meet with their regular full-time, regular part-time, and regular casual employees at least annually to conduct a performance appraisal or have a performance based conversation. In-service education will be provided based on the outcome of these reviews .PURPOSE To recognize performance, measure results, establish development opportunities, and set goals for the coming year .PROCESS 1. The performance review process is an opportunity for an employee and their supervisor to talk openly about how each other feels about how the employee is doing in their position and set performance and development goals for the upcoming year . Review of Staff A's personnel file revealed that her last documented performance appraisal was signed and dated on 1/16/2019. Further review failed to reveal evidence of any performance appraisals after 1/16/2019. Indicating the provided facility policy, .In-service education will be provided based on the outcomes of these reviews . was not followed. During a surveyor interview on 12/21/2022 at approximately 3:45 PM with the Human Resource Manager she was unable to provide evidence that yearly performance appraisals were completed for Staff A, since 1/16/2019. Record review of an individual performance improvement plan provided to this surveyor on 12/21/2022, which was to be initiated with CNA Staff A on 12/22/2022, revealed in part, Reason Description: Unsatisfactory job performance .Date of Event: 12/16/2022 .Description of Event: [Staff A] transferred resident without gait belt, not following plan of care (2 person transfer [with] gait belt) resulting in resident falling . During a surveyor interview on 12/21/2022 at approximately 4:00 PM with the Director of Nursing Services, she acknowledged that the resident requires two staff members for all transfers. She further acknowledged that on 12/16/2022 the resident was transferred by one CNA, which lead to a fall resulting in fractures. Additionally, she acknowledged that the facility failed to follow its policy or complete annual performance appraisals for Staff A, since 1/16/2019.

Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents relative to eating for 1 of 7 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled, Meal Service with a revision date of [DATE] states in part, Policy: Person-centered meal service includes the delivery of a safe, sanitary, and comfortable environment for meals . Review of a facility reported incident received by the Rhode Island Department of Health on [DATE] states in part, At approx. [approximately] 7:30 pm during evening snack pass resident was given a tuna sandwich and drink by request. Resident was sitting with bed elevated and call light with in reach. At approx. 9 pm nurse went into room to administer meds to roommate and noticed [resident] was not breathing. [His/her] dentures were found in bed, [his/her] lowers were in [his/her] mouth with a bite of sandwich . Record review revealed that the resident was readmitted to the facility in August of 2019 with diagnoses including, but not limited to, dysphagia, oropharyngeal phase (difficulty swallowing) and schizophrenia. Review of a Minimum Data Set assessment dated [DATE], revealed the resident required supervision of one staff member to eat. Review of the November Medication Administration Record revealed an order with a start date of [DATE] that stated, RESIDENT NEEDS TO BE OUT OF BED TO EAT FOOD DUE TO CHOKING RISK. Every day and evening shift for protection. The above order was signed as completed on [DATE]. Review of a Speech Therapy SLP [Speech Language Pathology] Discharge Summary signed [DATE] stated in part, .Patient required occasional cues for smaller bites and alternating solids/liquids . Review of a Speech Therapy Evaluation with treatment dates from [DATE] through [DATE], revealed results from a previous Modified Barium Swallow (MBS,a procedure to determine if food or liquid is entering the resident's lungs) that stated, Patient presents with severe oropharyngeal dysphagia .affecting the safety and efficiency of the swallow . Review of a Modified Barium Swallow performed on [DATE] revealed the resident had an elevated risk of choking. Review of a Optum Comprehensive assessment dated [DATE] revealed a diagnosis of dysphagia with a plan to continue to monitor for coughing or choking with meals. Review of a progress note dated [DATE] at 11:04 PM stated in part, at 9pm, resident found deceased . time of death 9:10pm. found with half eaten sandwich in mouth. upon cleaning mouth,dentures pulled out of back of mouth or throat by cna [certified nursing assistant] . During a surveyor interview on [DATE] at 10:23 AM with CNA, Staff A she revealed that she gave the resident a tuna sandwich while s/he was in bed between 7:00 PM and 7:30 PM and did not return to check on him/her. Additionally, she revealed that she was unaware the resident should have been out of bed to eat and that she gives him/her a sandwich in bed often without any supervision. During a surveyor interview on [DATE] at 10:30 AM with the Rehab Director she revealed that the resident had a history of being anxious while eating and would over stuff his/her mouth while eating. She further revealed that she would expect the nursing staff to get the resident out of bed to eat and that she would not recommend anyone be given food while in bed and then not checked on for 2 hours. During a surveyor interview on [DATE] at 10:07 AM with Registered Nurse (RN), Staff B she revealed that one of the CNA's gave the resident a sandwich during the evening snack pass at approximately 7:30 PM. Additionally, she revealed that at approximately 9:00 PM she went into the resident's room to administer the roommate medication. She noted the resident appeared gray and ashen and could see part of a sandwich in his/her mouth. Additionally, she indicated that the resident was not breathing. Staff B indicated that was aware the resident had a history of choking and an order to be out of bed for food intake. Additionally she acknowledged the resident was not provided with supervision while eating in bed on [DATE]. During a surveyor interview on [DATE] at 3:18 PM with CNA, Staff C, she revealed that she removed large amounts of a sandwich from the resident's mouth and his/her bottom dentures from his/her throat. Additionally, she acknowledged that she was aware the resident required to be out of bed and should be supervised for food intake and that s/he was not out of bed or supervised while eating on the night that s/he died . During a surveyor interview on [DATE] at 12:17 PM, with the Director of Nursing Services she was unable to provide evidence that the resident had been out of bed and adequately supervised while eating to prevent an accident, although resident had a significant history of choking.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to not following physician's order for 1 of 7 residents reviewed, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] indicates that at approximately 7:30 PM on [DATE], during the evening snack pass, the resident was given a tuna sandwich and a drink. At approximately 9:00 PM, the nurse went into room to administer medications to the roommate and noticed that the resident was not breathing. His/her upper dentures were found in his/her bed, his/her lower dentures were in his/her mouth with a bite of the sandwich. Record review revealed the resident was readmitted to the facility in August of 2019 with a diagnosis which included, but is not limited to, dysphagia, oropharyngeal phase (difficulty swallowing) following a choking event in the facility. Record review revealed a progress note dated [DATE] at 11:04 PM which states in part, at 9pm, resident found deceased . time of death 9:10pm. found with half eaten sandwich in mouth. upon cleaning mouth, dentures pulled out of back of mouth or throat by cna [certified nursing assistant] . Record review revealed a physician's order with a start date of [DATE] which states, RESIDENT NEEDS TO BE OUT OF BED TO EAT FOOD DUE TO CHOKING RISK. Record review of the [DATE] Medication Administration Record revealed the above-mentioned order was documented as completed twice daily, including on [DATE], the day the incident occurred. Record review of the facility provided staff statements, revealed that the resident was provided a sandwich while in bed around 7:30 PM on [DATE]. During a surveyor interview on [DATE] at 12:17 PM with the Director of Nursing Services she was unable to provide evidence the physician's order for the resident to be out of bed to eat food due to the resident being a choking risk was followed. During a surveyor interview on [DATE] at 9:07 AM with the Medical Director, she revealed that she was aware that the resident had a history of choking. Furthermore, she revealed she would have expected the staff to follow the physician's order.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to prevent and contain the potential spread and transmission of COVID-19 in relation to isolation and empiric transmission-based precautions for Residents, ID #s 8, 11, 25, 32, 48, 76, 85, and 241. Additionally, the facility failed to ensure appropriate personal protective equipment (PPE) is worn while caring for residents on transmission-based precautions for two staff observed, Nursing Assistant (NA), Staff J and Licensed Practical Nurse (LPN), Staff B. Furthermore, the facility failed to provide a sanitary environment relative to blood glucose monitoring for 3 of 3 residents observed during the medication administration task, Resident ID #s 50, 57, and 79. Findings are as follows: According to the COVID-19 guidance for Rhode Island Nursing Homes dated 10/12/2022 states in part, .Isolation [separates sick people with a contagious disease from people who are not sick] starts on the first day of symptoms or on the day of a positive test if there are no symptoms .Residents .isolate at least 10 full days since the date of their first positive test .Empiric transmission-based precautions [precautions includes the use of gown, gloves, goggles or face shield, and N95 mask] may be considered after close contact when a resident .unable to be tested or wear source control [PPE] for 10 full days following exposure .Resides on a unit experiencing ongoing COVID-19 transmission that has not been .controlled with initial interventions .If empiric transmission-based precautions are used, residents should quarantine and wear source .control around others until COVID-19 infection is ruled out. Empiric transmission-based precautions .for residents may be discontinued after .10 full days if they don't develop symptoms OR .7 full days following exposure if they test negative on 3 consecutive tests . 1. Record review revealed Resident ID #8 tested positive for COVID-19 on 10/20/2022 and s/he was within the recommended 10-day isolation period. Additional record review reveals the resident requires the physical assistance of one staff member and utilizes a walker to ambulate with staff supervision. Record review revealed Resident ID #241 tested positive for COVID-19 on 10/20/2022 and s/he was within the recommended 10-day isolation period. Additional record review reveals the resident requires the assistance of two plus staff members for locomotion and utilizes a wheelchair for mobility. Record review revealed Resident ID #s 32 and 85 were on COVID-19 Empiric transmission-based precautions (quarantine) related to a COVID-19 close contact exposure, these residents are roommates of Resident ID #s 8 and 241. During continuous surveyor observation of the Lily Unit's dining/activities area on 10/24/2022 between 12:17 PM and 1:30 PM, Resident ID #s 241 and 8, COVID-19 positive residents, were observed sitting in the dining/activities area without face masks on, waiting for the lunch meal to be served. Additionally, Resident ID #8 was noted to be coughing. Furthermore, Resident ID #s 32 and 85, residents on COVID-19 empiric transmission-based precautions, were also in the dining room without face masks on. In addition to these residents, there were approximately 20 COVID-19 negative residents observed in the dining/activities area, sitting, and wandering, without face masks on. Additionally, there were three NA's, one of which was Staff K, and one LPN, Staff H, observed to be going in and out of the dining/activities area, initially transporting residents into the area to prepare for lunch service, delivering lunch trays from the dietary trucks and then assisting with feeding of the residents when indicated. Further observation failed to reveal evidence that staff had made any attempts to prevent the negative and positive residents from coming into close contact with each other. Furthermore, staff failed to encourage any of the residents in the dining/activities area to wear face masks or maintain social distancing. During the above observation, at 1:07 PM, Resident ID #48, a COVID-19 negative resident, approached Resident ID #8, a COVID-19 positive resident, and picked up his/her cup of red liquid and drank from that cup. Resident ID #48 then attempted to pick up Resident ID #8's half-eaten sandwich when Staff K intervened and removed Resident ID #8's lunch tray. Staff K continued to gather other residents lunch trays and failed to direct or assist Resident ID #48 to perform hand hygiene. Resident ID #48 returned to the area where Resident ID #8 was seated and was then observed touching a bedside table and walker that was located directly next to Resident ID #8. During an additional surveyor observation on 10/24/2022 at approximately 2:20 PM, Staff K was observed transporting Resident ID #241, a COVID-19 positive resident, from the back of the dining/activities area, past approximately 20 COVID-19 negative residents, while Resident ID #241 was wearing his/her face mask below his/her chin. During an interview with Staff K on 10/24/2022 at approximately 2:30 PM, she acknowledged that Resident ID #48, the COVID-19 negative resident, consumed fluids from the cup of Resident ID #8, a COVID-19 positive resident, during the lunch meal that day. Additionally, she indicated that she did not assist Resident ID #48 with hand hygiene after s/he was observed touching the bedside table, lunch tray and walker that were located directly next to Resident ID #8. She further revealed that she was aware that Resident ID #241 had tested positive for COVID-19 and that she had transported the resident through the dining/activities area while his/her mask was around his/her chin within 6-feet of other residents, that were COVID-19 negative. During a surveyor interview on 10/24/2022 at 2:53 PM with LPN, Staff H, she indicated that she was aware that COVID-19 positive and COVID-19 negative residents should be kept isolated from one another. Additionally, she indicated her expectations are that staff are to assist residents with proper positioning of their face masks, to ensure their nose and mouths are covered. 2. Record review revealed a nursing progress note dated 10/25/2022 at 5:35 AM indicated that Resident ID #25 was sent to the emergency room and had returned to the facility at 5:00 AM from the hospital after being diagnosed at the hospital with a urinary tract infection and COVID-19. Further review of this progress notes indicates that Resident ID #25 was placed on precautions. During a surveyor observation of the Lily Unit dining/activities area on 10/25/2022 at 11:25 AM, revealed Resident ID #25, was observed sitting in the area wearing his/her face mask under his/her chin. Additionally, Resident ID #85, who was on empiric transmission-based precautions due his/her roommate testing positive for COVID-19, was also in the dining/activities area wearing his/her face mask under his/her chin. Additionally, there were approximately 20 COVID-19 negative residents sitting and wandering in the room without face masks on. During a surveyor interview on 10/25/2022 at 11:31 AM, with Unit Manager, LPN, Staff F, he acknowledged that residents who were on empiric transmission-based precautions and who have tested positive for COVID-19 were co-mingling with COVID-19 negative residents in the dining/activities area room without appropriate PPE. 3. According to the Rhode Island Department of Health guidance dated 10/12/2022, titled, COVID-19 Information for Nursing Homes, states in part, .All healthcare settings, such as nursing homes, should use the statewide community transmission rate to guide decisions about extra precautions related to infection prevention and control practices .during high community transmission (greater than or equal to 100/100,000 people) or outbreaks . Review of the Rhode Island Department of Health's COVID-19 Data Response Portal revealed the community transmission rate was high during the week of 10/24/2022. During a surveyor observation on 10/26/2022 at 11:42 AM in the presence of the Infection Control Nurse revealed Hospice NA, Staff J, wearing a surgical mask in the Lily unit kitchenette. Additionally, Resident ID #11 was in the kitchenette wearing his/her mask below the chin. Immediately following the above observation Staff J was observed transporting the resident out of the kitchenette and down the hallway without wearing proper PPE until the surveyor brought it to her attention. During a surveyor interview on 10/26/2022 at approximately 11:45 AM Staff J indicated she had been to multiple units in the facility visiting other residents and was never informed of the PPE that was required to be worn in the facility. During a surveyor interview on 10/26/2022 at 11:52 AM with the Infection Control Nurse, she acknowledged that she failed to ensure that all contracted staff on the COVID-19 positive unit were wearing the appropriate PPE as required. 4. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/28/2022, the day after the survey team had exited the facility, alleges that COVID-19 positive residents are in the activity/dining area of the Lily unit co-mingling with COVID-19 negative residents without proper PPE. After this State Agency received this complaint a member of the survey team returned to the facility. A surveyor observation on 10/28/2022 at approximately 12:45 PM of the Lily Unit, revealed Resident ID #25, a COVID-19 positive resident, co-mingling with COVID-19 negative residents in the dining room, with his/her face mask below his/her nose and chin. Although at this time staff was observed to be directed Resident ID #25 to reposition his/her face mask. Record review revealed a care plan for the resident dated 10/25/2022 that states in part, .If resident comes out of room redirect back to room .and away from non-positive resident . During additional surveyor observations on 10/28/2022 at 1:20 PM and 1:34 PM revealed Resident ID #25 sitting at a table in the dining/activity area room with a COVID-19 negative resident, Resident ID #76, both residents were wearing their masks below their chins. Additionally, Resident ID #25 was observed to cough without wearing his/her mask at 1:54 PM. During a surveyor interview with the Infection Control Nurse immediately following the above-mentioned observations, she acknowledged that Resident ID #'s 25 and 76 were not wearing their masks properly or social distancing. 5. Review of the facility policy titled, Cleaning and Disinfecting dated 10/24/2022, states in part, .reusable medical equipment is cleaned and disinfected appropriately .PRACTICE STANDARDS .Non-critical items are objects that do not come into contact with [MEDICATION(S)] membranes, but do come into contact with intact skin ( .glucose meters [a small, portable machine used by people with diabetes to check their blood sugar levels after pricking the skin] .). These items require cleaning between patient use . During a surveyor observation of the medication administration task/glucose monitoring on 10/25/2022 with LPN, Staff B revealed the following: - 11:33 AM, Staff B was observed obtaining the blood sugar for Resident ID #50. She failed to clean/disinfect the glucometer after use. -11:45 AM, Staff B was observed obtaining the blood sugar for Resident ID #79. She failed to clean/disinfect the glucometer before and after use. -12:26 PM, Staff B was observed obtaining the blood sugar for Resident ID #57. Staff B failed to clean/disinfect the glucometer before use. During a surveyor interview on 10/25/2022 at 12:29 PM with Staff B, she acknowledged that she did not clean the glucometer per facility policy. Additionally, she indicated that she was not aware the glucometer is to be cleaned between each resident. During a surveyor interview on 10/27/2022 at approximately 12:30 PM with the Regional Clinical Director, she indicated that her expectation is for the nurse to clean/disinfect the glucometer between each resident. 6. Review of a facility policy titled, Contact Precautions revised 11/15/2021, states in part, .Contact Precautions will be used for diseases transmitted by direct or indirect contact with the patient or the patient's environment .Staff must use barrier precautions when entering the room .Wear gown and gloves . Record review revealed Resident ID #39 was diagnosed with [MEDICATION(S)] [MEDICATION(S)] on 10/25/2022. During a surveyor observation on 10/26/2022 at 10:40 AM of the signage outside of Resident ID #39's room indicated a mask, gown, and gloves should be worn when entering the room. Staff B was observed in Resident ID #39's room obtaining his/her blood pressure without wearing a gown. During a surveyor observation on 10/26/2022 at 10:51 AM, Staff B was observed in the resident's room administering medication with just a mask on, no gloves or gown. She remained in the resident's room without the appropriate PPE on until 10:55 AM. During a surveyor interview with Staff B on 10/26/2022 at 10:56 AM, she acknowledged she was not wearing the appropriate PPE per the signage on the door. During a surveyor interview with the Infection Control Nurse on 10/27/2022 at 10:08 AM, she indicated that she expects staff to wear PPE as stated on the signage outside of the resident's room.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure a resident's environment remains as free of accident hazards as possible for 2 of 4 residents reviewed for falls, Resident ID#'s 1 and 5. Findings are as follows: During surveyor observations on 9/1/2022 at 11:45 AM and 9/2/2022 at 11:00 AM revealed a 7-foot cement walkway. The walkway had multiple areas of broken cement. The transition between the walkway and the asphalt had an approximate 2-inch gap. 1. Record review of a facility reported incident relative to Resident ID #5 sent to the Rhode Island Department of Health (RIDOH) on 6/23/2022, states in part .Resident being transported back to facility from appointment. Transport workers wheeling resident towards building and resident fell off the stretcher. Resident sent to ED . Record review reveals Resident ID #5 was admitted to the facility in December of 2020 with diagnoses to include, but are not limited to, repeated falls, lung, and [CONDITION(S)]. Review of the Minimum Data Set (MDS) assessment dated [DATE] reveals a Brief Interview for Mental Status (BIMS) score of 15/15 indicating the resident is cognitively intact. Record review of a nursing note dated 6/23/2022 at 7:39 PM, relative to Resident ID #5's incident, indicates that the resident was status post fall from stretcher in the parking lot. The primary care provider requested to send the patient to the emergency room for evaluation and treatment as the resident was complaining that s/he hit his/her head on the ground, and s/he had pain in the right wrist and hand. Record review of the hospital discharge records indicated that Resident ID #5 fell from a stretcher after [CONDITION(S)]. The resident had scattered ecchymosis (bruising) along the anterior deltoid and upper bicep of the right arm with pain when touched to this region, range of motion was limited both actively and passively. The resident had x-rays and was prescribed a thumb spica splint (splint used to provide support for thumb injuries). Record review revealed an order dated 6/24/2022 to monitor bruise to right shoulder, thigh, left upper and lower arm, increase/decrease in size, pain, swelling and report to MD (medical doctor) every shift. The order was discontinued on 7/17/2022. During an interview with Resident ID #5 on 9/2/2022 at approximately 12:30 PM, s/he indicated that s/he was returning from [CONDITION(S)] on 6/23/2022 at approximately 5:30 PM via a medical transport service. When s/he was being wheeled via stretcher into the facility the resident stated, I felt a jolt, like the wheel got caught on something. The stretcher fell over with me strapped in. Resident ID #5 indicates after the incident s/he was sent to the hospital and was kept for nine hours and then returned to the facility. S/he reported that his/her right side was black and blue. The resident reported pain to the surveyor to his/her right shoulder since the incident on 6/23/2022. Review of the facility investigation revealed a statement from a facility visitor, Witness A, that states in part As the people were taking the patient out of the van. They pulled the stretcher out, once they closed the van doors, they started moving the stretcher sideways. The stretcher wheels hit the gap between the driveway and sidewalk, at that time the stretcher tipped over, the patient hit the ground on [his/her] left side [his/her] legs were still strapped to the stretcher. During a surveyor interview on 9/6/2022 at 10:15 AM with Witness A, s/he indicated that s/he was visiting another resident on 6/23/2022 and witnessed the incident with Resident ID #5. S/he reported that while the resident was being transported via a stretcher back into the building it appeared the wheel got caught on the sidewalk and the resident tipped over in the stretcher. During a surveyor interview with transport staff, Witness B, on 9/7/2022 at 1:45 PM he indicated he and his partner were taking the resident from the transport van into the facility on a stretcher and the stretcher wheel got caught in a crack. He further indicated that the crack is between the pavement and the asphalt. During an interview on 9/1/2022 at 1:45 PM with the Director of Nursing she acknowledged that the front entrance is used as the ambulance entrance. Additionally, she acknowledged that the area presented a risk for accidents as there were uneven surfaces. During an interview on 9/2/2022 at 12:17 PM with the Maintenance Technician he acknowledged the gap in the transition from the walkway to the asphalt. 2. Record review of a facility reported incident relative to Resident ID #1 sent to RIDOH on 8/31/2022 states in part .on 8/30/2022 at 6:15 AM, Resident noted to have bruise to right side of abdomen and rt [right] hand .stated the transport company had dropped [him/her] off stretcher when they left .I reviewed video camera with Administrator .we were able to see resident and stretcher tip over . Record review revealed Resident ID #1 was admitted to the facility in July of 2017 with a re-admission in October of 2020, diagnoses to include, but are not limited to, complete amputation of the left lower leg at the knee and [CONDITION(S)]. Review of the MDS assessment dated [DATE] reveals a BIMS score of 14/15 indicating the resident is cognitively intact. Record review of a nursing note dated 8/31/2022 at 11:57 AM, relative to Resident ID #1's incident, states in part, Resident has a large bruise to right hip area and right 4th and 5th digits. Asked if [s/he] knew how it happened stated that transport guys tipped over stretcher when I went to HD [hemodialysis]. C/o [complaints of] feeling sore to right hip area. Will get X-ray today . Record review revealed x-rays of right hip and right hand were obtained and were negative for acute fracture. Additional record review revealed a new physician order dated 9/2/2022 for Asper Cream with [MEDICATION(S)] 4%. Apply to right side of abdomen/back topically every day and evening shift for bruising pain until 9/7/2022 and apply to affected areas topically as needed for bruising/pain. During a surveyor observation on 9/1/2022 at approximately 11:23 AM, in the presence of the Director of Nurses, video surveillance of Resident ID #1's incident on 8/30/2022 was viewed. The surveillance video revealed Resident ID #1 being transported from the facility on a stretcher by a medical transport company. In the video the resident was being wheeled out of the front entrance of the facility by two transport staff. When the stretcher is turned from the walkway to the pavement, the wheel at the foot of the stretcher catches a gap in the transition from the walkway to the asphalt entering the parking lot. At this time the resident tipped to the right side while in the stretcher and landed on the asphalt. During a surveyor interview and on 9/1/2022 at approximately 2:05 PM with Resident ID# 1, s/he revealed that the stretcher tipped as they left the facility after hitting a lip on the sidewalk. S/he tried to brace the fall, but the stretcher tipped over with him/her on it. S/he further revealed that s/he has a large bruise to his/her hip from when s/he hit the pavement after tipping. During a surveyor observation immediately following revealed the resident has a large ecchymotic area to his/her right hip and his/her right hand was swollen and ecchymotic. During a surveyor interview with transport staff, Witness C, on 9/7/2022 at 1:54 PM, he revealed that he and his partner were wheeling the resident out of the building early in the morning and it was still a little dark outside. He further revealed the stretcher wheel got caught in the hole outside of the building and it was hard to see because it was dark. He also stated that this is a hazard because the wheels get stuck in the gap and the stretcher tips over. During a surveyor interview on 9/2/2022 at approximately 12:15 PM with the Maintenance Technician, he informed us that he had not been made aware of the incidents with either resident. He acknowledged that there is a gap in the transition from the walkway and the asphalt entering the parking lot and it should be fixed. Additionally, he indicated this gap could cause an accident/hazard to residents being transported via stretcher as the wheels could get stuck in the gap.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice for 1 of 3 residents reviewed who were admitted with surgical wounds, Resident ID #1. Findings are as follows: Review of the facility's record revealed a policy titled, Skin Integrity Management states in part, Practice Standards . 1. Review pre-admission information to plan for patient's needs prior to admission. 2. Complete comprehensive evaluation of the patient upon admission/re-admission to the Center . 3. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information . 3.2 Perform skin inspection on admission/re-admission and weekly. Document on treatment administration record (TAR) or in Point Click Care (PCC) [electronic medical record]. 3.3 Perform wound observations and measurements and complete 'Skin Integrity Report' .upon initial identification of altered skin integrity .with anticipated decline of wound. 3.4 Perform daily monitoring of wounds or dressings for presence of complications or declines and document . 4. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated . 4.5 For surgical wounds .follow specific orders from the surgeon . 4.7 Implement special wound care treatments/techniques, as indicated and ordered . 11. Document daily monitoring of ulcer site, with or without dressing. 11.1 For wounds that do not require a daily dressing change, monitor: 11.1.1 Status of the dressing (intact and clean). 11.1.2 Status of the tissue surrounding the dressing (free of new redness or swelling) . 11.2.1 If unanticipated decline in wound, surrounding tissue, or new or increased wound pain, complete the skin integrity report and notify physician/APP[advanced practice provider]. Record review revealed the resident was admitted to the facility from an intensive care surgical step down unit post-operative day 7 on 1/14/2022 after a right cutdown thromboembolectomy (emergency surgical removal of emboli which are blocking blood circulation), placement of external iliac artery stent (a small wire mesh tube that is used to hold open an iliac artery that has been narrowed by artery disease), and fasciotomies (a surgical procedure where the connective tissue is cut to relieve tension or pressure in order to treat the resulting loss of circulation). Further review revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the continuity of care post-acute facility document dated 1/14/2022 revealed recommendations for wound care as follows: Your right medial wound is dressed using a wound vacuum [vac] [vacuum assisted closure of a wound for healing] that should be changed three times a week. It was last changed on 1/14. A black sponge should be cut to the size of the medial wound and placed in the wound bed. The blistered skin along the superior aspect of the wound should be dressed with a single layer of xeroform [an occlusive dressing that keeps air out]. This should all be covered with a clear sticker overlay and connected to the suction tubing in the usual fashion. The right leg should be elevated and wrapped from toes to upper thigh with ACE wrap for gentle but continuous compression to minimize swelling and help faster recovery. Right groin with staples in place that will be discontinued in clinic. Please place gauze over this wound and tape in place at least daily. It can be changed more frequently if soiled, but the area should remain dry. You should inspect your incision daily to ensure there are no problems healing or evidence of infection. You should expect some swelling, bruising, and tenderness. If there is skin separation, beefy red color, pus, smelly drainage, or other concerns, please call your surgeon's office. The assessment indicates the resident's right leg was UTA (unable to assess) on 1/13/2022 and a bandage roll; compression bandage was present. Record review of the resident's discharge summary from the hospital dated 1/14/2022, revealed the resident was discharged with a wound vac to his/her medial right calf, a surgical incision with sutures to his/her lateral right calf, a surgical incision with staples to his/her right groin, and areas containing blisters and skin breakdown. This document was not provided by the facility and obtained from the hospital during the investigation. During an interview with the admitting Nurse, Staff A, on 1/26/2022 at 2:45 PM, she stated she admitted the resident who arrived at the facility around 4/4:30 PM on 1/14/2022. She stated her supervisor was present who was assisting her with the admission, but she was the nurse who performed the admission assessment. She stated the resident arrived with a wound vac dressing in place to the right medial leg. She stated her supervisor connected the wound vac to the existing tubing and the dressing remained in place. She stated she removed a wrap to observe the wound vac dressing and observed the area superficial to the wound which was underneath the adhesive dressing and covered with xeroform but did not remove the xeroform dressing to assess the wound underneath. She further stated she observed staples in the resident's right groin. Review of an admission assessment dated [DATE] revealed documentation of new skin injury/wound which indicated the presence of incisions. A description of the incisions was documented as RLE (right lower extremity)/groin. The document failed to describe locations, appearance, and/or drainage of incisions. The assessment of the resident's bilateral feet revealed palpable pedal pulses and bilateral non-pitting [CONDITION(S)]. The assessment further indicated there was no evidence of redness, softening, or breakdown of the resident's bilateral feet. During an interview with the evening supervisor, Staff Nurse B, on 1/27/2022 at 11:48 AM, she stated she assisted Staff A with the wound vac but did not remove the ACE wrap that was present on the resident's right leg. She stated she was unaware of the incision on the resident's right lateral leg. Additionally, she stated when she entered the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Cleanse right groin with 0.9% n/s (normal saline). Apply gauze over qd (daily). 2. Negative Pressure Wound Therapy to RLE. SET Unit to 125mmHg (millimeters of mercury) INTERMITTENT Cleanse with 0.9% n/s. Place foam into wound. Apply skin prep to intact skin around the wound cover with occlusive dsg (dressing) and secure tubing per manufacturer guide as needed If NWPT needs to be turned off for any care, tests/procedures (Bathing .etc), or for transport; remove dsg entirely, cleanse wound with 0.9% n/s, apply wet to dry dsg and cover with abd (abdominal pad) and kling Wound(s): Monitor site(s) Daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable Additional Documentation in NN (nurses note) if needed every day shift. Review of resident's Order Summary Report dated 1/14/2022 to 1/16/2022 failed to reveal evidence of the following treatments: daily application of xeroform to lateral surgical incision, and application of ACE wrap from toes to upper thigh for gentle continuous compression. During a surveyor interview with the Unit Manager, Staff C, on 1/21/2022 at 1:53 PM, she revealed that she was unaware of the resident's lateral wound incision until she went in to assess the wound vac site on 1/17/2022, three days after the resident was admitted . She also revealed that when she removed the lateral wound dressing, the wound had profuse amounts of thick, dark red/brown drainage which was seeping through the dressing. During a subsequent interview with Staff C on 1/26/2022 at 1:00 PM she further revealed that she applied a wound treatment to the surgical wound then wrapped it with a bandage. She stated the physician was present but left the building emergently, so she took photos of the wounds that were sent to the physician. She was unable to provide evidence of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, she was unable to determine if the wound had improved or deteriorated upon her assessment on 1/17/2022. During surveyor interviews with Staff C on 1/20/2022 at 2:45 PM, 1/21/2022 at 1:53 PM, and 1/26/2022 at 1:00 PM, she revealed she was unaware of the condition of the resident's right foot until she went to change his/her wound vac dressing on 1/17/2022. Upon assessment, she observed the resident's foot to be swollen, red and purple in color, with both open and closed blisters coverings the top of his/her foot and toes. She further revealed his/her right great toe, second toe, and third toe had necrotic tissue. Additionally, she revealed there was a bloody blister which was also unstageable. She stated the physician was sent the pictures of the wound and confirmed receipt but did not initiate any orders for care of the wounds present on the foot. She explained that the wound specialist would be present at the facility the following day (1/18/2022) to assess the wounds. Further record review revealed a progress note written by the Wound Nurse Practitioner, Staff D, dated 1/18/2022, which states in part, [S/He] is seen today per nursing request for initial evaluation of [his/her] lower extremity wounds and surgical sites .Reports areas are tender to the touch .concern about the appearance of the wounds and [his/her] swelling. Has [CONDITION(S)] throughout the leg .The medial calf wound has wound vac in place. Vac to remain in place until tomorrow and not taken down at time of this visit. Lateral calf incision with large necrotic area extending medially and copious bloody/purulent drainage. Sutures in place. Slight surrounding [CONDITION(S)]. Right foot with large area of purple dusky discoloration with multiple areas of blistering with seropurulent drainage. Plantar surface of the foot is extremely [swollen], [purple] and also with blistering .Condition of limb very poor with concerns for advancing infection wet vs gas gangrene [dangerous and potentially fatal condition that happens when the blood flow to a large area of tissue is cut off] in addition for recurrent critical limb ischemia. Very high risk for further decline/loss of limb/life if [s/he] were to remain in the center. At this point [s/he] needs urgent surgical eval [evaluation]/intervention, imaging, IV abx [intravenous antibiotics] therapy, [etc]. Will send to the [hospital] ED [emergency department] for acute eval and treatment . Review of the resident's record revealed s/he was discharged to the hospital for evaluation on the day mentioned above. Additional record review of the hospital's admission note dated 1/18/2022, states in part, .11 days status post [MEDICAL RECORD OR PHYSICIAN ORDER] . His/her pulse exam is notable for absent pulse on the right DP [pulse of the lower leg] .We will plan for CTA [computed tomography angioplasty, dye injected into body to produce pictures of blood vessels] of the lower extremities to assess for new vascular injury . Review of the hospital paperwork revealed that on 1/20/2022, the resident's right groin staples were removed and purulent drainage was expressed from the area. Redness was observed extending down the thigh. The right lateral fasciotomy site was observed with necrotic [dead] fibrous material in the wound bed with drainage of a decompressing hematoma. Further review of a surgical note dated 1/22/2022 revealed the resident returned to the operating room for a [NAME] (thin, long, superficial muscle in the anterior compartment of the thigh) flap, right groin washout and debridement with wound vac placement, right lower extremity wound debridement and wash out. During surveyor interviews with the Director of Nursing Services on 1/20/2022 at 4:04 PM and on 1/21/2022 at 2:48 PM, she revealed that she would expect the resident's wounds to be fully assessed on admission, including descriptions of the wounds, location, and drainage. She was unable to provide evidence that the hospital's recommendations for treatment were put into place and that the lateral surgical wound on the resident's right calf had orders in place for treatment.

Based on record review and staff interview, it has been determined that the facility failed to have nursing staff with the appropriate skill sets to provide nursing and related services to assure resident safety and failed to provide care including, but not limited to; assessing, and implementing wound care and wound vacuum (vac) management for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: According to the American Nurses Association, standards of nursing practice: Standard 1: Assessment: The registered nurse collects comprehensive data pertinent to the patient's health or the situation. Standard 2: Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Standard 3: Outcomes Identification: The registered nurse identifies outcomes for a plan individualized to the patient or the situation. Standard 4: Planning: The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. Standard 5: Implementation: The registered nurse implements the identified plan. Review of the facility's record revealed a policy titled, Skin Integrity Management states in part, Practice Standards . .2. Complete comprehensive evaluation of the patient upon admission/re-admission to the Center . 3. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information . 3.2 Perform skin inspection on admission/re-admission and weekly. Document on treatment administration record (TAR) or in Point Click Care (PCC) [electronic medical record]. 3.3 Perform wound observations and measurements and complete 'Skin Integrity Report' .upon initial identification of altered skin integrity .with anticipated decline of wound. 3.4 Perform daily monitoring of wounds or dressings for presence of complications or declines and document . 4. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated . 4.5 For surgical wounds .follow specific orders from the surgeon . 4.7 Implement special wound care treatments/techniques, as indicated, and ordered . 11. Document daily monitoring of ulcer site, with or without dressing. 11.1 For wounds that do not require a daily dressing change, monitor: 11.1.1 Status of the dressing (intact and clean) 11.1.2 Status of the tissue surrounding the dressing (free of new redness or swelling) . Record review revealed Resident ID #1 was admitted to the facility in January of 2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's hospital record titled, DISCHARGE SUMMARY dated 1/14/2022 revealed, .Patient was discharged with instructions on dressing change with wound vac to his/her medial right lower extremity wound that needs changing x3 weekly, with daily application of xeroform [an occlusive dressing that keeps air out] to lateral incision and areas of blister/skin breakdown, with ACE [an elasticized cloth bandage wrapped around an ankle, knee, etc. to provide firm support] wrap from toes to upper thigh for gentle continuous compression. This document was not provided by the facility and obtained from the hospital during the investigation. Review of the resident's Order Summary Report dated 1/14/2022 to 1/16/2022 failed to reveal evidence of the following treatments: daily application of xeroform to lateral surgical incision, and application of ACE wrap from toes to upper thigh for gentle continuous compression. During a surveyor interview with the resident's admitting Nurse, Staff A, on 1/25/2022 at 2:44 PM, she was asked if there was a dressing on the right lateral surgical incision, she stated I don't remember but if there was, probably gauze with tape. Additionally, when the surveyor asked where to look for her wound assessments, she stated Whenever I document it, it would have been in assessments. Review of an admission assessment dated [DATE] completed by Staff A, revealed documentation of new skin injury/wound which indicated the presence of incisions. A description of the incisions was documented as RLE (right lower extremity)/groin. The document failed to describe locations, appearance, and/or drainage of incisions. The assessment of the resident's bilateral feet revealed palpable pedal pulses and bilateral non-pitting [CONDITION(S)]. The assessment further indicated there was no evidence of redness, softening, or breakdown of the resident's bilateral feet. During a surveyor interview with the weekend supervisor Nurse Staff B on 1/27/2022 at 11:48 AM, she stated I put in the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When the surveyor asked for information related to the resident's right lateral surgical incision, she stated I don't remember reading any of that. During a surveyor interview on 1/26/2022 at 11:19 AM with Nurse Staff F, who cared for the resident on the day shift of 1/15/2022 and 1/16/2022, she revealed that she changed the dressing on the right lateral aspect of the leg on 1/16/2022 because of large amounts of serous (thin, watery constitution) brown drainage. When the surveyor asked if she assessed the resident's right lateral incision, she stated I don't remember seeing the sutures, it was under the wound vac dressing. Additionally, when asked if she documented changing the dressings to the right leg, she stated I would have documented changing a dressing and about the drainage. Review of the resident's medical record from 1/14/2022 - 1/16/2022 failed to reveal evidence related to the documentation of assessment or application of treatment to the resident's right lateral incision. During surveyor interview with the Unit Manager Staff C on 1/26/2022 at 12:00 PM, she acknowledged that there was no order in place to treat the resident's right lateral surgical incision from 1/14/2022 to 1/16/2022. During a surveyor interview with the resident representative on 1/27/2022 at 12:38 PM, s/he stated they [facility] didn't know how to take care of the wounds .One time there was no gauze covering it [groin incision] .The wound vac was full, and they didn't know if they had to change the cannister or empty it . Additionally, she stated that the facility did not have a supply of ACE wrap and re-applied a soiled bandage. During a surveyor interview with the Nurse Educator, Staff E, on 1/26/2022 at 8:22 AM, she failed to provide evidence of staff education and/or staff competencies related to wound vac management. During surveyor interviews with the Director of Nursing Services on 1/20/2022 at 4:04 PM, on 1/21/2022 at 2:48 PM, and on 1/26/2022 at 12:21 PM, she revealed that she would expect the resident's wounds to be fully assessed on admission, including descriptions of the wounds, location, and drainage. She was unable to provide evidence that the hospital's recommendations for treatment were put into place and that the lateral surgical incision on the resident's right calf had orders in place for treatment. Additionally, she was unable to provide evidence of staff education related to the wound vac management.