Every finding on record at Kent Regency Center

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical well-being relative to obtaining follow up appointments and failing to obtain radiology services to meet the needs of its residents for 1 of 1 resident reviewed, Resident ID #6. Findings are as follows:1a. Record review revealed Resident ID #6 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, neurocognitive disorder with Lewy bodies dementia (a progressive neurodegenerative disorder characterized by the accumulation of protein deposits called Lewy bodies in the brain) and shoulder pain.Record review of the hospital discharge document dated 7/9/2025 indicated the facility was to follow up with an Alzheimer's Disease and Memory Disorder Center as soon as possible for a visit in 1 week.Record review of a nursing progress note dated 7/10/2025 states, Called Alzheimer's Disease & Memory Disorders Center (Neuro) office to make a follow up appt. from the hospital. Left a voicemail, waiting on a call back.Record review of a nursing progress note dated 7/16/2025 states, Called Neuro office to make a follow up appt. from the hospital. Left a second voicemail, waiting on a call back.Record review of a nursing progress note dated 7/16/2025 states, Neuro Called back. They need a cognitive test done and PCP [Primary Care Provider] notes faxed over to the office. Also need a referral.Record review revealed a Brief Cognitive Assessment Tool (BCAT(R)) was completed on 7/22/2025.Record review failed to reveal evidence that the results from the BCAT were faxed or a follow up appointment with the Alzheimer's Disease and Memory Disorder Center had been scheduled.During a surveyor interview on 9/4/2025 at 10:45 AM with the Unit Manager (UM), Staff B, she revealed that she was unaware if the resident had a follow up appointment with the Alzheimer's Disease and Memory Disorder Center. Subsequently, she was unable to provide evidence that the resident had his/her consult as ordered.1b. Record review of a progress note authored by the Nurse Practitioner on 8/6/2025, states in part, .Patient seen today to review pain mgmt. [management]. Patient has been receiving Tramadol [an opioid medication prescribed to treat moderate to severe pain] since admission.for Right shoulder pain s/p [status post] fall. Upon examination patient was icing [his/her] shoulder + guarding. Patient describes the pain as burning/lightning starting in [his/her] shoulder radiating to.elbow. Patient states [his/her] pain level can be as high as an 8 or a 9. Pain is worse after therapy. Patient with guarding and wincing on exam.Record review revealed the following physician's orders dated 8/7/2025:- Referral to an orthopedic- Right shoulder X-ray- Continue Tramadol 75 milligrams (mg) every 6 hours for pain- Increase gabapentin (a medication prescribed to treat nerve pain) 100 mg 3 times a day- Voltaren gel (a medicated gel used to treat muscle and joint pain) 3 times a day as neededRecord review failed to reveal evidence that an orthopedic consult or an X-ray were obtained.During a surveyor interview on 9/4/2025 at 10:45 AM with Staff B, she was not able to provide evidence that an orthopedic consult was made, or that a referral was faxed by the facility.During a surveyor interview on 9/4/2025 at 11:03 AM with the outpatient orthopedic receptionist, she revealed that she had no information or an appointment scheduled for Resident ID #6.During a surveyor interview on 9/4/2025 at 11:47 AM with the Director of Nursing Services in the presence of the Regional Clinical Manager, she was unable to provide evidence that a follow-up appointment with the Alzheimer's Disease and Memory Disorder Center had been scheduled, an orthopedic consult was obtained, or that a right shoulder X-ray was completed as ordered for Resident ID #6.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 3 residents wound treatments observed, Resident ID #s 27 and 52.Findings are as follows:Review of a facility procedure titled, WOUND DRESSINGS: ASEPTIC reviewed on 12/1/21, states in part, .1. Verify order. 2. Gather supplies.1. Record review revealed that Resident ID #27 was readmitted to the facility in February of 2025, with a diagnosis including, but not limited to, dementia.Record review revealed a physician's order dated 8/1/2025 to cleanse the coccyx (tailbone) wound with wound cleanser, apply medihoney (a wound ointment) then calcium with silver (absorbent dressing with antimicrobial properties) and cover with a foam dressing.Review of Resident ID #27's care plan last revised on 8/29/2025, revealed that s/he has an unstageable pressure ulcer (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by yellow, tan, gray, green, brown, or black tissue in the wound bed) to his/her sacrum (the triabgular bone at the base of the spine), with interventions including, but not limited to, provide wound treatment as ordered.During a surveyor observation on 9/4/2025 at 1:08 PM, with Registered Nurse, Staff C, of Resident ID #27's wound care treatment revealed, Staff C applied a square of collagen AG (stimulates new tissue growth) over the wound and surrounding skin and not directly in the base of the wound. Staff C failed to apply calcium alginate AG as ordered. Additionally, Staff C failed to cut the wound dressing to fit to the size of the wound.Review of the collagen AG packaging revealed .cut the dressing to fit the exact wound size.During a surveyor interview with Staff C immediately following the above-mentioned observation, she acknowledged that she put collagen AG on the wound and not the calcium alginate with AG, as ordered. Additionally, she acknowledged that she failed to cut the dressing to the size of the wound bed as indicated in the application directions for collagen AG. 2. Record review revealed that Resident ID #52 was readmitted to the facility in February of 2025, with a diagnosis including, but not limited to, pain in the left foot. Record review revealed a physician's order dated 6/27/2025 to cleanse the left heel wound with normal saline, apply a nickel thick amount of Santyl (wound treatment) to the wound bed followed by collagen powder (stimulates new tissue growth), and cover with a silicone bordered foam dressing daily.Review of Resident ID #52's care plan last revised on 7/21/2025, revealed that s/he has a left heel deep tissue injury (a pressure ulcer that affects underlying tissues such as muscles and bones due to pressure or shear forces), with interventions which include, but are not limited to, provide wound treatment as ordered.During a surveyor observation on 9/4/2025 at 12:09 PM, with Licensed Practical Nurse, Staff D, of Resident ID #52's wound care treatment revealed, Staff D failed to apply collagen powder to the wound bed. During a surveyor interview with Staff D immediately following the above-mentioned observation, he acknowledged that he failed to apply the collagen powder to the wound bed as ordered.During a surveyor interview on 9/4/2025 at 12:50 PM and 1:36 PM, with the Director of Nursing Services, she indicated that she would expect the staff to follow the physician's orders for wound care treatments for Resident ID #s 27 and 52. Additionally, she revealed she would expect the wound dressing to be cut to size for Resident ID #27. During a surveyor interview on 9/5/2025 at 8:09 AM, with the Wound Physician, she revealed that she would expect the staff to follow wound treatments as ordered for Resident ID #s 27 and 52.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 3 of 4 medication carts observed.Findings are as follows:Review of a facility policy titled, Storage of Medication dated 1/2025 states in part. Medication and biologicals are stored properly, following manufactures' s or pharmacy recommendations, to keep their integrity and to support safe, effective drug administration.Medication requiring refrigeration.are kept in the refrigerator with a thermometer to allow temperature monitoring.unless otherwise directed on the label.1. During a surveyor observation on 9/4/2025 at approximately 9:00 AM of the D Unit Medication Cart in the presence of Certified Medication Technician, Staff E, the following was revealed:-2 Breo Elipta 100-25 micrograms (mcg) inhalers (a medication prescribed to treat long term chronic obstructive pulmonary disease) opened and undated. The manufacturer's instructions on the box indicate to discard 6 weeks after opening.-2 bottles of Brimonidine eye drops (a medication prescribed to reduce the pressure inside the eyes) opened and undated. The manufacturer's instructions on the box indicate to discard 28 days after opening. -1 bottle of Visine eye drops opened and undated. The manufacturer's instructions on the box indicate to discard 28 days after opening.-2 bottles of fluticasone propriate (a steroid nasal spray used to treat hay fever or allergy symptoms) opened and undated. The manufacturer's instructions on the box indicate to discard 60 days after opening. During a surveyor interview immediately following the observation, Staff E acknowledged that the above-mentioned medications were opened and undated.2. During a surveyor observation on 9/4/2025 at 10:15 AM of the A unit Medication Cart in the presence of Registered Nurse, Staff C, the following was revealed:-1 Breo Elipta 100-25 mcg inhaler opened and undated. The manufacturer's instructions on the box indicate to discard 6 weeks after opening.-1 bottle of Lactulose (a laxative prescribed to treat chronic constipation and hepatic encephalopathy) 10 grams/15 milliliters opened and undated. The manufacturer's instructions on the box indicate to discard 6 months after opening.-2 bottles of Lorazepam (a medication used to treat anxiety disorders and short-term anxiety symptoms) 2 milligram/milliliter opened and undated. The manufacturer's instructions on the box indicate to discard 30 days after opening if refrigeration is not possible. During a surveyor interview immediately following the observation, Staff C acknowledged that the above-mentioned medications were opened and undated.3. During a surveyor observation on 9/4/2025 at approximately 11:00 AM, of the B Unit Medication Cart, in the presence of Licensed Practical Nurse, Staff B, the following was observed:-1 Bottle of Visine eye drops opened and undated. The manufacturer's instructions on the box indicate to discard 28 days after opening. During a surveyor interview immediately following the observation, Staff B acknowledged that the above-mentioned medication was opened and undated.During a surveyor interview on 9/4/2025 at approximately 2:00 PM with the Director of Nursing Services in the presence of the Assistant Director of Nursing and the Regional Clinical Nurse, she indicated that she would have expected staff to date the medication when they are opened, as required.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to post the results of the most recent surveys in a readily accessible area for the residents, families, and visitors. Findings are as follows:A surveyor observation on 9/3/2025 at 10:39 AM, revealed a sign was posted to a bulletin board located outside the Director of Nursing Service's (DNS) office which stated, [NAME] REGENCY MOST RECENT SURVEY RESULTS Any surveys conducted in the past three years available upon request. please see the receptionist.A surveyor observation on 9/3/2025 at 10:43 AM, of the Receptionist desk, revealed a sign posted which stated, The most recent annual Rhode Island Department of Health Survey results are located on the bulletin board outside the Director of Nursing office.During a surveyor interview on 9/3/2025 at 10:45 AM, with Central Supply Clerk, Staff A, she revealed that she was covering the reception desk, as the receptionist was unavailable. She further revealed that she was unaware where the survey results binder was located.During a surveyor interview on 9/3/2025 at 10:52 AM, with Staff A, she revealed that she found the survey results binder, located behind the receptionist desk, and provided the surveyor with the binder.Review of the binder titled, [NAME] REGENCY SURVEY RESULTS AVALIABLE FOR REVIEW FOR THE LAST THREE YEARS, provided to the surveyor by Staff A, revealed the most recent survey results were dated 1/22/2021.During a surveyor interview on 9/3/2025 at 10:55 AM, with the DNS, she revealed that she was unaware the survey results must be readily accessible to residents and visitors, without them having to ask, and revealed that the Administrator has the survey results binder in her office.During a surveyor interview on 9/3/2025 at 10:58 AM, with the Administrator, she acknowledged that the survey results must be accessible to the residents and visitors and must contain the last three years of results, however, she revealed that the binders containing the most recent survey results from the past three years were in her office.During a surveyor interview on 9/3/2025 at 11:50 AM, with the Administrator, she revealed that the last three years of survey results were now in a binder located at the receptionist's desk and the most recent annual survey results were posted outside of the DNS office.

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (NA), at least once every 12 months, for 5 of 5 NA personnel records reviewed, Staff E, F, G, H, and I. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NA's: -Staff E, hired in July 2014 -Staff F, hired in May 2015 -Staff G, hired in March 2018 -Staff H, hired in April 2019 -Staff I, hired in January 2023 During a surveyor interview with the Director of Nursing Services on 8/21/2024 at 2:20 PM, she was unable to provide evidence that performance evaluations were completed within the last 12 months for the above-mentioned NA's.

Based on record review and staff interview, it has been determined that the facility failed to implement comprehensive person-centered care plans for each resident for 4 of 4 residents reviewed with indwelling urinary catheters (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 2, 3, 56 and 95. Findings are as follows: 1. Record review for Resident ID #2 revealed s/he was originally admitted to the facility in March of 2018 with a diagnosis including, but not limited to, stroke. Review of the resident's care plan revised on 6/18/2024, revealed the resident requires an indwelling urinary catheter due to neurogenic bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination) with interventions to monitor urine for sediment, cloudiness, odor, or blood. Further record review failed to reveal evidence that the facility has been monitoring Resident ID #2's urine for sediment, cloudiness, odor, or blood. During a surveyor interview on 8/21/2024 at 12:52 PM with the Assistant Director of Nursing Services, she was unable to provide evidence that Resident ID #2's urine was being monitored for sediment, cloudiness, odor, or blood. 2. Record review for Resident ID #3 revealed s/he was admitted to the facility in June of 2024 with a diagnosis including, but not limited to, chronic kidney disease. Record review of a physician's order dated 6/20/2024 revealed the resident has an indwelling urinary catheter for urinary retention (inability to completely empty the bladder). Review of the resident's care plan dated 6/20/2024 revealed the resident requires an indwelling urinary catheter with interventions to report to physician promptly if the urine contains any sediment, blood, cloudiness or is odorous. Further record review failed to reveal evidence that the facility was monitoring Resident ID #3's urine for sediment, cloudiness, odor or blood. During a surveyor interview on 8/21/2024 at 11:49 AM with Registered Nurse (RN), Staff A, she was unable to provide evidence Resident ID #3's urine was being monitored for sediment, blood, cloudiness, or odor. 3. Record review for Resident ID #56 revealed s/he was readmitted to the facility in September of 2023 with diagnoses including, but not limited to, kidney cancer and benign prostatic hyperplasia (enlarge prostate gland). Record review of a physician's order dated 4/5/2024 revealed the resident has an indwelling urinary catheter for a diagnosis of bladder cancer. Record review of a care plan revised on 7/30/2024, indicates the resident requires an indwelling urinary catheter due to urinary retention and obstructive uropathy (structural or functional hindrance of normal urine flow) with interventions to monitor urine for sediment, cloudiness, odor, and blood. Further record review failed to reveal evidence that the facility has been monitoring Resident ID #56's urine for sediment, cloudiness, odor, or blood. 4. Record review for Resident ID #95 revealed s/he was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, urinary tract infection and urinary retention. Record review of a care plan dated 4/3/2024 revealed the resident requires an indwelling urinary catheter due to a pressure ulcer to the coccyx with interventions to monitor for signs and symptoms of infection and report to the physician. Further record review failed to reveal evidence that the facility was monitoring Resident ID #95 for signs and symptoms of infection. During a surveyor interview on 8/21/2024 at 12:52 PM with RN, Staff B, she was unable to provide evidence that Residents ID #56's urine output was being monitored for sediment, cloudiness, odor, and blood or that Residents ID #95 was being monitored for signs and symptoms of infection. During a surveyor interview on 8/21/2024 at 4:37 PM with the Director of Nursing Services, she was unable to provide evidence that Resident ID #s 2, 3, 56 and 95's care plans were implemented.

Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for each residentfor 4 of 4 residents review with indwelling urinary catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 2, 3, 56 and 95. Findings are as follows: According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 252 states the usual daily urine volume in the adult is 1-2 Liters or 1000-2000 cubic centimeters (cc). According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage. 1. Record review for Resident ID #2 revealed s/he was originally admitted to the facility in March of 2018 with a diagnosis including, but not limited to stroke. Review of the resident's care plan revised on 6/18/2024, revealed the resident requires an indwelling urinary catheter due to neurogenic bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination) with interventions to monitor urine for sediments, cloudiness, odor, or blood. Further record review failed to reveal evidence that the facility has been monitoring the resident's urine for sediment, cloudiness, odor, or blood. Additionally record review failed to reveal evidence that the facility was recording the urine output for Resident ID #2. During a surveyor interview on 8/21/2024 at 12:52 PM with the Assistant Director of Nursing Services, she was unable to provide evidence that the urine output has been monitored and recorded. 2. Record review for Resident ID #3 revealed s/he was admitted to the facility in June of 2024 with a diagnosis including, but not limited to, chronic kidney disease. Record review of a physician's order dated 6/20/2024 revealed the resident has an indwelling urinary catheter for urinary retention (inability to completely empty the bladder). Review of the resident's care plan dated 6/20/2024 revealed the resident requires an indwelling urinary catheter with interventions to report to physician promptly if the urine contains any sediment, blood, cloudiness or is odorous. Further record review failed to reveal evidence that the facility was monitoring the resident's urine for sediments, cloudiness, odor or blood. Additionally record review failed to reveal evidence that the facility was recording the urine output for Resident ID #3. During a surveyor interview on 8/21/2024 at 11:49 AM with Registered Nurse (RN), Staff A, she was unable to provide evidence that the urine output was being monitored and recorded. 3. Record review for Resident ID #56 revealed s/he was re-admitted to the facility in September of 2023 with diagnoses including, but not limited to, kidney cancer and benign prostatic hyperplasia (enlarge prostate gland). Record review of a physician's order dated 4/5/2024 revealed the resident has an indwelling urinary catheter for a diagnosis of bladder cancer. Additionally, record review of a care plan revised on 7/30/2024, indicates the resident requires an indwelling urinary catheter due to urinary retention and obstructive uropathy (structural or functional hindrance of normal urine flow) with interventions to monitor urine for sediment, cloudiness, odor, and blood. Further record review failed to reveal evidence that the facility has been monitoring the resident's urine for sediments, cloudiness, odor, or blood. Additionally, record review failed to reveal evidence that the facility was recording the urine output for Resident ID #56. 4. Record review for Resident ID #95 revealed s/he was re-admitted to the facility in May of 2024 with diagnoses including, but not limited to, urinary tract infection and urinary retention. Record review of a care plan dated 4/3/2024 indicates the resident requires an indwelling urinary catheter due to a pressure ulcer to the coccyx with interventions to monitor for signs and symptoms of infection and report to the physician. Further record review failed to reveal evidence that the facility was monitoring the residents for signs and symptoms of infection. Additionally record review failed to reveal evidence that the facility was recording the urine output for Resident ID #95. During a surveyor interview on 8/21/2024 at 12:52 PM with RN, Staff B, she was unable to provide evidence that the urine output was being monitored or recorded for Residents ID #56 and 95. During a surveyor interview on 8/21/2024 at 4:37 PM with the Director of Nursing Services, she was unable to provide evidence that the above-mentioned residents' urinary output was being monitored and recorded, per the professional standards of practice.

Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 2 of 8 residents reviewed, Resident ID #s 67 and 48. Findings are as follows: Review of the facility's policy revised on 2/1/2023 titled, PROCEDURE: WEIGHTS AND HEIGHTS states in part, .1. Obtaining and Documenting Weight: 1.1 A licensed nurse or designee will weigh the patient . 1.1.4 If the body weight is not expected, re-weigh the patient . 1.2 The weight will be entered in the PointClickCare (PCC) Weights/Vital Signs module on that shift . 2. Significant Weight Change Management: 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment. 2.1.1 Significant weight change is defined as: 2.1.1.1 5% in one month, 2.1.1.2 10% in six months. 2.2 The licensed nurse will: 2.2.1 Notify the physician/APP [Advance Practice Provider] and Dietitian of significant weight changes; 2.2.2 Document notification of physician/APP and Dietitian in the PCC Weight Change Progress Note . 1. Record review revealed Resident ID #67 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, Alzheimer's disease, dysphagia (difficulty swallowing) and abnormal weight loss. Record review of the nutritional care plan initiated on 5/16/2024 revealed the resident is a nutritional risk, with potential for weight fluctuation related to appetite and weight loss. Interventions include, but are not limited to, weigh and alert dietitian and physician to any significant loss or gain and monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to the dietitian and physician as indicated. Record review of the physician's orders revealed an order dated 5/9/2024 with a stop date of 5/29/2024 for weekly weights. Record review of the resident's admission weight obtained on 5/8/2024 revealed a weight of 173.8 lbs. (pounds) and a subsequent weight obtained on 5/15/2024 revealed a weight of 169.8 lbs., indicating the resident experienced a 4 lb. weight loss in one week. Record review of the physician's orders revealed an order dated 5/16/2024 for a house supplement two times a day due to poor intake and a weight loss of 4 lbs. in one week. Further review of the physician's orders revealed an order dated 7/12/2024 to increase the house supplement to three times a day for weight loss. Record review of the subsequent documented weights revealed the following: 5/22/2024 176.6 lbs. 5/30/2024 172.4 lbs. 6/5/2024 174.4 lbs. 6/6/2024 178.8 lbs. 6/13/2024 180.8 lbs. 6/20/2024 169.2 lbs. 6/27/2024 170.4 lbs. 7/1/2024 167.8 lbs. 7/4/2024 169.0 lbs. 7/12/2024 162.4 lbs. 7/18/2024 156.6 lbs. 7/18/2024 156.6 lbs. 7/25/2024 162.0 lbs. 7/25/2024 162.0 lbs. 7/29/2024 160.2 lbs. 8/1/2024 160.2 lbs. 8/8/2024 155.0 lbs. 8/15/2024 153.8 lbs. Record review of the resident's weight record revealed the resident experienced a severe weight loss of 20 lbs. (11.5%) from his/her admission weight obtained on 5/8/2024 to his/her weight obtained on 8/15/2024. Further record review failed to reveal evidence that any additional interventions were implemented after 7/12/2024, when the resident experienced a further significant weight loss of 8.6 lbs. (5.3%). Additionally, the facility failed to obtain a re-weigh when the resident experienced a significant weight loss of 11.6 lbs. (6%) from 6/13/2024 to 6/20/2024. Record review of a nursing progress note dated 8/6/2024 authored by the Unit Manager, Staff B, states in part, .Weight loss alert reported to [Registered Nurse Practitioner]. No new orders obtained at this time .Dietician made aware. During a surveyor interview with the Registered Dietitian (RD), Staff C, on 8/20/2024 at 11:56 AM, she acknowledged that there should have been a re-weigh obtained on 6/20/2024 after the resident experienced a significant weight loss of 11.6 lbs. and she would have expected the weight to be obtained immediately. Additionally, Staff C acknowledged that there were no further interventions put in place since 7/12/2024 and that the resident should have been re-evaluated already for further interventions, such as fortified foods and increasing his/her caloric intake to mitigate any further weight loss. During a surveyor interview on 8/21/2024 at 2:51 PM with the Registered Nurse Practitioner, Staff D, she revealed that when the weight loss was reported to her, she referred the weight loss to the RD and that her expectation is that the RD would further assess the resident and implement appropriate interventions. During a surveyor interview with the Director of Nursing Services (DNS) on 8/20/2024 at 1:58 PM, she was unable to provide evidence that any new interventions were implemented after 7/12/024 to prevent the resident from experiencing further weight loss. 2. Record review revealed Resident ID #48 was originally admitted to the facility in May of 2024 and readmitted in July of 2024 with diagnoses including, but not limited to, cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis of one side of the body) following a stroke, diabetes mellitus, and chronic kidney disease. Review of the care plan dated 7/9/2024 states in part, Resident is at nutritional risk r/t [related to] chewing/swallowing difficulty, with a goal that s/he will not have significant weight changes, with an intervention including, but not limited to, .weigh and alert the dietitian and physician to any significant loss or gain . Record review of the resident's weights revealed the following: 5/27/2024 174.8 lbs. 7/3/2024 174 lbs. 7/17/2024 173.2 lbs. 7/24/2024 164 lbs. 8/5/2024 160.2 lbs. 8/14/2024 161.8 lbs. Review of the documented weights revealed on 7/17/2024, the resident weighed 173.2 lbs. and on 7/24/2024, the resident weighed 164 lbs., indicating a severe weight loss of 9.2 lbs. (5.31 %) in one week. Record review of the resident's progress notes failed to reveal evidence that the dietitian or the providers were notified of the weight loss, or that an intervention was implemented. Further review of the documented weights revealed on 7/3/2024, the resident weighed 174 lbs. and on 8/14/2024, the resident weighed 161.8 lbs., indicating a significant weight loss of 12.2 lbs. (7.01 %) in six weeks. Record review of the resident's progress notes failed to reveal evidence that the dietitian or the providers were notified of the weight loss, or that an intervention was implemented. During a surveyor interview on 8/21/2024 at 2:04 PM with the Assistant DNS, in the presence of the DNS, they were unable to provide evidence that any new interventions were implemented to prevent Resident ID #48 from further weight loss. 37158

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store food in accordance with professional standards of food service safety relative to the main kitchen. Findings are as follows: Record review of the Rhode Island Food Code, 2018 Edition, states: Section 3-501.17 Ready-to Eat, Time/Temperature Control for Safety, Date Marking .(A) refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 Celsius (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Section 3-602.11 Food Labels states, .(B) Label information shall include: (1) The common name of the food . During the initial tour of the main kitchen on 8/19/2024 at 8:30 AM revealed the following observations in the walk-in refrigerator: - An opened, plastic bag of whipped topping not dated. - A large rectangular tray with 19 cups of orange jello, 6 cups of an unidentifiable pudding-like substance, and 1 cup of applesauce. The tray was loosely covered by a piece of parchment paper. Additionally, the items did not have a date of preparation or a date by which the food must be consumed by. - A second large rectangular tray contained 6 cups of canned peaches, 8 cups of an unidentifiable pureed substance, 2 cups of canned pears, and 1 cup of canned pineapple. The tray was loosely covered by a piece of parchment paper. Additionally, the items did not have a date of preparation or a date by which the food must be consumed by. During a surveyor interview immediately following the above observations, with the Food Safety Manager, Staff J, she was unable to provide evidence of when the above-mentioned items were prepared. Additionally, she acknowledged that the above items were not covered, labeled, dated, or that the items were kept free from contamination.

Based on record review and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 2 discharged residents reviewed for Levothyroxine (a medication used to replace or provide more thyroid hormone), Resident ID #1. Findings are as follows: Record review of the discharge policy titled Discharge and Transfer states in part, .the registered nurse is ultimately responsible to ensure there is a safe and coordinated discharge . Record review of a community complaint reported to the Rhode Island Department of Health on 7/23/2024, alleges Resident ID #1 was discharged home with another resident's (Resident ID #2's) medications. Record review of Resident ID #1 revealed s/he was admitted to the facility in July of 2024 with diagnoses including, but not limited to, hypothyroidism (low thyroid hormone) and anxiety disorder. Record review revealed Resident ID #1 was prescribed Levothyroxine 88 MCG at the time of his/her discharge. Record review reveals Resident ID #2 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, hypothyroidism and anxiety disorder. Record review reveals that Resident ID #2 was prescribed Levothyroxine 25 Micrograms (MCG) at the time of Resident ID #1's discharge. Review of a facility document titled Discharge RX Sending Medications Home for Resident ID #1 revealed Levothyroxine 88 MCG was printed on the form. The document further revealed the 88 MCG was crossed off and 25 was handwritten in place with 15 tablets sent home with Resident ID #1. Further review of this document and the discharge summary failed to reveal when the last dose of medication was administered to Resident ID #1 or when the next dose was due to be administered. During a surveyor interview with LPN Staff A, on 7/24/2024 at 9:42 AM, she acknowledged that she completed the discharge for Resident ID #1. She further revealed that, during the discharge, she identified that the pack of Levothyroxine that was sent home with the resident was for 25 MCG and not the 88 MCG that was listed on the Discharge RX Sending Medication Home form. Furthermore, she revealed that she altered the document to reflect the Levothyroxine 25 MCG and that she did not verify that the medication was changed or that the medication was prescribed to Resident ID #1. She revealed that she discharged Resident ID #2 the following day and that his/her Levothyroxine 25 MCG was unavailable but that she did not put the two together until 7/23/2024 when she was notified that she sent Resident ID #1 home with Resident ID #2's Levothyroxine. During a surveyor interview with the Director of Nursing Services (DNS) on 7/24/2024 at 11:27 AM, she acknowledged that Resident ID #1 was discharged with Resident ID #2's medication as listed above and that the Continuity of Care Discharge/Transfer of Patient Form was not completed in its entirety to include when the last dose of medication was administered and when to administer the next dose. Additionally, she was unable to provide evidence that all pre-discharge medications were reconciled with the resident's post-discharge medications prior to Resident ID #1 being discharged home from the facility.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent accidents, relative to supervision while toileting for 1 of 4 residents reviewed, Resident ID #1. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards . Record review of a facility reported incident reported to the Rhode Island Department of Health on 3/8/2024 states that Resident ID #1 was transferred to the bathroom with the assistance of two staff members. One of the staff then stepped out of the room for a moment to get a wheelchair and supplies. When the staff member returned to the resident, s/he was found on the floor. This report states in part, .No injury was noted after initial assessment by Nursing . Additionally, the report revealed that the resident's family requested for the resident to be transferred to the hospital for evaluation and s/he was admitted with a diagnosis of intracerebral hemorrhage (brain bleed) on 3/7/2024. Record review revealed that the resident was admitted to the facility from the hospital in March of 2024 with diagnoses including, but not limited to, cerebral infarction (stroke), left sided weakness, and diabetes. Record review of hospital documentation titled Discharge Summary, dated 3/6/2024, states in part, Diagnoses .Ischemic stroke .Cerebral edema .Cognition- .pt [patient] has sig [significant] impaired attention with max 30 seconds. Pt highly distracted .[S/he] started on low dose Ritalin to assist with stroke-related cog [cognition] impairment/inattention .OT [Occupational Therapy] Discharge Summary: two assist for toileting hygiene for safety .limiting function: Balance deficits, Cognition, endurance, pain, positioning, Postural control, Upper Extremity Function . Record review of the resident's care plan dated 3/6/2024 states in part, Resident requires assistance/is dependent for ADL [Activities of Daily Living] .toileting related to: s/p [status post] CVA [cerebrovascular accident], Additional review of the care plan revealed an intervention stating in part, .stand on weaker side of resident/patient when assisting with ADLs or other activities . Record review of an admission nursing progress note dated 3/6/2024 states in part, .Pt is lethargic with flat affect. Able to follow simple instructions. Spanish speaking only .Pt has L-arm [left] sling due to L-sided weakness with facial droop. Incontinent of bowel and bladder . Resident is a two person assist for all transfers and uses a wheelchair for assistive device. Additional record review revealed a progress note authored by the Nurse Practitioner (NP) on 3/7/2024 which indicates that the resident sustained a fall off the toilet earlier that morning at approximately 8:30 AM. The note revealed s/he was transferred to the toilet by staff and was then left in the bathroom alone for approximately two minutes while a Nursing Assistant (NA) went to go get a wheelchair. When the staff returned, the resident was found on the floor. The resident was assisted back to bed by staff and was examined by the Nurse Practitioner with recommendations to send him/her to the hospital emergency room per the family's request. During her examination, the resident denied dizziness, pain, or hitting his/her head. Record review of a RI EMS [Emergency Medical Services] Patient Care Report dated 3/7/2024 states in part, .Pt is alert and oriented, Spanish speaking only, family on scene is able to interpret .CC [complaints] of left sided head pain, left scapula area pain, left sided neck pain, following a fall from a seated position on the toilet .Pt has mild tenderness to the left scapula area . Record review of a progress note dated 3/7/2024 at 5:40 PM states, Resident was admitted to [hospital name redacted] at 1700 [5:00 PM] for Fall/ICH [Intracerebral hemorrhage]. Record review of a hospital document titled, ED [Emergency Department] Provider Note dated 3/7/2024, states in part, History of present illness .[S/he] fell off toilet today in [his/her] rehab center .[s/he] struck the left side of [his/her] head and left shoulder .[S/he] only complains of head and chronic left shoulder pain . Record review of an additional hospital document titled, ED to Hospital admitted d 3/7/2024, states in part, [S/he] presents after minor trauma. Neuroimaging identifying subacute and acute hemorrhagic transformation within [his/her] right MCA [middle cerebral artery] chronic infarct [a small, localized area of dead tissue resulting from failure of blood supply] . During a surveyor interview on 3/12/2024 at 1:52 PM with NA, Staff A, she revealed that she and NA, Staff B transferred the resident to his/her wheelchair and then onto the toilet. She further revealed the resident is Spanish speaking and she was translating for the resident and Staff B. Additionally, she revealed that after the resident was transferred to the toilet, she left the room to assist other residents. During a surveyor interview on 3/12/2024 at 2:04 PM with NA, Staff B, she revealed that on 3/7/2024 at approximately 8:15 AM, she assisted the resident with Staff A to his/her wheelchair and then transferred the resident from his/her wheelchair onto the toilet. While she was in the bathroom with Resident ID #1, a staff member from the Therapy Department came into the room and needed to take the wheelchair. She further revealed that she then left the resident alone in the bathroom to go and find another wheelchair. Additionally, she revealed that when she returned to the bathroom after approximately two minutes, she found the resident on the floor. During a surveyor interview with the Director of Nursing Services on 3/12/2023 at approximately 9:44 AM, she acknowledged that Resident ID #1 was left alone in the bathroom prior to his/her fall. She was unable to provide evidence that the resident received adequate supervision to prevent an accident. 50004

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receive adequate supervision based on the resident's assessed needs and risks identified to protect residents from accidents, relative to an incident that occurred involving self-inflicted wounds, Resident ID #1. Findings are as follows: On 9/18/2023 the Rhode Island Department of Health received a facility reported incident which revealed that Resident ID #1's roommate had activated the call light and the NA (nursing assistant) responded to the room. Resident ID #1's roommate stated s/he observed Resident ID #1 taking medications from their bag. Resident ID #1 denied taking medication from his/her bag and then requested a band aid for a cut on his/her hand. The nurse was notified by the NA and went to assess Resident ID #1, who was noted to have several self-inflicted cuts to his/her left hand from his/her pocketknife. Resident ID #1 stated s/he wants to die and that s/he will cut his/her throat. Resident ID #1 also stated s/he felt better after seeing the blood. The resident's provider was notified of the incident, and s/he was subsequently sent to the hospital for further evaluation. Record review revealed Resident ID #1 was admitted to the facility in September of 2023 with diagnoses including, but not limited to traumatic subdural hemorrhage without loss of consciousness, depression, anxiety disorder, non-suicidal self-harm, and personal history of suicidal behavior. Record review of an Admission Minimum Data Set (MDS) assessment dated [DATE] revealed s/he had a Brief Interview for Mental Status (screening tool to assess cognition) score of 10 out of 15, indicating moderate cognitive impairment. Additional review of the MDS Section for Mood, completed by the facility Director of Social Services, Staff A, on 9/15/2023, under the section Resident Mood Interview (PHQ-9-patient health questionnaire that assesses for the presence and severity of depression) revealed the resident scored a 14, indicating moderate depression. Further, the resident was asked the question from the MDS, Over the last 2 weeks, have you been bothered by any of the following problems .I. Thoughts that you would be better off dead, or of hurting yourself in some way? with the resident's response indicating, yes, with symptom frequency of 2-6 days. Record review of a care plan dated 9/13/2023 with a focus for, Resident exhibits or is at risk for distressed/fluctuating mood symptoms related to: Sadness/depression caused by current medical conditions and loss of independence. Anxiety/fear caused by panic attacks that resident has signs and symptoms of recurring with interventions including, but not limited to, observe for signs and symptoms of worsening sadness/depression, anxiety/fear/anger/agitation, determine the cause for the resident's sadness/depression, anxiety/fear, or persistent anger/agitation. Refer to behavioral health specialist as needed. Additional review of the resident care plans revealed a care plan dated 9/13/2023 with a focus for, Resident is at risk for complications related to the use of psychotropic drugs with interventions including, but not limited to, monitor for changes in mental status and functional level and report to the physician and obtain psych evaluation as ordered. Record review of the progress notes failed to reveal evidence that the resident's provider was informed of the resident's responses to Staff A's MDS assessment completed on 9/15/2023. Record review of a nursing progress note dated 9/16/2023 at 12:15 AM revealed in part, Suicidal threat with self-inflicted injury to the resident's left hand at 12:05 AM. The resident's roommate put the call light on and reported that s/he took medications from his/her bag. Resident admitted having medications in his/her bag but denied taking any. The bottle of medications included three of the resident's current medications and it was removed by staff. The resident's wounds were treated and a 1:1 sitter was provided. The provider was called to be notified of the incident. During a surveyor interview at 9/20/2023 at 1:00 PM and again at 2:15 PM with Staff A, she revealed that she completed an interview with the resident on 9/15/2023 between 1:00 - 2:00 PM and documented her findings relative to the Mood section of the MDS. Additionally, Staff A revealed the resident indicated to her that sometimes s/he feels that life is too much, relative to his/her overall medical condition and functional decline being a burden and s/he sometimes feels s/he is better off dead. Further, after the resident revealed this to her, Staff A then asked the resident if s/he had any current thoughts of harming him/herself or others, in which the resident responded, No. Staff A then revealed that she provided the resident encouragement and at no time did she feel the resident was at risk of harming him/herself. During a surveyor interview on 9/20/2023 at 3:29 PM with Registered Nurse, Staff B, she acknowledged that she was the nurse that assessed the resident on the night of the incident, which she noted him/her with multiple small superficial cuts to his/her left hand. Additionally, the resident revealed to her that s/he had cut him/herself with a knife and s/he threatened to slice his/her throat and wished s/he was dead. Further, Staff B revealed she and another nurse were able to remove the knife from the resident and Staff B indicated that the resident had cut himself/herself to see blood, as this calms him/her down. Staff B then revealed she removed any items in the resident's room that could harm him/her and placed a staff member for 1 to 1 supervision, who remained with the resident until transport to the hospital arrived. Lastly, Staff B revealed when the resident was assessed by her, s/he was calm, initially refused the hospital transfer, but then was agreeable. During a surveyor interview at 9/20/2023 at 9:22 AM and again at approximately 1:30 PM with the Director of Nursing Services (DNS), she revealed that she was unaware that the resident had a bottle of pills and a pocketknife in his/her possession. Additionally, the DNS was not aware of the assessment findings in the MDS Mood Section, until brought to her attention by the surveyor. Further, she revealed the resident has a history of depression and if the resident had verbalized that s/he had plans to harm him/herself, she would have intervened immediately and would have had the resident seen by psychiatric services. During a surveyor interview with the resident's physician on 9/20/2023 at 2:47 PM, after revealing the above-mentioned MDS assessment findings to her, the provider revealed that she would have expected Staff A to communicate the findings with the provider herself, the nursing supervisor, or the Director of Nursing Services. Additionally, she revealed had she been made aware of the results of the screening, she would have wanted psychiatric services contacted to meet with the resident.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 1 of 3 residents reviewed relative to falls, Resident ID #1. Findings are as follows: Review of a facility policy titled, Falls Management, dated 8/7/2023, states in part, Patients will be assessed for risk of falling as part of the nursing assessment process .fall is defined as unintentionally coming to rest on the ground, floor, or other lower level .total lift will be used to lift patients off of the floor, unless contraindicated . Record review revealed the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke), left sided weakness and paralysis. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating the resident has moderately impaired cognition. Additional review of the MDS Assessment revealed the resident is not ambulatory and requires extensive assist of 2+ persons with transfers. Review of a progress note dated 9/4/2023 at 5:02 AM and authored by Registered Nurse Staff A, revealed fall evaluation, which states in part . I saw pt [patient] feet going over side of bed .one assist back to bed .witnessed fall-no injuries .pt had a non-injury fall, no evidence of trauma observed/assessed. Review of a change in condition evaluation dated 9/4/2023, also authored by Staff A, states in part .pt [patient] stated s/he was trying to turn over when his/her feet went off the bed followed by the rest of his/her body .was witnessed by this staff person and pt promptly placed back into bed with one assist. Review of a progress note dated 9/4/2023 at 3:57 AM and authored by APN, Staff B, which states in part .pt [patient] stated s/he was trying to turn over when his/her feet went off the bed followed by the rest of his/her body .was witnessed .pt promptly placed back into bed with one assist. During a surveyor interview on 9/14/2023 at 1:41 PM with Staff A, she acknowledged that she assisted the resident back into bed and did not use a 2+ person assist as the resident requires, nor did she use a lift as per facility policy when a patient is transferred from the floor. During a surveyor interview on 9/14/2023 at 2:00 PM with the Director of Nursing Services (DNS), she acknowledged the facility policy is for staff to use a lift when a resident is on the floor. She further acknowledged that a lift was not used with the resident when s/he was assisted back into bed. The DNS revealed her expectation is that staff would provide care in accordance with the resident's needs and will follow the facility policy.

Based on record review and staff interview, it has been determined that the facility failed to ensure its nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 4 of 6 nursing staff reviewed for competencies relative to CLIA (Clinical Laboratory Improvement Amendments), IV (intravenous) insertion, Donning/Doffing PPE (putting on and taking off personal protective equipment), and Safe Resident Handling, for Staff H, I, J, and K. Additionally, the facility failed to ensure any of the nurses were competent to provide management of an AV fistula (an AV fistula is a surgical connection made between an artery and a vein which is used to receive dialysis). Findings are as follows: Review of the Facility Assessment states in part, .Staff training and education, with competency, if applicable, is provided to meet the level and types of support and care of the resident population .skills/training/competency will be determined by identified needs . 1. Review of the document provided by the facility titled Competencies revealed the required competencies for nurses include med pass upon hire/annually, CLIA annually, safe resident handling for lift devices upon hire/annually and IV insertion. Further review revealed the required competencies for Nursing Assistants (NAs) include, but are not limited to, Safe resident handling for [lift] devices upon hire/annually. Additional review revealed all staff are required to complete Donning/doffing PPE. Review of Registered Nurse, Staff H's personnel record failed to reveal evidence of a completed competency related to CLIA or IV insertion. Review of Nursing Assistant, Staff I's personnel record failed to reveal evidence of a completed competency related to Donning/Doffing PPE. Review of Registered Nurse, Staff J's personnel record failed to reveal evidence of a completed competency related to Donning/Doffing PPE. Review of Registered Nurse, Staff K's personnel record failed to reveal evidence of a completed competency related to Safe resident handling. During a surveyor interview on 8/23/2023 at approximately 3:30 PM with the Director of Nursing Services, she indicated that she would expect staff competencies to be completed as outlined in the facility assessment. 2. Review of a facility procedure last revised on 6/2022 titled DIALYSIS: HEMODIALYSIS (HD) GRAFT AND FISTULA CARE [hemodialysis- a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately], states in part, .2. Evaluate access site daily .observe for signs of complication 2.1 Inspect fistula site for decrease or absence of vein dilation. 2.2 Palpate [touch] for distal thrill [a rumbling sensation that you can feel when touching the area] 2.3 Auscultate[listen] for bruit [an audible vascular sound associated with turbulent blood flow] . 3 .notify physician/advanced practice provider (APP) and hemodialysis staff for . 3.4 Absence of pulse distal [pulse points that are the furthest from the trunk] to access site 3.5 Absence of bruit or thrill . 5. Avoid trauma and treatment procedures in the accessed extremity, such as . 5.2 Blood pressure measurement . Record review revealed the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, end stage renal disease (when your kidneys can no longer support your body's needs) and dependence on renal dialysis. Record review failed to reveal evidence of documentation that the AV fistula pulses distal to the area were being assessed or that the bruit and thrill were assessed every shift per the facility policy from the resident's admitted until 8/22/2023, which was 12 days. Record review of the resident's vital signs document revealed the resident's blood pressures were taken 15 times between 8/10/2023 through 8/21/2023 on his/her left arm, which is the arm that had the AV Fistula. During a surveyor interview and simultaneous observation on 8/23/2023 at approximately 1:15 PM with Registered Nurse, Staff G, she revealed she did not realize that the resident had an AV fistula. Additionally, the resident was observed to have a pink arm band on his/her left wrist, indicating that arm had an AV fistula, and therefore blood pressures should not be taken on that arm. Record review completed on 8/23/2023 of the resident's care plan indicated a new intervention was implemented on 8/22/2023 that states in part, .new AV fistula placed 7/13/2023, no BP [blood pressure]/blood draw left arm . Additionally, record review also revealed a physician's order was initiated on 8/22/2023 to assess the resident's left upper extremity AV fistula for a bruit and thrill every shift. During a surveyor interview on 8/23/2023 at approximately 3:15 PM with the Clinical Lead Nurse, she revealed that on 8/22/2023 she identified that staff was not assessing the resident's bruit and thrill and an order was put in place. During a surveyor interview on 8/23/2023 at approximately 3:20 PM and at 5:42 PM, with the Infection Preventionist, she acknowledged that the blood pressures were being taken on the resident's left arm. Additionally, she was unable to provide evidence that any of the facility's nursing staff completed competencies relative to AV fistula care. 46118

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for 1 of 1 resident reviewed receiving dialysis treatments and with an arteriovenous fistula (an AV fistula is a surgical connection made between an artery and a vein which is used to receive dialysis), Resident ID #263. Findings are as follows: Review of a facility procedure last revised on 6/2022 titled DIALYSIS: HEMODIALYSIS (HD) GRAFT AND FISTULA CARE [hemodialysis- a machine that filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately], states in part, .2. Evaluate access site daily .observe for signs of complication 2.1 Inspect fistula site for decrease or absence of vein dilation. 2.2 Palpate [touch] for distal thrill [a rumbling sensation that you can feel when touching the area] 2.3 Auscultate[listen] for bruit [an audible vascular sound associated with turbulent blood flow] . 3 .notify physician/advanced practice provider (APP) and hemodialysis staff for . 3.4 Absence of pulse distal [pulse points that are the furthest from the trunk] to access site 3.5 Absence of bruit or thrill . 5. Avoid trauma and treatment procedures in the accessed extremity, such as . 5.2 Blood pressure measurement . Record review revealed the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, end stage renal disease (when your kidneys can no longer support your body's needs) and dependence on renal dialysis. Record review failed to reveal evidence of documentation that the AV fistula pulses distal to the area were being assessed or that the bruit and thrill were assessed every shift per the facility policy from the resident's admitted until 8/22/2023, which was 12 days. Record review of the resident's vital sign document revealed the resident's blood pressures were taken 15 times on his/her left arm between 8/10/2023 through 8/21/2023, which is the arm that has the AV Fistula. Record review completed on 8/23/2023 of the resident's care plan indicated a new intervention was implemented on 8/22/2023 that states in part, .new AV fistula placed 7/13/2023, no BP [blood pressure]/blood draw left arm . Additionally, record review also revealed a physician's order was initiated on 8/22/2023 to assess the resident's left upper extremity AV fistula for a bruit and thrill every shift. During a surveyor interview and simultaneous observation on 8/23/2023 at approximately 1:15 PM with Registered Nurse, Staff G, she revealed she did not realize that the resident had an AV fistula. Additionally, the resident was observed to have a pink arm band on his/her left wrist, indicating that arm had an AV fistula, and therefore blood pressures should not be taken on that arm. During a surveyor interview on 8/23/2023 at approximately 3:15 PM with the Clinical Lead Nurse, she revealed that on 8/22/2023 she identified that staff was not assessing the resident's bruit and thrill and an order was put in place During a surveyor interview on 8/23/2023 at approximately 3:20 PM and at 5:42 PM, with the Infection Preventionist, she acknowledged that the blood pressures were being taken on the resident's left arm prior to 8/22/2023.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 2 of 7 residents reviewed who are at risk for developing pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), Resident ID #s 65 and 76. Findings are as follows: 1. Record review for Resident ID #65 revealed s/he was admitted to the facility in September of 2022 with diagnoses including, but not limited to, stroke, diabetes mellitus, morbid obesity, and weakness. Record review of the Quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident is at risk for pressure ulcers/injuries and requires extensive assistance of two for bed mobility. Record review of a care plan initiated on 10/16/2022 with a focus of being at risk for skin breakdown was an intervention initiated on 6/20/2023 to offload heels with pillows under calves while in bed as tolerated. Additionally, review of the resident's care card, a tool utilized by direct care staff to implement the interventions found in the resident's care plan, revealed to Offload heels with pillows under calves while in bed as tolerated. Record review of the physician's orders revealed an order dated 6/20/2023 to offload heels with pillows under calves while in bed as tolerated every shift. Surveyor observations on the following dates and times revealed the resident's heels were resting directly on the mattress: 8/21/2023 at 2:52 PM 8/22/2023 at 11:00 AM 8/23/2023 at 9:51 AM Record review failed to reveal evidence that the resident refused or did not tolerate offloading his/her heels on the above mentioned dates and times. During a surveyor interview on 8/23/2023 at 9:51 AM with Registered Nurse, Staff A, he acknowledged the resident's heels were observed resting directly on the mattress. Staff A further revealed that he would expect the interventions on the care card and the physcian's order to be followed. During a surveyor interview on 8/23/2023 at 9:54 AM with Unit Manager, Staff B, she indicated that she would expect staff to attempt to offload the resident's heels as ordered. 2. Record review for Resident ID #76 revealed s/he was readmitted to the facility in October of 2022 with diagnoses including, but not limited to, cachexia (disorder causing extreme weight loss and muscle wasting) and dementia. Record review of the Quarterly MDS assessment dated [DATE] revealed the resident is at risk for pressure ulcers/injuries and requires extensive assist of one for bed mobility. Record review of the care plan created on 10/6/2022 with a focus of being at risk for skin breakdown, was an intervention initiated on 12/30/2022 to Off Load/Float heels while in bed with offloading boots as tolerated. Additionally, review of the resident's care card revealed an intervention to Off load/float heels while in bed with offloading boots as tolerated. Record review of the physician's orders revealed an order dated 5/22/2023 for offloading boots while in bed for skin integrity as tolerated every shift. Surveyor observations on the following dates and times failed to reveal the resident was wearing his/her boots as ordered: 8/22/2023 at 1:06 PM 8/22/2023 at approximately 5:00 PM 8/23/2023 at 8:50 AM 8/23/2023 at 9:07 AM, 9:31 AM and 10:01 AM Record review failed to reveal evidence that the resident refused or did not tolerate his/her boots on the above mentioned dates and times. During a surveyor interview on 8/23/2023 at 10:01 AM with Nursing Assistant, Staff C, who was assigned to the resident, she revealed the resident's boots are applied prior to her shift. Additionally, she revealed she will remove the boots to provide care to the resident, and then reapply the booties after care is completed. Lastly, Staff C revealed the resident's boots were not applied. During a surveyor observation on 8/23/2023 at 11:36 AM in the presence of Registered Nurse, Staff D, revealed the resident's right outer ankle had a reddened area which was approximately the size of a half dollar, blanchable (reddened areas of skin tissue that are white or pale when pressed firmly with a finger or device), with a scab to the center. Additionally, Staff D touched the resident's right ankle and s/he complained of pain, stating It burns. Subsequently, Staff D notified the Advanced Practice Registered Nurse, Staff E, of the new area. During a surveyor interview on 8/23/2023 at 11:46 AM and again at 12:20 PM with the Staff E, she revealed that the resident's ankle should be offloaded. She further revealed that she would expect the offloading boots are applied. During a surveyor interview on 8/23/2023 at 3:12 PM with the Director of Nursing Services, she acknowledged the new reddened, scabbed area to the resident's right ankle. Additionally, she would expect staff to apply the resident's boots as ordered and if the resident did not tolerate them, staff would document it in the resident's record. 47939 37158

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent accidents, relative to supervision while eating for 1 of 2 residents observed, Resident ID #44. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards . Record review revealed that the resident was readmitted to the facility in June of 2023 with diagnoses including, but not limited to, stroke and dysphagia oropharyngeal phase (a condition that causes disruption or delay in swallowing). Record review of the resident's care profile noted in the electronic medical record states in part, Special instructions Honey-thick liquids .one to one supervision for meals. Record review of the care plan dated 8/11/2022 states in part, Resident exhibits or is at risk for impaired swallowing related to history of stroke .the resident will be free from signs/symptoms of aspiration [when you swallow something and it enters your airway]. Monitor for sign/symptoms of aspiration i.e., [example] coughing . Record review of the resident's care card, a tool utilized by direct care staff to implement the interventions found in the resident's care plan, revealed interventions including, but not limited to, one to one supervision for meals, monitor for sign/symptoms of aspiration coughing and choking, check mouth for pocketing food, and encourage double swallows after several bites. Record review of the nursing assistant assignment sheet includes a note for this resident to supervise the resident with his/her meals. Record review revealed, the resident received speech therapy services from 5/4/2023 through 7/6/2023. During a continuous surveyor observation on 8/21/2023 at 12:42 PM through 12:58 PM of the lunch meal, the resident was observed without 1:1 staff supervision. Additionally, the resident was noted to be coughing on three occasions during this observation. During a surveyor interview on 8/23/2023 at 11:28 AM with Nursing Assistant, Staff F, he acknowledged the resident requires supervision for meals. Staff F further revealed he did not provide supervision to the resident as he was on his lunch break. Record review of the resident's POC (point of care) document dated 8/21/2023 at 2:14 PM revealed documentation by staff that indicated the resident was independent with his/her meals and that s/he was not provided staff assistance at anytime. Record review of the speech language pathology Discharge summary report authored by the Speech Therapist dated 7/6/2023 states in part, LTG [long term goal] met on 7/6/2023 PT[patient] will demonstrate tolerance to 90% of least restrictive and safest diet/liquid textures with 1 to 1 caregiver assistance and mod [moderate] verbal /tactile cues for safe swallowing strategies. To facilitate safety it is recommended that the patient use the following strategies during oral intake: alternation of liquids/solids, bolus [bite] size modifications, cyclic ingestion technique [double swallow] .during meals .Prognosis .Excellent with consistent staff support. During a surveyor interview on 8/23/2023 at 11:33 AM with the Advance Practice Registered Nurse, Staff E, she revealed she would expect staff to follow the Speech Therapists recommendations. During a surveyor interview on 8/23/2023 at 1:03 PM with the Speech Therapist, she revealed the resident requires supervision and cues for swallowing. Additionally, she stated that the resident requires 1:1 supervision to make sure [s/he] is okay. During a surveyor interview with the Director of Nursing Services on 8/23/2023 at 3:12 PM, she acknowledged the resident requires supervision with meals. She further revealed she would expect the staff to provide safe swallowing strategies per the speech therapy recommendations. Additionally, she was unable to provide evidence that the facility provided adequate supervision to prevent accidents for Resident ID #44.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 25 opportunities for errors observed during the medication administration task, there were 3 errors resulting in an error rate of 12%, involving Resident ID #s 61 and 117. Findings are as follows: 1. Record review revealed Resident ID #61 has a physician's order for Humalog 100 unit/milliliter, administer 10 units subcutaneously (under the skin) before meals for diabetes mellitus, and hold for a capillary blood sugar (CBG) less than 100 or if the resident is not eating. During a surveyor observation of the medication administration task on 8/22/2023 at 12:21 PM with Registered Nurse, Staff L, she obtained the resident's CBG which was 98. She was then observed to draw up 10 units of Humalog Insulin into a syringe and acknowledged to the surveyor that she was ready to administer the insulin to the resident. Staff L was prompted by the surveyor to stop the medication administration and review the physician's order. During a surveyor interview immediately following this observation with Staff L, she acknowledged that she should not have prepared the 10 units of Humalog to administer to the resident, as his/her CBG was less than 100. 2. Record review revealed Resident ID #117 has a physician's order for Vitamin D3 ultra strength oral capsule 125 mcg (micrograms) (5000 units) in the morning for supplements. During a surveyor observation of the medication administration task on 8/22/2023 at 8:19 AM with Registered Nurse, Staff L, she was observed administering Vitamin B-12 1000 mg (milligrams) instead of Vitamin D3 125 mcg to the resident as ordered. Record review failed to reveal evidence of an order for Vitamin B-12. During a surveyor interview immediately following this observation with Staff L, she acknowledged administering Vitamin B to Resident ID #117 without an order. Additionally, Staff L was unable to provide evidence that the resident received Vitamin D3 125 mcg as ordered. During a surveyor interview with the Director of Nursing Services on 8/23/2023 at 11:02 AM, she acknowledged the above mentioned errors. Additionally, she would expect that the residents receive their medications as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility has failed to follow standard precautions to prevent the spread of infections for 1 of 2 wound treatments observed. Findings are as follows: Record review of a facility policy titled, Procedure: Wound Dressing: Aseptic [clean] states in part, .Discard soiled dressing and gloves .Perform hand hygiene .Apply and secure clean dressing .Remove gloves .Perform hand hygiene . Record review of Resident ID #45 revealed that s/he had an open wound to his/her right lower leg. Review of a physician's order dated 7/11/2023 revealed a wound treatment to the resident's right lower extremity, .cleanse wound with NS [normal saline] then pat dry. Apply skin prep to peri-wound [around wound], apply santyl [wound ointment] to wound bed, apply maxorb [absorbent wound dressing] and cover with 6 x 6 bordered foam and secure with ace wrap. During a surveyor observation on 8/23/2023 at 12:57 PM of the resident's dressing change to his/her right calf wound, Registered Nurse, Staff A, failed to perform hand hygiene following the removal of the soiled dressing, which was observed to have moderate drainage. Furthermore, Staff A failed to perform hand hygiene after securing the clean dressing. Additionally, he was observed removing the wound dressing supplies from the resident's room and placing them on the treatment cart without performing hand hygiene. During a surveyor interview immediately following the observed dressing change with Staff A, he acknowledged that he failed to perform hand hygiene at the above mentioned times and should have. During a surveyor interview on 8/23/2023 at 3:40 PM with the Director of Nursing Services, she indicated that she would expect the nurse to perform hand hygiene following the removal of gloves.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections relative to the legionella prevention program. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/27/2023, alleges that the facility .has mold on the ceiling tiles in the D wing hallway and it periodically leaks water . Record review of a facility policy titled, Genesis Legionella Prevention Program [NAME] Regency January 2023 .Introduction: [NAME] Regency Center promotes proactive steps to establish healthy, infection-free environments for their residents, staff and visitors. When residents contract Legionnaires' disease[a type of pneumonia cause by spread of droplets of water containing bacteria], it is often the result of exposure to inadequately managed building water systems, which can be prevented .area where Legionella could grow and spread .legionella can grow in many parts of building water systems that are continually wet, and certain devices can the spread contaminated water droplets . During a surveyor interview on 7/31/2023 at 9:40 AM with the Director of Maintenance he revealed that due to dripping condensation from heating,ventilation, and air conditioning (HVAC) pipes the facility has drip pans in the ceiling to collect the dripping condensation from those pipes. Record review of a facility document titled Logbook documentation .HVAC-Air Handlers: inspect air filter, verify operation. Marked done on-time by [Maintenance Director] on July 11, 2023 .Check drain pan, drain line, coil, and other areas of moisture accumulation for visible signs of biological growth. Clean and verify proper operation .inspect for evidence of moisture carryover beyond the drain pan from cooling coils. Clean as needed .check condensate pump. Clean and verify proper operation . During a surveyor interview on 7/31/2023 at approximately 12:50 PM with the Director of Maintenance, he revealed that with completion of the above-mentioned logbook document he had only changed the air filters in the facility on 7/11/2023. He acknowledged that he did not check the drain pan, drain line, coil, and other areas of moisture accumulation for visible signs of biological growth. He also did not clean and verify proper operation, inspect for evidence of moisture carryover beyond the drain pan from cooling coils and did not check the condensate pump. During a surveyor interview on 7/31/2023 at 1:10 PM with the facility Maintenance Assistant, he revealed that the facility HVAC system utilizes drip pans for collection of condensates dripping from piping. He further revealed that recently both the C- unit and D -unit drip pans were noted without draining pipes. He further revealed that all areas of the facility have not been reviewed for additional areas of concern. During a surveyor interview on 7/31/2023 at 3:36 PM with the Administrator in the presence of the Maintenance Director, she was unable to provide evidence that the HVAC drip pans received regular preventative maintenance. Additionally, she was unable to provide evidence that the condensate drip pans were included in the facility's Legionella prevention program.