Every finding on record at Lincolnwood Rehabilitation and Healthcare Center

Based on record review, surveyor observations, and staff interviews, the facility failed to provide food that is palatable, attractive, and served at an appetizing temperature, for 1 of 1 units reviewed, the third floor secured unit.Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 8/10/2026 alleges in part, concerns that food trays are being left in hallways before staff can deliver them to residents, resulting in hot food items being served cold and at unappetizing temperatures.According to the United States Food and Drug Administration 2022 Food Code Chapter 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding states, .Except during preparation, cooking, or cooling.TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained:(1) At 57 C (degrees Celsius) (135 F) (degrees Fahrenheit) or above .During surveyor observations on 8/11/2026 at 1:26 PM with the Food Service Director (FSD), of the plated meals for the third-floor residents revealed the following:-A plated portion of spinach with a temperature of 105 F-A plated portion of Florentine chicken with a temperature of 111 F-A plated portion of couscous with a temperature of 107 FFurther observation revealed a partially melted cup of chocolate ice cream.During a surveyor interview immediately following the above observations, the FSD acknowledged the above temperatures. Additionally, he was unable to provide evidence that the food served to the residents was maintained at safe and appetizing holding temperatures. During a surveyor interview on 8/12/2026 at 3:54 PM with the Administrator, she revealed that she would expect the food provided to the residents to be served per the food code and at adequate temperatures.

Based on clinical record review and resident and staff interviews, the facility failed to ensure that the resident's record was complete and accurately documented relative to a gastrostomy tube (G-tube; a surgically placed tube that provides direct access to the stomach for nutrition, fluids, or medication) site care orders, for 1 of 1 resident reviewed, Resident ID #1.Findings are as follows:According to Fundamentals of Nursing, Seventh Edition dated 2011, states in part, Documenting Nursing Care .Remembering the legal truth it wasn't done if it wasn't documented .Documentation Guidelines.Aim: Complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/20/2026 alleges in part, that the facility failed to meet this resident's nutritional needs as required by his/her medical condition.Record review revealed the resident was admitted to the facility in March of 2026 with diagnoses including, but not limited to, cerebrovascular accident (a stroke) and encounter for attention to G-tube.Record review of a Minimum Data Set (MDS) assessment, dated 5/27/2026, revealed a Brief Interview for Mental Status score of 12 of 15, indicating the resident has moderately impaired cognition.Record review of a care plan initiated on 6/6/2026 revealed a focus area that indicates the resident has the potential for impaired cognitive function or impaired thought processes related to a stroke. Interventions include reorient and supervise the resident as needed and to monitor cognitive baseline such as, decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status.Record review of the August 2026 Treatment Administration Record (TAR) revealed an order with a start date of 7/24/2026, that states in part, Educate resident on safe self-care (clean the G tube site) practices. Assist and supervise to ensure safety and to promote independence. Keep the G-tube site clean with gentle soap and water. Apply loose dressing if needed. Every day shift for G-tube. Additional review of the August 2026 TAR revealed that the treatment was signed as completed on 8/11/2026 by Registered Nurse (RN), Staff B.During a surveyor interview on 8/11/2026 at approximately 1:00 PM, with the resident s/he revealed that s/he sometimes waits for up to five days to have his/her G-tube cleaned and dressing changed. During a surveyor observation immediately following the above-mentioned interview, the resident showed the surveyor a split dressing gauze attached to his/her abdomen with tape that was placed around the G-tube, additionally neither the tape nor the dressing was dated or initialed. The dressing was noted to have dark brown dried discoloration around the area of the tubing. Additionally, the resident lifted the dressing revealing what appeared to be a dry red and brown substance surrounding both the G-tube insertion site and the plastic G-tube stabilizer. During a surveyor interview with Unit Manager, Staff A, and Staff B on 8/11/2026 at approximately 2:40 PM, Staff B revealed that she did not complete the treatment nor did she sign off doing so in the resident's record. She further expressed concerns that someone was able to sign off the treatment with unauthorized access to her login credentials. Staff A and B acknowledged that the treatment was not completed by either of them on 8/11/2026, prior to this surveyor's interview.During a follow-up interview on 8/12/2026 at approximately 2:00 PM with Staff A, she revealed that Nursing Supervisor, Staff C had signed off completing the treatment in Resident ID #1's record on 8/11/2026 by accessing Staff B's login credentials. Additionally, Staff A was unable to provide an explanation for Staff C utilizing Staff B's login credentials. During a surveyor interview on 8/12/2026 at approximately 3:30 PM with the Director of Nursing Services (DNS), she revealed that she did not know how Staff C was able to sign off the G-tube treatment in Resident ID #1's record with Staff B's login credentials.

Based on record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed for Morphine Sulfate solution (a medication prescribed to treat pain), Resident ID #1 and for 1 of 2 residents reviewed for insulin use, Resident ID #4.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/14/2026, alleged Resident ID #1 was transferred to the hospital after receiving 10 times the prescribed dose of Morphine Sulfate.Review of a facility policy titled, Administering Medications dated April of 2019, states in part, .Medications are administered in accordance with prescriber orders.Medication errors are documented, reported, and reviewed.If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication.the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route administered; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug. Record review revealed the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, acute and chronic respiratory failure and chronic pain disorder.Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 of 15, indicating intact cognition. Further review revealed that the resident frequently experience pain.Record review revealed a physician's order dated 6/29/2026, for Morphine Sulfate 10 milligrams (mg) per 5 milliliters (mL), administer 2.5 mL (5 mg) by mouth every six hours as needed for pain.Review of the Pyxis transaction report (a machine which dispenses medications) revealed Morphine Sulfate 100 mg/5mL was dispensed on 7/9/2026 at 12:37 PM, a concentration of medication which is 10 times more potent than the amount indicated in the order. Review of an E-Rx New Prescription Request dated 7/9/2026 revealed an order for Morphine Sulfate concentrate 100 mg/5 ml, take 1/4 ml by mouth every six hours as need for pain, 0.25 ml (5 mg).Record review of the July 2026 Medication Administration Record (MAR) failed to reveal evidence that the above-mentioned new prescription was transcribed into the resident's record.Record review of the narcotic administration book revealed that on 7/9/2026, 2.5 mL of Morphine Sulfate 100 mg/5 mL was administered to the resident at 12:45 PM. A total dose of 50 mg, 10 times the prescribed dose. Further review of the narcotic administration book failed to reveal evidence that the directions for administration, dosage, route, date received, and date opened were documented.Record review failed to reveal evidence that the provider was notified of the above medication error until 7/10/2026, over 24 hours after ten times the prescribed dose of Morphine Sulfate was administered to the resident. Review of an Optum (a contracted ancillary healthcare provider network) clinical note dated 7/10/2026, authored by Optum Registered Nurse (RN), Staff C, revealed .This writer was returning a call to SNF (Skilled Nursing Facility0; Nurse [Staff D] reported to this writer that [Resident ID #1] received wrong dose of medication. This writer asked which medication/dose and informed [Staff D] that this writer will be calling [Optum Nurse Practitioner (NP), Staff B]. Discussed with [NP, Staff B] about medication error in which [Staff B] wanted to do a three way call with [facility] nurse [Staff D]. Orders given by [NP, Staff B]. After further discussion, [Staff B] gave order to send out to hospital for monitoring and further eval due to medication error.Review of a Continuity of Care Consultation and Referral Form dated 7/10/2026 which was sent with the resident when transferred to the hospital, states in part, .Received wrong dose of morphine initially on 10 mg/5 mL and 2.5 ml to be given PRN (as needed) .2.5 mL [by mouth] was given from a bottle of morphine 100 mg/5 mL (10 times the initial dose).During a surveyor interview on 7/15/2026 at 12:47 PM with Resident ID #1, s/he revealed that s/he was given 10 times too much medication and was not told about the medication error until the facility was sending him/her to the hospital, over 24 hours later. The resident further revealed that after s/he was over dosed with morphine, s/he sat up in his/her wheelchair rocking and nodding off. During a surveyor interview on 7/15/2026 at approximately 10:45 AM with Licensed Practical Nurse (LPN), Staff F, he acknowledged that ten times the prescribed dose of Morphine had been administered to Resident ID #1 on 7/9/2026. He further revealed that a nurse must have another nurse present to obtain a narcotic from the Pyxis and at that time the two nurses should reconcile the medication on hand with the physician's order. The two nurses then sign the reconciled medication into the narcotic book together prior to administering the medication.During a surveyor interview on 7/16/2026 at 3:30 PM with Optum RN, Staff C, in the presence of the Optum NP Supervisor, she revealed that she was made aware that Resident ID #1 needed a refill for the Morphine Sulfate and contacted Optum NP, Staff B via text message to request a refill on behalf of the facility and the NP responded with a thumbs up emoji. She revealed that she later had a discussion with NP Staff B, at which time Staff B mentioned that she thought that the current dose was odd and was going to change the order. She further revealed that she did not contact the facility following the discussion with Staff B. Additionally, Staff C revealed that she was contacted by Licensed Practical Nurse (LPN), Staff D on 7/10/2026 at approximately 4:50 PM (over 24 hours after the medication error occurred) and was notified that Resident ID #1 had received 10 times the prescribed dose of Morphine. She revealed that she then contacted NP, Staff B and had a three-way call to include Staff B, Staff D, and herself to discuss the situation. She further revealed that Staff B gave an order to assess the resident, obtain his/her vital signs and to administer Narcan, as she was under the impression that the medication error had occurred that day. LPN Staff D then informed Staff B that Narcan was not available in the facility. Furthermore, she revealed that NP Staff B then provided an order to transfer Resident ID #1 to the hospital for further evaluation due to the overdose of Morphine SulfateDuring a surveyor interview on 7/15/2026 at 3:21 PM with RN, Staff G, he revealed that he was the charge nurse on 7/9/2026 and on 7/10/2026, on the 3:00 PM - 11:00 PM shift. He further revealed that on 7/9/2026 he was told by the 1st shift nurse that the resident received one dose of morphine for pain that day, however, he was not aware of the medication error until 10:00 PM. Additionally, he revealed that he told the 11:00 PM - 7:00 AM nurse to correct the discrepancy and did not notify the provider or supervisor of the overdose documented in the narcotic book. Furthermore, he revealed that when he returned to the facility on 7/10/2026 at approximately 3:00 PM, he asked the 1st shift nurse, Staff D, if she had notified the provider regarding the morphine overdose and that she revealed she had not yet notified the provider. During a surveyor interview on 7/16/2026 at 3:15 PM with LPN, Staff H, he revealed that he was the charge nurse on 7/9/2026 into 7/10/2026 during the 11:00 PM - 7:00 AM shift. He further revealed that the second shift nurse, RN Staff G, informed him that a dose of Morphine Sulfate was administered to Resident ID #1 earlier that day that was different than what should have been administered. Furthermore, he acknowledged that he failed to notify the provider of the medication error during his shift. During surveyor interviews on 7/15/2026 at 2:26 PM and on 7/20/2026 at 11:36 AM with LPN, Staff D, she revealed that she identified the medication error on 7/10/2026 when she administered a 0.25 mL dose of Morphine at 2:30 PM, after observing a bottle of Morphine Sulfate solution 100 mg/mL that had been delivered from the pharmacy on 7/9/2026. She further revealed that the instructions for the administration on the bottle indicated to give 0.25 mL. She revealed that she did not reconcile the Morphine Sulfate solution order that was on the medication bottle delivered by the pharmacy with a physician's order, because there was not a physician's order entered into the electronic medical record for the concentration that was delivered. Additionally, she revealed that she administered the medication to the resident without reconciling the medication order and without an active physician's order for the concentrated dose. Furthermore, she revealed that she notified the Optum RN of the medication error at approximately 5:00 PM on 7/10/2026 and did not notify the provider directly.During a surveyor interview on 7/16/2026 at 9:48 AM with Optum Nurse Practitioner, Staff B, she revealed that she was informed that Resident ID #1 was out of his/her Morphine Sulfate 10 mg/5 mL and required a new prescription to be sent to the pharmacy on 7/9/2026. She further revealed that she reviewed the resident's active Morphine order and decided that the concentration should be changed. She then sent a new prescription to the pharmacy for Morphine Sulfate concentrate 100mg/5mL, give 0.25 mL every six hours as needed for pain. Additionally, she revealed that she failed to notify the facility and to communicate that she had discontinued the previous Morphine order and sent a new prescription for Morphine Sulfate, which was 10 times the concentration of the previous dose. She revealed that instead of communicating the order changes with the facility, she only communicated with the Optum RN, Staff C. Furthermore, she revealed that she was informed on 7/10/2026 by Optum RN Staff C, that Resident ID #1 was administered 10 times the ordered dose of Morphine Sulfate, at which time LPN, Staff D, was contacted via telephone. Staff B stated that she was under the impression that the medication error had just occurred that day and so she provided orders to obtain an assessment, obtain vital signs, administer Narcan, and ultimately to transfer the resident to the hospital for an evaluation, as she was informed that Narcan was not available in the facility. Staff B revealed that she failed to complete an NP clinical note on 7/9/2026 or on 7/10/2026.During a surveyor interview on 7/16/2026 at approximately 1:30 PM with the Optum NP Supervisor, she revealed that she would expect the NP to give orders directly to the facility's nurse.During a surveyor interview on 7/16/2026 at 3:29 PM with the Administrator and the Regional Nurse, they revealed that two nurses are expected to remove a narcotic from the Pyxis and that two nurses are expected to reconcile that medication and document it in the narcotic administration book.During surveyor interviews on 7/15/2026 at approximately 3:50 PM, 7/16/2026 at 9:45 AM and on 7/17/2026 at approximately 12:40 PM with the Director of Nursing Services, she revealed that the Optum NPs should enter their orders into the electronic medical record or communicate those orders with the facility's nurse, and the nurse is expected to transcribe and confirm those orders. She further acknowledged that Resident ID #1 was administered 10 times the prescribed dose of morphine on 7/9/2026 and was not transferred to the hospital until 7/10/2026, over 24 hours after the medication error and via non-emergent transport. Additionally, she revealed that she would expect a provider to be notified directly and immediately following a medication error and that nurses are to follow physician's orders.2. Record review revealed Resident ID #4 was admitted to the facility in December of 2025, with a diagnosis including, but not limited to, diabetes mellitus type 2.Record review of a Physician's order dated 3/16/2026 for blood glucose monitoring twice daily with instructions to call the provider if the blood glucose results are greater than 400 milligrams (mg)/deciliter (dl) (normal adult range 70-99 mg/dl).Record review of a progress note dated 7/13/2026 authored by LPN, Staff H, revealed a blood glucose reading of 410 mg/dl was obtained for the resident on 7/13/2026. Further review revealed a new order was given by the provider for a one-time dose of Humalog 4 units (a fast-acting insulin; a medication prescribed to treat high blood sugar) and to recheck the resident's blood glucose in 2 hours.Record review failed to reveal evidence that the Humalog order was transcribed for the resident.Record review of the July of 2026 MAR failed to reveal evidence that the resident received the 4 units of Humalog insulin or that his/her blood sugar was rechecked, as ordered.During a surveyor interview on 7/20/2026 at 11:07 AM with Licensed Practical Nurse, Staff D, she acknowledged that the record failed to reveal evidence that the 4 units of Humalog insulin was administered or that the resident's blood sugar was retaken, as ordered.During a surveyor interview on 7/20/2026 at 3:10 PM with the DNS, she was unable to provide evidence that the Humalog insulin was administered to Resident ID #4 or that the blood sugar was retaken, as ordered.Cross reference F710

Based on clinical record review and staff interview, the facility failed to ensure the medical care of each resident was supervised by a physician when the ordering provider failed to communicate the discontinuation of a Morphine Sulfate (a narcotic; a controlled medication classified as an opioid, prescribed to treat severe pain) order and the initiation of a new more concentrated Morphine Sulfate order, for 1 of 1 resident reviewed, who was administered 10 times the prescribed dose of Morphine Sulfate and required transfer to the hospital for an evaluation, Resident ID #1. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/14/2026, alleges Resident ID #1 was transferred to the hospital after receiving 10 times the prescribed dose of Morphine Sulfate one day prior.Record review revealed the resident was admitted to the facility in October of 2023 with diagnoses including, but not limited to, acute and chronic respiratory failure and chronic pain disorder.Record review revealed a physician's order dated 6/29/2026 for Morphine Sulfate 10 mg/5 mL, give 2.5 mL by mouth every six hours as needed for moderate to severe pain, for a total dose of 5 mg.Review of an E-Rx New Prescription Request dated 7/9/2026 revealed on order for Morphine Sulfate concentrate 100 mg/5 mL, take 1/4 mL by mouth every six hours as need for pain, 0.25 mL/5 mg.Record review of the July 2026 Medication Administration Record (MAR) failed to reveal evidence that the 6/29/2026 Morphine Sulfate order for 10 mg/5 mL, give 2.5 mL was discontinued on 7/9/2026. Additional review failed to reveal evidence that the 7/9/2026 prescription for Morphine Sulfate concentrate 100 mg/5 mL, take 1/4 mL was transcribed in the resident's MAR that day.Record review of the narcotic administration book revealed that on 7/9/2026, 2.5 mL of Morphine Sulfate 100 mg/5 mL was administered at 12:45 PM. A total dose of 50 mg, 10 times the prescribed dose indicated in the active physician's order.Record review of an Optum (a contracted ancillary healthcare provider network) Clinical Note dated 7/10/2026 at 12:10 PM, authored by Optum Nurse Practitioner (NP), Staff A, revealed the NP assessed the resident on 7/10/2026 and the nurse reported no new concerns. Further review revealed the following new orders:-Repeat labs-Vital signs every shift for three daysRecord review failed to reveal evidence that the above-mentioned new orders were transcribed into the resident's record.During a surveyor interview on 7/16/2026 at approximately 1:30 PM with the Optum NP, Staff A, she revealed that she assessed the resident on 7/10/2026 for a routine follow up and had not been notified of the Morphine Sulfate overdose that occurred on 7/9/2026.During a surveyor interview on 7/16/2026 at 9:48 AM with Optum Nurse Practitioner, Staff B, she revealed that she was informed that Resident ID #1 was out of his/her Morphine Sulfate 10 mg/5 mL and required a new prescription to be sent to the pharmacy on 7/9/2026. She further revealed that she reviewed the resident's active Morphine order and decided that the concentration should be changed. She then sent a new prescription to the pharmacy for Morphine Sulfate concentrate 100mg/5mL, give 0.25 mL every six hours as needed for pain. Additionally, she revealed that she did not notify the facility or communicate that she had discontinued the previous Morphine order and sent a new prescription for Morphine Sulfate, which was 10 times the concentration of the previous dose. She revealed that instead of communicating the order changes with the facility, she only communicated with the Optum RN, Staff C. Furthermore, she revealed that she was informed on 7/10/2026 by Optum RN Staff C, that Resident ID #1 was administered 10 times the ordered dose of Morphine Sulfate, at which time LPN, Staff D, was contacted via telephone. Staff B stated that she was under the impression that the medication error had just occurred that day and so she provided orders to obtain an assessment, obtain vital signs, administer Narcan, and ultimately to transfer the resident to the hospital for an evaluation, as she was informed that Narcan was not available in the facility. Staff B revealed that she failed to complete NP clinical notes on 7/9/2026 or on 7/10/2026.During a surveyor interview on 7/16/2026 at 3:30 PM with Optum RN, Staff C, in the presence of the Optum NP Supervisor, she revealed that she was made aware that Resident ID #1 needed a refill for the Morphine Sulfate and contacted Optum NP, Staff B via text message to request a refill on behalf of the facility and the NP responded with a thumbs up emoji. She revealed that she later had a discussion with NP Staff B, at which time Staff B mentioned that she thought that the current dose was odd and was going to change the order. She further revealed that she did not contact the facility following the discussion with Staff B. Additionally, Staff C revealed that she was contacted by Licensed Practical Nurse (LPN), Staff D on 7/10/2026 at approximately 4:50 PM (over 24 hours after the medication error occurred) and was notified that Resident ID #1 had received 10 times the prescribed dose of Morphine. She revealed that she then contacted NP, Staff B and had a three-way call to include Staff B, Staff D, and herself to discuss the situation. Additionally, she revealed that LPN Staff D reported that the resident was sleeping and that she had not completed an assessment on the resident or obtained vital signs. She further revealed that Staff B gave an order to assess the resident, obtain his/her vital signs and to administer Narcan, as she was under the impression that the medication error had occurred that day. LPN Staff D then informed Staff B that Narcan was not available in the facility. Furthermore, she revealed that NP Staff B then provided an order to transfer Resident ID #1 to the hospital for further evaluation due to the overdose of Morphine Sulfate.During a surveyor interview on 7/16/2026 at 11:46 AM with Unit Manager, Staff E, she revealed that the Optum RN assesses residents in the facility a few times a week. She further revealed that in some cases, the Optum NP will communicate only with the Optum RN and the Optum RN will communicate the new orders to the facility's staff. During a surveyor interview on 7/16/2026 at approximately 1:30 PM with the Optum NP Supervisor, she revealed that she would expect the NP to give orders directly to the facility's nurse. Additionally, she revealed that would expect the NP to document within 48 hours, if there is a change to the resident's plan of care.During a surveyor interview on 11/16/2026 at 11:35 AM with the Director of Nursing Services, she revealed that she would expect that the Optum NPs speak with the facility's staff directly when giving orders and that the facility nurse contacts the provider directly. Additionally, she could not provide evidence that the discontinuation and concentration change of Morphine Sulfate was communicated appropriately between the provider and the facility's nurse. Lastly, she was unable to provide evidence that the notification of the 10-fold Morphine overdose for Resident ID #1 was communicated directly to his/her provider. The facility's failure to ensure the provider communicated changes to the resident's plan of care to the facility's nursing staff, rather than to a Registered Nurse within their own organization, resulted in a significant breakdown in physician oversight, clinical communication, and the safe management of a controlled substance. As a result, Resident ID #1 received a 10-fold overdose of a prescribed opioid medication, requiring the resident being transferred to the hospital for an evaluation. The facility further failed to ensure timely and effective identification, assessment, intervention, and response to this serious medication error, demonstrating a failure to provide adequate physician supervision of the resident's medical care. This absence of appropriate physician oversight placed the resident at risk for serious injury, serious harm, serious impairment, or death.Cross reference F760

Based on clinical record review and staff interview, the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident reviewed with a history of trauma, Resident ID #4.Findings are as follows:Review of a facility policy last updated in August of 2022, titled, Trauma Informed Care and Culturally Competent Care states in part, .Purpose.To address the need of trauma survivors by minimizing triggers and/or re-traumatization.Traumatic events which may affect residents during their lifetime include.interpersonal or community violence.For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization.Triggers are highly individualized.provide universal screening of residents.Screening may include information such as.trauma history, including type, severity and duration.Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma as well as identification of triggers.Develop individualized care plans that address past trauma in collaboration with the resident and family.Record review revealed Resident ID #4 was admitted to the facility in December of 2025, with diagnoses including, but not limited to, vascular dementia, major depression, anxiety, and bipolar disorder (a mental health condition).Record review of a care plan with a start date of 7/10/2026 revealed the resident has a history of Post Traumatic Stress Disorder (PTSD; a mental health condition that develops after experiencing or witnessing a traumatic event, characterized by intrusive memories, avoidance, negative mood changes, and heightened arousal or reactivity) with interventions including, but not limited to, avoid situations that may cause flashbacks, ask the resident about his/her triggers and incorporate them into his/her plan of care.Review of the comprehensive care plan failed to identify triggers or include interventions to eliminate or mitigate triggers that may cause re-traumatization of the resident.Record review failed to reveal evidence that a trauma informed care assessment was completed following the identification that the resident had experienced a traumatic event in his/her past. During a surveyor interview on 7/20/2026 at approximately 9:50 AM, with the Social Worker, Staff L, she acknowledged that after she was made aware of the resident's trauma history, she failed to complete a trauma informed care assessment. Additionally, she revealed that she is unaware of how to complete a trauma informed care assessment for a resident with a newly identified trauma history.During a surveyor interview on 7/20/2026 at approximately 10:30 AM, with the Director of Nursing Services, she revealed it would be her expectation that a trauma informed care assessment would be completed for a resident with a newly identified history of trauma, to enable staff to identify and mitigate his/her triggers. Additionally, she could not provide evidence that a trauma informed care assessment was completed after 7/10/2026 to identify the resident's triggers or that the comprehensive care plan was revised to include interventions to eliminate or mitigate triggers that may cause re-traumatization.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure residents were free from misappropriation of property relative to a narcotic medication for 1 of 1 resident reviewed with an opened medication bottle of Morphine Sulfate solution that had been found to be missing 1 milliliter (mL) of medication, but had not been administered to the prescribed resident, Resident ID #6.Findings are as follows:Review of a facility policy titled Controlled Substances last revised in November of 2022, states in part, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services [DNS].the [DNS] documents irreconcilable discrepancies in a report to the administrator.The administrator, consultant pharmacist, and/or [DNS] determine whether other action(s) are needed, e.g. [example] notification of police or other enforcement personnel.Record review revealed that Resident ID #6 was admitted to the facility in May of 2026 with diagnoses including, but not limited to, dementia and osteoarthritis.Record review revealed a physician's order dated 5/11/2026 for Morphine Sulfate solution 20 milligrams (mg) per 1 milliliter (mL), give 0.25 mL by mouth every four hours as needed for pain. Review of the May, June, and July 2026 Medication Administration Records (MAR) revealed the resident had not been administered the Morphine Sulfate solution.Review of the narcotic book revealed 15 mL of Morphine Sulfate solution 100 mg/ 5 mL (20 mg/1 mL) was received from the pharmacy on 5/12/2026. Further review revealed that on 6/13/2026 it was documented as being adjusted and the amount on hand was changed to 14 mL. Two nurses, Licensed Practical Nurse (LPN), Staff I and LPN Staff J signed the narcotic book as witnesses to the adjustment of the medication on hand. Additional review failed to reveal documentation of when the bottle had been opened. During a surveyor observation on 7/17/2026 at approximately 1:00 PM, in the presence of LPN, Staff I, Resident ID #6's Morphine Sulfate solution medication bottle was opened and appeared to contain approximately 14 mL of the medication. Staff I acknowledge the observation. During a surveyor interview on 7/17/2026 immediately following the above observation with Staff I, she revealed that she worked on the 7:00 AM - 3:00 PM shift on 6/11/2026 and the Morphine Sulfate solution medication bottle was sealed as when it was delivered. She further revealed that when she completed the narcotic count at the beginning of her 7:00 AM- 3:00 PM shift on 6/13/2026, she noticed that the bottle had been opened. She revealed that the medication had not been administered to the resident and the nurse who had worked the 11:00 PM - 7:00 AM shift, Staff J, was unaware of why the medication was opened. Additionally, she revealed that she notified the Unit Manager, Staff K, who instructed the nurses to adjust the medication on hand to 14 mL.The surveyor attempted to contact LPN, Staff J on 7/17/2026 at approximately 2:00 PM however, she was unavailable for an interview at that time.During a surveyor interview on 7/17/2026 at approximately 1:15 PM with the Unit Manager, Staff K, she revealed that she was notified of the discrepancy on the morning of 6/13/2026 and instructed the nurses to adjust the amount on hand. She further revealed that she thought the plastic seal may have fallen off and that the medication may have evaporated. Additionally, she revealed that she failed to notify the Administrator or the DNS.During a surveyor interview on 7/17/2026 at approximately 1:30 PM with the DNS, she revealed that she had not been made aware of the potential misappropriation of Resident ID #6's Morphine Sulfate solution and that an investigation had not been initiated by the facility, until after the concern was brought to the facility's attention by the surveyor.

Based on clinical record review, resident, and staff interview, the facility failed to administer physician-ordered bolus tube feedings as prescribed to maintain an acceptable nutritional status for 1 of 1 resident reviewed who required enteral nutrition via feeding tube, Resident ID #2. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/30/2026, alleges in part, that Resident ID #2 requires tube feedings four times per day, has been losing weight, and is only receiving tube feedings twice per day.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.Review of the facility policy titled, Enteral Tube Feeding via syringe (bolus) [a bolus tube feeding is administered in a single, meal-sized amount of formula through a feeding tube] last revised in November of 2018 states in part, .The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally.Verify that there is a physician's order for this procedure.check the order to verify the type, amount.of administration.fill the syringe with prescribed amount of enteral feeding to be given.Documentation: The person preforming the procedure should record the following information in the resident's medical record.Amount of feeding and amount of water administered.How the resident tolerated the procedure. If the resident refused the procedure, the reason(s) why and the intervention taken.Record review revealed Resident ID #2 was admitted to the facility in May of 2026 with diagnoses including, but not limited to, dysphagia (difficulty swallowing) following a stroke, protein calorie malnutrition and end stage renal disease. Additional record review revealed the resident receives dialysis in the dialysis den in the facility three times a week, on Mondays, Wednesdays and Fridays at 3:00 PM. Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15, indicating the resident has moderately impaired cognition. Further review revealed the resident requires tube feedings for his/her nutrition.During a surveyor interview on 7/15/2026 at 10:06 AM with the resident, s/he revealed that nursing staff had not consistently administered his/her prescribed tube feedings as ordered. The resident reported that, at times s/he had to notify nursing staff when his/her tube feeding was overdue, and that there were occasions when the prescribed tube feedings were not administered at all.Record review revealed the following physician's orders for Nepro (a specialized liquid supplement for nutrition):-6/3/2026 - 300 milliliters (mL) at 9:00 AM and 7:00 PM, 275 ml at 1:00 PM and 10:00 PM- order discontinued on 6/16/2026-6/16/2026 - 325 mL at 9:00 AM and 7:00 PM, 200 ml at 1:00 PM and 300 ml 10:00 PM- order discontinued on 6/20/2026-6/20/2026 - 325 mL at 9:00 AM and 7:00 PM, 200 ml at 1:00 PM and 300 ml 10:00 PM - order discontinued on 6/22/2026-6/22/2026 - 325 mL at 9:00 AM and 7:00 PM, 200 ml at 1:00 PM and 300 ml 10:00 PM - order discontinued on 6/23/2026-6/23/2026 - 350 mL at 9:00 AM and 7:00 PM, 250 ml at 1:00 PM and 325 ml at 7:00 PM and 10:00 PM - order discontinued on 7/9/2026 Record review of the June and July 2026 Medication Administration Record failed to reveal evidence that the resident received the prescribed Nepro on the following dates and times:-6/3/2026 at 1:00 PM, 7:00 PM and at 10:00 PM-6/15/2026 at 7:00 PM and at 10:00 PM-6/18/2026 at 7:00 PM-6/19/2026 at 1:00 PM-6/20/2026 at 10:00 PM-6/22/2026 at 1:00 PM and at 7:00 PM -6/23/2026 at 9:00 AM and at 1:00 PM-7/7/2026 at 10:00 PM During a surveyor interview on 7/15/2026 at approximately 12:45 PM and 3:45 PM with the dietitian, she acknowledged the above documentation and indicated that she was not aware that the resident had not received his/her tube feedings as ordered on the above dates and times, until it was brought to her attention by the surveyor.During a surveyor interview on 7/15/2026 at 1:30 PM with the Director of Nursing Services, she was unable to provide evidence that the resident received his/her tube feedings as ordered.During a surveyor interview on 7/20/2026 at 11:32 AM with the resident's Physician, he revealed that it would be his expectation for the resident to have received his/her tube feedings as ordered. Additionally, he indicated that it would be his expectation that if the resident is away from the facility for scheduled appointments, the order should be reviewed with the provider so the resident can receive the bolus feeding prior to leaving or upon return to the facility.

Based on clinical record review and staff and resident interview, the facility failed to ensure residents who are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed with a gastrojejunostomy tube (G-J tube, a specialized medical device that allows healthcare providers to access both stomach and small intestine through a single physical opening on the outside of the body, by having 2 separate access ports, a G-port to the stomach and a J-port to the small intestine), Resident ID #1.Findings are as follows:Record review of a report titled, Hospital Events Reporting received by the Rhode Island Department of Health on 6/17/2026, alleged that the facility failed to ensure proper maintenance of enteral feeding tubes for Resident #1. Resident #1 had a G-J tube placed on 5/8/2026 and while residing in the facility, the jejunal (J) portion of the tube repeatedly clogged, requiring consecutive replacements on 6/3/2026, 6/8/2026, and 6/13/2026. This recurrent failure and frequent invasive intervention resulted in documented resident frustration.Record review revealed the resident was admitted to the facility in July of 2026 with diagnoses including, but not limited to, malignant neoplasm of ascending colon (colon cancer), gastroparesis (a digestive disorder where the stomach takes too long to empty its contents), and gastroesophageal reflux disease (a chronic digestive condition where the stomach acid frequently flows back up into the canal that connects the throat to the stomach).Review of a Comprehensive Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status Score of 15 out of 15, indicating the resident has intact cognition.During a surveyor interview with the resident on 6/17/2026 at 11:00 AM, s/he alleged that staff has been mixing up the utilization of his/her G-J tube. S/he revealed that s/he utilizes the G-J tube, the G-port for receiving medications through his/her stomach, and the J-port for receiving his/her enteral nutrition (liquid nutrients and fluid directly into the gastrointestinal tract). Resident ID #1 alleged that some of the nurses have been administering medications through the J-port, which was contraindicated to his/her surgeon's orders.Review of the resident's hospital discharge notes dated 6/2/2026, revealed a physician's order to administer medications through the G-port and to utilize the J-port only for enteral feedings.Review of the nursing progress note dated 6/8/2026, authored by Registered Nurse (RN), Staff B, revealed that the resident's J-tube had difficulty flushing, was non-patent, and was unable to administer medications or feedings via J-tube due to subsequent obstruction. The resident was eventually sent to the emergency room (ER) for evaluation.Record review of the ER notes on 6/8/2026, revealed the resident's J-port was malfunctioning which was resolved in the ER and orders were provided to flush the feeding tube after each meal and before going to bed.During a surveyor interview on 6/17/2026 at 3:00 PM, with RN Staff B, in the presence of the DNS, regarding the resident's ER visit on 6/8/2026, Staff B was initially unable to identify which port of the G-J tube was obstructed. She stated that the proper ports for medication administration and enteral nutrition are specified within the physician's orders.During a surveyor interview on 6/17/2026 at 3:20 PM, with the Director of Nursing Services (DNS), she was unable to provide evidence that the resident received the appropriate treatment to prevent multiple ER visits related to the clogging of the J port of his/her G-J tube. On 6/18/2026, the DNS provided the surveyor with a written statement authored by RN Staff B, dated 6/17/2026, describing the differences between a G-tube and a J-tube. In the statement, Staff B indicated that she had incorrectly documented her nursing progress note dated 6/8/2026 and intended to document that the G-port was occluded rather than the J-port. However, this statement was not provided until after surveyor interviews and requests for clarification regarding the resident's repeated tube obstructions. Furthermore, this statement is inconsistent with the hospital documentation from the resident's 6/8/2026 ER visit, which explicitly identified the J-port, not the G-port, as the obstructed line.

Based on clinical record review and staff interview, the facility failed to ensure that positive airway pressure therapy (a mechanical device used to support breathing and maintain airway patency) was provided to a resident in accordance with professional standards of practice for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Record review revealed Resident ID #1 was admitted to the facility in February of 2026 with a diagnosis including, but not limited to, acute and chronic respiratory failure with hypercapnia (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, resulting in retention of [NAME] dioxide).Record review revealed a physician's order dated 2/10/2026 for use of a CPAP machine ( a continuous positive airway pressure machine, a medical device designed to help individuals maintain consistent breathing while sleeping by keeping the airways open) at bedtime and as needed for naps, with instructions to verify proper placement and function, and to administer 4 liters of oxygen with the device. The order also included individualized settings for the CPAP machine.Record review revealed the resident was transferred to the hospital on 2/28/2026 with a diagnosis of a pleural effusion (the buildup of excess fluid between the thin membranes that line your lungs). The resident returned to the facility on 3/12/2026.Review of the hospital continuity of care form dated 3/12/2026 revealed discharge orders to continue nighttime BiPAP therapy (Bilevel Positive Airway Pressure, a device that assists with breathing. The machine uses two pressure levels: a higher pressure when you breathe in to help fill your lungs, and a lower pressure when you breathe out to make exhaling easier) with individualized settings.Record review failed to reveal evidence that an order was initiated for the resident to continue BIPAP therapy upon readmission on [DATE]. Further review failed to reveal evidence that the physician had been contacted regarding the therapy.Record review revealed a physician's order dated 3/13/2026 which stated, Follow up in the a.m. with BIPAP. Family will bring it in but there is a question of whether or not they returned it to the rental agency. In the morning Alert Unit Manager to follow up with BIPAP needs.Record review revealed that the above-mentioned order was signed off as completed from 3/13/2026 through 3/29/2026. Record review failed to reveal evidence that the resident was provided with BIPAP therapy from 3/12/2026 through 3/29/2026 which indicates s/he went without the use of his/her BIPAP therapy for 18 days. Record review of the weekly schedule from 3/12/2026 through 3/29/2026 revealed Licensed Practical Nurse (LPN) Staff C, worked the 11:00 PM to 7:30 AM shift nightly as the charge nurse on the resident's unit. During a surveyor interview conducted on 4/16/2026 at 1:30 PM, Staff C stated he was unaware that the resident required BiPAP therapy until the device was delivered by an oxygen vendor on 3/30/2026. He acknowledged that the resident did not receive BiPAP therapy from the time of readmission on [DATE] through 3/30/2026 during the 11:00 PM to 7:30 AM shift.During a surveyor interview on 4/16/2026 at 3:45 PM with the facility's Medical Director, Staff D, he revealed that he would have expected the resident to receive his/her BiPAP therapy upon readmission to the facility.

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. This deficient practice was identified 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 an injury that required hospital transfer on [DATE]. The complaint further alleged that diagnostic imaging at the hospital identified three new rib fractures. Record review revealed that the resident was readmitted to the facility in March of 2026 with diagnoses including, but not limited to, seizures and muscle weakness.Record review revealed the following progress notes:[DATE] at 9:22 AM, authored by the on-call provider, revealed the resident sustained an unwitnessed fall and was found lying on his/her left side with a left elbow skin tearXXX[DATE] at 5:44 PM, authored by Licensed Practical Nurse (LPN), Staff A, revealed the resident complained of pain following the fall, refused a meal, and stated, I am in pain. Assessment findings included pain in the left shoulder and left rib cage. The provider was notified, and an order was obtained for x-rays of the left shoulder and ribsXXX[DATE] at 10:24 PM, authored by LPN, Staff B, revealed she spoke with the nurse practitioner informing them that the resident had a fall with a left clavicle (the collarbone) fracture with a new order to send the resident to the emergency room for further evaluation.Record review of a CT scan (a medical imaging technique aiding in the diagnosis of varying conditions) report dated [DATE] at 1:04 PM failed to reveal evidence of a clavicle fracture; however, findings identified acute fractures of the right first rib and the left second and third ribs.Record review revealed the resident expired on [DATE]. During surveyor interviews conducted on [DATE] at 10:30 AM, 10:45 AM, and 3:57 PM with the Director of Nursing Services, she acknowledged that the resident sustained acute rib fractures as a result of the [DATE] fall prior to his/her death. Additionally, she was unable to provide evidence that the facility reported the death to the appropriate authorities, including the State Survey Agency, as required under applicable State law governing long-term care facilities.

Based on surveyor observation, record review, and staff interview, the facility failed to ensure sufficient food and nutrition service support personnel possessed the appropriate competencies and skill sets to safely carry out the functions of the food and nutrition service. Specifically, the facility failed to ensure that the cooks who were in charge during meal preparation and service obtained the required Food Manager's Certification, as required, to ensure safe food handling practices and resident safety. Findings are as follows:Record review of the U.S. Food and Drug Administration Food Code, 2022 Edition, Section 2-102.11 Demonstration, states in part, .the person in charge shall demonstrate knowledge by.(B) Being a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM.During the initial tour of the main kitchen on 3/15/2026 at approximately 8:11 AM, Cook, Staff J, revealed that he was the staff member in charge of food service that morning. During a surveyor interview on 3/15/2026 at approximately 8:40 AM with the Food Service Director (FSD), she revealed that the two cooks that had prepared and served the breakfast meal, had obtained Food Handlers Certifications (an accredited credential verifying that a food service employees had basic knowledge of food safety), not a Food Manager's Certification (an accredited credential verifying that a food service employees has knowledge of food safety to prevent foodborne illnesses, sanitation, temperature control, hygiene, and regulatory compliance). She further revealed that Cooks Staff K, L, and herself had obtained the Food Manager's Certification, as required, for the person in charge.Record review of an undated document titled Meal Truck Delivery Times revealed that the prepared meals are brought from the kitchen to the units at the following times:Breakfast starts at 7:30 AM through 9:15 AMLunch starts at 11:30 AM through 1:15 PMDinner starts at 4:30 PM through 6:15 PMRecord review of the dietary schedules on 3/16/2026 for February and March 2026, failed to reveal evidence that a person with a Food Manager's Certification was scheduled during all three meals that are prepared and served to residents on the following dates: 2/1, 2/4, 2/6, 2/11, 2/13, 2/14, 2/15, 2/18, 2/20, 2/25, 2/27, 2/28, 3/1, 3/4, 3/6, 3/7, 3/11, 3/13, 3/14, and 3/15/2026During a surveyor interview on 3/18/2026 at 2:04 PM, the FSD, in the presence of the Regional FSD, she acknowledged that 2 of the 4 cooks on staff did not obtain the Food Manager's Certification required to safely and effectively carry out the functions of the food and nutrition services. She further acknowledged that the facility's schedule included periods when a staff member holding a Food Manager's Certification was not present during the preparation and service of residents' meals.

Based on surveyor observation and staff interview, the facility failed to maintain the hallway handrails in a safe operating condition for 3 of 4 units observed. Findings are as follows:During a surveyor observation on 3/17/2026 at approximately 12:54PM, revealed the wall railing to the left of room [ROOM NUMBER] was noted to move slightly when this surveyor leaned against the wall. Further observation of the railing revealed that the right side of that railing was not secured to the wall. Additional surveyor observations on 3/18/2026 at approximately 9:30 AM, revealed that the hallway handrails were in disrepair and were becoming detached from the wall in the following locations:Second floor by stairwell ASecond floor south unit by the storage roomSecond floor north unit by resident room [ROOM NUMBER]Second floor north unit by resident room [ROOM NUMBER]Third floor north unit by the elevatorThird floor north unit by resident room [ROOM NUMBER]Third floor north unit by resident room [ROOM NUMBER]During a surveyor interview with the Maintenance Director on 3/19/2026 at approximately 10:10 AM, he acknowledged that the hallway handrails in the above-mentioned locations were in disrepair and were becoming detached from the walls.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that each resident was treated with respect and dignity for 1 of 2 residents reviewed, in relation to a dressing change, Resident ID #4. Findings are as follows:Record review of a facility policy titled Resident Rights Guidelines for All Nursing Procedures last revised in October of 2010, states in part, .1. For any procedure that involves direct resident care, follow these steps.Close the room entrance door and provide for the resident's privacy.Record review revealed a physician's order dated 3/15/2026 to clean the wound to his/her coccyx (tailbone) and apply a treatment daily and as needed.During a surveyor observation of a dressing change on 3/18/2026 at approximately 10:00 AM, Licensed Practical Nurse (LPN), Staff A, was observed entering and exiting the room while preparing wound care supplies at the resident's bedside table. Staff A failed to provide privacy, as the privacy curtain was not drawn and the door to the resident's room was left open. The resident was observed without pants, wearing only a brief, and was exposed to individuals passing in the hallway.During a surveyor interview with Staff A following the above observation, she acknowledged that she should have pulled the privacy curtain or covered the resident while going in and out of the room.During a surveyor interview on 3/18/2026 at 1:00 PM with the Director of Nursing Services, in the presence of the Regional Director of Clinical Services, she was unable to provide evidence that staff ensured the resident was provided with privacy during the dressing change.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 3 residents reviewed related to a BiPAP machine (Bilevel Positive Airway Pressure - a noninvasive ventilator machine prescribed to assist breathing by delivering pressurized air through a mask), Resident ID #s 161 and 204.Findings are as follows:Record review of a facility policy titled .BIPAP Support. states in part, .Preparation.3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure [Positive End-Expiratory Pressure - a medical ventilator setting that maintains positive pressure in the lungs at the end of exhalation].for the machine.General Guidelines for Cleaning.4. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed.5. Humidifier (if used):a. Use clean, distilled water only in the humidifier chamber.b. Clean humidifier weekly and air dry.c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly.6. Filter cleaning;a. Rinse washable filter under running water once a week to remove dust and debris.7. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses.1. Record review revealed Resident ID #161 was readmitted to the facility in March of 2026 with a diagnosis including, but not limited to, chronic diastolic congestive heart failure (a long-term condition where the left ventricle of the heart becomes stiff, causing shortness of breath and other medical symptoms).Record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.a. Record review revealed a physician's order to apply BiPAP at bedtime and as needed for naps, check placement and functioning while applied.Further review of the physician's orders failed to reveal evidence of an order to clean the BiPAP, per the facility policy.Surveyor observations on 3/15/2026 at 10:56 AM and 3/17/2026 at 8:45 AM, the surveyor noted the resident was using a BiPAP while sleeping.During a surveyor observation on 3/17/2026 at 3:19 PM with the Unit Manager (UM), Staff F, the BiPAP device was noted to have small brown particles inside the face mask and a brown discoloration within the tubing. During a surveyor interview on 3/18/2026 at 9:35 AM with the Director of Nursing Services (DNS), and the Regional Director of Clinical Services, they stated that, per facility policy, there should be an order to clean the BiPAP mask daily and the tubing weekly.b. Record review of the BiPAP manufacturer's user manual revealed that room temperature distilled water must be utilized for filling the machine's humidifier.During a surveyor observation and interview with the resident on 3/18/2026 at 12:42 PM, the BiPAP machine's water chamber (humidifier) was found to be empty. The resident reported that the BiPAP dries out his/her face and mouth, and that staff do not consistently fill the humidifier with distilled water.Record review failed to reveal evidence that the BiPAP's humidifier is filled with distilled water when being utilized, according to the manufacturer's manual.During a surveyor interview on 3/18/2026 at 12:58 PM with the UM, Staff F, she failed to provide evidence that staff fill the BiPAP's humidifier with distilled water. 2. Record review revealed Resident ID #204 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, obstructive sleep apnea (a serious sleep disorder where breathing repeatedly stops and starts because throat muscles relax, causing the airway to collapse or narrow during sleep) and chronic respiratory failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, resulting in low oxygen).Record review revealed a physician's order dated 9/9/2024 for use of a BiPAP machine at bedtime and as needed for naps, with instructions to verify proper placement and function, and to administer 2 liters of oxygen via nasal cannula under the mask. The order also included individualized settings for the BiPAP machine.Record review revealed the resident was discharged to the hospital and admitted on [DATE] with diagnoses of pericardial and pleural effusion (abnormal accumulations of fluid in the chest surrounding the heart or lungs, resulting in difficulty breathing). The resident returned to the facility on 3/10/2026. Record review failed to reveal evidence that an order was initiated for the resident to continue BiPAP therapy for obstructive sleep apnea upon readmission on [DATE], nor had the physician been contacted regarding the therapy. A readmission progress note signed on 3/12/2026 by Nurse Practitioner, Staff G, subsequently indicated a plan to continue BiPAP therapy for the resident's obstructive sleep apnea. A surveyor observation of the resident on 3/16/2026 at 10:27 AM, revealed the resident was sleeping and not utilizing the BiPAP machine. Record review of the March 2026 Medication Administration Record failed to reveal evidence of a physician's order for use of a BiPAP for the resident.During a surveyor interview on 3/18/2026 at 11:33 AM with the UM, Staff H, she revealed that the resident has not been using his/her BiPAP machine since returning from the hospital as s/he did not have a physician's order. She stated that she has reported this to Nurse Practitioner, Staff G, when she assessed the resident on 3/12/2026 and several following occasions, however, Staff G failed to provide an order.During a surveyor interview on 3/18/2026 with Staff G at 11:34 AM, she revealed that she assessed the resident on 3/12/2026 and wanted the resident to continue utilizing the BiPAP machine for the treatment of obstructive sleep apnea. However, she acknowledged that she did not write an order. Record review revealed that on 3/19/2026 at 12:33 PM, Staff G initiated a physician's order for the resident to use a BiPAP machine with 2 liters of oxygen via nasal cannula under the mask during nighttime and naps. This indicates that the order was not implemented until 24 hours after the issue was brought to Staff G's attention by the surveyor.During a surveyor interview on 3/19/2026 at 12:54 PM with the resident's physician, Staff I, he revealed that he would have expected Staff G to provide the BiPAP treatment order as soon as possible and for Resident ID #204 to receive his/her BiPAP therapy upon readmission to the facility.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents with pressure ulcers (localized damage to the skin and underlying tissues caused by constant pressure on an area over a long period of time) receive necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 5 residents reviewed, Resident ID #s 17 and 31.Findings are as follows:According to Lippincott Nursing Center Procedure titled Wound Assessment, Management, and Documentation dated October 2022, states in part, .The initial assessment should be completed when the wound is first observed. Follow-up assessments should be completed at least weekly.the physician will help identify medical interventions related to wound management .Review of a facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol with a revision date of 2014, states in part, .In addition, the nurse shall describe and document/report the following: a full assessment of pressure sore [ulcer] including location, stage, length, width, and depth, presence of exudates [liquid that seeps from wounds] or necrotic [dead tissue] tissue.the physician will help identify medical interventions related to wound management . 1. Record review revealed Resident ID #17 was admitted to the facility in February of 2026 with diagnosis including, but not limited to, unstageable pressure ulcer (a full thickness wound where the depth and extent of tissue damage cannot be determined as it is obscured by dead tissue) to the right heel.Record review of a care plan dated 3/8/2026 revealed, the resident has a pressure injury on the right heel and has the potential to develop a pressure ulcer related to immobility. Staff interventions include, but are not limited to, documenting wound length, width, and depth where possible, status of wound perimeter, and wound bed.Record review of weekly skin assessments dated 3/3/2026 and 3/9/2026, failed to reveal evidence that the resident's right heel unstageable pressure ulcer was indicated on these assessments. Additionally, the assessments failed to reveal evidence of measurements of the pressure ulcer including length, width, and depth, and a full description of the pressure ulcer including location, stage, and the presence of exudates or necrotic tissue, per the facility's policy.During a surveyor interview on 3/17/2026 at 3:11 PM with the Unit Manager (UM), Staff F, she acknowledged Resident ID #17 has an unstageable pressure ulcer to his/her right heel and was unable to provide evidence the pressure ulcer was measured and documented weekly for the weeks of 3/3/2026 and 3/9/2026.During a surveyor interview on 3/18/2026 at 9:35 AM with the Director of Nursing Services (DNS), in the presence of the Regional Director of Clinical Services (RDCS), she stated that Resident ID #17 was admitted to the facility with an unstageable pressure ulcer to his/her right heel and would have expected the wound to be measured weekly with a full description documented on the skin assessment. She was unable to provide evidence that the weekly measurements for Resident ID #17's pressure ulcer were obtained for the weeks of 3/3/2029 and 3/9/2026.2. Per the National Pressure Injury Advisory Panel, an intact blister located over a pressure area is classified as a stage 2 pressure injury (a partial-thickness loss of skin with exposed dermis (middle layer of skin)). a. Record review revealed Resident ID #31 was admitted to the facility in February of 2026 with a diagnosis including, but not limited to, vascular dementia. Record review of a physician's order dated 2/4/2026 indicated that skin prep (a barrier agent used on intact skin that should not be applied to an open wound bed) was to be applied to three intact blisters on the coccyx (tailbone) twice daily. Record review of the skin assessments dated 2/4, 2/9 and 2/16/2026, revealed the resident had a blister on his/her coccyx. Additionally, the assessments failed to reveal evidence of measurements of the pressure ulcer including length, width, and depth, and a full description of the pressure ulcer including location, stage, and the presence of exudates or necrotic tissue, per the facility's policy.b. Record review revealed that on 2/25/2026, a wound care provider assessed the resident and determined that the coccyx wound had progressed to a stage 3 pressure ulcer (full-thickness skin loss and exposure of the fatty tissue beneath). The provider recommended cleansing the wound with normal saline, applying medicated honey, and covering with a silicone foam dressing daily.The record failed to reveal these recommendations were implemented until 2/28/2026. In the interim, staff continued to apply skin prep to the wound site, which was no longer appropriate, as the previous stage 2 intact blisters had become an open wound, and skin prep should not be used on open wounds.During a surveyor interview on 3/17/2026 at 2:57 PM with the UM, Staff F, she stated that Resident ID #31 was admitted with blisters to his/her coccyx and acknowledged that the blisters were not measured because they do not measure blisters. Additionally, Staff F acknowledged that there were no measurements documented of the blisters until 2/25/2026 when it was identified as a stage 3 pressure ulcer.During additional interviews on 3/18/2026 at 9:30 AM and 3/19/2026 at 2:31 PM with the DNS, in the presence of the RDCS, she stated that a blister is considered a stage 2 pressure ulcer and that staff are expected to measure and document blisters weekly. She further indicated that Resident ID #31 was seen by the wound provider on 2/25/2026, at which time the coccyx blister was identified as a stage 3 pressure ulcer. The DNS was unable to provide evidence that the new wound treatment order from the provider was implemented on 2/25/2026. She also did not clarify the standard process staff are to follow when a provider writes a recommendation for an order. Additionally, the DNS could not provide evidence that Resident ID #31 received appropriate treatment for the stage 3 pressure ulcer on 2/26/2026 and 2/27/2026.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to transmission based precautions for 2 of 2 residents reviewed who have a central venous catheter (CVC - a thin, flexible tube that is placed into the large vein above the heart) used for dialysis (a medical treatment that filters waste, toxins, and excess fluid from the blood when the kidneys are failing), Resident ID #s 1 and 2.Findings are as follows:Review of the Center for Disease Control (CDC) reference for Health Care Providers dated June 28, 2024, states in part, .Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) .Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk .Indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized .Record review of the facility's policy titled Enhanced Barrier Precautions - Lincolnwood Rehabilitation and Healthcare reveals in part, .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents .Indwelling medical devices include central lines .Further review of the facility's policy reveals that they do not place residents on EBP when they have a central line to receive dialysis treatments through, which is not in alignment with CDC's guidance. 1.Record review revealed Resident ID #1 was admitted to the facility in December of 2021 with diagnoses including, but not limited to, end stage renal disease (permanent kidney failure) and dependence on renal dialysis.Record review of the resident's physician's orders revealed:- Resident receives dialysis in-house on Monday, Wednesday and Fridays-Monitor right chest CVC dialysis access site for signs/ symptoms of infection, drainage, bruising, and bleeding every shift, and as clinically indicated. Every shift, document abnormal findings in the progress notes, and report to the Physician.Record review failed to reveal evidence of an order for EBP for the resident who has an indwelling medical device (CVC catheter).Surveyor observation of the entrance to the resident's room on 2/10/2026 at 9:38 AM, revealed signage indicating the resident was on EBP. However as the surveyor was reaching into the PPE bin located outside of the resident's room, she was stopped by the Regional Director of Clinical Services and was informed that Resident ID #1 did require EBP. She revealed that the signage and bin were placed at the entryway to the resident's room in anticipation of a new admission.2. Record review revealed Resident ID #2 was admitted to the facility in June of 2025 with diagnoses including, but not limited to, Parkinson's disease (a movement disorder of the nervous system) and dependance on renal dialysis.Record review of the resident's physician's orders revealed:- Resident receives dialysis in-house on Monday, Wednesday and Fridays - Monitor right chest CVC dialysis access site for signs/ symptoms of infection, drainage, bruising, and bleeding every shift, and as clinically indicated. Every shift, document abnormal findings in the progress notes, and report to the Physician. - Check catheter dressing site every shift to ensure that it is intact and in place. Change as needed for soiling or if the dressing is no longer in place/ secure. Every shift and as needed.Record review failed to reveal evidence of an order for EBP for the resident who has an indwelling medical device (CVC catheter).During a surveyor interview on 2/10/2026 at 2:53 PM with the Regional Director of Clinical Services, she revealed that the facility does not follow EBP for residents that have a CVC for dialysis. Additionally, she acknowledged the CDC's recommendation for EBP for residents with an indwelling medical device, including central lines.

Based on surveyor observation, clinical record review, staff and resident interviews, the facility failed to provide the residents with an environment that remains as free of accident hazards as is possible and that each resident receives adequate supervision to prevent accidents for 1 of 1 newly admitted resident who started a fire with a lighter, Resident ID # 1. Findings are as follows:Record review of a community reported complaint report submitted to the Rhode Island Department of Health on 12/29/2025 alleges that a resident had ignited their oxygen tubing while using a lighter. Record review revealed that Resident ID #1 was admitted to the facility in December of 2025 with diagnoses including but not limited to multiple fractures of ribs and a history of falling. Record review of the hospital documentation revealed Resident ID #1 is a smoker. During a surveyor interview with the Regional Director of Clinical Services, the Regional Director of Operations, and the [NAME] President of Operations, on 12/29/2025 at approximately 10:10 AM, they revealed that an incident had occurred just before 4:00 AM in Resident ID # 1's room. Resident ID #1 used a lighter to locate his /her shoes in the dark when s/he accidentally ignited his/her oxygen tubing which caused minor fire damage to the floor and the oxygen concentrator. The Regional Director of Clinical Services indicated that the facility was aware the resident was a smoker at the time of his/her admission. During a surveyor observation on 12/29/2025 at approximately 11:10 AM of Resident ID #1s room revealed a discolored area of the floor that was approximately 9 inches by 12 inches in size. During a surveyor interview with the Regional Director of Operations at the time of the above observation, he revealed that the burnt oxygen tubing and the damaged oxygen concentrator had been removed from the room prior to this survey. Additional surveyor observations on 12/30/2025 at approximately 2:00 PM revealed photos obtained from the local fire department which revealed burnt melted oxygen tubing still in place on the floor and burn marks to the front of the oxygen concentrator. During a surveyor interview with Resident ID #1, on 12/30/2025 at approximately 11:35 AM, s/he revealed that s/he was using his/her personal lighter to find his/her shoes when s/he got the lighter too close to the oxygen tubing and it caught fire. During a surveyor interview with the Regional Director of Clinical Services on 12/30/2025 at approximately 1:35 PM, she was unable to provide evidence that the facility provided the residents with an environment that remains as free of accident hazards as possible.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who received Dilantin (a medication prescribed to treat seizures) in error on 18 occasions without a diagnosis of a seizure disorder, instead of receiving the intended medication, Diltiazem (a medication prescribed to treat high blood pressure) which was not transcribed. Additionally, the resident was transferred to the hospital where s/he received emergent hemodialysis (a medical treatment to remove waste and excess fluids that the kidneys are unable to perform this function adequately) for the Dilantin use, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on [DATE] alleges that Resident ID #1 was administered the medication Dilantin instead of the prescribed medication Diltiazem for his/her heart condition after recovering from a cardiac stent surgery. Additionally, the complainant indicated that the resident's condition was getting worse, believing that the Dilantin caused his/her death.Review of a facility document titled Administering Medications stated in part, Medications are administered in a safe and timely manner.medications are administered in accordance with the prescriber's orders.Record review revealed Resident ID #1 was readmitted to the facility following a hospital admission in December of 2024 with diagnoses including, but not limited to, hypertension (high blood pressure), heart failure and post-cardiac surgery. Additional review of the record failed to reveal evidence that the resident had a diagnosis of a seizure disorder.Record review of his/her admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident has intact cognition.Record review of the hospital continuity of care (COC) document dated [DATE] revealed a physician's order to continue the medication Diltiazem 30 milligrams (mg) by mouth three times a day. Additional review of the COC failed to reveal evidence of a physician's order for Dilantin.Review of the facility's admission orders revealed a physician's order dated [DATE] for Dilantin 30 mg three times daily, noted as being prescribed for atherosclerosis of native arteries of extremities with rest pain, right leg. This diagnosis does not constitute an appropriate indication for the use of Dilantin.Additional review of the [DATE] and [DATE] MARs revealed that the resident was administered Dilantin on multiple dates by eight different nurses. Dilantin is prescribed to treat seizure disorders, yet the documented diagnosis was atherosclerosis of native arteries. In contrast, the resident had a cardiac diagnosis that would have more appropriately aligned with the use of Diltiazem, highlighting a clear mismatch between the prescribed medication and the resident's clinical condition. This indicates multiple missed opportunities including the physician to identify and correct the medication error.Review of the Medication Administration Records for [DATE] and [DATE] revealed that the resident received Dilantin on multiple dates, administered by eight different nurses. This suggests there were numerous opportunities to recognize and address the medication error: - [DATE] - 3 times - [DATE] - 1 time - [DATE] - 3 times - [DATE] - 2 times - [DATE] - 3 times - [DATE] - 3 times - [DATE] - 3 timesRecord review revealed the resident received the medication Dilantin in error instead of the ordered Diltiazem, indicating the resident received the incorrect medication 18 times since his/her admission to the facility.Additional record review failed to reveal evidence that the resident received his/her Diltiazem as ordered. Record review of a nursing progress note dated [DATE] at 11:02 AM, authored by the Unit Manager, Staff D, revealed the resident's ordered medication, Diltiazem 30 mg three times a day, was incorrectly transcribed as Dilantin 30 mg three times a day.Record review of a nursing progress note dated [DATE] indicates that Resident ID #1 presented with a change in mental status, weakness and was hypotensive (low blood pressure) and was transferred and admitted to the hospital. During a surveyor interview on [DATE] at 1:34 PM with Staff D, she revealed that she transcribed an order for Dilantin 30 mg instead of the ordered Diltiazem 30 mg in error, on the day of his/her admission to the facility. Additionally, she acknowledged that while she was transcribing the admission orders, she failed to verify that the correct medication, Diltiazem, was transcribed as ordered. During a surveyor interview on [DATE] at 1:55 PM with the resident's physician, he acknowledged that he assessed the resident on [DATE], the day after his/her readmission to the facility. He indicated that he reviewed the resident's hospital discharge summary document, including the medication orders. Additionally, he acknowledged that he failed to review the resident's medication orders that were transcribed into the facility system upon his/her admission, and he failed to reconcile the facility's orders with the hospital's discharge orders. Furthermore, he revealed that he did not identify that the medication Dilantin was transcribed instead of the ordered Diltiazem.During a surveyor interview with the Director of Nursing Services (DNS) on [DATE] at 2:24 PM, she revealed that the transcription error was identified when the nurse approached the resident to reorder his/her Dilantin and the resident informed the nurse that s/he has never been prescribed Dilantin. The DNS was unable to provide evidence that Resident ID #1 was kept free from significant medication error as s/he received Dilantin in error and did not receive his/her prescribed Diltiazem as ordered.Record review of the hospital paperwork revealed the resident was admitted to the intensive care unit, received emergent hemodialysis for phenytoin [Dilantin] use. The resident coded on [DATE] and was provided high quality cardiopulmonary resuscitation and s/he subsequently expired on [DATE] at 12:38 PM. As a result of this survey, it was determined that Resident ID #1 was placed at risk for serious harm, injury, impairment, or death due to Staff D's failure to accurately transcribe the physician-ordered medication Diltiazem. Consequently, the resident was erroneously administered Dilantin, a medication not prescribed for his/her condition and did not receive the ordered Diltiazem. This medication error may have contributed to the resident's subsequent hospital transfer and ICU admission, where s/he later required emergent hemodialysis and later expired.Upon further interview with the Director of Nursing Services, she indicated that the following interventions were put into place after the incident:a) The facility completed an ad hoc Quality Assurance and Performance Improvement Plan to review the incident and identify areas of improvement.b) Education was provided to all licensed nursing staff on the Medication Administration policy and Reconciliation of Medications on admission policy.c) An audit was completed for all residents that had the potential to have been affected by this error These interventions were completed by the facility on [DATE] and reviewed by the surveyor on [DATE]. Therefore, this citation is considered past noncompliance. Cross reference F 710.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's physician completed a medication reconciliation upon admission, failing to identify a medication transcription error, resulting in the resident receiving Dilantin (a medication prescribed to treat seizures) in error on 18 occasions without a diagnosis of a seizure disorder, instead of receiving the intended medication, Diltiazem (a medication prescribed to treat high blood pressure) which was not transcribed. Additionally, the resident was transferred to the hospital where s/he received emergent hemodialysis (a medical treatment to remove waste and excess fluids that the kidneys are unable to perform this function adequately) for the Dilantin use, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on [DATE] alleges that Resident ID #1 was administered the medication Dilantin, instead of the prescribed medication Diltiazem for his/her heart condition, after recovering from a cardiac stent surgery. Additionally, the complainant indicated that the resident's condition was getting worse, believing that the Dilantin caused his/her death.Record review revealed the resident was readmitted to the facility following a hospital admission in December of 2024 with diagnoses including, but not limited to, hypertension (high blood pressure), heart failure and post-cardiac surgery. Additional review of the record failed to reveal evidence that the resident had a diagnosis of a seizure disorder. Record review of the hospital continuity of care (COC) document dated [DATE] revealed a physician's order to continue the medication Diltiazem 30 milligrams (mg) by mouth three times a day. Additional review of the COC failed to reveal evidence of a physician's order for Dilantin.Review of the facility's admission orders revealed a physician's order dated [DATE] for Dilantin 30 mg three times daily, noted as being prescribed for atherosclerosis of native arteries of extremities with rest pain, right leg. This diagnosis does not constitute an appropriate indication for the use of Dilantin.Record review of a progress note dated [DATE], authored by the resident's physician, Staff E, revealed he personally reviewed the resident's records including the acute care hospital, the skilled nursing facility and the therapy records. Additional review of the progress note failed to reveal evidence that the physician identified that the Dilantin was ordered in error.During a surveyor interview on [DATE] 1:55 PM with the resident's physician, he acknowledged that he assessed the resident on [DATE], the day after his/her readmission to the facility. He indicated that he reviewed the resident's hospital discharge summary document, including the medication orders. Additionally, he acknowledged that he failed to review the resident's medication orders that were transcribed into the facility system upon his/her admission, and he failed to reconcile the facility's orders with the hospital's discharge orders. Furthermore, he revealed that he did not identify that the medication Dilantin was transcribed instead of the ordered Diltiazem.Record review of the [DATE] and [DATE] Medication Administration Records (MARs) revealed the resident mistakenly received the medication Dilantin instead of the ordered Diltiazem 18 times since his/her admission. Additional review of the [DATE] and [DATE] MARs revealed that the resident was administered Dilantin on multiple dates by eight different nurses. Dilantin is prescribed to treat seizure disorders, yet the documented diagnosis was atherosclerosis of native arteries. In contrast, the resident had a cardiac diagnosis that would have more appropriately aligned with the use of Diltiazem, highlighting a clear mismatch between the prescribed medication and the resident's clinical condition. This indicates multiple missed opportunities including the physician to identify and correct the medication error.Record review of a progress note dated [DATE] at 11:02 AM authored by the Unit Manager, Staff D, revealed that the resident's medication Diltiazem 30 mg three times a day was incorrectly transcribed as Dilantin 30 mg three times a day.Record review of a nursing progress note dated [DATE] indicates that Resident ID #1 presented with a change in mental status, weakness and was hypotensive (low blood pressure) and s/he was transferred and admitted to the hospital. During a surveyor interview with the Director of Nursing Services on [DATE] at 2:24 PM, she was unable to provide evidence that the resident's physician completed a medication reconciliation upon his/her admission to the facility. Record review of the hospital paperwork revealed the resident was admitted to the intensive care unit, received emergent hemodialysis for phenytoin [Dilantin] use. The resident coded on [DATE] and was provided high quality cardiopulmonary resuscitation and s/he subsequently expired on [DATE] at 12:38 PM. As a result of this survey, it was determined that Resident ID #1 was placed at risk for serious harm, injury, impairment, or death due to the facility's failure to ensure the resident's physician completed a medication reconciliation upon admission which contributed to a transcription error going undetected, as Staff D failed to accurately transcribe the physician-ordered medication Diltiazem. Consequently, the resident was erroneously administered Dilantin, a medication not prescribed for his/her condition and did not receive the ordered Diltiazem. This medication error may have contributed to the resident's subsequent hospital transfer and ICU admission, where s/he later required emergent hemodialysis and later expired.Cross Reference: F 760.

Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following physician's orders for 1 of 2 residents recently admitted to the facility, Resident ID #3. Findings are as follows:Record review revealed the resident was admitted to the facility in June of 2025 with diagnoses including, but not limited to, end stage renal disease, dependence on renal dialysis (a medical treatment to remove waste and fluids from the blood when the kidneys do not function properly) and constipation.Record review of the July 2025 admission Minimum Data Set Assessment revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact.Record review of the admission Transfer/Discharge Report dated 6/26/2025 revealed an order for Polyethylene Glycol 3350 (Miralax; a medication prescribed to treat constipation) 17 grams (gm) by mouth every 24 hours as needed (PRN) for constipation, hold for loose stools.Record review of the physician's orders revealed an order with a start date of 6/27/2025 for Miralax 17 gm, give one packet by mouth every morning, hold for loose stools. Record review of the June and July 2025 Medication Administration Records (MARs) revealed the resident was administered Miralax every morning instead of PRN since his/her admission.Record review of the physician's orders revealed that the above-mentioned order for Miralax was discontinued on 7/16/2025.During a surveyor interview on 7/17/2025 at 2:54 PM with Licensed Practical Nurse (LPN), Staff A, when asked why the Miralax order had been discontinued on 7/16/2025, Staff A revealed that she had changed the order from daily to PRN after the resident had requested it to be ordered PRN. Additionally, she acknowledged that the Miralax was initially supposed to be transcribed as PRN but was transcribed as daily instead.During a surveyor interview on 7/17/2025 at 2:58 PM with the nurse that transcribed the admission order for the Miralax, LPN, Staff B, she revealed that after reviewing the admission orders, she inaccurately transcribed the Miralax order as daily, and it should have been transcribed as PRN.During a surveyor interview on 7/18/2025 at 12:58 PM with the resident, s/he revealed that after being admitted to the facility, s/he received Miralax daily. The resident further revealed that s/he recently requested that the medication be made PRN as s/he never receives this medication daily prior to his/her admission to the facility and only has taken it PRN. Additionally, the resident denied that s/he had ever requested for the medication order to be changed to daily upon admission. Record review of the progress notes failed to reveal evidence that the admission order for Miralax PRN was ever changed by the provide upon admission to the facility to daily. During a surveyor interview on 7/18/2025 at approximately 2:00 PM with the Regional Clinical Director and the Director of Nursing Services, they were unable to provide evidence that the resident received the Miralax medication as ordered from 6/27/2025 to 7/16/2025.

Based on record review, staff and resident interviews, it has been determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for 1 of 1 resident reviewed who sustained a fall from an improperly secured mechanical lift (hoyer lift) which resulted in broken bones, hospitalization , and surgical intervention, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/16/2025 revealed the resident was being transferred with a mechanical lift and s/he started to slide out of the sling that was attached to the mechanical lift. The resident's leg hit the mechanical lift, and s/he was transferred to an acute care hospital and diagnosed with a left femur fracture (broken thigh bone). Review of a facility policy titled, Lifting Machine, using a Mechanical states in part, Attach sling straps to sling bar, according to manufacturer's instructions. Make sure the sling is securely attached to the clips and that it is properly balanced .before resident is lifted, double check the security of the sling attached . Record review revealed the resident was admitted to the facility in January of 2025 with diagnosis including, but not limited to paraplegia (a type of paralysis that affects the lower half of the body including the legs, making it impossible to stand or walk). Record review of an Admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15. This score indicates the resident's cognition is intact. Further review of the MDS Assessment revealed the resident requires extensive assistance with bed mobility and is dependent on two staff for transfers. Record review of a care plan dated 2/26/2025 revealed the resident is at risk for falls related to paraplegia and limited mobility. Additionally, the care plan revealed the resident has selfcare deficits and requires a mechanical lift with two staff for transfers. Record review revealed a progress note dated 4/15/2025 at 11:47 AM, which states in part, Pt [patient] seen this AM [morning] after fall from a height while in Hoyer lift .Pt hoisted [raised] above floor, when one strap either slipped off hook or broke . Record review of a nursing progress note dated 4/15/2025 at 12:04 PM, authored by Licensed Practical Nurse, Staff A, revealed the resident had a fall from the Hoyer lift landing on his/her left side and the left hip/thigh was noted to be swollen. Further review of this progress note revealed that as the resident adjusted him/herself while in the Hoyer lift, the strap slipped off, and the resident slid out of the Hoyer lift. Record review of a Continuity of Care Consultation and Referral Form completed by the facility and sent with the resident to the emergency room (ER) dated 4/15/2025, states in part, .Reason for transfer: S/P [status post] fall .Description of Problem: Fall from Hoyer lift to left side . Record review of a hospital document titled Triage assessment dated [DATE], states in part, .staff was using a portable Hoyer lift to get pt [patient] to [his/her] wheelchair when the strap reportedly broke/malfunctioned, and [s/he] fell to the ground . Further review of a Computed Tomography (CT scan, a medical imaging technique that uses X-rays and a computer to create detailed cross sectional images of the body) radiology report dated 4/15/2025 revealed the resident was diagnosed with a left femur fracture (a fracture in the middle of the femur, near the hip) and a nondisplaced left sacral alar fracture (a break in the wing of the bone in the pelvis). Record review of a facility's document titled Incident Statement Form dated 4/15/2025 that was obtained from Nursing Assistant, Staff B, revealed that when the resident was being transferred with the Hoyer lift, the loop on the Hoyer pad slipped off and the resident fell . During a surveyor interview on 4/18/2025 at 7:57 AM with Staff B, she acknowledged that on 4/15/2025 at approximately 10:30 AM, she assisted Nursing Assistant, Staff C to transfer the resident using a Hoyer lift from the bed to the wheelchair. Staff B indicated that one of the loops on the left side of the Hoyer pad slipped off, and the resident fell . During a surveyor interview on 4/18/2025 at 9:23 AM with Staff A, she indicated that on the morning of 4/15/2025 she heard a commotion coming from the resident's room and upon entering the room, she observed the resident on the floor in the presence of Staff B and Staff C. She indicated that she was told by Staff B that one of the Hoyer lift straps had slipped off during the transfer causing the resident to fall. During a surveyor interview on 4/21/2025 at 9:51 AM with the resident, s/he indicated that on 4/15/2025 while being transferred with a Hoyer lift from the bed to the wheelchair, one of the straps from the left side of the Hoyer lift came off and s/he fell to the floor hitting his/her leg on a foot piece of the Hoyer lift. The resident acknowledged that s/he was not lowered to the floor by the staff as alleged by the facility. Additionally, the resident indicated that when Staff A came to assess him/her after this incident on 4/15/2025, s/he informed Staff A that s/he had fallen out of the Hoyer lift because one of the straps on the Hoyer lift became unattached during the transfer. During surveyor interviews on 4/18/2025 at 9:50 AM and at 11:00 AM with the Director of Nursing Services (DNS) in the presence of the Administrator, the DNS indicated that the resident did not fall out of the Hoyer lift when s/he was transferred. The DNS and the Administrator acknowledged that they were not present during this incident was unable to provide evidence that the resident was safely transferred from the bed to the wheelchair by Staff B and C. Both the DNS and the Administrator were unable to provide evidence that the resident had been interviewed to obtain a statement of an exact account of what had happened during the transfer which led to the resident sustaining a major injury. Upon further interview with the DNS, she indicated that the following interventions were put into place after the accident and before the survey team entered the facility therefore this citation will be cited as past non-compliance: a) Investigate the incident-obtain statements from staff that transferred the resident, create a timeline of events. b) Validate that the Nursing Assistant (NA) who transferred the resident to the wheelchair from the bed have competencies in place. If so, complete disciplinary action as necessary. c) Conduct an Ad-Hoc Meeting to review the situation and develop a Root Cause Analysis. d) Complete a house audit of all residents' safe patient handling assessments for residents requiring a total lift (mechanical lift) to ensure that recommendations have been carried over to the care plan. e) Complete a house audit of all residents that require total assistance of two for transfers with a total lift to assure that care plan and Kardex are accurate. f) Re-educate the NAs and nurses on how to transfer residents using a total lift. g) Complete competency tests of all NAs and nurses on how to complete total lift transfers and how to appropriately determine sling size for residents. h) Randomly observe transfers of residents that require two-persons total lift transfers to ensure that care plans are being followed. Audits will occur weekly for four weeks then monthly for two months, and until substantial compliance is met. i) Housekeeping to assess all Hoyer pads to ensure they are in good condition, that is, no rips, tears, and missing pieces. j) Laundry to label all lift pads with size so it can be easily identified. k) Hoyer books to be created for each unit. Book will include resident's room number and copy of Kardex which shows sling size. l) The administrator will have overall responsibility for this plan.

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 3 residents reviewed who were discharged from the facility, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 11/19/2024, alleges that Resident ID #1 was discharged home with Resident ID #2's medications. This resulted in one of the medications being taken by Resident ID #1 on two separate dates following his/her discharge. Record review for Resident ID #1 revealed s/he was admitted to the facility in October of 2024 with diagnoses including, but not limited to, liver cell carcinoma, end stage renal disease and dependence on renal dialysis (a procedure that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly). Further review revealed the resident was discharged to his/her home on 11/10/2024. Record review revealed Resident ID #2 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, hyperlipidemia (high cholesterol) and hypertension (high blood pressure). Record review of Resident ID #2's physician orders revealed a current order for Atorvastatin (a medication prescribed to treat high cholesterol) 40 milligrams (mg) daily and two other medications that were discontinued on 11/6/2024, Lisinopril 40 mg and Amlodipine 2.5 mg (medications prescribed to treat high blood pressure). During a surveyor interview on 11/20/2024 at 11:48 AM with the complainant, s/he revealed that when the admitting nurse from the home care agency was reviewing Resident ID #1's medications, s/he noted 3 medications, Atorvastatin, Lisinopril and Amlodipine, included with Resident ID #1's medications, belonging to Resident ID #2. Additionally, s/he revealed that Resident ID #1 self administered the Atorvastatin 40 mg, to himself/herself on 11/11/2024 and 11/12/2024. During a surveyor interview on 11/20/2024 at 10:37 AM with Licensed Practical Nurse, Staff A, she revealed that she was part of Resident ID #1's discharge on 11/10/2024. Staff A revealed that the resident's medications were already placed in a bag prior to his/her discharge on 11/10/2024. Staff A was unsure who placed the medications in the bag prior to the resident's discharge. She acknowledged that she did not reconcile the medications that were included in the bag to ensure the resident had the correct medications. Staff A further revealed that she did not provide instructions for the medications to Resident ID #1 or his/her family member at the time of the discharge. Additionally, she revealed she placed the discharge paperwork in the bag with the resident's medications before taking the resident out to his/her car. Record review of the Discharge/Transfer of Patient form for Resident ID #1 revealed a discharge date of [DATE]. Further review of the document failed to reveal evidence of any medication orders listed or any evidence that discharge medication instructions were provided to either the resident or his/her family member. Record review of the nursing progress notes failed to reveal evidence that the resident was discharged on [DATE] or that any medication teaching or instructions were provided to the resident or the resident's family member upon the resident's discharge. During a surveyor interview with the Director of Nursing Services on 11/20/2024 at approximately 11:15 AM, she was unable to explain why a medication reconciliation of all pre-discharge medications with the resident's post-discharge medications was not completed and that discharge instructions for each medication were not provided to either Resident ID #1 or his/her family member upon discharge from the facility. This facility's failure to complete medication reconciliation and provide discharge medications instructions to residents being discharged places the facility's residents at risk for serious harm, serious impairment, serious injury or death.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the residents environment remains free of accident hazards relative to falls for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported compliant submitted to the Rhode Island Department of Health on 10/14/2024 revealed that the resident had a witnessed fall in his/her room and was transferred to the hospital via 911 with head lacerations. Record review revealed that the resident was readmitted to the facility in October of 2024 with a diagnosis including, but is not limited to, dementia. Review of the Fall Risk Evaluation, dated 10/8/2024, revealed the resident is at high risk for falls. Review of a Functional Abilities & Goals (Admission) assessment dated [DATE] revealed that the resident is dependent on staff for rolling to the left and right. It further revealed an intervention which included, but is not limited to, the resident is dependent on two staff while utilizing a sheet for turning and repositioning. Review of the resident's care plan revealed a problem start date of 10/10/2024 that the resident has an Activity of Daily Living self-care performance deficit related to dementia. Further review revealed an intervention which includes, but is not limited to, the resident is dependent on two staff and a sheet for turning and repositioning. Review of the resident's Kardex (a tool used by the direct care staff to provide pertinent information to guide resident care) from 10/10/2024 revealed that the resident is dependent on two staff while utilizing a sheet for turning and repositioning. Review of a progress note dated 10/14/2024 at 11:39 AM, revealed the nurse was called to the resident's room by a Certified Nursing Assistant (NA). Upon entering the resident's room, the resident was noted to be lying on the floor on his/her back. The resident was observed to be bleeding from his/her head. Further assessment revealed that the resident was noted with a laceration to his/her forehead and was bleeding from the back of his/her head. The note further revealed that the NA turned the resident onto his/her side and then turned away from the resident to pick up some wipes. The resident rolled over and hit his/her face on the bed side chair and then fell on to the floor landing on his/her back. The resident was transported to the hospital via 911. Record review revealed a nursing note dated 10/15/2024 indicated that the resident returned from the emergency room at 12:15 AM. S/he had dissolvable sutures to the laceration above the right eye and a dressing covering the laceration to the back of the head. During a surveyor interview with NA, Staff A on 10/17/2024 at approximately 9:12 AM she indicated that she was in the room alone providing care to the resident. She indicated that when she rolled the resident over to provide incontinence care, the resident jerked a little and fell down face first. The resident's face then hit the arm of the bed side chair where the resident then did a 360 and ultimately landed on his/her back. Staff A revealed that the facility uses an online Kardex and care plan to identify what care and assistance each resident requires. She further indicated that she was unaware that the resident required two staff members to assist with bed mobility and turning in bed. During a surveyor interview with Licensed Practical Nurse, Staff B, on 10/17/2024 at 10:11 AM, she revealed that the facility utilizes a Kardex to communicate the residents needs to the staff. Staff B reviewed the Kardex with the surveyor and acknowledged that the resident requires two staff members to assist with bed mobility and turning in bed and acknowledged that there was only one staff member present at the time of the fall. During a surveyor interview with the Director of Nursing Services on 10/17/2024 at approximately 11:49 AM, she revealed that the resident should have been a one assist with care, although she acknowledged that the facility assessed the resident as a two assist with care. She further stated that the formal assessment tool titled Functional Abilities & Goals (Admission) which triggered the resident require a two assist with bed mobility and turning, was in error. She further acknowledged that the Kardex and the care plan that two staff members are required to provide care and assistance with bed mobility and turning to the resident at the time s/he fell out of bed and sustained a laceration to his/her forehead and the back of his/her head was also in error. It is to be noted that this injury to the resident resulted in one staff member assisting with care and not the two staff as required based upon the results of the assessment tool.

Based on record review and staff interview it has been determined that the facility failed to ensure that all residents are free from significant medication errors relative to the administration of medications to the incorrect resident, for 1 of 1 resident reviewed, Resident ID #5. Findings are as follows: Review of a community reported complaint received by the Rhode Island Department of Health on 8/21/2024 alleged that Resident ID #5 received another resident's medications on 8/13/2024. Record review revealed that the resident was admitted to the facility in August of 2024 with diagnoses including, but not limited to, pneumonia and abnormal weight loss. Review of a progress note dated 8/9/2024 revealed the resident received his/her roommates' medications and it was reported to the nurse practitioner with new orders to monitor the resident for low blood pressure. Review of a facility document titled Full QA Report dated 8/9/2024, states in part, .received roommates' medication today .nurse did not perform 5 checks .wrong resident . Additionally, the document revealed that the resident received hydralazine 50 milligrams (mg) and labetalol 200 mg (medications used to treat high blood pressure). Additionally, review of an addendum to the document above dated 8/28/2024 authored by the Director of Nursing Services, states in part, .resident became hypotensive [blood pressure was low] but was asymptomatic .new order obtained to give the resident IV [intravenous] fluids . During a surveyor interview on 8/28/2024 at approximately 2:50 PM with the Director of Nursing Services she acknowledged that the resident received his/her roommate's medications, which resulted in him/her experiencing low blood pressure and requiring IV fluids.

Based on record review and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and Resident ID #2, resulting in significant injury of Resident ID #1. Findings are as follows: Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program states in part, Residents have the right to be free from abuse .The .prevention program consists of a facility wide commitment and resource allocation to support the following objectives .Protect residents from abuse .by anyone including .other residents . According to State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised ,d+[DATE], .Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident to Resident Abuse of Any Type A resident to resident altercation should be reviewed as a potential situation of abuse .Also, when investigating an allegation of abuse between residents, the surveyor should not automatically assume that abuse did not occur, especially in cases where either or both residents have a cognitive impairment or mental disorder. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. In determining whether F 600-Free from Abuse and Neglect should be cited in these situations, it is important to remember that abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach .The facility may provide evidence that it completed a resident assessment and provided care planning interventions to address a resident's distressed behaviors such as physical, sexual or verbal aggression. However, based on the presence of resident to resident altercations, if the facility did not evaluate the effectiveness of the interventions and staff did not provide immediate interventions to assure the safety of residents, then the facility did not provide sufficient protection to prevent resident to resident abuse. For example, redirection alone is not a sufficiently protective response to a resident who will not be deterred from targeting other residents for abuse once he/she has been redirected . Record review of a community reported complaint submitted to the Rhode Island Department of Health on [DATE] alleges in part Staff lied about the death of a patient [Resident ID #1] was succumbed by [his/her] injuries that [s/he] received by a very aggressive patient . Record review revealed Resident ID #1, the alleged victim, was admitted to the facility in April of 2024 with diagnoses including, but not limited to Parkinson's disease and lack of coordination. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status was completed with a score of 14 out of 15 indicating intact cognition. Further review revealed s/he required extensive assistance of one staff for transfers and ambulation. Record review of Resident ID #1's progress notes revealed the following: -[DATE] at 11:16 AM: Resident sustained an unwitnessed fall. Upon arrival to the room the resident was observed on his/her left side between both beds and his/her head was under the bedside table. S/he was bleeding from the back of the head. The resident was unable to move his/her right leg and complained of right hip pain. S/he stated the black old [gender] walked into my room and was going through my belongings, when I asked [him/her] to stop and get out [s/he] pushed me and I fell . Resident ID #2 was observed in the resident's room at the time of this incident. Resident ID #1 sent to the hospital via 911. -[DATE] at 3:55 AM: Resident ID #1 returned to facility at 3:35 AM. While at the hospital the resident was diagnosed with a right proximal femoral fracture with intertrochanteric and subtrochanteric involvement (hip fracture). Record review of a hospital document dated [DATE] titled emergency room Visit Notes states in part, .presenting from [facility] for evaluation after an unwitnessed fall. Another resident of the facility apparently pushed [him/her] causing [him/her] to fall .[s/he] appears uncomfortable .discussed given the extent of the hip fracture that this will likely require surgery. Declined proceeding with surgery .[s/he] will be discharged back with P.O. [by mouth] Morphine . Record review revealed the following new physician orders: -Morphine Sulfate 7.5 MG (milligrams) by mouth every 6 hours as needed -Morphine Sulfate 15 MG give two times daily for pain Record review of a Pain Level Summary revealed the resident experienced moderate pain (pain rated, 4 to 6 of 10) to severe pain (pain rated, 7 to 10 of 10) on the following dates and times: -[DATE] at 2:04 PM, 5 out of 10- Resident received the PRN dose of Morphine -[DATE] at 7:19 PM, 10 out of 10 -[DATE] at 8:24 PM, 5 out of 10 -[DATE] at 7:46 AM, 7 out of 10 Further record review of the resident's progress notes revealed the following: -[DATE] at 12:00 AM: Resident seen today with family at beside. Resident stating to this writer, my pain is ,d+[DATE] and the family member stated s/he has been in increased pain after falling. Hospice was declined by the resident. -[DATE] at 11:31 AM: Resident seen by Psychiatric Nurse Practitioner for follow up after altercation with another resident. No new recommendations. -[DATE] at 9:30 PM: The Registered Nurse was called to the room and the resident was found to be unresponsive without respirations or a pulse. His/her heart sounds were absent, and his/her pupils were fixed and dilated. The resident was declared deceased at 9:07 PM. -[DATE] at 10:25 PM: The Medical Examiner was contacted to report Resident ID #1's death. The Nurse Practitioner gave an order to release the body. Record review of a psychiatric evaluation and consultation note for Resident ID #1 dated [DATE], states in part, .being seen today a follow up after resident to resident. The patient was reportedly pushed by another resident .and [s/he] fell , which required hospitalization leading to multiple lower body fractures .Endorses pain throughout the day . Record review for Resident ID #2 (alleged perpetrator) revealed s/he was admitted to the facility in March of 2022, with diagnoses including, but not limited to, Alzheimer's disease, dementia, and adjustment disorder. Record review of Resident ID #2's Admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status was completed with a score of 0 out of 15, indicating severe cognitive impairment. Record review of Resident ID #2's care plan revealed the following focus care areas: -[DATE] states in part, I have a behavioral problem r/t [related to] Dementia with behaviors: Disruptive behavior: wandering, lack of impulse control, aggression, and refusal of care with interventions including, but not limited to, intervene as necessary to protect rights and safety of others. Monitor behavior episodes and attempt to determine underlying cause. -[DATE] and revised [DATE] states in part, I am/have the potential to demonstrate physical behaviors related to dementia, decreased impulse control with interventions including, but not limited to, When I become agitated, staff will intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggression staff to walk away calmly, and approach later and monitor/document/report to MD of danger to self or others, ([DATE])- 1:1 with staff until interdisciplinary team determines this is no longer necessary. -[DATE] states in part, I have the potential for psychosocial well being problem r/t negative interaction with another resident with interventions including, but not limited to, administer medications as ordered and consult psychiatry as needed. Record review for Resident ID #2 revealed the following: -[DATE] at 1:52 PM- Resident exhibiting disruptive behaviors at 4:00 PM. S/he was putting socks and bra in the sink and flooded the room. S/he was upsetting another resident with his/her intrusive behaviors. S/he was difficult to redirect and when staff attempted to redirect him/her, s/he became physically aggressive. -[DATE] at 1:31 PM- Resident exhibiting agitation and aggressive behaviors. S/he was angry when redirected to step aside. S/he started screaming and hitting staff. Record review of the [DATE] documentation Behavior monitoring report revealed on [DATE] during the day shift (7:00 AM - 3:00 PM) the resident was documented as physically aggressive toward others, expresses frustration and anger at others, making disruptive sounds, entering other resident's rooms or personal space and rummaging through their things. -[DATE] at 4:15 PM- Resident refusing all ADL's -[DATE] at 11:25 AM- Resident got into a physical altercation with another resident. -[DATE] at 10:08 PM- It was reported to this writer when the floor nurse called the family to report the transfer to the hospital after the altercation with another resident the family stated they were going to go to the hospital to make sure [s/he] does not get admitted . Upon the resident [return] from the hospital the [family member] was with [him/her]. -[DATE] at 10:47 PM- The resident returned to the facility and was placed on 15-minute checks. -[DATE] at 1:10 AM- Resident refused to stay in bed. S/he was going through drawers belonging to his/her roommate. Verbal redirection was provided without effect and one on one supervision (one staff member to one resident supervision) was provided. -[DATE] at 1:11 PM- Resident was observed going through the trash. When the staff attempted to redirect the resident s/he became aggressive and yelling out you are the devil. -[DATE] at 2:12 PM- Increased agitation noted. The resident was kicking, pushing and was unable to be redirected. -[DATE] at 8:17 AM- The resident was sent out for a Geri psych evaluation. Record review of a staff witness statement authored by the Nursing Assistant assigned to Resident ID #1 revealed that on [DATE] she was in the dining room when she heard a loud thump. She revealed she observed Resident ID #2 in Resident ID #1's room touching his/her personal items. Additionally, she revealed that Resident ID #1 was on the floor and bleeding badly. Record review of a 5-day investigation report submitted to the Rhode Island Department of Health on [DATE] by the facility reveals in part, [Resident ID #1's] account of the event remained consistent upon transfer to the hospital. Upon return from the hospital [Resident ID #1] was interviewed by the Administrator. When asked if the resident remember the incident [s/he] stated Yes, [Resident ID #2] came to my room and was going through my drawer. When I explained to [him/her] this was a [gender] room [s/he] went to hit me, but then I put my arms out as they are longer than [his/hers] to avoid it. Next thing I remember was being on the floor, and I yelled for help .[Resident ID #2] is monitored for behaviors of intrusive wandering and can be resistive to staff with care and redirection .and does have a remote history of behaviors aimed towards other residents .[Resident ID #1] returned to the facility that evening was diagnosed with a right hip fracture without surgical intervention due to comorbidities and the [family's] wishes .[Resident ID #1] has since expired . During a surveyor interview on [DATE] at approximately 3:35 PM with the Director of Nursing Services, she acknowledged that prior to the incident Resident ID #2 had exhibited physical aggression towards staff with redirection. Additionally, she was unable to provide evidence that Resident ID #1 was kept free from resident-to-resident abuse. Upon further interview with the Director of Nursing Services, she indicated that the following interventions were put into place after the incident: a) The facility completed a Quality Assurance and Performance Improvement Plan to review the incident and identify areas of improvement. b) The facility completed an audit of current residents that exhibit aggressive behaviors, and they identified if the appropriate treatment is in place, that the provider is aware of the behaviors and that the family is in agreement with the plan of care. c) Education was provided to all staff on how to manage residents that exhibit aggressive behaviors. d) The perpetrator in this incident was placed on a 1:1 status. S/he will remain on a 1:1 until the interdisciplinary team reassesses the efficacy of the interventions.

Based on record review and staff interview it has been determined that the facility failed to ensure that the residents were free from significant medication errors for 1 of 4 residents reviewed, Resident ID #2. Findings are as follows: Record review of a community reported complaint sent to the Rhode Island Department of Health on 6/23/2023 alleges that Resident ID #2 was neglected at the nursing home where s/he resides for short term rehabilitation. Record review revealed the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, hypotension (low blood pressure) and enterocolitis (inflammation of both the small intestine and the colon) due to clostridium difficile (C-Diff- a bacterial infection that cause watery or bloody diarrhea). 1. Review of a progress note dated 6/14/2023 at 7:34 PM authored by Nurse Practioner, Staff B, states reviewed labs- K (Potassium) critically low @ [at] 2.9 [normal potassium level is 3.6 to 5.2 millimoles per liter] .orders placed stat [immediately] in PCC [point click care] PO [by mouth] potassium 80 Meq (milliequivalent) potassium ER [extended released] over the next 4 hrs [hours] . An additional progress note dated 6/15/2023 at 3:21 AM, authored by Staff B, indicates to give potassium 40 mEq stat followed by potassium 20 mEq times two doses given one hour apart. Record review of the June 2023 Medication Administration Record (MAR) failed to reveal evidence that the resident received the two doses of Potassium 20 mEq one hour apart as ordered, after receiving the initial 40 mEq of Potassium. During a surveyor interview on 6/30/2023 at 11:46 AM with Staff B, she acknowledged prescribing the Potassium as the resident had a critically low Potassium value of 2.9. She indicated that she originally ordered the Potassium on 6/14/2023 and the facility called to clarify her order, which was the order written on 6/15/2023 at 3:21 AM. She further revealed that she was not made aware that the resident did not receive the two doses of Potassium 20 mEq one hour apart as ordered, after receiving the initial 40 mEq of Potassium. 2. Record review of a progress note dated 6/15/2023 at 12:46 PM authored by Nurse Practioner, Staff C, states .hx of CDIFF-likely reoccurring CDIFF- this would be patient's first reoccurrence to CDIFF- Treat with course of oral Vanco for first reoccurrence according to guidelines . Record review of the June 2023 MAR revealed an order for Vancomycin HCI oral suspension (antibiotic used to treat an infection) give 125 MG (milligram) by mouth every 6 hours for recurring c-diff for 10 days. Further review of the June 2023 MAR revealed that the resident missed 7 of 9 opportunities to receive the Vancomycin (there are two doses that are signed off as administered, although one of the doses that was signed as administered the resident was not in the facility as s/he was in the emergency room ). Record review of a progress note dated 6/16/2023 at 9:48 PM revealed that the resident continues, to have diarrhea, B/P [Blood pressure] this shift was low with a repeat of 71/55 mmHg . Additional record review reveals the resident was sent to the hospital on 6/17/2023 at 11:56 PM for evaluation. S/he was admitted to ICU (intensive care unit) at the hospital to rule out sepsis. The resident was found to be hypokalemic (low potassium) with potassium level of 2.2, hypotensive and was started on Norepinephrine (a medication used to treat hypotension). During a surveyor interview on 6/30/2023 at 11:18 AM with the Assistant Director of Nursing, she revealed that the Vancomycin was not administered to the resident because they had difficulty getting it from the pharmacy. During a surveyor interview on 6/30/2023 at 12:56 PM with Staff C, she acknowledged prescribing the Vancomycin on 6/15/2023 as the resident's white blood count was elevated. She further revealed that she was not made aware that the ordered Vancomycin was not being administered to the resident as ordered. During a surveyor interview on 6/30/2023 at approximately 1:00 PM with the Director of Nursing Services and the Regional Nurse, they were unable to provide evidence as to why the Vancomycin and the potassium were not given to the resident as ordered. During a surveyor interview on 7/3/2023 at 10:00 AM and at 10:28 AM, with the pharmacy technician and his supervisor, they revealed that they called the facility multiple times on 6/15/2023 regarding the Vancomycin order. They further indicated that the facility failed to return the call or to check on the medication delivery status until 6/17/2023, two days after the medication was ordered. They indicated that the Vancomycin was delivered to the facility on [DATE] at 6:00 PM.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive and consume food in the appropriate form for 1 of 4 residents observed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 2/13/2023 alleges in part, .almost choked on a pizza .does not have teeth .dentures were lost by the facility. Record review of a progress note dated 2/9/2023 at 10:36 PM states in part, .slice of pizza was given to resident by activities staff member .Res [resident] .showing visible sign of distress .started abdominal thrusts known as Helmlich [Sic] .a piece of pizza came out of [his/her] mouth . Record review revealed the resident was admitted to the facility in February of 2018 with diagnoses including, but not limited to, multiple sclerosis (a chronic, progressive disease of the central nervous system that can cause muscle weakness), dementia, anxiety, and mild cognitive impairment. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 out of 15, indicating mild cognitive impairment. Record review of a Speech Therapy document dated 2/10/2023 states in part, referred for ST [Speech Therapy] evaluation .choking episode with pizza .Pt's [patient] is edentulous [without natural teeth] .waiting for new dentures . Record review revealed a dietary order dated 1/6/2023 for .Mechanical Soft [foods that are easy to chew and swallow] texture . Record review of a document titled, NDD [National Dysphagia (difficulty swallowing) Diet] DYSPHAGIA ADVANCED (LEVEL 3) states in part, .Mechanical Soft Diet .Foods still need to be moist and in bite size pieces. Use this diet when Mechanical Soft is ordered .Foods to Avoid .Pizza . During a surveyor interview on 2/17/2023 at 12:20 PM with the Food Service Director, she provided the above-mentioned document and revealed those are the guidelines for the mechanical soft diet followed for the resident. During a surveyor interview on 2/17/2023 at 9:19 AM with the Speech Language Pathologist, she revealed the pizza consumed by the resident was not appropriate for a mechanical soft texture diet. During a surveyor interview on 2/16/2023 at 2:42 PM with the Activities Director, she revealed on the day the choking incident occurred, the facility was celebrating National Pizza Day and had pizza delivered to the facility for the residents. She further revealed the Activity Aides know what the residents can and cannot have relative to their diet order because they know the residents. Furthermore, she revealed the Activity Aides would ask the nurse if they were unsure of a resident's diet order. Additionally, she revealed she was able to access the resident's diet orders in the Electronic Medical Record, but acknowledged the slips are not provided to the Activity Aides for reference prior to any snack or drink distributions. She was unable to provide evidence that a system is in place for the Activity Aides to follow and understand resident specific diet orders. During a surveyor interview on 2/17/2023 at 9:08 AM with the Activity Aide, Staff C, she revealed staff were passing out pizza at approximately 3:45 PM on the day of the choking incident. She further revealed she noted the resident was turning red and ran to get the nurse. Additionally, she revealed the pizza was a triangular slice of pizza and was not cut up. Furthermore, she indicated if she is unsure of a resident's diet, she then would ask the nurse. A subsequent interview on 2/17/2023 at 2:15 PM with Staff C, she revealed she is unaware what a mechanical soft diet is and acknowledged she is not provided with a list of resident's diets prior to any snack or drink distributions. During a surveyor interview on 2/17/2023 at 9:25 AM with the Activity Aide, Staff D, she revealed that she was had given the resident the slice of pizza that s/he choked on. She further revealed she did not ask the nurse about his/her dietary restrictions prior to giving the resident pizza because I know the residents. During a subsequent interview on 2/17/2023 at 1:52 PM with Staff D, she was unable to explain what a mechanical soft diet is and acknowledged she is not provided with a list of resident's diets prior to any snack or drink distributions. Additionally, she revealed she would only ask the nurse what the resident's diet is if she didn't know the resident. During an interview with the Director of Nursing Services on 2/20/2023 at 2:30 PM, it was indicated that her expectation would be that the resident would receive a mechanical soft diet as ordered.

Based on surveyor observation record review and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to disinfecting blood glucose meters (a device used to monitor blood glucose) for 2 of 2 residents observed, Resident ID #s 14 and 367 and 1 of 2 residents observed during a wound treatment, Resident ID #75. Findings are as follows: According to the facility's policy revised October 2019, titled, Blood Glucose Meter Cleaning, Disinfecting and Storage states in part, Blood Glucose Meter must be appropriately cleaned and disinfected between uses .4. After use, the blood glucose meter must [be] cleaned and disinfected per manufacturer guidelines .6. Appropriate wipes are indicated in the manufacturer guidelines . According to the EVENCARE G3 Blood Glucose Monitoring System User's Guide, under Cleaning and Disinfecting Procedure for the Meter .the following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter: -Dispatch (R)Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8) -Medline Micro-Kill+ (Trademark)Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10) -Clorox Healthcare (R) Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12) -Medline Micro-Kill (Trademark)Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1) . Other EPA registered wipes may be used for disinfecting the EVENCARE G3 system, however, these wipes have not been validated and could affect the performance of your meter . 1. Surveyor observation on 1/4/2023 at 11:34 AM during the medication pass on the South 1 Unit with Licensed Practical Nurse, Staff A revealed the following: Staff A failed to disinfect the blood glucose meter before obtaining Resident ID #14's blood sugar. After obtaining the resident's blood sugar, Staff A then placed the blood glucose meter on the medication cart without disinfecting it. At 11:42 AM, Staff A was observed obtaining Resident ID #367's blood sugar with an additional blood glucose meter. Staff A failed to disinfect that blood glucose meter prior to obtaining his/her blood sugar. After obtaining the resident's blood sugar, she placed the blood glucose meter next to the other blood glucose meter on the medication cart. Additionally, after Staff A obtained both residents' blood sugars, she entered the medication room at approximately 12:00 PM, which is behind the nurse's station, to retrieve the Spectrum Hand Sanitizer Wipes and proceeded to clean each blood glucose meter with the hand sanitizer wipes. During a surveyor interview immediately following the observations with Staff A, she revealed, We used to use bleach wipes to disinfect the blood glucose monitor, but the battery was losing charge too quickly with those wipes, so we use the Spectrum Hand Sanitizer wipes. Further review of the manufacturer's instructions on the container of the Spectrum Hand Sanitizer wipes revealed the wipes are used to decrease bacteria on the skin .warning for external use only on hands .hand sanitizer wipe (70%) alcohol . During a surveyor interview on 1/4/2023 at 12:26 PM with the Infection Preventionist (IP), after reviewing the facility policy and procedure for disinfecting the blood glucose meters and the manufacturer's instructions for the Spectrum Hand Sanitizer wipes, she acknowledged these were not the appropriate wipes to disinfect the blood glucose meter. During a subsequent surveyor interview with both the IP and Staff A on 1/4/2023 at 12:33 PM, Staff A revealed she just used the Spectrum Hand Sanitizer wipes today, further revealing that they didn't have the bleach wipes available on the unit. The IP then revealed that she would provide the bleach wipes to Staff A. Record review of additional resident's blood sugars obtained by Staff A on 1/4/2023 revealed the following: -Resident ID #3 at 8:35 AM and 11:30 AM -Resident ID #52 at 8:06 AM and 11:28 AM -Resident ID #108 at 8:00 AM -Resident ID #14 at 8:40 AM and 11:36 AM -Resident ID #17 at 8:19 AM -Resident ID #219 at 8:15 AM During a surveyor telephone interview on 1/6/2023 at 12:20 PM with Staff A, she revealed she worked at the facility full time, often working double shifts, on all units, but usually the South 1 Unit. Additionally, she revealed when she is working, she obtains all residents' blood sugars, as she is the sole nurse on the unit. Further, she revealed she usually uses bleach wipes to disinfect the blood glucose meters, but that day on 1/4/2023, she used the Spectrum Hand Sanitizer wipes because the bleach wipes were not available on the unit. Lastly, she revealed she was unaware that she could not use the hand sanitizer wipes to disinfect the blood glucose meter. During an interview on 1/4/2023 at 3:34 PM with the Director Nursing Services (DNS), she acknowledged Staff A failed to follow the policy and manufacturer's guidelines for disinfecting blood glucose meters. The DNS further revealed there is a resident in the facility, Resident ID #148, that has a history of Hepatitis B infection. Record review revealed Resident ID #148 was admitted to the facility in June of 2022 with diagnoses including, but not limited to, Hepatitis B infection (bloodborne pathogen disease that is commonly spread by exposure to infected bodily fluids, i.e. blood) and diabetes mellitus. Additionally, record review revealed Resident ID #148 has the following orders dated 9/22/2022: -Glucagon 1 mg (milligram), inject 1 ml (milliliter) intramuscularly as needed for Blood Sugars less than 60 and unconscious . -Glucose gel 40% Give 1 application by mouth as needed for Blood Sugars less than 60 and conscious, recheck blood sugar in 15 minutes . Further record review revealed Resident ID #148 had his/her blood sugar checked on 12/4/2022 and 12/17/2022. Staff A failed to clean and disinfect blood glucose meters per device and disinfectant manufacturer's instructions for use. They are used for more than one resident, and there is a resident with a known bloodborne pathogen in the facility which potentially places other residents at risk for exposure to bloodborne pathogens. 2. Record review of the facility policy titled, Dressings, Dry/Clean states in part, .Steps in the Procedure 3. Use disposable cloth .to establish a clean field on the resident's overbed table. 4. Prepare supplies on the clean field using clean technique .6. Prepare a plastic bag or wastebasket for discarded materials .8. Perform hand hygiene and put on clean gloves. Remove soiled dressing and discard into designated container. 10. Remove gloves and perform hand hygiene. Put on clean gloves .18. Discard disposable items into designated container. Remove gloves and discard. Perform hand hygiene . Record review for Resident ID #75 revealed s/he was admitted to the facility in September of 2022 with diagnoses including, but not limited to, pressure ulcer (a localized injury to the skin or underlying tissue due to pressure) of the sacral region, stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) and osteomyelitis (infection of the bone) of vertebra, sacral, and sacrococcygeal region. During a surveyor observation on 1/5/2023 at 10:40 AM of Licensed Practical Nurse, Staff J completing the resident's dressing change, she was observed removing the old dressing from the resident's sacral ulcer, which was saturated with exudate (drainage from wound). Staff J then placed the saturated soiled dressing adjacent to the clean dressing on the bedside table, failing to maintain a clean field. Staff J failed to remove her dirty gloves and perform hand hygiene after removing the soiled dressing as per the policy. With the soiled gloves, she continued to complete the resident's dressing change. After the dressing change was completed, Staff J removed one dirty glove from her hand, placed sanitizer in the ungloved hand, then with the gloved hand, she picked up the soiled dressing and carried it out to the hallway to discard it, instead of using the designated container in the room, as per the policy. During a surveyor interview immediately following the above observation with Staff J, she could not explain why she did not follow the procedure for the wound dressing change. During a surveyor interview on 1/5/2023 at 12:14 PM with the DNS, she acknowledged Staff J did not follow the policy for dressing changes. 39496 41542

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 2 resident's closed records reviewed for medication administration, Resident ID #164, and 1 of 2 residents observed relative to intravenous (IV) medication administration, Resident ID #375. Findings are as follows: 1. Record review revealed Resident ID #164 was admitted to the facility in September of 2022 with diagnoses including, but not limited to, heart-valve replacement, atrial fibrillation (AFIB, rapid and irregular heartbeat), hypertension (high blood pressure), congestive heart failure (CHF-a condition where your heart is not strong enough to pump adequately) and chronic kidney disease. Record review revealed the following physician's orders for anticoagulant (blood thinner) medications: - 9/27/2022, start date 9/27/2022, Coumadin (Warfarin Sodium) Give 1 mg [milligram] orally in the evening every Mon, Tue, Thu, Sat for [heart] valve & AFIB INR [international normalized ratio, blood test used to determine the clotting tendency of blood] goal 2.5 -3.5 . -9/27/2022, start date 9/28/2022, Coumadin .Give 2 mg orally in the evening every Wed, Fri, Sun . Record review revealed a physician's order dated 10/5/2022 for, INR in the morning . Review of the Lab Results Report dated 10/6/2022, revealed the blood was drawn on 10/6/2022 at 6:49 AM and the results were reported to the facility on [DATE] at 12:24 PM. The lab report results indicated an, INR 5.2 HH [high value]. Further review of the 10/6/2022 Lab Results Report revealed that the lab results were reviewed by Licensed Practical Nurse, Staff I on 10/6/2022 at 2:25 PM. Record review of a provider progress note authored by the Registered Nurse Practitioner (RNP), Staff F, states in part, Date of Services: 2022-10-06 .Chief Complaint: Abnormal Labs .PT [patient] seen today for abnormal labs, INR 5.2 .Assessment and Plan: .Supratherapeutic [an amount of the drug above the therapeutic level] INR : Hold Coumadin, Give Vitamin K [to decrease INR level] 5 mgPO [by mouth] x 1 . Further record review failed to reveal evidence of an order to hold Coumadin on 10/6/2022. Additional record review revealed a physician's order dated 10/6/2022 at 2:26 PM and entered into the system by the RNP, Staff F, for Warfarin Sodium Tablet 5 MG Give 1 tablet by mouth in the evening for treating/preventing blood clots for 1 day . Record review of the October 2022 Medication Administration Record (MAR) indicated the Warfarin 5 mg was administered on 10/6/2022 at 5:11 PM. Additional record review of the Lab Results Report revealed that an INR was obtained on 10/7/2022 at 6:40 AM with a documented result of 6.4. An additional INR was obtained on 10/8/2022 at 10:52 AM with a documented result of 6.5. During an interview with the Director of Nursing Services (DNS) on 1/6/2023 at 11:53 AM and again at 12:13 PM, she acknowledged the INR results obtained on 10/6/2022 were supratherapeutic and that the resident received Coumadin 5 mg on 10/6/2022. During a surveyor interview on 1/9/2023 at 1:28 PM with the RNP, Staff F, she was unable to explain why the Warfarin 5 mg was ordered on 10/6/2022 at 2:26 PM and administered at 5:11 PM, following the supratherapeutic INR results of 5.2. She further revealed that the Date of Services on her provider progress note indicates the date of the orders. 2. Record review for Resident ID #375 revealed s/he was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, endocarditis (infection of the inner lining of the heart). Record review revealed a physician's order dated 1/3/2023 with a start date of 1/4/2023 for Ceftriaxone Sodium Solution [antibiotic] Reconstituted [the process of adding a liquid diluent to a dry ingredient] Use 2 gm [grams] intravenously [via the vein] in the morning for endocarditis . Review of the medication administration instructions on the Ceftriaxone intravenous [IV] bag indicated to mix the medication in 50 ML (milliliters) of normal Saline and infuse over 30 minutes. During a surveyor observation on 1/9/2023 at 8:58 AM revealed Registered Nurse, Staff K, attempting to administer Ceftriaxone intravenously as ordered. However, in an attempt to prime (run IV fluid through the IV tubing, from the IV bag, to remove all air prior to attaching the IV tubing to the patient) the IV bag for administration, a large amount of the IV medication was allowed by Staff K to run through the IV tubing and into the trash can. Additionally, Staff K continued to attempt to administer the medication, even though the medication IV bag was empty and the IV pump would not start the infusion. During a subsequent observation on 1/9/2023 at approximately 9:17 AM, the Assistant Director of Nursing Services (ADNS) entered the resident's room and acknowledged that there was not enough fluid in the medication bag and a new medication bag was needed. During a surveyor observation on 1/9/2023 at 9:26 AM, Staff K attempted to administer the new bag of IV medication and again while priming the IV tubing, allowed the IV medication to run into the trash, having wasted almost all of the IV medication in the IV bag. Additionally, the observation of the IV medication infusion began at 9:33 AM. During a surveyor observation on 1/9/2023 at 9:42 AM, the IV pump began alarming. During a surveyor interview on 1/9/2023 at 9:48 AM and 12:38 PM with Staff K, she revealed the medication had finished infusing when the pump began alarming. Additionally, she acknowledged the medication had not been infused over 30 minutes as per instructions on the IV medication bag. During a surveyor interview on 1/9/2023 at approximately 2:30 PM with the DNS, she could not provide evidence that the medication was infused per the instructions on the IV bag.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents are offered sufficient fluid intake to maintain proper hydration and health for 1 of 3 residents reviewed, Resident ID #1, and failed to ensure residents receive nutritional supplements to maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed, Resident ID #3. Findings are as follows: Record review of an undated facility policy, titled, Resident Hydration and Prevention of Dehydration states in part, .This facility will strive to provide adequate hydration and to prevent and treat dehydration .Minimum fluid needs will be calculated and documented on .significant change assessments .Nurses will assess for .dehydration during daily care .Orders may be written for extra fluids to be encouraged .Nursing will monitor and document fluid intake . 1. Record review for Resident ID #1 revealed s/he was originally admitted to the facility in January of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note dated 10/9/2022 at 11:58 AM, stated in part, Found resident unresponsive @ [at] approx. [approximately] 7:45am;; called 911 .resident possibly had a [CONDITION(S)]/stroke . and was admitted to the hospital on 10/9/2022. Review of the hospital record indicated the resident was admitted to the hospital with a problem list including, but not limited to, AMS (altered mental status), [CONDITION(S)], bilateral humerus (bone of upper arm) fractures, and AKI (acute kidney injury). Additionally, the resident was medically cleared for discharge on 10/13/2022. Review of the hospital COC (continuity of care) form dated 10/13/2022 revealed the resident had a medical procedure requiring IV contrast (a solution given through a vein that helps highlight and outline organs, blood vessels, and other structures from other tissues during imaging. IV contrast can reduce blood supply to the kidneys causing potential harm). Further review of the COC form revealed a lab value for creatinine (a blood test to assess kidney function) conducted on 10/9/2022, the day of hospital admission, of 1.59, which is above the normal range of 0.64-1.27 MG (milligrams)/DL (deciliter). Further review revealed the creatinine level improved with fluid and was 1.48 MG/DL on 10/13/2022, the day of discharge from the hospital and readmission to the facility. Furthermore, the COC indicated, .continue to hydrate patient as patient received contrast. Record review of the resident's orders upon readmission to the facility failed to reveal evidence of an order to continue to hydrate the resident. Additionally, review of the hospital COC form revealed in part, .Suspect [CONDITION(S)] as [s/he] also had bilateral humerus fracture most likely a sequelae [consequence of a previous condition or injury] from violent convulsions .Orthopaedic Discharge Instructions .Non weight bearing [NWB] bilateral upper extremities in gunslinger slings . Review of a nursing progress note dated 10/13/2022 at 3:59 PM revealed in part, the resident was readmitted for .possible [CONDITION(S)] activity with dislocation of both shoulders .Slings to be worn at all times, NWB . Further review of a provider progress note dated 10/14/2022 revealed .Bilateral shoulder fracture dislocations: continue shoulder immobilizers . Review of a care plan initiated 2/1/2022 revealed a goal stating in part, I will be free from s/sx [signs/symptoms] of dehydration . with an intervention to Encourage adequate fluid and meal intake. Additionally, the care plan was not revised to include a focus area for hydration. Record review of a nutrition progress note written by the Dietitian dated 10/17/2022 at 3:28 PM revealed in part, .Estimated needs .Fluid: 2400ml .dependent on staff for meals .Nutrition Goals .Resident will maintain adequate hydration status . Review of the record failed to reveal evidence that the resident's fluid intake was documented or that the resident was provided with adequate hydration. Review of a progress note dated 10/17/2022 at 1:23 PM, revealed the resident .reported not feeling well. Resident appeared very sweaty and clammy: crackles [abnormal lung sound] heard in left base . Further record review revealed a chest X-Ray was obtained on 10/17/2022, which revealed [CONDITION(S)], and an order was obtained to administer [MEDICATION(S)] (drug to reduce extra fluid in the body) and to .Monitor fluid status . Record review revealed [MEDICATION(S)] ([MEDICATION(S)]) was administered on 10/17/2022 at 7:42 PM and on the morning of 10/18/2022. Further review of a provider progress note on 10/18/2022 at 1:01 PM revealed in part, Pt [patient] had two doses of [MEDICATION(S)] .lab 10/18/22 reviewed .Creat [creatinine] 1.73 .possible hypovolemia [low fluid volume circulating in the body] .stop [MEDICATION(S)], proper oral hydration . Further review of a progress note on 10/21/2022 at 2:35 PM revealed in part, .sent out 911 via stretcher r/t [related to] change in mental status. Resident refused breakfast and lunch. Appears very sleepy, diaphoretic [excessive sweating], skin clammy like . Review of the hospital discharge summary dated 10/25/2022 revealed upon presenting to the ER (emergency room ) on 10/21/2022, .sodium was elevated at 155 [normal range 135-145MEQ [milliequivalent]/L [Liter] .creatinine 1.92 [normal range 0.64-1.27MG/DL] .[s/he] looked clinically dry, and was felt to be dehydrated .admitted to the medical service for further hydration. Additional review of the discharge summary revealed in part, .Patient to be offered water .every 1-2 hours at nursing home .Prerenal AKI [acute kidney injury] .secondary to dehydration . Review of a progress note dated 10/25/2022 at 9:46 PM revealed the resident was readmitted from the hospital. Additional review of a progress note dated 10/26/2022 at 10:21 AM revealed in part, .readmitted .with altered mental status, [CONDITION(S)] [high sodium levels in the blood associated with water loss] and acute [CONDITION(S)] [altered brain function]. During ER visit, [s/he] was dehydrated and started on D5 W [intravenous fluid replacement] . During a surveyor observation on 10/26/2022 at 11:19 AM and subsequent interview with the resident, his/her lips appeared dry, and the resident stated, mouth dry, can't talk. During a surveyor interview with the Nurse Practitioner, Staff D, on 10/26/2022 at 2:08 PM, she was asked to clarify the provider progress note dated 10/18/2022 regarding proper oral hydration, she revealed that she expects the resident to receive 120 milliliters (mL) to 240 mL of fluid three times a day in addition to meals. Additionally, during a surveyor interview with Nurse Practitioner, Staff E, on 10/26/2022 at 2:26 PM, she acknowledged she assessed the resident by nursing staff request. She revealed she authored the 10/18/2022 progress note that was co-signed by Staff D. When asked to clarify the phrase, proper oral hydration, She indicated the resident needed to be given additional fluids. She further revealed she gave the nursing staff a verbal order, but could not remember who it was she spoke to. During a surveyor interview with Licensed Practical Nurse, Staff A, on 10/26/2022 at 2:41 PM, she revealed she worked on 10/18/2022, but was unaware of the verbal orders relating to proper oral hydration. During a surveyor interview with Unit Manager, Staff B, on 10/26/2022 at 2:45 PM, she acknowledged she worked on 10/18/2022, but was unaware of the verbal orders for proper oral hydration. She further revealed if she was aware of the order for proper oral hydration, she would notify the Dietitian and formulate a plan of care regarding how much fluid to provide and frequency to give additional fluids. During a surveyor interview with the Director of Nursing Services on 10/26/2022 at 3:26 PM, she was unable to provide evidence that the care plan was revised to ensure the resident receive proper oral hydration. Additionally, she was unable to provide evidence that his/her fluid intake was monitored and documented as per facility policy. 2. Record review for Resident ID #3 revealed s/he was originally admitted to the facility in April of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Related Diagnoses; MODERATE PROTEIN-CALORIE MALNUTRITION .Give 120cc [cubic centimeter] .TID [3 times a day] . Record review revealed the resident has a care plan dated 5/6/2019 for .is at potential for nutritional risk r/t [related to] recent wt [weight] loss .Hospice care initiated and weight loss and nutrition decline anticipate . with intervention to include but not limited to, .Supplements as tolerated. Diabetic House Supplement 120cc TID . Record review failed to reveal evidence that the house supplement was given as ordered or that the resident refused. During an interview with the Unit Manager, Staff F, on 10/27/2022 at 2:40 PM, she acknowledged that the house supplement was not given as ordered since July of 2021.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide adequate supervision to prevent an accident for 2 of 3 residents who are at risk for wandering and/or elopement, Resident ID's #1 and 2. Findings are as follows: 1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2022, with diagnoses including, but not limited to, dementia, major depressive disorder and [CONDITION(S)]. Review of the hospital discharge paperwork dated 4/5/2022 revealed in part, that the resident presented .to the hospital for eloping from the apartment and wandering the streets . Additional review of this document revealed an Assessment and Plan which included .continue to require monitoring with 1:1 [one on one] sitter due to elopement risk. Record review of a document labeled NOTIFICATION OF ADMISSION revealed in part, wander & elopement risk. Record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating his/her cognition is severely impaired. Record review of the admission Wander/Elopement Risk Evaluation dated 4/6/2022 revealed the resident was at high risk for wandering. Further review of this document failed to indicate that s/he had a history of eloping or was at risk for elopement. Review of the resident's care plan dated 4/21/2022 failed to reveal evidence that a focus for wandering/elopement was in place. Record review of a nursing progress note dated 6/4/2022 revealed At approx. 6:00pm nurse on N3 [North 3] unit was unable to locate [Resident ID #1] .Search of all units and facility conducted. Unable to locate [Resident ID #1] .Resident was located by police and returned to facility at approx. 9:30pm .resident noted with blisters to bilateral feet . Record review of the resident's Treatment Administration Record (TAR) revealed an order with the start date of 6/5/2022 for Skin prep to closed blister on right ball of foot .every shift for Wound care. Additional review of the TAR revealed additional orders with the start dates of 6/6/2022 for Open blister to left ball cleanse with NS [Normal Saline] pat dry and apply [MEDICATION(S)](Silicone boarder gauze) on left ball of foot Change daily . and Open blister to right ball cleanse with NS pat dry and apply [MEDICATION(S)] (Silicone boarder gauze) on right ball of foot Change daily one time a day for wound care . During a surveyor interview with the Administrator and the Director of Nursing Services (DNS) on 6/6/2022 at 1:38 PM, they revealed that the resident exited the secured unit by means of a staff member using the elevator. They further revealed that the resident exited through the main entrance doors and that there was no staff member at the receptionist desk at the time of the elopement. Additionally, they revealed the police were notified at 7:20 PM, approximately 1 hour and 20 minutes after the resident was unable to be located, and that the resident was found by the police approximately four miles away from the facility. During a surveyor interview with Dietary Aid, Staff A on 6/6/2022 at 2:58 PM, she revealed that at dinner time on 6/4/2022 she brought a dietary cart to the secured dementia unit. Resident ID #1 was attempting to enter the elevator pushing another resident in a wheelchair. She further revealed that Resident ID #1 was not wearing employee identification and did not verify whom s/he was prior to leaving the secured unit with the resident. She stated that the resident told her she was a nurse leaving the floor at the end of her shift. Additionally, she stated that she rode the elevator to the 1st floor with the resident. During a surveyor interview with the unit manager on 6/6/2022 at 3:33 PM, she revealed that the resident had previously exited the locked unit via an ajar stairwell door but was easily redirected back onto the unit. She further revealed that the resident was not wearing a wander guard prior to the elopement. Additionally, she revealed that the resident was assessed to have blisters to his/her bilateral feet upon returning to the facility after the elopement. 2. Record review revealed that Resident ID #2 was admitted to the facility in January of 2019 with diagnoses including, but not limited to, dementia, major depressive disorder and adjustment disorder with mixed anxiety and depressed mood. Record review of the MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, indicating his/her cognition is severely impaired. Record review of a Wander/Elopement Risk Evaluation dated 4/19/2022 revealed the Resident currently wanders .a high risk for wandering. Record review of a progress note dated 5/10/2022 revealed the resident was wandering room to room .with blood on both hands .resident had a razor in [his/her] hand and [s/he] had a small cut on the right thumb . Record review of the May 2022 TAR revealed an order with the start date of 5/11/2022 stating a cut on right thumb, cleanse with ns, apply [MEDICATION(S)] ointment and cover with DCD [Dry Clean Dressing] twice daily . Further review of this order revealed this treatment was in place for 9 days. During a surveyor observation of the secured dementia unit on 6/6/2022 at approximated 3:30 PM, Resident ID #2 was observed wandering the unit and exiting another resident's room holding an incontinent brief and a packet of fluid thickener. During a surveyor observation on 6/7/2022 at 11:40 AM, it was revealed that the unit shower room door was open and unlocked. Further observation revealed the tub room was unlocked with personal hygiene supplies on storage shelving. Additionally, razors were discovered on a low shelf in the unlocked unit tub room including, 1 uncovered disposable razor with hair in the blades, 2 additional uncovered disposable razors, 5 disposable razors out of original packaging with plastic blade covers on them, and 2 unopened packages of multiple disposable razors. During a surveyor interview with Registered Nurse, Staff B on 6/7/2022 at approximately 11:45 AM, she revealed the razors should be kept in the locked room behind the nurses' station. She acknowledged that the razors were easily accessible to the residents and could be potentially harmful. During a surveyor interview with the unit manager on 6/7/2022, she revealed that the razors were typically stored in the unlocked tub room. She acknowledged that this was unsafe practice and that the razors should be stored where they are not easily accessible to cognitively impaired residents. During a surveyor interview with the DNS on 6/7/2022 at 12:01 PM, she was to unable to explain why razors were stored in an unlocked room on the dementia unit. Additionally, she acknowledged that razors should be kept in a locked medication room. Based on review, past non-compliance was identified for F689-J.

Based on record review and staff and interview, it has been determined that the facility has failed to ensure that residents are free of significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported incident sent to the Rhode Island Department of Health, dated 3/1/2022, states in part .Resident was admitted .with opiate withdrawal .Resident was prescribed [MEDICATION(S)] [ a medication used for opioid dependence]. The three days prior to hospitalization , resident was not receiving [his/her] [MEDICATION(S)] resulting in [him/her] coming to the hospital. Record review reveals this resident was admitted to the facility in February of 2022, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Further record review reveals a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet sublingually in the evening. Record review of the February Medication Adminitration Record revealed that the resident did not receive the [MEDICATION(S)] on 2/25/2022, 2/26/2022, and 2/27/2022. Record review of the Narcotic Book revealed the resident received their last dose of [MEDICATION(S)] on 2/24/2022. Record review of a nursing progress note, dated 2/28/2022, states in part .Patient sent to ER [emergency room ] .related to N/V/D [nausea, vomiting and diarrhea]. Patient w/o [without] [MEDICATION(S)] for w/d [withdrawal] of opiods, Day 3 unable to fill prescription Record review of the hospital paperwork states in part .past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] .presents today from [nursing home] after they stopped [his/her] Subaxone prescription .[S/he has had abdominal pain, vomiting and some chest pain with shortness of breathe .as well as diaphoresis [sweating] and feeling of general malaise. [S/he] is endorsing persistent, non-radiating, moderate, cramping, epigastric pain as well as non-radiating, no associated symptoms, chest pain persistent .Also endorses nausea, vomiting . Additional record review of the hospital paperwork revealed the resident's blood pressure upon arrival was 224/119 (normal blood pressure is 120/80). The resident was administered a fluid bolus alongside multiple doses of intravenous [MEDICATION(S)] (a medication used to treat nausea), [MEDICATION(S)] (a medication used to treat high blood pressure), [MEDICATION(S)] ( a medication used to treat pain) and [MEDICATION(S)]. Resident was admitted to the hospital for opiate withdrawal, more opiates and [MEDICATION(S)] for blood pressure management. During an interview with the Director of Nurses and Administrator on 3/3/2022 at approximately 3:00 PM, they acknowledged the resident did not receive his/her [MEDICATION(S)] as ordered on 2/25/2022, 2/26/2022, and 2/27/2022.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 2 of 7 residents sampled for medication review (Resident IDs #3 and 8). 1. Record review for Resident ID# 3 on 4/4/2019 at approximately 3:00 PM revealed s/he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Additional record review revealed an INR (blood laboratory test used to monitor individuals who are being treated with [MEDICATION NAME] with narrow therapeutic range of 2.0 - 3.0) result dated 3/22/2019 with a level of 2.7. Licensed Practical Nurse Staff C reported the INR level to the doctor on this date and received a verbal physician's orders [REDACTED]. Recheck INR on 3/29/2019. Further review of Resident ID#3's clinical record revealed that the recheck of the INR on 3/29/2019 had not been completed. During an interview with the DNS on 4/4/2019 at approximately 3:25 PM surveyor findings were brought to his attention and he acknowledged that the resident had not received his/her [MEDICATION NAME] since 3/28/2019 and did not have their INR levels checked on 3/29/2019 as ordered. Anticoagulation in [MEDICAL CONDITION] Fibrillation https//www.ncbi.nlm.nih.gov/pmc/articles/PMC 91/ states in part Patients with [MEDICAL CONDITION] (AF) are at increased [MEDICAL CONDITION] risk (stroke), and they suffer more severe [MEDICAL CONDITION] with worse outcomes .Most [MEDICAL CONDITION] complications of AF are eminently preventable with oral anticoagulation .AF increases the risk of stroke fivefold .the benefit of [MEDICATION NAME] ([MEDICATION NAME]) is dependent on the amount of time that patients spend with their INRs in therapeutic range .The optimal INR .for protection against [MEDICAL CONDITION] (stroke) has been established as 2.0-3.0, with increased risk of [MEDICAL CONDITION] and bleeding complications outside of this range. The resident's INR had fallen to 1.5, which is sub theraputic,when tested on [DATE], the day the medication omission was discovered, putting the resident at increased risk of stroke. During an additional interview with the DNS on 4/4/2019 at approximately 4:00PM, he indicated that while Nurse Staff C had entered the correct order for the [MEDICATION NAME] with the correct stop date of 3/28/2019, she failed to enter an order for [REDACTED]. 2. Record review for Resident ID#8 revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additional record review revealed s/he had MEDICATION ORDERS FOR [REDACTED]. On 1/29/2019 Resident ID#8 reported to nursing staff s/he did not receive his/her 12:00PM medications as scheduled for that date. Review of the Medication Administration Record [REDACTED]. During an interview immediately following the incident Staff B indicated she poured the medication, lost track of time and discarded it into the sharps container. According to the facility investigation, the sharps container was opened, and both the [MEDICATION NAME] and [MEDICATION NAME] were found, validating that the resident had not received her 12:00PM medications. During an interview with the DNS on 4/5/2019 at approximately 2:00PM he acknowledged the resident had not received his/her medication as ordered.