Every finding on record at Holiday Operator, LLC DBA Holiday Rehabilitation a

Based on clinical record review, and staff and resident interview, the facility failed ensure that Resident ID #2's environment remained free of accident hazards, as possible, relative to the resident's assessed transfer needs and facility policy. Specifically, the facility failed to implement the Physical Therapist's recommendation for the use of a mechanical lift following the resident's identified decline in strength and mobility on 5/11/2026 and failed to ensure staff utilized a gait belt during manual transfers. As a result, Resident ID #2 was subjected to unsafe transfer practices including, being lifted under the arm and elbow area, which resulted in swelling, extensive bruising, and increased pain to the resident's left upper extremity. Requiring medical evaluation, diagnostic testing, pain medication, and ongoing monitoring. These failures resulted in actual harm for 1 of 1 resident reviewed with an injury of unknown origin, Resident ID #2.Based on clinical record review and staff and resident interviews, the facility failed to ensure that Resident ID #2's environment remained free of accident hazards, as possible, relative to the resident's assessed transfer needs and facility policy. The failure of the facility to implement a recommendation of a mechanical lift on 5/11/2026, resulted in actual harm including swelling, extensive bruising, and increased pain to the resident's left upper extremity for Resident ID #2.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/29/2026 alleged that Resident ID #2 was discovered with significant bruising. The resident's spouse had visited the resident the night prior and there was no bruising. The report further alleged that when the complainant asked about the incident s/he was told two Nursing Assistants (NA) used the wrong equipment to transfer the resident.Review of a facility policy titled, SAFE PATIENT HANDLING AND MOVEMENT POLICY states in part, .to ensure that its .residents are cared for safely.direct care staff on high/risk .resident care areas should assess high risk patient handling tasks in advance to determine the safest way to accomplish them.mechanical lifting equipment.should be used to prevent lifting and handling of patients/residents when absolutely necessary.it is the duty of employees to take reasonable care of their health and safety.and their patients.by following this policy. Non-compliance will indicate the need for retraining.All patients are assessed by a nurse on admission, and with any changes, for the safest and most appropriate method of transfer. This is documented on the Smooth Moves Resident Handling Assessment .Patient handling and movement requirements.use of mechanical lifting devices and other approved patient handling aids (devices designed to help nursing staff and other direct care workers safely lift, move, and reposition residents without overexertion, i.e. Gait Belts, a safety device worn around the resident's waist over the clothes to aid caregivers in safely supporting and transferring individuals with mobility challenges).training: Staff to complete and document training as required to correct improper use/understanding of safe patient handling and movement.Record review revealed Resident ID #2 was originally admitted to the facility in February of 2026 with diagnoses including, but not limited to, dementia with behavioral disturbance, muscle weakness, and falls.Record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 4 out of 10, indicating the resident has severe cognitive impairment. Additional review revealed the resident is totally dependent (The helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) with dressing, toileting, and transfers.Record review of the resident's Kardex (NA Care plan- a documentation system that enables nurses to write, organize, and easily reference key resident information that shapes a nursing care plan) revealed the resident requires substantial/maximum assistance, or is totally dependent of the staff to safely transfer from a sitting to standing position.1a. Record review of a Physical Therapy (PT) Evaluation dated 5/11/2026 revealed the resident experienced a new onset of muscle weakness and difficulty walking.Record review of a PT Encounter Note dated 5/11/2026 revealed the Physical Therapist, Staff A, discussed with nursing that the resident requires a mechanical lift (a device designed to safety transfer individuals with limited mobility that cannot safely move from one surface to another) for transfers until the resident is consistent with transfers for everyone's safety. Additional review revealed the resident's Kardex was updated to reflect the need for a mechanical lift transfer.Record review failed to reveal evidence that a new Smooth Moves assessment was completed for the resident after his/her change in transfer status was identified on 5/11/2026, per facility policy.Review of the Kardex revealed Resident ID #2 required a mechanical lift for transfers with the assist of two staff members.Record review revealed the following progress notes:-5/13/2026 at 5:19 AM, the resident was seen by the Nurse Practitioner (NP) swelling and bruising to the left arm. Additionally, new orders were given to elevate the left arm, obtain a PT/INR (a blood test that checks how quickly the blood clots) and a STAT (immediate) ultrasound of the left arm.-5/13/2026 at 8:09 AM, a deep purple discoloration/bruise was identified on the resident's left upper arm.-5/13/2026 at 9:48 PM the resident continues with swelling to the left hand and bruising to the left arm.-5/14/2026 at 12:00 AM authored by the NP revealed the PT/INR results were within normal limits indicating the resident's blood was clotting normally.Additional review of the progress note revealed the following new orders were given:-Hold the resident's Eliquis (a medication prescribed to thin the blood) for two days-Obtain an x-ray of the resident's left arm ordered to evaluate a contusion, redness and swelling of the left upper arm. -Tramadol (a medication prescribed to treat moderate to severe pain) 25 milligrams (MG) twice daily for pain.-5/14/2026 at 6:47 AM the resident woke up around 1:00 AM complaining of knee and left arm pain.Record review of a progress note dated 5/14/2026 at 11:47 AM authored by the Assistant Director of Nursing (ADON) revealed that after talking with staff, the bruise appears to be due to improper positioning of the resident's arm during transfers. Further, review revealed the progress note was documented as a late entry on 5/19/2026 at 11:49 AM, six days after the bruising was identified.During a surveyor interview on 6/8/2026 at 12:09 PM, with the resident's spouse, s/he indicated that s/he received a call from facility staff on 5/13/2026 to inform him/her of new bruising to his/her spouse's left arm. Additionally, s/he indicated when s/he visited the night before there was no bruising present. Further, s/he revealed that the facility staff indicated there would be an investigation into the cause of the bruising but as of 6/8/2026 the spouse had not heard back.During a surveyor interview on 6/9/2026 at approximately 8:15 AM, with Registered Nurse (RN), Staff B, she indicated that she was not aware that the resident had been evaluated by PT on 5/11/2026 with the recommendation to utilize a mechanical lift for transfers for safety. Additionally, she indicated that she spoke with the NA, Staff C, working on the unit and she indicated that the resident transfers with the assistance of two staff members without a mechanical lift. Further she indicated that when she spoke with NA, Staff C, she reported that the resident was experiencing weakness and difficulty with his/her manual transfers. The RN, Staff B, changed his/her transfer status to utilize a mechanical lift on 5/13/2026 for safety, although staff B was not aware that the resident had been evaluated by PT on 5/11/2026 and his/her transfer status was changed to a mechanical lift.During a surveyor interview with NA, Staff C, on 6/9/2026 at 8:57 AM she acknowledged that she was assigned to care for the resident on 5/12/2026 during the 3:00 PM to 11:00 PM shift. She revealed that she was not aware of the PT recommendation for a mechanical lift transfer and acknowledged that she transferred the resident manually with another staff member. Further, she indicated that at times the resident is dead weight and is difficult to lift manually.During a surveyor interview with NA, Staff E, she revealed that she worked the evening of 5/11/2026 during the 3:00 PM to 11:00 PM shift and transferred the resident manually with another staff member. Additionally, she indicated that she was not made aware of the PT recommendation for a mechanical lift for transfer given on 5/11/2026. During a surveyor interview on 6/9/2026 at 9:46 AM with Licensed Practical Nurse, Staff F, she revealed that she was the nurse assigned to the resident on 11:00 PM to 7:00 AM shifts on 5/11/2026, 5/12/2026, and 5/13/2026. Additionally, she indicated she was not aware of the recommendation from PT made on 5/11/2026 for the use of a mechanical lift for transfers. Further, she indicated that on the above-mentioned shifts staff were transferring the resident manually with two staff members. During a surveyor interview on 6/9/2026 at 11:39 AM with NA, Staff G, she acknowledged that she was assigned to care for the resident on 5/12/2026 during the 11:00 PM to 7:00 AM shift along with NA, Staff D. She revealed that she was not given a report from the nurse that the resident required a mechanical lift for transfers. Additionally, she acknowledged that she assisted Staff D, in transferring the resident from the wheelchair into the recliner manually by lifting the resident under his/her arm/elbow area. During a surveyor interview on 6/9/2026 at 12:40 PM with the Director of Nursing Services, he indicated it would be his expectation for staff to utilize a mechanical lift to transfer the resident after the recommendation was made by PT on 5/11/2026.1b. Review of a facility policy titled [Facility] Gait Belt Policy and Procedure states in part, it is the policy of [Facility] to use a gait belt for all resident transfers and ambulation.During a surveyor interview on 6/9/2026 at 8:39 AM with NA, Staff D, she acknowledged she worked the 11:00 PM to 7:00 AM shift on 5/12/2026 and provided care for the Resident ID #2. Additionally, she revealed she attempted to transfer the resident to the toilet by grabbing his/her pants and lifting him/her under the arm without using a gait belt. Further, Staff D stated that the resident required two staff members utilizing a manual transfer method.During a surveyor interview on 6/9/2026 at 11:39 AM with NA, Staff G, she acknowledged that she was assigned to care for the resident on 5/12/2026 during the 11:00 PM to 7:00 AM shift along with Staff D. Staff G, acknowledged that she did not utilize a gait belt to transfer the resident.During surveyor interviews on 6/8/2026 at 12:54 PM, 6/9/2026 at 12:55 PM, and 1:28 PM with the Assistant Director of Nursing Services, she indicated that it would be her expectation for staff to utilize a gait belt during manual transfers. Additionally, she revealed that the bruising was not present on 5/12/2026 when the resident's spouse visited and believes an inappropriate transfer occurred by pulling on the resident's arm between 5/12/2026 and when the bruising was identified on 5/13/2026 at approximately 8:00 AM. During a surveyor interview on 6/10/2026 at 1:48 PM with the Medical Director he revealed it would be his expectation that staff would have implemented the recommendation made by PT on 5/11/2026, prior to the next time they transferred the resident. The facility's failure to timely implement the Physical Therapist's recommendation for a mechanical lift, communicate the resident's change in transfer status to direct care staff, complete a revised transfer assessment, and ensure staff utilized a gait belt during resident transfers resulted in Resident ID #2 being transferred utilizing unsafe transfer techniques. Consequently, the resident sustained swelling, significant bruising, and pain to the left upper extremity, requiring physician assessment, diagnostic testing, medication changes, pain management interventions, and continued clinical monitoring. The deficient practice resulted in actual harm to the resident. Cross Reference F610.

Based on clinical record review and staff interview, the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 1 of 1 resident reviewed for bruising, Resident ID #2.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/29/2026 alleged that Resident ID #2 was identified with new significant bruising. The resident's spouse had visited the resident the night prior and there was no bruising. The report further alleged that when the complainant asked about the incident s/he was told two Nursing Assistants (NA) used the wrong equipment to transfer the resident.Review of a facility policy titled, Abuse prohibition states in part, .Injuries of unknown origin .the source of the injury was not observed, or the source cannot be explained by the resident .Investigation .begin the initial investigation .obtain statements from witnesses, notify the appropriate administrative personnel so that a comprehensive internal facility investigation can be carried out .Record review revealed Resident ID #2 was originally admitted to the facility in February of 2026 with diagnoses including, but not limited to, dementia with behavioral disturbance, muscle weakness and falls.Record review of the progress notes revealed the following:-5/13/2026 at 8:09 AM, a deep purple discoloration/bruise was identified on the resident's left upper arm.-5/14/2026 at 11:47 AM authored by the Assistant Director of Nursing (ADON) revealed that after talking with staff, the bruise appears to be due to improper positioning of the resident's arm during transfers. Further, review revealed the progress note was documented as a late entry on 5/19/2026 at 11:49 AM, six days after the bruising was identified.During a surveyor interview on 6/8/2026 at 12:09 PM, with the resident's spouse s/he indicated that s/he received a call from facility staff on 5/13/2026 to inform him/her of new bruising to his/her spouse's left arm. Additionally, s/he indicated when s/he visited the night before there was no bruising present. Further, s/he revealed that the facility staff indicated there would be an investigation into the cause of the bruising but as of 6/8/2026 s/he had not heard back.Record review of the facility nursing schedule revealed Staff D and G were assigned to care for the resident on 5/12/2026 during the 11:00 AM to 7:00 AM shift.Further record review failed to reveal evidence that staff witness statements were collected from Staff D and G relative to the injury of unknown origin per the facility policy.During surveyor interviews on 6/9/2026 at 12:55 PM and 1:28 PM with the Assistant Director of Nursing Services, she revealed that the bruising was not present on 5/12/2026 when the resident's spouse visited and believes an inappropriate transfer occurred by pulling on the resident's arm between 5/12/2026 and when the bruising was identified through 5/13/2026 at approximately 8:00 AM. Further record review failed to reveal evidence that a thorough investigation had been conducted to determine the origin of the bruising.Cross reference F689.

Based on clinical record review and resident and staff interviews, the facility failed to provide dental services for 1 of 2 residents reviewed with dentures, Resident ID #1. Additionally, the facility failed to have a policy that addressed instances when a resident's dentures are lost or damaged.Findings are as follows:Record review of a community reported complaint submitted to Rhode Island Department of Health on 5/29/2026, alleged the resident's family has been required to purchase several sets of dentures lost by the facility.Record review revealed the resident was originally admitted to the facility in September of 2022 with diagnoses including, but not limited to, stroke and dysphagia (difficulty swallowing).Record review of a Significant Change Minimum Data Set assessment dated [DATE] revealed, the resident is edentulous (having no natural teeth).Record review revealed a Brief Interview for Mental Status dated 6/4/2026 with a score of 12 out of 15, indicating moderately impaired cognition.Record review failed to reveal evidence identifying when the resident's bottom denture was misplaced.During a surveyor interview on 6/7/2026 at approximately 12:00 PM, with the Medical Director, he revealed it would be his expectation for the facility to have coordinated a follow-up appointment up to address the loss of the bottom denture.1a. During a surveyor interview on 6/9/2026 at approximately 1:30 PM, with the resident, s/he indicated that his/her bottom denture has been missing and s/he has lost his/her appetite due to the lack of dentures.Record review of a care plan dated 2/12/2026 revealed, the resident is edentulous with interventions, including but not limited to, ensure the dentures are provided to the resident and assist the resident with placement.During a surveyor interview on 6/8/2026 at 12:54 PM, and email correspondence on 6/10/2026 at 10:21 AM, with the Assistant Director of Nursing Services (ADNS), she acknowledged that the residents' lower denture is missing and indicated the loss occurred sometime after 5/18/2026. Additionally, she was unable to provide evidence that a follow up appointment had been made for the resident. 1b. Record review failed to reveal evidence of a facility policy that addresses instances when a resident's dentures are lost or damaged. During a surveyor interview via email correspondence on 6/10/2026 at 10:21 AM with the ADNS, she acknowledged that the facility failed to have a policy that 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, the facility failed to ensure that a resident receives timely and appropriate pain and symptom management consistent with professional standards of practice, for end-of life-care including the prompt administration of physician-ordered medications for pain and anxiety, for 1 of 2 residents reviewed who were receiving hospice services, Resident ID #1. This failure resulted in the resident experiencing unmanaged pain, terminal agitation, and psychosocial distress during his/her final hours of life.Findings are as follows:According to the American Nurses Association (2018) Position Statement titled, The Ethical Responsibility to Manage Pain and the Suffering It Causes, nurses have an ethical responsibility to relieve pain and suffering through individualized interventions, ongoing assessment, and coordinated approaches to pain management.Record review of a community-reported complaint submitted to the Rhode Island Department of Health on [DATE] alleged Resident ID #1, a hospice resident receiving end-of-life care, experienced terminal agitation and did not receive prescribed comfort medications promptly to provide relief, comfort, and dignity.Record review revealed Resident ID #1 was readmitted to the facility in [DATE] with diagnoses including acute respiratory failure with hypoxia (a condition in which the body does not receive enough oxygen) and heart failure.Review of the resident's care plan dated [DATE] identified a risk for impaired comfort and directed staff to administer pain medication as ordered, monitor the effectiveness of treatment, and observe for non-verbal signs of pain including grimacing and agitation.Review of physician orders revealed the following: - [DATE]: Assess pain every shift - [DATE]: Acetaminophen 975 milligrams every 8 hours for mild painRecord review revealed the resident was admitted to hospice services on [DATE].Review of the hospice admission visit note dated [DATE] at 7:30 PM revealed the resident exhibited signs of respiratory distress, including a respiratory rate of 30 breaths per minute (normal adult range 12-20 breaths per minute), pursed-lip breathing, and pain rated at 6/10. The hospice nurse requested facility staff administer pain medication as needed for symptom management.Record review of the hospice recommendations provided to Licensed Practical Nurse (LPN) Staff A on [DATE] revealed the following medication recommendations: - Morphine concentrate 5 mg every 6 hours - Morphine concentrate 5 mg every 2 hours as needed for pain and shortness of breath - Lorazepam intensol 0.5 mg every 6 hours - Lorazepam intensol 0.5 mg every 2 hours as needed for restlessness and anxietyReview of a nursing progress note dated [DATE] at 7:20 PM authored by Staff A documented the resident was moaning and groaning.Record review failed to reveal evidence the hospice recommendations received on [DATE] were reviewed with the provider. Further review failed to reveal evidence the resident received medication to address the documented pain level of 6/10, moaning, groaning, and respiratory distress.Record review revealed the resident received a follow-up hospice visit on [DATE] at 10:35 AM.Review of the hospice note dated [DATE] revealed the recommendations made on [DATE] had not yet been reviewed, approved, or implemented by the facility.Clinical record review revealed the following provider orders were entered on [DATE]: - Morphine concentrate 5 mg every 6 hours - Morphine concentrate 5 mg every 2 hours as needed for pain and shortness of breath - Lorazepam intensol 0.5 mg every 6 hours - Lorazepam intensol 0.5 mg every 2 hours as needed for restlessness and anxietyReview of the [DATE] Medication Administration Record (MAR) revealed the scheduled Morphine doses due on [DATE] at 5:55 PM and 10:26 PM were marked unavailable.Additional review revealed scheduled lorazepam doses due on [DATE] at 2:04 PM and 10:26 PM were also marked unavailable.Record review failed to reveal evidence the provider was notified the resident missed scheduled doses of Morphine and lorazepam.Record review revealed the pharmacy delivered Morphine to the facility on [DATE] at 11:03 PM.During surveyor observation on [DATE] at approximately 2:30 PM, Morphine 20 mg/ml was observed available in the facility's Pyxis MedStation, an automated medication dispensing system.During interview on [DATE] at approximately 2:35 PM, LPN Staff B acknowledged Morphine was available in the Pyxis system and stated staff could access the medication using a pharmacy-issued code.During interview on [DATE] at 3:10 PM, Staff A stated the hospice nurse reviewed the medication recommendations with her on [DATE]. Staff A further acknowledged she did not notify the Nurse Practitioner the resident had been seen by hospice and failed to communicate the hospice medication recommendations.During interview on [DATE] at 12:14 PM, Registered Nurse (RN) Staff C stated she did not have access to the Pyxis system because she was an agency nurse. Staff C further acknowledged she did not seek assistance from another staff member to obtain the medication for the resident.Further record review failed to reveal evidence that any effective pain relief interventions were offered, refused, or implemented from [DATE] at 7:20 PM until [DATE] at 12:00 AM, when the resident received the first documented dose of Morphine.Review of a nursing progress note dated [DATE] at 7:20 PM revealed the resident experienced an unwitnessed fall and was found face down on the floor bleeding from the nose and forehead. Hospice was notified.Review of a hospice note dated [DATE] at 7:45 PM revealed the resident sustained a forehead laceration and hematoma and was observed restless, moaning, and calling out.Further hospice documentation revealed the resident had an elevated heart rate of 128 beats per minute (normal adult range 60-100), rapid breathing, shallow and labored respirations, pursed-lip breathing, and visible respiratory distress. The hospice nurse documented the previously administered Morphine and lorazepam had poor effect and requested additional as-needed doses during the visit, which also had little or no effect.The hospice nurse further recommended immediate escalation of comfort measures including: - Discontinue previous Morphine orders - STAT (immediately and without delay) dose of Morphine 10 mg - STAT dose of lorazepam 1 mg - Morphine 10 mg every 4 hours scheduled - Morphine 10 mg every 1 hour as needed for pain and shortness of breathReview of the [DATE] MAR revealed the resident received Morphine 5 mg at 8:43 PM from the previous as-needed order approximately one hour after the hospice nurse recommended immediate STAT dosing, despite continued signs of distress including moaning and restlessness.Record review failed to reveal evidence that staff performed a follow-up assessment to determine whether the medication relieved the resident's symptoms.Review of a progress note dated [DATE] at 9:47 PM revealed the provider approved the hospice recommendations.Further clinical record review failed to reveal evidence the STAT Morphine and lorazepam doses were administered as recommended following provider approval.Record review revealed the resident expired on [DATE] at 1:15 AM.During interview on [DATE] at 1:03 PM, the Director of Nursing Services was unable to provide evidence hospice recommendations for pain and symptom management were reviewed and implemented timely. He further acknowledged facility staff failed to utilize Morphine available in the Pyxis MedStation system.During interview on [DATE] at 2:24 PM, the resident's physician stated it would be expected that hospice recommendations be implemented as soon as possible in end-of-life situations, as the goal of care is relief of pain and suffering.Due to the facility's failure to timely review and implement hospice recommendations and administer available comfort medications, the facility failed to provide appropriate end-of-life care and symptom management for Resident ID #1. As a result, the resident experienced unnecessary and avoidable pain, unmanaged terminal agitation, respiratory distress, and psychosocial suffering during the final hours of life.

Based on clinical record review and staff interview, the facility failed to ensure that an allegation involving an accident resulting in serious injury, which occurred prior to a resident's death, was reported to the appropriate authorities, including the State Survey Agency, as required by State law, for 1 of 1 resident reviewed Resident ID #1.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on [DATE] alleged that Resident ID #1 sustained a fall with a head injury. The complaint further alleged that the resident expired approximately six hours after his/her fall.Record review revealed that Resident ID #1 was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, acute respiratory failure with hypoxia (a condition where the tissues and cells of the body do not receive enough oxygen to function properly) and heart failure.Record review of a progress note dated, [DATE] at 7:02 PM, authored by Licensed Practical Nurse, Staff D, revealed the resident sustained an unwitnessed fall and was lying face down on the floor. The note further documented active bleeding from the resident's nose and forehead following the fall.Further record review of a hospice visit note dated [DATE] at 7:50 PM documenting that the resident was evaluated by hospice nursing staff secondary to the unwitnessed fall with head injury. Upon assessment, the resident was noted to have a hematoma (a collection of clotted blood between the tissues) and a laceration to the forehead.Record review failed to reveal evidence that the facility reported the death to the appropriate authorities, including the State Survey Agency, in accordance with state law through established procedures.Record review revealed the resident expired on [DATE] at 1:15 AM.During a surveyor interview on [DATE] at 1:03 PM with the Director of Nursing Services, he acknowledged that the resident sustained a head injury as a result of the fall on [DATE] prior to his/her death. Additionally, he was unable to provide evidence that the facility reported the death to the appropriate authorities, including the State Survey Agency, in accordance with state law through established procedures.

Based on clinical record review and staff interview, the facility failed to ensure each resident's care plan is revised by the interdisciplinary team, for 1 of 2 residents reviewed relative to falls, Resident ID #2.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/3/2026 revealed Resident ID #2 had a fall on 3/30/2026 and was subsequently diagnosed with a left wrist fracture.Record review revealed Resident ID #2 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, Alzheimer's disease and a history of falls. Record review revealed Resident ID #2 sustained falls on 3/29/2026 and 3/30/2026.Further record review revealed the resident was transferred to the hospital following the 3/30/2026 fall and was subsequently diagnosed with a left wrist fracture. Additional record review revealed that on 4/4/2026, the resident was diagnosed with a left hip fracture.Record review of the resident's care plan revealed a problem area initiated on 3/25/2026 addressing the resident's increased risk for injury related to impaired balance, history of falls, and cognitive impairment. Further review of the care plan failed to reveal evidence that interventions were revised or updated following the 3/29/2026 and 3/30/2026 falls to address the resident's ongoing risk for injury. During a surveyor interview on 5/8/2026 at 1:03 PM with the Director of Nursing Services, he was unable to provide evidence that the resident's care plan was revised or updated with additional interventions following the above-referenced falls.

Based on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and services in accordance with professional standards of practice and physician orders, relative to the transcription and implementation of physician-approved hospice medication orders, for 1 of 2 residents reviewed, Resident ID #1.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 5/5/2026 alleged that Resident ID #1 was experiencing terminal agitation and was not provided prescribed medications promptly to provide comfort, relief, and dignity at the end of his/her life.According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed Resident ID #1 was readmitted to the facility in October of 2025 with diagnoses, including, but not limited to, acute respiratory failure with hypoxia (a condition where the tissues and cells of the body do not receive enough oxygen to function properly) and heart failure. Further review revealed the resident was admitted to hospice services on 5/1/2026. 1. Record review revealed a hospice note dated 5/1/2026 with a recommendation to start levsin (a medication prescribed to treat excessive salivation) 0.125 milligram (mg) tablet under the tongue every four hours, as needed, for secretions.Further record review of a progress note dated 5/2/2026 at 12:14 PM revealed the provider approved the order for levsin.Record review failed to reveal evidence that the physician-approved order was transcribed into the medical record or implemented by facility staff.During a surveyor interview on 5/7/2026 at 3:48 PM with the Assistant Director of Nursing Services, she acknowledged that the levsin order had not been transcribed into the medical record and should have been implemented, as ordered. 2. Record review of a hospice note dated 5/3/2026 revealed recommendations including, but not limited to: - Lorezapam intensol (a medication prescribed to treat restlessness and agitation) two mg per milliliter (ml); 1mg (0.5ml), as needed for agitation and restlessness. - Morphine Concentrate 20mg/ml; 10 mg (0.5ml) every one hour, as needed for pain or shortness of breathRecord review of a progress note dated 5/3/2026 at 9:47 PM revealed the provider approved the above recommendations.Record review revealed the following physician's orders were incorrectly transcribed on 5/3/2026: - Lorezapam intensol two milligrams (mg) per milliliter (ml) give 1mg (0.5ml), scheduled for every one hour - Morphine Concentrate 20mg/ml give 10 mg (0.5ml), scheduled for every one hourFurther review of the May 2026 Medication Administration Record (MAR) revealed that the above medications were administered on 5/4/2026 at 12:00 PM as scheduled medications, rather than on an as-needed basis, as ordered, by the physician. During a surveyor interview on 5/7/2026 at 4:19 PM, Registered Nurse, Staff F, acknowledged that she incorrectly transcribed the Lorazepam and Morphine orders as scheduled medications instead of as-needed medications, per the physician's orders.During a surveyor interview on 5/8/2026 at 2:24 PM, with the Physician, Staff E, he acknowledged that the levsin order had been approved and should have been transcribed. He further acknowledged that the Morphine and Lorazepam orders had been approved as needed orders, not as scheduled medications as transcribed by facility staff.

Based on clinical record review and staff interview, the facility failed to ensure residents receive care and services in accordance with professional standards of practice related to post-fall assessments, neurological monitoring, care plan revision, and adherence to advance directives, for 1 of 1 resident who sustained a fall with head injury, Resident ID #1.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on [DATE], alleged that Resident ID #1 experienced a fall with a head injury and passed away in the facility within 6 hours. The complaint further alleged that the facility failed to implement new or enhanced fall interventions and his/her Advance Directive wishes were not followed.Record review revealed Resident ID #1 was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, acute respiratory failure with hypoxia (a condition where the tissues and cells of the body do not receive enough oxygen to function properly), heart failure, and fall. 1. Record review revealed Resident ID #1 had falls on [DATE] and [DATE].Record review of a progress note dated [DATE] at 7:44 PM revealed staff heard the resident yelling out and the resident was found lying in the bathtub with his/her head against the tub.Record review revealed a care plan dated [DATE] revealed the resident was at increased risk for injury related to impaired balance, cognitive impairment, and history of falls with a goal for the resident to remain free from injury.Further review of the care plan failed to reveal evidence that interventions were revised or updated following the resident's fall on [DATE] to address the resident's ongoing and escalating fall risk. 1b. Record review of an undated facility policy titled Resident Falls Documentation Requirements revealed that neurological checks must be initiated following an unwitnessed fall. Record review of a progress note dated [DATE] at 7:20 AM, authored by Licensed Practical Nurse (LPN), Staff D, revealed that the resident experienced an unwitnessed fall and was found on the floor, face down, bleeding from the nose and forehead. Record review failed to reveal evidence that the neuro checks were completed after s/he experienced a fall with a head injury on [DATE], ER facility policy. 2. Record review of a document titled, Advance Directive dated [DATE] revealed instructions for Do Not Resuscitate (DNR). This refers to the withholding of emergency resuscitation in the event of a cardiac arrest.Additional record review revealed the above-mentioned Advance Directive form was signed by the Physician and Resident ID #1 on [DATE].Record review revealed a physician order dated [DATE] confirming a DNR order for the resident.Record revealed the following progress notes: - [DATE] at 1:20 PM: the resident was found without a pulse, respirations, or blood pressure at 1:15 AM. - [DATE] at 2:41 PM authored by LPN, Staff G: 911 was called due to inability to locate the Medical Examiner's contact information in a timely manner. Upon EMS arrival, staff were unable to immediately provide or produce the resident's advance directive documentation, resulting in the initiation of Cardiopulmonary Resuscitation (CPR) by the responders. Record review of an EMS Prehospital Patient Care Report revealed, when first responders arrived at the facility there were no facility staff initially present. EMS documented that the advance directive status could not be verified at the time of care, and CPR was initiated.During a surveyor interview on [DATE] at 8:51 AM with LPN, Staff G, she acknowledged that she was unable to locate the Medical Examiner's telephone number and called 911 for the number. Additionally, she acknowledged she was unable to locate and print the Advance Directive with the DNR status document prior to or upon EMS arrival to the facility and that CPR was initiated by the responders.During a surveyor interview on [DATE] at 1:03 PM, the Director of Nursing Services (DNS) was unable to provide evidence that Resident ID #1's comprehensive care plan was revised to include interventions and approaches for staff to implement following the resident's fall on [DATE]. The DNS acknowledged that the resident sustained a fall with head injury on [DATE] and revealed he would have expected neurological monitoring to have been completed in accordance with the facility policy following the unwitnessed fall with head injury. Additionally, he acknowledged emergency medical services (911) were inappropriately summoned to the facility after staff was unable to readily retrieve the Medical Examiner's telephone number. Furthermore, the DNS acknowledged Staff D was unable to produce the resident's Advance Directive for the EMS responder's, resulting in the initiation of CPR despite the resident having a physician order for DNR.

Based on clinical record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 1 of 2 residents reviewed who are receiving hospice services, Resident ID #1.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 5/5/2026 alleged that Resident ID #1 was admitted to hospice services on 5/1/2026. Additionally, the complaint alleged s/he was experiencing terminal agitation and the facility failed to timely implement hospice recommendations promptly to provide comfort, relief, and dignity at the end of his/her life. Record review revealed that Resident ID #1 was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, acute respiratory failure with hypoxia (a condition where the tissues and cells of the body do not receive enough oxygen to function properly) and heart failure.Record review revealed that the resident was admitted to hospice services in May of 2026.Review of the resident's electronic and paper medical record failed to reveal evidence that the required hospice documentation was maintained and readily accessible including the following: - The most recent hospice plan of care- Hospice election form- Physician certification and recertification of the terminal illness- Names and contact information for hospice personnel involved in hospice care- Instructions on how to access the hospice's 24-hour on-call system- Hospice medication information- Hospice physician and attending physician ordersAdditional record review failed to reveal evidence of Hospice Recommendation forms for all hospice nursing visits. These forms are utilized by hospice to communicate resident assessments, clinical updates, and recommendations to facility staff to support continuity of care. During a surveyor interview on 5/8/2026 at 1:03 PM, with the Director of Nursing Services (DNS), he revealed that the facility does not have individual hospice binders for each resident receiving hospice services and indicated that all hospice documents should be scanned into the electronic medical record. The DNS was unable to provide evidence that the above-mentioned hospice documents including all hospice recommendation forms were present in the resident's medical record.

Based on clinical record review, resident and staff interview, the facility failed to keep a resident free of significant medication errors for one of two residents reviewed, Resident ID #3. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/24/2026, alleges in part that on 1/31/20266, a nurse incorrectly transcribed Farxiga (a medication used to treat type 2 diabetes, kidney disease, and congestive heart failure) into the medical records of two residents. The error was identified 18 days later. Record review revealed Resident ID #3 was readmitted to the facility on [DATE], with diagnoses including, but not limited to, edema and hypokalemia. Record review of a Medication Error Form dated 2/18/2026, revealed that the Nurse Practitioner identified that the resident had been receiving Farxiga 5 milligrams daily, which was intended for another resident. This error persisted for 19 days. Record review of a written statement by the Assistant Director of Nursing, dated 2/18/2026, revealed that Staff A indicated she had mistakenly transcribed the Farxiga order into the wrong resident's chart.During a surveyor interview on 4/16/2026 at 11:42 AM with the Director of Nursing Services, he acknowledged that Resident ID #3 received Farxiga for 19 days in error.

Based on clinical record review and staff interview, the facility failed to ensure that residents receive care, consistent with professional standards of practice relative to physician's orders, for 1 of 1 resident who requires two staff members at all times during care, Resident ID #3 and for 1 of 1 resident who requires a cardiology consult, Resident ID #1.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 8/28/2025 revealed in part, on 8/27/2025 Resident ID #3 was taken to the shower room and a hospice Nursing Assistant (NA) attended to him/her for his/her shower. During the shower the resident was noted with active bleeding from an unidentified source. A skin assessment was completed, and the resident was observed with an open area to his/her great toe.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 the resident was readmitted to the facility in July of 2025, with diagnoses including, but not limited to, chronic inflammatory demyelinating polyneuropathy (an autoimmune disorder that affects the protective layer surrounding peripheral nerves) and lymphedema (an accumulation of protein rich fluid in the body's tissues).Record review revealed a physician's order dated 7/10/2025, for two staff members at all times for resident care.Record review revealed the following progress notes:-8/27/2025 at 10:14 AM- During the resident's shower, the Nursing Assistant, (NA) observed active bleeding but was unable to identify the source. Upon nursing arrival, a pool of blood was noted in the bathroom. A skin assessment revealed and open area to the top of the right great toe with a split to the skin. Initial pressure was applied for approximately 20 minutes, but the bleeding persisted.-8/27/2025 at 9:03 PM- traumatic wound to right great distal tip of great toe 0.3 centimeters (cm) by 0.5 cm by 0.1 cm, copious amount of blood drainage on dressing and active bleeding noted when the dressing was removedDuring a surveyor interview with NA, Staff A, she indicated that she was assigned to the resident on 8/27/2025 during the 7:00 AM to 3:00 PM shift. Additionally, she revealed she assisted the resident into the shower chair via the Hoyer lift (a mechanical device used to support the resident with transferring) along with the hospice, NA. Further, she indicated that she was not aware that the resident required two staff members for care at all times and revealed that the hospice aid showered the resident alone.Record review failed to reveal evidence that the resident was provided two staff members at all times for care during his/her shower on 8/27/2025 during the 7:00 AM to 3:00 PM shift as ordered.2. Record review revealed Resident ID #1 was readmitted to the facility in September of 2025 with diagnoses including, but not limited to, myocardial infarction (a heart attack) and cerebral infarction (a stroke).Record review revealed the following physician's orders: -3/21/2025 Aspirin 81 milligrams (mg) daily -3/21/2025 Plavix (a medication used to thin the blood) 75 mg dailyRecord review of a progress notes dated 10/30/2025 revealed the resident is on a dual antiplatelet therapy of aspirin and Plavix. The pharmacy has recommended discontinuation of the Plavix. This recommendation was reported to the physician with a new order received to consult with a cardiologist prior to the discontinuation of the medication. Additional record review revealed a physician's order dated 10/31/2025 to obtain a cardiology consult per the Physician for possible discontinuation of Plavix. Record review failed to reveal evidence that a cardiology consult had been scheduled as ordered.During a surveyor interview on 12/23/2025 at 1:22 PM with the Scheduler, Staff B, she indicated she was unaware that the resident needed an appointment with cardiology, and she had not reached out to schedule an appointment for the resident.During a surveyor interview on 12/23/2025 at 2:59 PM with the Director of Nursing Services, he revealed it would be his expectation that two staff members would have been present as ordered during the shower provided to Resident ID #3 on 8/27/2025 and that the cardiology appointment would have been scheduled for Resident ID #1 per the physician's order.

Based on clinical record review and staff interview, the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 1 of 1 resident reviewed for bruising, Resident ID #3.Findings are as follows:Review of a facility policy titled, Abuse prohibition states in part, .Injuries of unknown origin .the source of the injury was not observed, or the source cannot be explained by the resident .Investigation .begin the initial investigation .obtain statements from witnesses, notify the appropriate administrative personnel so that a comprehensive internal facility investigation can be carried out .Record review revealed the resident was readmitted to the facility in July of 2025, with diagnoses including, but not limited to, chronic inflammatory demyelinating polyneuropathy (an autoimmune disorder that affects the protective layer surrounding peripheral nerves) and lymphedema (an accumulation of protein rich fluid in the body's tissues).Record review of the progress notes revealed the following:-8/26/2025 at 7:26 PM a large bruise was noted to right upper buttock-9/8/2025 at 6:22 AM during care at 12 AM, staff found a large bruise on his/her left proximal thigh area which was deep purple in color and measures approximately 18 centimeters (cm) by 22 cm.Further record review failed to reveal evidence that an investigation had been conducted to determine the origin of the bruises.During a surveyor interview on 12/23/2025 at approximately 2:30 PM with the Director of Nursing Services, he indicated when new bruising is identified an investigation should be completed to determine the etiology of the bruising. It then should be documented in the resident's clinical record. Additionally, he was unable to provide evidence that an investigation was completed to determine the etiology of the bruising documented on 8/26/2025 and 9/8/2025.

Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices relative to 3 of 8 residents reviewed with an mattress, Resident ID #s 86, 91, and 135, 1 of 3 residents reviewed for oxygen administration, Resident ID #70, and for 1 of 1 resident reviewed for the use of an incentive spirometer (a handheld medical device used to help patients improve the functioning of their lungs, by training patients to take slow and deep breaths), Resident ID #66. Findings are as follows: 1a. Record review revealed Resident ID #86 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, Parkinson's disease and adult failure to thrive. Record review revealed a physician's order dated 2/26/2024 which states in part, Air mattress to bed for comfort and pressure reduction. Check Setting according to resident weight. Special Instructions: Check settings every shift . Record review revealed the resident weighed 119.6 pounds (lbs.) on 6/5/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 300 lbs.: - 6/10/2025 at 8:57 AM - 6/11/2025 at 3:19 PM Record review of the June 2025 Treatment Administration Record (TAR) revealed that the order was signed off as completed during first shift on 6/10 and 6/11/2025. During a surveyor interview with Licensed Practical Nurse (LPN), Staff A, on 6/11/2025 at 3:19 PM, she acknowledged that the air mattress was set to 300 lbs and that the air mattress was not set to the resident's weight. During a surveyor interview with Staff A on 6/11/2025 at 3:19 PM, she acknowledged the air mattress was set to 350 lbs. and that it was not set to the resident's weight. Additionally, she revealed that she had documented the order as completed 6/11/2025 without checking what weight the air mattress was set to. 1b. Record review revealed Resident ID #91 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, Ankylosing hyperostosis (a condition where ligaments and tendons become hard and calcified, often leading to bone spurs and stiffness) and osteoarthritis. Record review revealed a physician's order dated 3/24/2025 which states in part, Air mattress to bed for comfort and pressure reduction. Special Instructions: Check settings every shift . During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 350 lbs.: - 6/9/2025 at 12:58 PM - 6/10/2025 at 3:27 PM - 6/11/2025 at 9:00 AM Record review of the June 2025 TAR revealed that the order was signed off as completed during first shift on 6/9, 6/10, and 6/11/2025. During a surveyor interview with Staff A on 6/11/2025 at 3:19 PM, she acknowledged the air mattress was set to 350 lbs. and that it was not set to the resident's weight. Additionally, she revealed that she had documented the order as completed on 6/9 and 6/11/2025 without checking what the air mattress was set to. 1c. Record review revealed Resident ID #135 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, sepsis, the need for assistance with personal care, and sciatica. Record review revealed a physician's order dated 5/8/2025 which states in part, Air mattress to bed for comfort and pressure reduction. Special Instructions: Check settings every shift . Record review revealed the resident weighed 175.8 lbs. on 6/9/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 100 lbs.: - 6/9/2025 at 9:10 AM - 6/11/2025 at 3:23 PM Record review of the June 2025 TAR revealed that the order was signed off as completed during first shift on 6/9 and 6/11/2025. During a surveyor interview with Staff A on 6/11/2025 at 3:23 PM, she acknowledged the resident's bed was set to 100 lbs. and that it was not set to the resident's weight. Additionally, she revealed that she had documented the order as completed on 6/9 and 6/11/2025 without checking what the air mattress was set to. During a surveyor interview with the Director of Nursing Services (DNS) on 6/12/2025 at 11:35 AM, he revealed that he would expect Resident ID #s 86, 91, and 135's air mattresses to be set to their weights. Additionally, he would expect nurses to sign off the orders as completed in the TAR after the air mattress settings are checked. 2. Record review revealed Resident ID #70 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, heart failure, edema (fluid accumulation in extremities), and an acute cough. Record review revealed a physician's order dated 3/15/2025 for oxygen at 2 Liters (L) per minute via nasal cannula (a medical device used to provide supplemental oxygen therapy) continuously. During surveyor observations, the resident was observed receiving oxygen at 4L per minute via nasal cannula on the following dates and times: - 6/9/2025 at 12:52 PM - 6/10/2025 at 9:01 AM, 12:35 PM, and at approximately 3:30 PM - 6/11/2025 at 8:45 AM Record review of the June 2025 Medication Administration Record (MAR) revealed that the resident was documented as receiving oxygen at 2L per minute on the above-mentioned dates and times, although the resident was observed by the surveyor receiving approximately 4L of oxygen. During a surveyor interview on 6/11/2025 at 3:19 PM with Staff A, she acknowledged that she signed off the resident's MAR on 6/9 and 6/11/2025 without checking the liter flow of oxygen. During a surveyor interview with the DNS on 6/12/2025 at 11:35 AM, he indicated that he would expect the physician's order would be followed relative to oxygen liter flow and that nurses would ensure the resident is receiving the correct liter flow of oxygen before documenting the order as completed. 3. Record review revealed Resident ID #66 was re-admitted to the facility in June of 2025 with diagnoses including, but not limited to, myocardial infarction (heart attack), chronic obstructive pulmonary disease, and acute/chronic respiratory failure with hypoxia (low oxygen levels). Record review revealed a physician's order dated 6/4/2025 to encourage the use of an incentive spirometer every shift. During surveyor observations on the following dates and times, there was no incentive spirometer located in the resident's room: - 6/9/2025 at approximately 10:30 AM - 6/12/2025 at approximately 10:00 AM Record review of the June 2025 TAR revealed the resident was documented as having been encouraged to use the incentive spirometer during first shift on 6/9 and 6/11 by Staff A and on 6/12 by LPN, Staff E. During a surveyor interview and observation with Staff E on 6/11/2025 at 10:00 AM, he indicated that he could not find the incentive spirometer in the resident's room and would need to order one. During a surveyor interview with Staff A on 6/12/2025 at 11:00 AM, she acknowledged that she documented the order as completed on 6/9 and 6/11 without encouraging the use of or checking to see if the resident used the incentive spirometer. During a surveyor interview with the DNS on 6/12/2025 at 11:35 AM, he indicated he would expect the nurses to complete the order before documenting it as completed in the resident's record. Cross Reference F-658

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 3 of 5 residents reviewed for antibiotic use, Resident ID #s 69, 85, and 135. Findings are as follows: According to a Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Perform antibiotic 'time outs.' .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions: - Does this resident have a bacterial infection that will respond to antibiotics - If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration? - Can the spectrum of the antibiotic be narrowed or the duration of therapy shortened (i.e., de-escalation)? - Would the resident benefit from additional infectious disease/antibiotic expertise to ensure optimal treatment of the suspected or confirmed infection . 1. Record review revealed that Resident ID #69 was admitted to the facility in January of 2020 with a diagnosis including, but not limited to, Parkinson's disease. Record review revealed the resident received doxycycline (an antibiotic) 100 milligrams (mg) twice daily from 6/3/2025 through 6/10/2025, for an infection of the great toe. Record review failed to reveal evidence that an antibiotic time out or a review was conducted. 2. Record review revealed that Resident ID #85 was readmitted to the facility in March of 2024 with a diagnosis including, but not limited to, type II diabetes. Record review revealed the resident received cephalexin (an antibiotic) 500 mg twice daily from 6/5/2025 through 6/12/2025 as a preventative measure related to a surgical incision. Record review failed to reveal evidence that an antibiotic time out or a review was conducted. 3. Record review revealed that Resident ID #135 was readmitted to the facility in May of 2025 with a diagnosis including, but not limited to, heart failure. Record review revealed the resident received doxycycline 100 mg twice daily from 6/6/2025 through 6/12/2025 for pneumonia. Record review failed to reveal evidence that an antibiotic time out or a review was conducted. During a surveyor telephone interview on 6/11/2025 at 9:15 AM with the Infection Preventionist, she acknowledged that there were no antibiotic timeouts completed for Resident ID #s 69, 85, and 135. Additionally, she revealed that she would expect antibiotic timeouts to be completed within 48 to 72 hours following the initiation of an antibiotic. Further, she revealed that she is on a leave of absence and indicated that there is not a designated staff member to complete the antibiotic timeouts.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 4 of 8 residents reviewed with an air mattress, Resident ID #s 86, 91, 111, and 135, 1 of 3 residents reviewed for oxygen administration, Resident ID #70, and for 1 of 1 resident reviewed with an order for daily weights, Resident ID #93. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1a. Record review revealed Resident ID #86 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, Parkinson's disease and adult failure to thrive. Record review revealed a physician's order dated 2/26/2024 which states in part, Air mattress to bed for comfort and pressure reduction. Check Setting according to resident weight. Special Instructions: Check settings every shift . Record review revealed the resident weighed 119.6 pounds (lbs.) on 6/5/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 300 lbs.: - 6/10/2025 at 8:57 AM - 6/11/2025 at 3:19 PM During a surveyor interview with Licensed Practical Nurse (LPN), Staff A on 6/11/2025 at 3:19 PM, she acknowledged the above observation. Additionally, she revealed that she was unaware of what the mattress should be set to. 1b. Record review revealed Resident ID #91 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, Ankylosing hyperostosis (a condition where ligaments and tendons become hard and calcified, often leading to bone spurs and stiffness) and osteoarthritis. Record review revealed a physician's order dated 3/24/2025 which states in part, Air mattress to bed for comfort and pressure reduction. Special Instructions: Check settings every shift . Record review revealed the resident weighed 141 lbs. on 10/1/2024. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 350 lbs.: - 6/9/2025 at 12:58 PM - 6/10/2025 at 3:27 PM - 6/11/2025 at 9:00 AM During a surveyor interview with Staff A on 6/11/2025 at 3:19 PM, she acknowledged the air mattress was set to 350 lbs. Additionally, she revealed that she was unaware of what the mattress should be set to. 1c. Record review revealed Resident ID #111 was admitted to the facility in September of 2022 with a diagnosis including, but not limited to, cerebral infarction (stroke). Record review revealed a physician's order dated 11/24/2024 which states in part, Air mattress to bed for comfort and pressure reduction set to 250 lb. Special Instructions: Check settings every shift . Record review revealed the resident weighed 212 lbs. on 6/9/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 325 lbs.: - 6/9/2025 at 10:30 AM - 6/10/2025 at 12:54 PM - 6/11/2025 at 1:35 PM During a surveyor interview with LPN, Staff B on 6/11/2025 at 2:38 PM, she acknowledged that the resident's air mattress was set to 325 lbs. and not to 250 lbs., per the physician's order. 1d. Record review revealed Resident ID #135 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, sepsis, the need for assistance with personal care, and sciatica. Record review revealed a physician's order dated 5/8/2025 which states in part, Air mattress to bed for comfort and pressure reduction. Special Instructions: Check settings every shift . Record review revealed the resident weighed 175.8 lbs. on 6/9/2025. During surveyor observations on the following dates and times, the resident was observed in bed with the air mattress set to 100 lbs.: - 6/9/2025 at 9:10 AM - 6/11/2025 at 3:23 PM During a surveyor interview with Staff A on 6/11/2025 at 3:23 PM, she acknowledged the resident's bed was set to 100 lbs. Additionally, she revealed the resident does not weigh 100 lbs. and the air mattress setting should be readjusted to be closer to the resident's weight. During surveyor interviews with the Director of Nursing Services (DNS) on 6/12/2025 at 11:27 AM and 11:35 AM, he revealed that he would expect Resident ID #111's air mattress to be set to 250 lbs. per the physician's order. Additionally, he revealed his expectation would be for Resident ID #s 86, 91, and 135's air mattresses to be set to the residents' weights and for the physician's orders to be clarified to include the residents' weights. 2. Record review revealed Resident ID #70 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, heart failure, edema (the accumulation of fluid in extremities), and an acute cough. Record review revealed a physician's order dated 3/15/2025 for oxygen at 2 Liters (L) per minute via nasal cannula (a medical device used to provide supplemental oxygen therapy) continuously. During surveyor observations the resident was observed receiving oxygen at 4 L per minute via nasal cannula on the following dates and times: - 6/9/2025 at 12:52 PM - 6/10/2025 at 9:01 AM, 12:35 PM, and at approximately 3:30 PM - 6/11/2025 at 8:45 AM During a surveyor interview on 6/11/2025 at 3:19 PM with Staff A, she acknowledged that the resident was not receiving oxygen at 2 L continuously, per the physician's order. During a surveyor interview with the DNS on 6/12/2025 at 11:35 AM, he indicated that he would expect the physician's order would be followed relative to the oxygen liter flow. 3. Record review revealed Resident ID #93 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, Alzheimer's disease, edema (swelling caused by too much fluid trapped in the body), and congestive heart failure. Record review revealed a physician's order dated 1/29/2025 to obtain daily weights three times per week on Monday, Wednesday, and Friday prior to the morning meal. Special Instructions indicate to notify the physician if there is a weight gain greater than 3 lbs. in a day or greater than 5 lbs. in a week. Record review of the June 2025 Treatment Administration Record revealed the resident weighed 145.8 lbs. on 6/2/2025 and 151.2 lbs. on 6/9/2025, indicating a weight gain of 5.4 lbs. Further record review failed to reveal evidence that the physician was notified of the above-mentioned weight gain. During a surveyor interview with Registered Nurse, Staff C, on 6/11/2025 at 2:57 PM, she revealed that the 3rd shift (11:00 PM - 7:00 AM) nurse obtained the resident's weight on the morning of 6/9/2025 and did not notify her of the weight discrepancy. Additionally, she revealed that she did not notify the physician of the resident's 5.4 lbs. weight gain. During a surveyor interview with the Nurse Practitioner on 6/11/2025 at 3:03 PM, she indicated that she would have expected to have been notified of the resident's weight gain, per the physician's order. During a surveyor interview with the DNS on 6/11/2025 at 3:06 PM, he acknowledged that the resident experienced a weight gain of over 5 lbs. in a week and would have expected the physician to be notified as ordered. Cross Reference F-842

Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident was offered or received the indicated pneumococcal vaccination or did not receive the vaccination due to medical contraindications or a refusal for 2 of 5 residents reviewed, Resident ID #s 88 and 111. Additionally, the facility failed to have updated policies regarding pneumococcal immunizations. Findings are follows: According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for adults 65 years or older who have received PCV13 (a type of pneumococcal conjugate vaccination) at any age and the PPSV23 at [AGE] years of age or older, are recommended to receive a single dose of the PCV20 or PCV21 vaccine after 5 or more years from the date of the last pneumococcal vaccine. 1a. Record review revealed Resident ID #88 was readmitted to the facility in March of 2025. Review of the resident's immunization records revealed that the resident received his/her PCV13 vaccine in November of 2015 (at age [AGE]) and his/her PPSV23 vaccine in September of 2019 (at age [AGE]). Record review failed to reveal evidence that the resident was offered, received, or declined the PCV20 or PCV21 vaccine. 1b. Record review revealed Resident ID #111 was readmitted to the facility in November of 2024. Review of the resident's immunization records revealed that the resident received his/her PPSV23 vaccine in December of 2013 (at age [AGE]) and his/her PCV13 vaccine in June of 2018 (at age [AGE]). Record review failed to reveal evidence that the resident was offered, received, or declined the PCV20 or PCV21 vaccine. During a surveyor interview on 6/12/2025 at 11:29 AM with the Infection Preventionist, she revealed that she follows the CDC guidance relative to pneumococcal vaccinations. Additionally, she was unable to provide evidence that Resident ID #s 88 and 111's medical records included documentation that indicates, at a minimum, if the residents were either offered, received, or refused the PCV20 or PCV21 pneumococcal vaccine. 2. Review of a facility policy titled, Resident Vaccination (Flu and pneumonia) dated 3/2020 states in part, .Vaccinations are to be provided in accordance with the most recent ACIP (Advisory Council on Immunization Practices) guidelines for these vaccinations. As of 2019, ACIP has recommended the following pneumonia vaccination schedule (Also follow CDC Vaccination for Elders guidelines): ACIP recommends a routine single dose of PPSV23 for adults aged greater than or equal to 65 years .and who have not previously received PCV13. If a decision to administer PCV13 is made, PCV13 should be administered first followed by PPSV23 at least 1 year later . During a surveyor interview on 6/12/2025 at 12:20 PM with the Director of Nursing Services, he acknowledged that the policy that the facility is currently using is not up to date and does not include the current guidelines for pneumococcal vaccinations.

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment relative to 1 of 3 kitchenettes and the main kitchen. Findings are as follows: 1. During the initial tour of the kitchen on 6/9/2025 at 9:54 AM, in the presence of the Food Service Director (FSD), the walk-in freezer was noted to have an accumulation of ice buildup on the sprinkler head and on the left fan, located near the ceiling of the freezer. During a surveyor interview, immediately following the above observation, the FSD acknowledged the ice buildup and indicated it should be cleaned. 2. During a surveyor observation on 6/9/2025 at approximately 10:30 AM, of the Jamestown Unit Kitchenette, in the presence of the FSD, revealed one microwave, mounted above the counter, which was noted to be severely cracked with peeling paint on the exterior of the microwave. During a surveyor interview, immediately following the above observation, the FSD acknowledged the cracks and peeling paint on the exterior of the microwave and indicated that the microwave would be removed.

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with edema (swelling due to excess fluid trapped in the body's tissues), Resident ID #51. Findings are as follows: Review of an undated facility policy titled, WHEN THERE IS A CHANGE OF CONDITION states in part, .The resident's attending physician or on-call physician must be notified when a change of condition has occurred .resident responsible party must be notified. Changes in condition include but are not limited to .A need to alter resident's medical treatment . Record review revealed the resident was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, Alzheimer's disease, acute kidney failure, hypertensive heart (a condition caused by chronic high blood pressure) and chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 4 out of 15, indicating the resident has severe cognitive impairment. Record review revealed the resident was seen by the physician on 6/1/2025 with no acute issues present. Record review revealed the following progress notes: -6/5/2025 at 4:31 PM, Resident had a non-productive cough this shift, lung sounds assessed, s/he has bilateral wheezing on exertion. -6/5/2025 at 2:50 PM, Resident continues on the respiratory protocol. -6/6/2025 at 5:02 AM, Resident was noted with a coughing episode from 1:30 AM until 1:45 AM and lung sounds diminished (a condition when the lungs do not fully inflate). -6/8/2025 at 5:33 PM, Resident has diminished lung sounds with a faint expiratory wheeze (a noise heard on exhaling) and an occasional cough was noted. During a surveyor observations of the resident on 6/9/2025 at approximately 10:30 AM and again at 3:36 PM, the resident was observed to have swelling to his/her lower legs and had a congested, non-productive cough. Record review revealed the following physician's orders: 3/28/2025 - Diuretic (a medication used to treat fluid retention and high blood pressure) use, monitor for edema, congestion and weight changes every shift. 5/3/2025 - Furosemide (Lasix-a diuretic medication) 40 milligrams (mg) twice a day. 6/5/2025 - Monitor respiratory status, include lung sounds and document in nursing notes every shift for three days. Further record review failed to reveal evidence that the resident's respiratory status was assessed per the above-mentioned orders on the following dates and shifts: -6/5/2025 3:00 PM - 11:00 PM -6/6/2025 7:00 AM - 3:00 PM -6/6/2025 3:00 PM - 11:00 PM -6/6/2025 11:00 PM - 7:00 AM -6/7/2025 7:00 AM - 3:00 PM -6/7/2025 3:00 PM - 11:00 PM -6/7/2025 11:00 PM - 7:00 AM During an additional surveyor observation on 6/11/2025 at approximately 9:00 AM through 9:45 AM, the resident was observed seated in his/her wheelchair with an occasional non-productive cough and swelling to both of his/her lower extremities. During a surveyor interview on 6/11/2025 at 10:03 AM with Certified Medication Technician, Staff D, he revealed that he observed the resident coughing on 6/10/2025 and 6/11/2025. He indicated that he wanted to give the resident a medication for his/her cough on 6/10/2025 but the resident did not have a physician's order. Additionally, he was unable to recall if he notified the nurse. During a surveyor interview on 6/11/2025 at 9:53 AM with Licensed Practical Nurse, Staff A, she acknowledged that she observed the resident coughing on 6/11/2025. She revealed that she had not assessed the resident's respiratory status. Record review of the June 2025 Treatment Administration Record (TAR) revealed Staff A signed off the physician's order to monitor the resident for edema and congestion on 6/9/2025 during the 7:00 AM to 3:00 PM shift as completed. During a surveyor interview with Staff A on 6/11/2025 at 12:49 PM, she revealed she did not assess the resident for the presence of edema on 6/9/2025 even though she had documented that the assessment was completed. Additionally, she indicated that the resident was experiencing crackles at the bases of both of his/her lungs on 6/9/2025. During a surveyor observation immediately following the above interview with Staff A, she began to assess the resident for the presence of edema in his/her bilateral extremities. Staff A indicated that the resident presented with 4+ pitting edema (when the edema is pressed it leaves a dimple this is called pitting edema. A 4+ pitting edema indicates severe edema that can take up to 2-5 minutes to rebound) in his/her right lower extremity and 3+ pitting edema(this indicates severe edema and can take up to 30 seconds or more to rebound) in his/her left lower extremity, after this concern was brought to her attention by the surveyor. Further review failed to reveal evidence that the physician was notified of the resident's change in condition until 6/11/2025, after it was brought to the facility's attention by the surveyor, 6 days after initially being assessed by a nurse on 6/5/2025. Record review revealed the following physician's orders were obtained after the surveyor brought the resident's change in condition to the facility's attention: -The order for Lasix was increased from 40 mg twice a day to 60 mg twice daily for 4 days - A chest x-ray was to be obtained - A basic metabolic panel (a blood test that measures eight different substances in your blood, providing information about your body's metabolism, fluid balance, and kidney function) was to be obtained - A Pro BNP (a blood test used to measure heart failure) was to be obtained Additional record review revealed the Pro BNP was obtained on 6/12/2025 with a result of 827.0 picograms/milLiliter (pg/mL), which indicates an elevated value (a normal reference range is 0-300.0 pg/mL). During a surveyor interview on 6/11/2025 at approximately 3:10 PM with the Nurse Practitioner, she revealed that she was not made aware of the resident's change in condition on 6/5/2025. She further indicated that she would have expected to have been notified. During a surveyor interview on 6/11/2025 at 1:12 PM, with the Director of Nursing Services, he indicated that he would expect the provider to be notified of the resident's change in condition when it was identified on 6/5/2025, that the resident would have been assessed every shift for three days as ordered, and the findings to be reported to the provider. Additionally, he indicated that he would expect that the nurses would monitor the resident for the presence of edema and congestion every shift per the physician's order.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE) for 1 of 1 resident observed for wound care and transfers, Resident ID #21. Findings are as follows: Review of a facility policy titled, .Policy for Enhanced Barrier Precautions [EBP] (infection control measures which require donning gown and gloves during high-contact residents' care activities) states in part, .the [facility name redacted] home is committed to ensuring the highest quality of care for our residents. It is to that end that this policy will follow CMS [Centers for Medicare and Medicaid Services] for guidance and or regulations of the RIDOH [Rhode Island Department of Health] and the Centers for Disease Control and Prevention associated with infection control practices related to Enhanced Barrier Precautions .Enhanced Barrier Precautions are indicated for nursing home residents with any of the follow[ing] .EBP is primarily intended to where high-contact care activities occurs, in the residents room, including transfers that are bundled together with other high contact activity such as morning or evening care . Signage must be present outside residents' rooms to signal individuals entering a room the specific actions they should take to protect themselves and the residents . Record review revealed the resident was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, muscle weakness and difficulty in walking. During a surveyor observation on 6/9/2025 at approximately 10:00 AM, there was an EBP sign observed outside of the resident's door which stated in part, .wear gloves and gown for this following High-Contact Resident Care Activities .Transferring . Record review of a physician's order revealed the following: - 3/5/2020 - the resident is to be assisted with a Hoyer lift by 2 staff for all transfers. - 5/5/2025 - Maintain Enhanced Barrier Precautions related to a wound. - 5/5/2025 - Cleanse the wound to the left ischium (a paired bone located within the pelvis which forms the lower and the back portion of the hip) with normal saline, pat dry with gauze, apply Medihoney (a medical-grade honey that aids in wound healing) follow by plain calcium alginate then cover with a dressing. Review of a document titled, Weekly Wound Assessment dated 6/2/2025 revealed a stage two pressure ulcer (a partial-thickness skin loss involving the the second layer of the skin) on the left ischium measuring 0.8 centimeters (cm) x 0.5 cm x 0.1 cm. 1. During a surveyor observation on 6/12/2025 at 7:50 AM, Registered Nurse (RN), Staff C, was observed entering the resident's room for a dressing change without wearing a gown as ordered. After removing the resident's soiled dressing with gloves, she entered the resident's bathroom to perform hand hygiene. However, when she exited the bathroom she indicated that she had forgotten to put on a gown before starting the wound dressing change. She exited the room, put on a gown and gloves then resumed the resident's wound dressing change. During the wound dressing change, Staff C was observed cleansing the wound with a gauze previously soaked with normal saline, she then placed the soiled gauze directly on the bedside table. Further, Staff C was observed placing the dirty cotton swabs used to spread the Medihoney and the calcium alginate to the wound bed, on the bedside table. Staff C failed to disinfect the bedside table after the wound dressing was completed. Furthermore, Staff C was observed exiting the resident's room to the hallway without taking off her gown. When she realized she still had the gown on, she went back to the room to take it off. During a surveyor interview immediately following the wound dressing observation, Staff C acknowledged she did not wear a gown as required prior to starting the resident's wound dressing change and failed to remove the gown prior to exiting the resident's room. Additionally, she acknowledged that she placed the soiled dressing items directly on the bedside table and did not disinfect it afterwards. 2. During a surveyor observation on 6/12/2025 at 8:16 AM two Nursing Assistants (NAs), Staff F and G, were observed entering the resident's room without wearing a gown or gloves. Additionally, Staff F and G were observed rolling the resident onto his/her side in attempts to place a Hoyer pad underneath him/her. Further, Staff F and G were observed transferring the resident from the bed to a wheelchair without wearing a gown or gloves. During a surveyor interview immediately following the above observation, both Staff F and G acknowledged that they failed to follow the EBP protocol as ordered and acknowledged that they should have when they transferred the resident. During a surveyor interview on 6/12/2025 at 10:54 AM with the Staff Educator, he indicated that he would expect the staff to follow the infection control protocol when required. Additionally, he indicated that he would expect the staff to wear the appropriate PPE before providing care to the residents who are on EBP, as ordered, and/or per the signage on the doors.

Based on record review and staff interview, it has been determined that the facility failed have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident relative to skin assessments for 6 of 6 licensed nursing staff reviewed, Staff IDs A, C, D, E, F and G. Findings are as follows: Review of a facility policy titled, Skin Care Program states in part, .The weekly skin assessments (documented under assessments) will be done for every resident . Review of the 2024 Facility Assessment revealed competencies to be provided to staff including, Resident assessment and examinations .skin assessment . Review of a community reported complaint received by the Rhode Island Department of Health on 8/14/2024 alleged that the resident was treated at the hospital on 8/4/2024 for multiple wounds to his/her feet. Additionally, maggots were present in the wounds. Review of photographs taken at the hospital dated 8/4/2024 revealed wounds between multiple toes with visible black tissue and white maggots. Review of hospital admission paperwork for Resident ID #1 dated 8/4/2024 states in part, .Upon removing a kerlix dressing to [the resident's ] rt [right] foot noted to have old blood, black colored tissue with maggots in between toes, top of right foot with redness. Pedal pulse weak .Seen by house resident, and supervisor, cleansed extensively with wound cleanser to partially remove many maggots and left open to air . Further review of the hospital admission paperwork revealed s/he was admitted with cellulitis to the right lower extremity and started on intravenous antibiotics. Review of a skin assessment completed by Registered Nurse (RN), Staff A dated 8/3/2024, the day prior to the resident's hospitalization , revealed that the resident had dry skin to his/her bilateral lower extremities and foot wounds were not identified. During a surveyor interview on 8/19/2024 at 9:40 AM with RN, Staff A, she revealed that she completed the skin assessment on 8/3/2024 and did not note any wounds to the resident's feet. Additionally, she revealed that she did not look in between the resident's toes to assess the skin in those areas. Record review of 6 licensed nursing staff (Staff IDs A, C, D, E, F and G) competencies failed to reveal evidence that they received competency-based training on skin assessments. During a surveyor interview on 8/19/2024 at 1:40 PM with the Director of Nursing Services (DNS), he revealed that he would expect the nursing staff to assess the skin between a resident's toes during a skin assessment. During a surveyor interview on 8/19/2024 at approximately 2:30 PM with the DNS and the Assistant Director of Nursing, they acknowledged that they do not provide competencies for the nursing staff regarding completing or documenting a skin assessment. Additionally, they were unable to provide evidence that the facility followed their facility assessment in regards to competency based training on skin assessments. The failure of the facility to accurately and thoroughly conduct skin assessments to ensure identification of wounds placed not only Resident ID #1 at risk for serious injury, serious harm, serious impairment or death, but all of the facility's 150 residents who require weekly skin assessments.

Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) relative to peripheral vascular disease for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review revealed that the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, cellulitis (a bacterial infection of the skin and the soft tissues underneath) and peripheral vascular disease (a condition where narrowed arteries reduce blood flow to the arms or legs). Review of a Minimum Data Set assessment dated [DATE] revealed the resident is dependent for lower body dressing and putting on/taking his/her shoes. Review of a community reported complaint received by the Rhode Island Department of Health on 8/14/2024 alleged that the resident was treated at the hospital on 8/4/2024 for multiple wounds to his/her feet that were infested with maggots. Review of photographs taken at the hospital dated 8/4/2024 revealed wounds between multiple toes with visible black tissue and white maggots. Review of hospital admission paperwork for Resident ID #1 dated 8/4/2024 states in part, .Upon removing a kerlix dressing to [the resident's] rt [right] foot noted to have old blood, black colored tissue with maggots in between toes, top of right foot with redness. Pedal pulse weak .Seen by house resident, and supervisor, cleansed extensively with wound cleanser to partially remove many maggots and left open to air . Further review of the hospital admission paperwork dated 8/4/2024 revealed s/he was admitted to the hospital with cellulitis to the right lower extremity and started on intravenous antibiotics. Review of a skin assessment completed by Registered Nurse (RN), Staff A, dated 8/3/2024 revealed the resident had dry skin to his/her bilateral lower extremities, but the wounds to his/her feet were not identified. During a surveyor interview on 8/19/2024 at 9:40 AM with RN, Staff A, she revealed that she completed the skin assessment on 8/3/2024 and did not note any wounds to the resident's feet. Additionally, she revealed that she did not look between the resident's toes to assess the skin in those areas. During a surveyor interview on 8/19/2024 at 10:03 AM with Nursing Assistant, Staff B, he revealed that he gave the resident a shower on 8/3/2024 and did not notice any wounds to his/her feet. During a surveyor interview on 8/19/2024 at approximately 10:30 AM with Licensed Practical Nurse (LPN), Staff C, she revealed that she assisted in applying a dressing to the resident's wounds between his/her toes on 8/3/2024. Additionally, she revealed she witnessed a fairly good sized wound with something moving inside the wound and redness to the resident's leg. Staff C further revealed that the resident's right leg was warm to the touch and s/he complained of sensitivity to his/her leg. Lastly, Staff C, revealed that a wound was visible without having to spread the resident's toes. Review of wound assessments dated 8/8/2024 revealed the following vascular wounds: Right foot toe interspaces -Between toes 1 and 2 - 3.3 centimeter (cm) x 1.0 cm -Between toes 2 and 3 - 2.5 cm x 0.5 cm -Between toes 3 and 4 - 3.5 cm x 1.2 cm -Between toes 4 and 5 - 2.0 cm x 1.5 cm Left foot toe 4 plantar 0.4 cm x 0.3 cm x 0.1 cm During a surveyor interview on 8/19/2024 at 1:40 PM with the Director of Nursing Services (DNS), he revealed that he would expect the staff to complete a full skin assessment including between a resident's toes. Additionally, he revealed that the facility does not have any standing orders for preventive care to avoid podiatric complications in residents with diabetes and circulatory disorders who are prone to developing foot problems. The DNS was unable to provide evidence that the facility provided preventative foot care for Resident ID #1. Cross reference F 726

Based on record review and staff and resident interview, it has been determined that the facility failed to ensure that a resident's environment remains as free of accident hazards for 1 of 1 resident, Resident ID #1. Findings are as follows: Record review of a facility reported incident that was received by the Rhode Island Department of Health on 8/13/2022, indicated the resident was being transported back to facility, by a Nursing Assistant (NA), in the facility's wheelchair van following an appointment. The resident's wheelchair was not secured properly in the van, resulting in the wheelchair tipping backwards and the resident sustaining injuries. Record review revealed the resident was admitted to the facility in December of 2019 with diagnoses that included but not limited to fracture of one rib, right side, subsequent encounter for fracture with routine healing, age-related [CONDITION(S)] without current pathological fracture, and spinal stenosis, site unspecified. A Brief Interview for Mental Status (BIMS) assessment was completed on 5/17/2022 with a score of 10/15, indicating the resident had a moderate cognitive impairment. During a surveyor interview on 8/16/2022 at approximately 8:52 AM with the transport aide/NA Staff A, she revealed that she was transporting the resident from an appointment back to the facility on the day of the incident. She further revealed when she wheeled the resident onto the transport van, she secured the wheelchair with the rear crisscross tie down straps and the passenger seatbelt. Additionally, she revealed she secured the left front tiedown strap and must have forgotten to secure the right front strap. She then indicated that the resident alerted her that the front straps were not secured, once the van was in motion. Staff A indicated when stopped at a red light she planned to pull over and check the straps, but once the light turned green and the vehicle was in motion, she heard a loud noise from the back of the van. Once she was able to pull over, Staff A went to the rear of the vehicle to assess the situation and observed the wheelchair had tipped back and the resident had slid partly out of the chair. Staff A contacted 911 for assistance and the resident was transported to the hospital for evaluation. Record review of the progress notes dated 8/12/2022 revealed that the admitting diagnosis to the hospital was multiple rib fractures. During a surveyor interview on 8/16/2022 at approximately 10:48 AM with the resident s/he revealed s/he was being transported for an imaging appointment the day of the incident. S/he further revealed that s/he told the driver that the front straps were not secured. Additionally, s/he revealed that s/he was admitted to the hospital with fractured ribs. During a surveyor interview with the Director of Nurses (DON) on 8/16/2022 at approximately at 2:30 PM he acknowledged the accident did occur. An additional surveyor interview with the Administrator on 8/16/2022 at approximately 2:40 PM he acknowledged the incident did occur.

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 informing the resident's physician immediately when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of an anonymous community reported complaint sent to the Rhode Island Department of Health on [DATE] revealed that on [DATE], Resident ID #1 had been screaming in pain since 6:00 AM. The nurse on the unit had indicated to the staff and the resident's spouse that she was waiting for the resident to have a bowel movement. The complainant indicated that s/he went to get further assistance in the afternoon as s/he felt Resident ID #1 required more attention. The complainant indicated that when Resident ID #1 was assessed by the supervisor s/he was immediately sent out to the hospital and passed away during CT-SCAN at the hospital. The complainant indicated that if the nurse on the unit had called the doctor earlier in the day this situation may have been prevented. Record review revealed that Resident ID #1 was admitted to the facility in January of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the staffing schedule on Resident ID #1's unit revealed the following: Licensed Practical Nurse (LPN), Staff A worked 7:00 AM to 3:00 PM on [DATE] Certified Medication Technician (CMT), Staff B worked 7:00 AM to 3:00 PM on [DATE] Certified Nursing Assistant (CNA), Staff C worked 7:00 AM to 3:00 PM on [DATE] Registered Nurse (RN), Staff D worked 7:00 AM to 3:00 PM on [DATE] (Nurse Supervisor for the facility) RN, Staff F worked 11:00 PM to 7:00 AM on [DATE] During a surveyor interview with RN, Staff F, on [DATE] at 11:52 AM, she revealed that she was the nurse working the 11 PM - 7 AM shift from [DATE] into [DATE]. She revealed that at approximately 6:30 AM, she heard Resident ID #1 yell out and start crying. She revealed that she saw a nursing assistant walk towards his/her room. She indicated that no staff came to get her, so she continued to complete the narcotic count with Staff A. She revealed that she suddenly heard a blood curdling scream coming from the Resident ID #1's room at 6:55 AM. Staff A then told her that she would go and check on the resident. She then indicated that she was unsure of the resident's outcome as she left the facility at approximately 7:00 AM. During a surveyor interview on [DATE] at approximately 11:00 AM with LPN, Staff A, she indicated that on [DATE] she started her shift at 7:00 AM and Resident ID #1 was screaming in pain. Staff A indicated that the resident kept repeating I can't go, I can't and was pointing to his/her stomach. Record review failed to reveal evidence that Staff A assessed Resident ID #1 or called the doctor when s/he was noted to be screaming pain on [DATE] at 7:00 AM. Record review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 17-gram dose, dissolve in 8 ounces of fluid and drink as needed for constipation once a day. The resident received this medication at 8:52 AM by CMT, Staff B. - Geri-Lanta 20 millimeters (mL) PO (by mouth) PRN (as needed) for an upset stomach. The resident received this medication at 9:14 AM by LPN, Staff A. Staff A entered this order into the system and administered it to the resident without calling the physician for his/her recommendation or approval. During the interview on [DATE] at approximately 11:00 AM with Staff A, she further indicated that after the [MEDICATION(S)], Resident ID #1 continued to scream so she then administered the Geri-Lanta. Staff A indicated that the resident became quiet after the administration of the Geri-Lanta. Staff A stated, I thought [s\he] was better. Staff A then indicated that at approximately 12:00 PM the resident began complaining of pain again. She indicated that she assessed the resident's bowel sounds at that time and said that his/her bowel sounds were hypoactive, so she administered a [MEDICATION(S)] suppository. Record review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] suppository 10 mg suppository, give one per day PRN for constipation if no effect from milk of magnesia or per resident request/preference. The resident received this medication at 12:21 PM by Staff A as she documented that the resident was yelling in discomfort. Staff A entered this order into the system and administered it to the resident without calling the physician for his/her recommendation or approval. Additional record review failed to reveal evidence that Staff A assessed the resident or his/her bowel sound or called the doctor when s/he was noted to be yelling in discomfort on [DATE] at 12:21 PM as she indicated in her interview. During the same an interview on [DATE] at approximately 11:00 AM with Staff A, she indicated that at approximately 1:30 PM, the nurse supervisor, Staff D came to the unit to assess Resident ID #1. She indicated that Staff D could not hear any bowel sounds and Staff D advised Staff A to send the resident to the emergency room via 911 and to call the physician. Staff A acknowledged that she did not call the physician her entire shift until Staff D had advised her to do so at approximately 2:00 PM. Record review of a document titled MD call log reveals that the physician on call received a call from the Holiday Retirement Home regarding Resident #1 on [DATE] on 2:11 PM that states in part . (911) NEEDS TO BE SEND OUT 911 . Record review of an Emergency Medical Service Report (911 report) dated [DATE] at 2:23 PM states in part .upon assessment .patient yells out in pain upon palpation . Further record review revealed a nursing note dated [DATE] at 5:45 PM that indicates the hospital called to inform the facility the Resident ID #1 had expired, and the cause of death was perforated viscus or an intestinal perforation (a major life-threatening condition with high morbidity and mortality that requires emergency surgery). During an interview on [DATE] at approximately 11:37 AM with Staff D, she indicated that she was the nurse supervisor on [DATE]. She indicated that Staff B and C approached her at approximately 2:00 PM on [DATE] and indicated that something was wrong with Resident ID #1 and the resident's spouse was concerned for his/her discomfort. Staff D immediately went to assess Resident ID #1 and conducted an assessment. She revealed that when she went to listen to the resident's bowel sounds that she placed her stethoscope on the resident's abdomen, and s/he immediately winced in pain. She revealed the resident's stomach was a funny color .almost like frost bite or mottling [blotchy, red-purplish marbling of the skin. Mottling of skin before death]. She did not hear bowel sounds and advised Staff A to call the physician and send the resident to the emergency room via 911. During an interview on [DATE] at approximately 11:47 AM with Staff C, she indicated that when she arrived for her shift at 7:00 AM Resident ID #1 was talking loudly and I knew something was wrong. She said that Staff A went in and gave him/her some medication. Staff C was not aware of the medication the resident was administered. She said that at 1:50 PM she knew something was not right as the resident did not respond to her questions, and she could tell by the resident's face that something was very wrong. She indicated that at this time she and Staff B went to get the nurse supervisor, Staff D. Additionally, she revealed that the resident was in pain for hours on [DATE]. During a subsequent interview with Staff A on [DATE] at 1:08 PM, she acknowledged that she did not call the physician until approximately 2:00 PM on [DATE]. She also acknowledged that she administered the Geri Lanta and [MEDICATION(S)] suppository without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 1:58 PM with Staff B she revealed that she was the Medication Technician on [DATE] on the 7:00 AM to 3:00 PM shift. She indicated that when she arrived on [DATE] at 6:30 AM, Resident ID #1 was screaming in pain at the top of his/her lungs stating, I can't, I can't. She indicated that the nurse asked her to administer the [MEDICATION(S)], which she did at 8:52 AM. Staff B said she went into the resident's room several times throughout her shift to give the resident clear liquids and to make sure s/he was okay. She said that although the resident stopped screaming at about 9:00 AM or 10:00 AM, his/her pain never went away. She then indicated that the resident's family arrived around 1:00 PM and they were uncomfortable with the amount of pain the resident was in. The family member told Staff B that the nurse (Staff A) was waiting for the resident to have a bowel movement. She indicated that she and Staff C went to alert the nurse supervisor, Staff D, around 1:50 PM as she felt the resident needed more help. She said that as soon as the nurse supervisor assessed the resident, s/he was sent out immediately to the hospital. She stated that I kept telling her (Staff A) that something was wrong. During an interview on [DATE] at approximately 3:00 PM with the Administrator, Director of Nursing Services, and the Assistant Director of Nursing Services they acknowledged that Resident ID #1 had a significant change in condition on [DATE]. They were unable to provide evidence that LPN, Staff A assessed this resident when s/he was exhibiting signs of pain starting at 6:30 AM on [DATE]. They also acknowledged that the physician was not called until approximately 2:00 PM, which was seven and half hours after the resident started experiencing pain. Additionally, they acknowledged that Staff A entered the Geri-Lanta and [MEDICATION(S)] suppository orders into the system and administered them to the resident without calling the physician for his/her recommendation or approval. During a surveyor interview with the resident's spouse on [DATE] at 9:41 AM, s/he revealed that s/he visited the resident at the facility on [DATE] at approximately 1:15 PM. S/he revealed that upon arriving to his/her room, s/he was complaining of severe pain, rubbing his/her stomach, moaning loudly, and his/her hands were shaking. S/he indicated that s/he went to the nurses' station to inform Staff A that the resident was in severe pain. S/he was told that the resident was constipated and was given something to move his/her bowels. S/he further revealed that the resident continued to scream out and was extremely upset as to why s/he continued to be in excruciating pain from constipation. The resident's spouse also revealed that s/he addressed the nurse (Staff A) a second time and demanded that something had to be done. S/he indicated that after the resident was assessed by Staff D, she called 911 at approximately 2:00 PM and had the resident sent to the hospital. During a surveyor interview with the Nurse Practitioner on [DATE] at 11:44 AM, she revealed that she would expect nurses to call the provider to obtain new orders for medications. Additionally, she would expect the nurse to contact the provider immediately if the resident was in severe pain. During a surveyor interview with the Medical Director on [DATE] at 1:30 PM, he revealed that a provider from his office was not contacted until 2:11 PM on [DATE] regarding Resident ID #1. He further revealed that at this time, the provider on call was notified that the resident was being sent to the hospital. Additionally, he indicated that he would expect the nurse to call the physician with an assessment of a resident in excruciating pain so that immediate actions could be taken.

Based on record review and staff interview, it has been determined that the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences for 1 of 6 residents reviewed for pain management, Resident ID #1. Findings are as follows: Record review of an anonymous community reported complaint sent to the Rhode Island Department of Health on [DATE] revealed that on [DATE], Resident ID #1 had been screaming in pain since 6:00 AM. The unit nurse caring for the resident had indicated to staff and the resident's spouse that she was waiting for the resident to have a bowel movement. The complainant indicated that s/he went to get further assistance in the afternoon as s/he felt Resident ID #1 required more attention. The complainant indicated that when Resident ID #1 was assessed by the supervisor, s/he was immediately sent out to the hospital and passed away during his/her CT-SCAN at the hospital. The complainant indicated that if the unit nurse had called the doctor earlier in the day, his/her death may have been prevented. Record review revealed that Resident ID #1 was admitted to the facility in January of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [DATE] order for pain assessment every shift. If resident has pain document intervention and effectiveness. - [DATE] order for Acetaminophen 325 mg, administer two tablets PO (by mouth) four times daily as needed for pain or fever. Record review revealed a care plan for alteration in comfort. The care plan indicates the resident's comfort will be maintained at an acceptable level as evidenced by verbal/non-verbal indications of pain with interventions to assess and document pain every shift, to monitor changes, monitor for complaints of pain and encourage the resident to report pain and request pain medication as needed and administer pain medications in the early stages of discomfort. Record review of the [DATE] Treatment Administration Record (TAR) revealed a pain assessment was completed by Licensed Practical Nurse Staff A, on [DATE] for the 7 AM - 3 PM shift, indicating that the resident had no pain. Further record review failed to reveal evidence that this resident received his/her Acetaminophen as needed for pain on [DATE]. Record review of the staffing schedule on the resident's unit revealed the following: Licensed Practical Nurse (LPN), Staff A, worked 7:00 AM to 3:00 PM on [DATE] Certified Medication Technician (CMT), Staff B worked 7:00 AM to 3:00 PM on [DATE] Certified Nursing Assistant (CNA), Staff C worked 7:00 AM to 3:00 PM on [DATE] Registered Nurse (RN), Staff D worked 7:00 AM to 3:00 PM on [DATE] (Nurse Supervisor for the facility) CNA, Staff E worked 11:00 PM to 7:00 AM on [DATE] RN, Staff F worked 11:00 PM to 7:00 AM on [DATE] During a surveyor interview with the RN, Staff F, on [DATE] at 11:52 AM, she revealed that she was the nurse working the 11 PM - 7 AM shift from [DATE] into [DATE]. She revealed that at approximately 6:30 AM, she heard Resident ID #1 yell out and start crying. She revealed that she saw a nursing assistant walk towards his/her room. She indicated that no staff came to get her, so she continued to complete the narcotic count with Staff A. She revealed that she suddenly heard a blood curdling scream coming from the resident's room at 6:55 AM. Staff A then told her that she would go and check on the resident. Staff F indicated she was unsure of the resident's outcome, as she left the facility at approximately 7:00 AM. During a surveyor interview on [DATE] at approximately 11:00 AM with Staff A, she indicated that on [DATE] she started her shift at 7:00 AM and Resident ID #1 was screaming in pain. Staff A indicated that the resident kept repeating I can't go, I can't and was pointing to his/her stomach. Record review failed to reveal evidence that Staff A assessed Resident ID #1 or called the doctor when s/he was noted to be screaming in pain on [DATE] at 7:00 AM. Record review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 17-gram dose, dissolve in 8 ounces of fluid and drink as needed for constipation once a day. The resident received this medication at 8:52 AM by CMT, Staff B. - Geri-Lanta 20 millimeters (mL) PO (by mouth) PRN (as needed) for an upset stomach. The resident received this medication at 9:14 AM by LPN, Staff A. Staff A entered this order into the system on [DATE] and administered it to the resident without calling the physician for his/her recommendation or approval. During the interview on [DATE] at approximately 11:00 AM with Staff A, she further indicated that after the [MEDICATION(S)] was administered, Resident ID #1 continued to scream in pain, so she then administered the Geri-Lanta. Staff A indicated that the resident became quiet after the administration of the Geri-Lanta. Staff A stated, I thought [s/he] was better. Staff A then indicated that at approximately 12:00 PM the resident began complaining of pain again. Staff A indicated that she assessed the resident's bowel sounds at that time and said that his/her bowel sounds were hypoactive, so she administered a [MEDICATION(S)] suppository. Record review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] suppository 10 mg suppository, give one per day PRN for constipation if no effect from milk of magnesia or per resident request/preference. The resident received this medication at 12:21 PM by Staff A as she documented that the resident was yelling in discomfort. Staff A entered this order into the system on [DATE] and administered it to the resident without calling the physician for his/her recommendation or approval. Additional record review failed to reveal evidence that Staff A assessed the resident or his/her bowel sound or called the doctor when s/he was noted to be yelling in discomfort on [DATE] at 12:21 PM as she indicated in her interview. During the same interview on [DATE] at approximately 11:00 AM with Staff A, she indicated that at approximately 1:30 PM, the nurse supervisor, Staff D came to the unit to assess Resident ID #1. She indicated that Staff D could not hear any bowel sounds and Staff D advised Staff A to send the resident to the emergency room via 911 and to call the physician. Record review of an Emergency Medical Service Report (911 report) dated [DATE] at 2:23 PM states in part, .upon assessment .patient yells out in pain upon palpation . Further record review revealed a nursing note dated [DATE] at 5:45 PM that indicates the hospital called to inform the facility the Resident ID #1 had expired, and the cause of death was perforated viscus or an intestinal perforation (a major life-threatening condition with high morbidity and mortality that requires emergency surgery). During an interview on [DATE] at approximately 11:37 AM with Staff D, she indicated that she was the nursing supervisor on [DATE]. She further indicated that Staff B and Staff C approached her at approximately 2:00 PM on [DATE] and indicated that something was wrong with Resident ID #1 and the resident's spouse was concerned for his/her discomfort. Staff D immediately went to the resident and conducted an assessment. She revealed that when she went to listen to the resident's bowel sounds, she placed her stethoscope on the resident's abdomen, and s/he immediately winced in pain. She further revealed she did not hear bowel sounds and advised Staff A to call the physician and send the resident to the emergency room via 911. During an interview on [DATE] at approximately 11:47 AM with Staff C, she indicated that when she arrived for her shift at 7:00 AM, Resident ID #1 was talking loudly and I knew something was wrong. At 1:50 PM Staff C indicated that the resident did not respond to her questions, and she could tell by the resident's face that something was very wrong. She indicated that at this time she and Staff B went to get the nurse supervisor. Additionally, she revealed that the resident was in pain for hours on [DATE]. During a subsequent interview with Staff A on [DATE] at 1:08 PM, she acknowledged that Resident ID #1 was in pain, and she never administered his/her as needed pain medication or followed his/her care plan. She also acknowledged that she documented that this resident did not have any pain when indeed s/he did. During an interview on [DATE] at 1:58 PM with Staff B, she revealed that she was the Medication Technician on [DATE] on the 7:00 AM to 3:00 PM shift. She indicated that when she arrived on [DATE] at 6:30 AM, Resident ID #1 was screaming in pain at the top of his/her lungs stating, I can't, I can't. She said that although the resident stopped screaming at about 9:00 AM or 10:00 AM, his/her pain never went away. She then indicated that the resident's family arrived around 1:00 PM and they were uncomfortable with the amount of pain the resident was in. The family member told Staff B that the nurse (Staff A) was waiting for the resident to have a bowel movement. She indicated that she and Staff C went to alert the nurse supervisor (Staff D) around 1:50 PM as she felt the resident needed more help. She revealed that as soon as the nurse supervisor assessed the resident, s/he was sent out immediately to the hospital. She stated that I kept telling her (Staff A) that something was wrong. During a surveyor interview with the Director of Nursing Services on [DATE] at 2:20 PM, he acknowledged that the facility did not manage Resident ID #1's pain on [DATE]. During a surveyor interview with Certified Nursing Assistant, Staff E on [DATE] at 1:43 PM, she revealed that she was working the 11 PM to 7 AM shift on [DATE] into [DATE]. She also revealed that she is very familiar with Resident ID #1. She indicated that on [DATE] at approximately 6:30 AM, she heard the resident suddenly start yelling out, Ow! I can't, I can't. She revealed that at this time, she called out for someone to help the resident. During a surveyor interview with the resident's spouse on [DATE] at 9:41 AM, s/he revealed that s/he visited the resident at the facility on [DATE] at approximately 1:15 PM. S/he revealed that upon arriving to his/her room, s/he was complaining of severe pain, rubbing his/her stomach, moaning loudly, and his/her hands were shaking. S/he indicated that s/he went to the nurses' station to inform Staff A that the resident was in severe pain. S/he was told that the resident was constipated and was given something to move his/her bowels. S/he further revealed that the resident continued to scream out and was extremely upset as to why s/he continued to be in excruciating pain from constipation. S/he also indicated that it was not typical for the resident to complain of pain, even before his/her dementia progressed. The fact that s/he was crying out and acting this way because of the pain was distressing. The resident's spouse also revealed that s/he addressed the nurse (Staff A) a second time and demanded that something had to be done. S/he indicated that after the resident was assessed by Staff D, she called 911 at approximately 2:00 PM and had the resident sent to the hospital. S/he further revealed that s/he was notified by the hospital's physician that his/her spouse was in pretty bad shape when s/he arrived at the hospital. During a surveyor interview with the Medical Director on [DATE] at 1:30 PM, he indicated that his office was not contacted relative to the resident's pain until 2:11 PM on [DATE]. Additionally, he revealed his expectations are for the nurse to call the physician with an assessment of a resident in excruciating pain so that immediate actions could be taken.