Every finding on record at Mansion Nursing and Rehab Center

Based on surveyor observations, record review, and staff interview, the facility failed to ensure that food is stored in accordance with professional food safety standards relative to the main kitchen.Findings are as follows:1. Review of the Rhode Island Food Code 2022 edition states in part, .Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.refrigerated, Ready-to-eat, Time/Time Temperature Control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed.(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises.3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition.A food specified in 3-501.17 (A) or (B) shall be discarded if it.Is in a container or package that does not bear a date or day.Section 3-602.11 Food Labels states in part, .(B) Label information shall include: (1) The common name of the food .During the initial tour of the main kitchen on 7/22/2026 at 9:36 AM, in the presence of the Food Service Director (FSD), revealed the following:A) A reach-in refrigerator containing the following: Stainless-Steel Steam Table Pan containing Vanilla pudding with a use-by date of 7/20A plastic disposable plate with pasta and a dinner roll, covered with plastic wrap, unlabeled and undated. B) An additional reach-in refrigerator revealed a 1/2-gallon of Sweet Baby Ray's Buffalo wing sauce, dated 1/26.Record review of the manufacturer's labeled that the buffalo wing sauce should be kept no longer than 4 months after opening.C) A chest freezer containing an undated large clear bag of donuts.D) An additional chest freezer contained the following:Breaded pieces of meat in a sealed plastic bag, unlabeled and undated.A package of what appeared to be raw chicken unlabeled and undated. During a surveyor interview on 7/22/2026 at 9:55 AM, the FSD acknowledged the above findings.During a subsequent surveyor observation on 7/22/2026 at 10:04 AM with Cook, Staff A, revealed the following: E) A chest freezer containing the following: 2 plastic bags containing 6 pieces of frozen French Toast, each bag was unlabeled and undated.A package wrapped in plastic approximately 5 x 4 labeled Ginger that was undated. The contents of the package were noted to have green streaks. During a surveyor interview immediately following the above observation with Staff A, she acknowledged the above findings and stated that the items should have been properly labeled and dated.2. Review of the Rhode Island Food Code, 2022 Edition, section 2-402.11 states in part, .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints .that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens .During a surveyor observation on 7/22/2026 at 10:02 AM Dietary Aide, Staff B, was observed handing food items without a hair net or beard restraint.During a surveyor interview immediately following the above observation, Staff B acknowledged that he was not wearing a hair net or beard restraint and should have been.During a surveyor interview on 7/22/2026 at 11:15 AM with the Administrator, she was unable to provide evidence that food is stored in accordance with professional food safety standards.

Based on record review and staff interview, it was determined that the facility failed to provide evidence of an ongoing system to monitor, track, measure and evaluate the facility's Quality Assurance and Performance Improvement (QAPI) program to ensure improvements are realized and sustained.Findings are as follows:Record review of the facility's QAPI program documents failed to reveal evidence that the facility has monitored, tracked, measured, and evaluated any of their performance improvement projects.During a surveyor interview on 7/27/2026 at 11:44 AM with the Administrator, she was unable to provide evidence of monitoring, tracking, measuring, and evaluating any of their performance improvement projects.

Based on record review and staff interview, the facility failed to ensure the continuing competencies of nurse aides (NA), no less than 12 hours per year for 3 of 5 NAs that have been employed at the facility for more than one year, Staff C, D, and E.Findings are as follows: Record review revealed that Staff C, did not receive at least 12 hours of training.Record review revealed that Staff D, did not receive at least 12 hours of training.Record review revealed that Staff E, did not receive at least 12 hours of training.During a surveyor interview on 7/27/2026 at 2:50 PM with the Director of Nursing Services, she was unable to provide evidence that the above-mentioned staff had completed at least 12 hours of mandatory competencies as required.

Based on clinical record review, resident, and staff interview, the facility failed to provide care and services in accordance with professional standards of practice and the resident's comprehensive care plan by failing to coordinate a consultation with Gastroenterology (GI; a medical specialty that focuses on the digestive system, including the esophagus, stomach and intestines) for 1 of 1 resident reviewed who was re-admitted to the facility with recommendations for further evaluation of a possible mass in his/her colon, Resident ID #7.Findings are as follows:Record review revealed the resident was re-admitted to the facility in May of 2026 with a diagnosis including, but not limited to, neurogenic bowel (the loss of normal bowel control and function caused by damage to the nervous system). Record review of a hospital document dated 5/9/2026, titled After Visit Summary, indicates a CT scan (imaging that uses x-rays to view cross sectional images inside the body) was performed with findings of a possible mass in the colon, which required further evaluation. The report further indicates to arrange for an outpatient appointment with Gastroenterology for a colonoscopy to further evaluate the possible mass seen on the CT Scan imaging. Record review of the nursing progress note dated 5/9/2026 at 1:36 PM, authored by Registered Nurse, Staff F, revealed that she received a report from the hospital indicating that Resident ID #7 had an abdominal CT scan performed which showed a questionable mass in the resident's colon and that s/he needed a follow up appointment with GI for a colonoscopy.During a surveyor interview on 7/24/2026 at 12:10 PM with Staff F, she revealed that she was not aware of an appointment made for the resident for a follow up consultation with a GI specialist. During a surveyor interview on 7/24/2026 at 12:22 PM with Licensed Practical Nurse, Staff G, she was unable to provide evidence that an appointment was made for Resident ID #7 for a consultation with a GI specialist.During a surveyor interview on 7/24/2026 at approximately 1:00 PM with the Director of Nursing Services, she was unable to provide evidence that an appointment was made for Resident ID #7 to follow up with a GI specialist for a possible mass in his/her colon and she would expect that nursing would have followed through with scheduling an appointment. During a surveyor interview on 7/27/2026 at approximately 3:00 PM with the resident's Physician, he was unaware of the hospital recommendation for the resident to be further evaluated by a GI specialist and would have expected that a follow up appointment would have been made.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing for 1 of 1 resident reviewed with a stage 3 pressure ulcer (full-thickness skin loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed), Resident ID #42.Findings are as follows:Record review revealed the resident was admitted to the facility in March of 2026 with diagnoses including, but not limited to, Alzheimer's disease and type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage caused by long-term high blood sugar). Record review of an admission Minimum Data Set assessment dated [DATE], indicated that the resident has an unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because the wound bed is obscured by slough; yellow, white, or tan dead tissue or eschar; a thick black or brown scab).Record review of the current physician's orders revealed a wound treatment order, dated 7/12/2026, to cleanse the left heel wound with wound cleanser, apply calcium alginate with silver (a sterile, absorbent medical wound dressing used to manage heavy drainage and fight infection), skin prep the peri (surrounding) wound and cover the wound with a bordered gauze every Monday, Wednesday, and Friday. Record review revealed the Consultant Wound Physician assessed the resident's left heel pressure ulcer on 7/20/2026 and indicated that the wound treatment caused blistering to the surrounding tissue due to accumulated drainage. Recommendations were made to discontinue the current treatment and implement a new treatment plan to cleanse the left heel daily with Vashe wound cleanser (a type of wound cleanser with a natural germ fighting formula), followed by a Xeroform gauze dressing (a sterile non-adherent fine-mesh gauze used to protect and maintain a moist wound environment) and cover the wound with a bordered gauze daily.Further review of the physician's orders on 7/27/2026 failed to reveal evidence that the new wound treatment recommendation made by the Wound Physician on 7/20/2026 was implemented.Record review of the July 2026 Medication Administration Record failed to reveal evidence that the new wound recommendation was implemented, indicating that the resident had not received the new recommended wound treatment for 6 days.During a surveyor interview on 7/27/2026 at 1:58 PM with Registered Nurse, Staff F, she revealed that she completed the resident's left heel wound treatment yesterday, utilizing the current treatment order, which was the calcium alginate with silver.Additional record review failed to reveal evidence that the left heel wound was assessed to include the description, or measurements for the week of 7/13/2026.During a surveyor interview on 7/27/2026 at 3:48 PM with Licensed Practical Nurse, Staff H, she revealed that she observed the resident's left heel on 7/13/2026 and concluded that it was just a callous. Additionally, she acknowledged that she did not obtain any wound measurements or description of the wound. During a surveyor interview on 7/27/2026 at 2:31 PM with the resident's physician, he revealed that he typically follows recommendations made by specialists and would have followed the Wound Physician's recommendations. Additionally, he would expect that the wound recommendations would be implemented. During a surveyor interview on 7/27/2026 at 2:42 PM with the Director of Nursing Services (DNS), she revealed that the Consultant Wound Physician assesses each wound with the unit nurse and they discuss each wound, and the preferred treatments. Additionally, the DNS revealed that the Consultant Wound Physician will complete his assessment and that document is uploaded into the medical record and any new treatment recommendations are reviewed with the physician by her, and orders are obtained for any recommended treatments. The DNS further revealed that she would expect the wound would have been assessed weekly, including measurements and a description. The DNS was unable to provide evidence that the wound recommendations made by the Wound Physician on 7/20/2026 were reviewed by the physician and implemented.

Based on record review and staff interview, the facility failed to establish and maintain a system that assures a full and complete accounting, according to generally accepted accounting principles, of each resident's personal funds. It further failed to ensure the individual financial record is available to the resident through quarterly statements upon request for 4 of 4 residents reviewed, Resident ID #s 14, 18, 40 and 46.Findings are as follows:1) Record review of a handwritten document titled, .[Resident ID #14] Personal needs account. revealed that as of 6/30/2026 the resident had $4112.72 in his/her account.2) Record review of a handwritten document titled, .[Resident ID #18] Personal needs account. revealed that as of 6/30/2026 the resident had $4049.81 in his/her account.3) Record review revealed a handwritten document titled, Balances as of 6/30/2026 which listed the amounts each resident currently has in their personal needs account. This document indicated that Resident ID #40 has $1406.00 as a balance. Further record review failed to reveal evidence of individual accounting of Resident ID #40's personal needs account.4) Record review of a handwritten document titled, .[Resident ID #46] Personal needs account. revealed that as of 6/30/2026 the resident had $4103.67 in his/her account.Further review of the record failed to reveal evidence that a financial record including, quarterly bank account statements, were provided to the residents or their representatives.During a surveyor interview on 7/27/2026 at approximately 10:00 AM with the Administrator, she was unable to provide evidence of a system that includes a full and complete accounting, including quarterly bank statements, for Resident ID #s 14, 18, 40, and 46. She further revealed that she does not provide quarterly statements to the residents or their representatives.

Based on record review and staff interview the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 3 of 3 resident's reviewed whose account exceeded the $4000.00 limit, Resident ID #s 14, 18, and 46.Findings are as follows:Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS) under section 2.4 (G) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities . requires that the facility shall: .(10) The nursing facility must notify the resident in writing when his/her balance reaches $200.00 less than the resource eligibility guideline, that Medicaid eligibility is jeopardized if the account exceeds the guideline.Review of a handwritten document titled, Balances as of 6/30/2026, revealed the following:1) Resident ID #14 had a current balance of $4112.722) Resident ID #18 had a current balance of $4049.883) Resident ID #46 had a current balance of $4103.67Record review failed to reveal evidence that the above-mentioned residents or residents' representatives were notified when the residents' account balances reached $200.00 less than the resource eligibility guideline.During a surveyor interview on 7/27/2026 at 10:00 AM with the Administrator, she was unable to provide evidence that she notified Resident ID #s 14, 18, and 46, or their representatives, when the amount in the residents' account balances reached $200.00 less than the resource eligibility guideline of $4000.00.

Based on record review and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and reasons for the move in writing, for 5 of 5 residents who were transferred to the hospital, Resident ID #s 1, 2, 3, 4, and 49.Findings are as follows:1) Record review for Resident ID #1, who was transferred to, and subsequently admitted to the hospital on [DATE], failed to reveal evidence that written notification was sent to the Office of the State Long-Term Care Ombudsman.2) Record review for Resident ID #2, who was transferred to, and subsequently admitted to the hospital on [DATE], failed to reveal evidence that written notification was sent to the Office of the State Long-Term Care Ombudsman.3) Record review for Resident ID #3, who was transferred to, and subsequently admitted to the hospital on [DATE], failed to reveal evidence that written notification was sent to the Office of the State Long-Term Care Ombudsman.4) Record review for Resident ID #4, who was transferred to, and subsequently admitted to the hospital on [DATE], failed to reveal evidence that written notification was sent to the Office of the State Long-Term Care Ombudsman.5) Record review for Resident ID #49, who was transferred to, and subsequently admitted to the hospital on [DATE], failed to reveal evidence that written notification was sent to the Office of the State Long-Term Care Ombudsman.During a surveyor interview on 7/24/2026 at 12:41 PM with the Administrator, she was unable to provide evidence of written notification to the Office of the State Long-Term Care Ombudsman when the facility transferred Resident ID #s 1, 2, 3, 4, and 49 to the hospital.

Based on clinical record review and staff interview, the facility failed to ensure residents were free from significant medication errors for 1 of 1 resident reviewed. Resident ID #1 was inadvertently administered multiple medications by the nurse assigned to Resident ID #1's roommate, Resident ID #2. The medications included, an insulin injection, two antipsychotics, an antidiabetic, a benzodiazepine, an anticonvulsant, two antidepressants, a laxative, and eye drops. Additionally, Resident ID #1 was previously administered his/her prescribed morning medications from the Medication Aide prior to mistakenly receiving his/her roommate's medications. As a result of the errors, Resident ID #1 became unresponsive and hypoglycemic (a condition that occurs when your blood sugar level drops below a healthy range) and required hospitalization. Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/26/2026, indicated that Resident ID #1 was inadvertently administered medications intended for another resident and s/he was subsequently transferred to the hospital where s/he was admitted . According to the policy titled, General Dose Preparation and Medication Administration, states in part, .3. Prior to administration of medication, facility staff should take all measures required.including but not limited to the following: 3.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.5. During medication administration, facility staff should take all measures required.including, but not limited to the following: 5.1 Verify resident identification per facility policy (e.g., picture.name).Record review revealed Resident ID #1 was re-admitted to the facility in January of 2026 with diagnoses including, but not limited to, Alzheimer's Disease, dementia, and type 2 diabetes mellitus (a metabolic condition when the body can't use insulin correctly and sugar builds up in the blood).Record review revealed that Resident ID #2 was re-admitted to the facility in November of 2024 with diagnoses including, but not limited to, type 2 diabetes mellitus with hyperglycemia (a condition that occurs when a person's blood sugar elevates to potentially dangerous levels), schizoaffective disorder, bipolar type (a chronic mental health condition combining the symptoms of schizophrenia such as false beliefs and seeing and hearing things that are not real with extreme mood swings characteristics of bipolar disorder), hypertensive heart disease without heart failure (thickening of the heart muscle due to uncontrolled high blood pressure), and other seizure disorders. During a surveyor interview on 5/27/2026 at 1:40 PM with Registered Nurse (RN), Staff A, she revealed that on 5/25/2026 she was assigned to work at the facility as an agency nurse, and that it was her first time working there in years. Staff A revealed that she received her assignment for the residents that she would be administering medications to. She indicated that she was assigned to administer medications to Resident ID #2 and not to Resident ID #1. Staff A explained that she prepared Resident ID #2's medications at the medication cart by reviewing each of the resident's medications, the resident's name with his/her profile picture in the electronic medical record and that she also observed both Resident ID #1 and ID #2's name on their room door before entering the room. Staff A indicated that at approximately 10:00 AM, once in the residents' room, she administered the medications intended for Resident ID #2 to Resident ID #1. At approximately 11:00 AM Staff A was informed by another nurse that she was monitoring Resident ID #1 due to lethargy (decrease in consciousness). At approximately 12:00 PM Staff A observed Resident ID #1 and that is when she realized she had mistakenly administered all Resident ID #2's medications to Resident ID #1, in error. Staff A indicated she assessed Resident ID #1 and s/he was unresponsive and had a blood sugar reading of 61 (a normal blood glucose level is 70-99). The physician was notified of the change in the resident's condition and ordered a Glucagon (a medication prescribed to raise blood sugar levels) injection, which was administered to the resident. Emergency Medical Services (EMS) was called and transferred the resident to the hospital for an evaluation. Additionally, Staff A acknowledged that she administered the following medications in error to Resident ID #1, which were intended for Resident ID #2:-Insulin Glargine 14 units (an antidiabetic)-Losartan 75 milligram (mg) (antihypertensive)-Aripiprazole 20 mg (antipsychotic)-Ativan 1 mg (benzodiazepine)-Brivaracetam 50 mg (antiseizure) -Clozaril 100 mg (antipsychotic)-Glipizide 20 mg (antidiabetic)-Miralax 17 grams (laxative)-Prednisolone 1% eye drops-Sertraline 100 mg (antidepressant)-Trazodone 75 mg (antidepressant)During a surveyor interview on 5/27/2026 at 2:34 PM with Medication Aide (MA), Staff B, she revealed that on 5/25/2026 she was assigned to work at the facility as an agency MA and that this was her first time at this facility. Staff B further revealed that she was assigned to administer medications to Resident ID #1 and indicated that she had administered all his/her morning medications between 8:00-8:30 AM. Additionally, Staff B acknowledged that she administered the following medications to Resident ID #1:-Olanzapine 2.5 mg (antipsychotic)-Duloxetine 60 mg (antidepressant) -Trazodone 75 mg (antidepressant)-Guanfacine 1 mg (antihypertensive)-Losartan 75 mg (antihypertensive)-Metformin 500 mg (antidiabetic)-Aspirin 81 mg chew (antiplatelet)-Senna 8.6 mg (laxative) -Miralax 17 grams (laxative)Record review of the EMS Prehospital Patient Care Report, dated 5/25/2026, revealed that upon arrival to the facility the resident was breathing but unresponsive, pale, and s/he was responding to physical stimuli with incomprehensible sounds. Vital signs (VS) from the facility staff given to EMS were as follows; blood pressure (BP) 78/57 (a normal blood pressure reading is 120/80), heart rate (HR) 49 (a normal heart rate reading is 60-100), respiratory rate (RR) 17 (a normal respiratory rate reading is 16-25) and his/her blood sugar was last noted as 64. The EMS staff administered intravenous (IV) fluids and reassessed the resident and his/her VS were as follows; BP 111/86, HR 47, RR 15 and his/her oxygen saturation level was 98% (normal level is 95-100). EMS then transferred the resident to the hospital for further evaluation. Record review of the hospital continuity of care document, dated 5/25/2026, revealed that Resident ID #1 arrived at the Emergency Department (ED) after being transported by EMS at approximately 2:15 PM, presenting obtunded (a state of reduced consciousness or alertness, typically requiring more than normal efforts to wake) but responsive to strong verbal and tactile stimulation. Due to the resident receiving his/her roommate's medications, as well as his/her own medications, the hospital's plan was to admit the resident and obtain hourly monitoring of the resident's blood sugars, continuous cardiopulmonary (heart and lungs) monitoring, EKG (electrical activity of the heart) monitoring, capnography (continuous monitoring of carbon dioxide levels to monitor the resident's ventilation ((movement of air in and out of the lungs)), metabolism ((chemical reactions within the body that sustain life)), and circulation ((continuous movement of blood throughout the body))), monitoring, and to obtain an chest x-ray. At approximately 3:00 PM laboratory findings indicated a pH venous level (measure of the acidity or alkalinity in the blood) of 7.24 (normal levels 7.31 to 7.41) and a pCO2 venous level (measure of the pressure of carbon dioxide gas dissolved in the blood as it travels back from the body's tissues to the lungs) of 66 (normal levels 35-45), indicating partially compensated respiratory acidosis (a condition where the lungs fail to adequately eliminate carbon dioxide). The record further indicated that at 5:30 PM, the resident's blood glucose reading was now 36 and required the administration of an amp of D50 (an IV solution of dextrose in water for rapid treatment of low blood sugar). Lastly the record stated .Hypoglycemia to 36 in the setting of Glargine and Glipizide consumption with concern for continued hypoglycemia giving [sic] long-acting effects of these medications . The resident's Metformin was held, and new physician's orders for medications were given in the event s/he had an additional episode of hypoglycemia.During a surveyor interview on 5/29/2026 at approximately 3:30 PM with the Director of Nursing Services, she acknowledged that Resident ID #1 inadvertently received Resident ID #2's medications on 5/25/2026, and that Resident ID #1 become unresponsive, with a blood glucose level of 61 and was given Glucagon. Additionally, the resident was subsequently transferred to the hospital and was admitted .As a result of the facility's failure to ensure medications were administered to the correct resident in accordance with facility policy, Resident ID #1 received multiple medications intended for another resident, despite having already received his/her own scheduled morning medications. Specifically, the facility failed to verify resident identity prior to medication administration, resulting in Resident ID #1 receiving an additional antidiabetic, antihypertensive, antipsychotic, antidepressant, antiseizure medication, benzodiazepine, and other medications prescribed for Resident ID #2.Consequently, Resident ID #1 experienced a significant decline in condition, becoming lethargic, unresponsive, hypoglycemic, hypotensive (low blood pressure), and bradycardic (low heart rate), requiring the administration of an emergency medication, emergency medical services transport, hospitalization, continuous cardiac and respiratory monitoring, and treatment for severe hypoglycemia and respiratory acidosis. This deficient practice had the potential to cause serious injury, impairment, or death and resulted in actual harm to Resident ID #1.

Based on clinical record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following provider orders for 40 of 48 residents reviewed, Resident ID #s 1 through 40.Findings are as follows:Record review of a facility-reported incident dated 1/14/2026 and submitted to the Rhode Island Department of Health revealed that during the 11:00 PM to 7:00 AM shift on 1/2/2026, Registered Nurse (Staff A) failed to fulfill assigned nursing responsibilities, including failure to complete the medication administration pass and failure to complete required treatments, monitoring, and documentation for the entire shift. Record review of the facility schedule revealed Staff A worked during the 11:00 PM to 7:00 AM shift on 1/2/2026.Record review failed to reveal medication orders were administered from 11:00 PM to 7:00 AM on 1/2/2026 into 1/3/2026 for 40 of 48 residents reviewed.Record review failed to reveal treatment orders were completed on the 11:00 PM to 7:00 AM shift on 1/2/2026 into 1/3/2026 for 40 of 48 residents reviewed.During surveyor interviews on 1/20/202 at approximately 10:30 AM with the Director of Nursing Services (DNS) and Administrator, they indicated when the missing documentation was identified by the oncoming shift, their first thought was that the agency nurse was diverting medications. The only medications that were documented as administered included Oxycodone, Ritalin, and Lorazepam. Additionally, her documentation was inaccurate. They revealed that they called the agency nurse, who refused to return to the facility to complete the documentation, so they contacted the agency.The DNS revealed that they reported the event to the department of health as well as the licensing board. The Administrator and the DNS were unable to provide evidence the facility's residents received medications and treatment in accordance with professional standards of practice from 11:00 PM on 1/2/2026 until 7:00 AM on 1/3/2026.

Based on clinical record review and staff interview, the facility failed to ensure that before a resident is transferred to a hospital or the resident goes on therapeutic leave that the facility provides written information to the resident or resident representative that specifies information about the bed hold policy, for Resident ID #1.Findings are as follows:Review of the facility's Bed Hold Policy, states in part, Whenever a resident is transferred from the facility for the purposes of hospitalization or therapeutic leave, the resident and/or representative is informed of the facility's policy concerning holding the bed. Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/11/2025, alleges in part, the resident was not given the right medication/dosages, was not offered a bed-hold when sent out to the hospital for a behavioral health evaluation. Record review revealed Resident ID #1 was admitted to the facility in November of 2025 with diagnoses including, but not limited to, intertrochanteric fracture of left femur with surgical repair, sepsis secondary to cellulitis (a bacterial skin infection that causes redness, swelling, and pain, typically affecting the lower legs) of the left lower extremity, and on daily Methadone (a medication prescribed to treat opioid addiction) for an opioid use disorder.Further record review revealed that the resident was sent to the hospital on [DATE] after a verbal altercation with staff members. Further review of the record failed to reveal evidence that the resident was offered a bed-hold upon transfer to the hospital.During a surveyor interview with the Directo of Nursing (DON) on 12/16/2025 at 12:42 PM, she revealed the resident did not receive a bed-hold policy on transfer to the hospital. During a surveyor interview on 12/16/2025 at 3:00 PM with the Administrator, she was unable to provide evidence that Resident ID #1 was offered a bed-hold upon transfer to the hospital. Cross reference F 760

Based on clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for one of three residents reviewed, Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/11/2025, alleges in part, that the resident did not receive his/her methadone (a medication prescribed to treat opioid addiction). Record review revealed Resident ID #1 was admitted to the facility in November of 2025 with diagnoses including, but not limited to, fracture of left femur with surgical repair, sepsis secondary to cellulitis (a bacterial skin infection that causes redness, swelling, and pain, typically affecting the lower legs) of the left lower extremity, and receives daily Methadone. Record review of the Medication Administration Record (MAR) for the month of November 2025, revealed a physician's order dated 11/25/2025 for Methadone Schedule II tablet, 40 milligrams (mg) once daily in the morning and 60 mg in once daily in the evening. Further review of the November 2025 MAR revealed the resident had not received Methadone on the following dates and times:~11/25/2025 40 mg AM dose~11/25/2025 60 mg PM dose~11/26/2025 40 mg AM dose~11/26/2025 60 mg PM doseDocumentation for all missed doses indicated Drug/Item unavailable as the reason.During a telephone interview on 12/16/2025 at 12:45 PM with the Director of Nursing (DON), she revealed that she faxed the orders for the Methadone on 11/24/2025 to the substance abuse treatment center, but they had already closed for the day. She also indicated that multiple calls were placed to the center and daily messages were left but the center wasn't calling the facility back. Additionally, the DON revealed that the Methadone didn't arrive until the residents' third day at the facility and there was concern for potential withdrawal symptoms from not having received the Methadone while at the facility. The DON revealed that on 11/26/2025 she had received a call at approximately 5:00 PM from the nurse on duty who explained that the resident had become verbally aggressive with her and that s/he was scaring the other residents. The DON advised the nurse to send the resident out for a behavioral health evaluation. During a surveyor interview on 12/16/2025 at 3:00 PM with the Administrator she was unable to provide evidence that Resident ID #1 was kept free from significant medication errors and acknowledged that the resident never received Methadone while residing at the facility.

Based on record review and staff interview, it has been determined that the facility failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ensure that problem areas are identified, and good faith efforts for improvements are achieved and sustained demonstrated by measurable objectives with statistical data documented.Findings are as follows:Record review of a facility policy titled, .Quality Assurance Performance Improvement QAPI PLAN 2025 . revealed in part, .Establish, maintain, support, and document evidence of an ongoing QAPI program that includes effective mechanisms for monitoring and evaluating resident care and for appropriate response to findings .Record review of the facility's 2024 and 2025 QAPI failed to reveal evidence of any actions, measurements, or tracking to ensure efforts for improvements of identified problem areas within the facility. During a surveyor interview on 7/18/2025 at approximately 11:00 AM with the Administrator, she was unable to provide evidence that the facility developed actions, measurements, or tracking systems to measure and track performance of identified problem areas within the facility.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 4 of 4 residents reviewed, Resident ID #s 5, 7, 14, and 25. Findings are as follows:Review of a facility policy titled, Consultant Pharmacist Reports dated November 2021 states in part, .Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing .The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention.1. Record review revealed that Resident ID #5 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, dementia, major depressive disorder, anxiety, and post-traumatic stress disorder (PTSD). Record review of the pharmacist's progress note, dated 6/25/2025, states the following, JUNE PHARMACIST MEDICATION REGIMEN REVIEW See report for any noted irregularities/recommendations.Record review failed to reveal evidence of the June 2025 pharmacy recommendations.During a surveyor interview on 7/18/2025 at 9:41 AM with the Director of Nursing Services (DNS) she was unable to provide the pharmacy recommendation for June 2025.2. Record review revealed that Resident ID #7 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, delusional disorder, personal history of mental and behavioral disorders and anxiety.Record review revealed the following physician's order for alprazolam (a medication prescribed to treat anxiety):-alprazolam 1 milligram (MG) three times a day, dated 8/18/2021Record review of the pharmacist's MRR, dated 3/19/2025, revealed the following recommendations: Consider a trial discontinuation of psychotropic medication alprazolam 1 mg three times a day due to a recent fall that resulted in a right distal femur fracture.Record review failed to reveal evidence that the pharmacy recommendation dated 3/19/2025 was reviewed by the provider.During a surveyor interview on 7/17/2025 at approximately 1:10 PM with the DNS, she could not provide evidence that the pharmacy recommendation was reviewed by the provider. 3. Record review revealed that Resident ID #14 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, dementia with psychotic disturbance and delusional disorders.Record review revealed the following physician's order for Seroquel (a medication prescribed to treat schizophrenia, bipolar disorder, and major depressive disorder): -Seroquel 12.5 mg at bedtime, dated 4/5/2023Record review of the pharmacist's MRR, dated 4/29/2025, revealed the following recommendations: Consider a trial discontinuation of a short acting dose of Seroquel 12.5 mg at bedtime per resident's recent fall and the increased risk for falls while on psychotropic medications.Record review failed to reveal evidence that the pharmacy recommendation dated 4/29/2025 was reviewed by the provider.During a surveyor interview on 7/17/2025 at approximately 1:10 PM with the DNS, she could not provide evidence that the pharmacy recommendation was reviewed by the provider.4. Record review revealed that Resident ID #25 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, dementia, bipolar disorder, anxiety, and PTSD. Record review of the pharmacist's progress note, dated 6/25/2025, states the following, JUNE PHARMACIST MEDICATION REGIMEN REVIEW See report for any noted irregularities/recommendations.During a surveyor interview on 7/18/2025 at 9:41 AM with the DNS, she was unable to provide the pharmacy recommendation for June 2025.During a surveyor interview on 7/18/2025 at approximately 2:30 PM with the DNS, she was unable to provide evidence that the pharmacy consultation reports with noted irregularities for Resident ID #s 5, 7, 14, and 25 were reviewed by the provider and acted upon, as required.

Based on record review, staff and resident interviews, it has been determined that the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for a resident who is diagnosed with a mental disorder and has a history of trauma, for 1 of 1 resident reviewed, Resident ID #28. Findings are as follows: Record review revealed that the resident was originally admitted to the facility in May of 2023 with diagnoses including, but not limited to, schizoaffective disorder, anxiety disorder, and post-traumatic stress disorder (PTSD). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of a Mood Interview dated 7/3/2025 revealed a score of 12 out of 27, indicating the resident has moderate depression.Record review of a psychiatric consultation document dated 7/10/2025 revealed the resident reported that s/he was experiencing .excess anxiety and having trouble settling in and asks for medications. Further review revealed the following recommendations: -Switch Sertraline (a medication prescribed to treat depression and anxiety) 100 milligrams (mg) at bedtime to daytime.-Trial Prazosin (a medication prescribed off label to alleviate nightmares and sleep disturbances associated with PTSD) 1 mg at bedtime for nightmares and anxiety.Record review revealed the psychiatric consultation documentation was sent to the facility via fax on 7/17/2025, after the document was requested by the surveyor on 7/16/2025. Record review failed to reveal evidence that the physician was made aware of the medication recommendations. Further record review failed to reveal evidence that the medications were put into place as recommended.During a surveyor interview on 7/15/2025 at 9:27 AM with Resident ID #28, s/he indicated that s/he requested a change in medications for anxiety about a week ago, however, has not heard anything since. During a subsequent interview on 7/16/2025 at 1:42 PM with the resident, s/he indicated that s/he has been experiencing an increase in his/her anxiety level and is not sleeping well as a result. S/he further indicated that s/he has told the staff about it but hasn't received any additional medications to help alleviate the symptoms. During a surveyor interview on 7/18/2025 at 11:07 AM with Registered Nurse, Staff A, she indicated that the unit nurse is responsible for contacting the physician regarding psychiatric recommendations. She further indicated that she was told about the psychiatric recommendations the day before, however she did not review them or contact the physician.During a surveyor interview on 7/18/2025 at 11:15 AM with the Director of Nursing Services, she indicated that the psychiatric provider usually emails her with any recommendations, however a new provider completed Resident ID #28's consult and did not send an email. Additionally, she acknowledged that the psychiatric medication recommendations had not yet been reviewed by the physician and had not been put into place, eight days after the consultation took place and the recommendations were made.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a medication with blood pressure parameters, Resident ID #3.Findings are as follows:Record review revealed the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, hypertensive heart disease without heart failure and orthostatic hypotension (a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position). Review of a physician's order dated 3/28/2025 revealed to administer midodrine (a medication prescribed to treat low blood pressure) 10 milligrams three times daily. Additionally, the special instructions indicate to hold the medication for a systolic blood pressure (the top number of the blood pressure reading) of more than 130.Review of the June and July 2025 Medication Administration Records (MARs) revealed that the resident received the medication when it was indicated to be held, per the physician's order on the following dates and times:- 6/9 6:00-7:00 AM with a documented blood pressure (BP) of: 133/88- 6/12 6:00-7:00 AM with a documented BP of: 133/95- 6/17 6:00-7:00 AM with a documented BP of: 139/87- 6/21 4:00-5:00 PM with a documented BP of: 132/92-7/14 6:00-7:00 AM with a documented BP of: 142/100During a surveyor interview on 7/18/2025 at 10:27 AM with Registered Nurse, Staff A, she acknowledged that the midodrine was signed off as administered on the above dates and times when it should have been held. During a surveyor interview on 7/18/2025 at 10:32 AM with the Director of Nursing Services, she was not able to provide evidence that the midodrine was held per the ordered parameters.

Based on record review and staff interview it has been determined that the facility failed to notify each resident, or resident representative, that receives Medicaid benefits upon death of a resident with a personal fund deposited with the facility, within 30 days of the resident's funds, and provide a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate, in accordance with State law for 2 of 2 residents reviewed who expired with funds remaining at the facility, Resident ID #s 57 and 58. Findings are as follows:1a) Record review revealed Resident ID #57 was admitted to the facility in August of 2020 and expired on [DATE].Record review revealed that the facility was holding funds for Resident ID #57, but they were unable to provide evidence of the amount of funds that were continuing to be held. 1b) Record review revealed Resident ID #58 was originally admitted to the facility in October of 2022 and expired on [DATE].Record review revealed that the facility was holding funds for Resident ID #58, but they were unable to provide evidence of the amount of funds that were continuing to be held.During a surveyor interview on [DATE] at approximately 9:15 AM with the Administrator, she indicated that the facility was still holding funds for Resident ID #s 57 and 58. Additionally, she was unable to provide evidence that the facility conveyed the residents' funds within 30 days of the residents' deaths, or the final accounting of those funds, to the individual or probate jurisdiction administering the residents' estates.

Based on surveyor observation and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to 1 of 1 ice machine and 1 of 1 kitchenette observed. Findings are as follows: 1. During a surveyor observation on 7/1/2024 at 8:40 AM of the ice machine, revealed an accumulation of a pink substance located on the bottommost edge of the ice dispenser shield. Additionally, the pink substance was easily removed by wiping it with a paper towel. During a surveyor interview immediately following the above observation with Licensed Practical Nurse, Staff D, she acknowledged the presence of the above-mentioned pink substance within the ice machine. 2. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . Review of the High-calorie (Hi-Cal) oral supplement Product Information guide states in part, .Storage and Handling .Once opened, reclose, label with time and date, refrigerate, cover and use within 48 hours . During a surveyor observation on 7/1/2024 at approximately 8:40 AM of the kitchenette, revealed 1 opened bottle of Hi-Cal dated 5/7/2024, approximately 3/4th's full. During a surveyor interview immediately following the above observation with Staff D, she acknowledged that the Hi-cal supplement was dated 5/7/2024 and should have been discarded. During a surveyor interview on 7/1/2024 at 9:00 AM with the Food Service Director, he acknowledged the accumulation of the pink substance within the ice machine and the Hi-Cal supplement dated 5/7/2024. He further revealed the Hi-Cal supplement should be discarded and the ice machine needs to be cleaned. 41729

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to the implementation of water system management control measures to mitigate the development of Legionella (a very serious type of lung infection caused by the bacteria called Legionella which can be found in water) and other opportunistic waterborne pathogens for 1 of 1 ice scoop and designated container. Additionally, the facility failed to maintain Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) for 2 of 3 residents reviewed, Resident ID #s 20 and 26. Findings as follows: 1) Record review of the Centers for Disease Control and Prevention document titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated June 2021, states in part, .The key to preventing Legionnaires' disease is maintenance of the water systems in which Legionella may grow .Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant . During a surveyor observation of the nourishment area on 7/1/2024 at 8:57 AM, the ice scoop was observed submerged in approximately 2 inches of stagnant water in the designated ice scoop container. During a surveyor interview immediately following the above observation on 7/1/2024 at 8:59 AM with Licensed Practical Nurse, Staff D, she acknowledged the ice scoop was submerged in approximately 2 inches of stagnant water. During a surveyor interview with the Food Service Director, on 7/1/2024 at 9:05 AM, he acknowledged the above-mentioned observations and stated, It should not be in standing water, he then removed the ice scoop container from the wall to empty the stagnant water from the container. Additionally, he indicated this was the only ice machine and scoop for the entire facility. 2) Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) Last Reviewed: August 1, 2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents .with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: -Dressing -Bathing/showering -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting -Device care or use of a device (i.e central lines, urinary catheters, feeding tubes . 2a) Record review revealed Resident ID #20 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, dementia and a wound on the right great toe. Surveyor observation of signage posted on the resident's door on 7/2/2024 at approximately 1:40 PM revealed in part, Enhanced Barrier Precautions; Attention: Caregivers, staff and visitors .Wear Gown and Gloves prior to these activities .During high-contact resident care activities .transferring, changing linen . During a surveyor observation on 7/2/2024 at approximately 1:44 PM, a Nursing Assistant (NA) Staff E, was observed not wearing a gown as required while in the resident's room changing his/her linens. During a surveyor interview immediately following the above observation with Staff E, she acknowledged that she was changing the resident's linens and failed to wear a gown. 2b) Record review revealed Resident ID #26 was admitted to the facility in May of 2014 with diagnosis including, but not limited to schizoaffective disorder ( a mental health condition that is marked by a mixed of symptoms). Surveyor observation of signage posted on the resident's door on 7/2/2024 at approximately 1:50 PM revealed in part, Enhanced Barrier Precautions; Attention: Caregivers, staff and visitors .Wear Gown and Gloves prior to these activities .During high-contact resident care activities .transferring .providing hygiene .changing linen . During a surveyor observation on 7/2/2024 at approximately 1:51 PM, Staff E, she was observed not wearing a gown as required while in the resident's room providing assistance with personal hygiene and toileting. During a surveyor interview immediately following the above observation with Staff E, she acknowledged that she had entered the resident's room and had assisted the resident with personal hygiene and toileting and failed to wear a gown. During a surveyor interview on 7/3/2024 at 2:40 PM with the Director of Nursing Services (DNS) in the presence of the Administrator, she acknowledged that Resident ID #s 20 and 26 are on EBP. She further indicated that she would expect the staff to wear gowns when assisting the residents with toileting, changing linens, and personal hygiene as indicated on the signage posted.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store all drugs and biological's in accordance with currently accepted professional principles for 1 of 1 medication storage room observed, 1 of 1 medication refrigerator, and 2 of 3 medication carts observed ([NAME] One and Two). Findings are as follows: Review of the facility policy titled LTC Facility's Pharmacy Services and Procedures Manual with a revision date of [DATE] states in part, Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record date opened on the primary medication container when the medication has a shorter expiration date once opened .If a multi-dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for the opened vial . 1. Surveyor observation of the medication refrigerator on the first floor on [DATE] at 11:28 AM in the presence of License Practical Nurse (LPN), Staff C, revealed a bottle of tuberculin purified protein derivative solution (a solution used in a skin test to help diagnose tuberculosis) opened and not dated. During a surveyor interview immediately following this observation with Staff C, she acknowledged the above-mentioned solution was opened and not dated. 2. Surveyor observation of the [NAME] One medication cart narcotic drawer on [DATE] at 11:35 AM, in the presence of a LPN, Staff D revealed a packet of 31 tablets of Lorazepam 0.5 milligrams (mg- a medication used to treat anxiety) with a discontinue date of [DATE]. During a surveyor interview immediately following this observation with Staff D, she acknowledged the medication should have been removed from the drawer. 3. Surveyor observation of the [NAME] Two medication cart on [DATE] at 11:44 AM in the presence of Staff D revealed a Trelegy Ellipta 100 microgram (mcg)/62.5 MCG/25 MCG inhaler and a Incruse Ellipta 62.5 MCG inhaler (medications used to treat respiratory disease) opened and not dated. Manufacturer instructions indicate to discard 6 weeks after opening or when the counter reads 0 or whichever comes first. During a surveyor interview immediately following this observation with Staff D, she acknowledged the inhalers were opened and not dated. 4. Surveyor observation of the medication storage room on [DATE] at 12:28 PM in the presence of the Director of Nursing Services (DNS), revealed the following: - Two bottles of Vitamin E 400 international unit with an expiration date of ,d+[DATE] - One bottle of Mucus relief tablet 400 MG with an expiration date of ,d+[DATE] - Two bottles of Fish oil capsules with an expiration date of ,d+[DATE] During a surveyor interview immediately following this observation with the DNS, she acknowledged the above-mentioned medications were expired and should have been discarded. During an additional interview on [DATE] at 2:05 PM with the DNS, she could not provide evidence the above-mentioned medications were stored appropriately as required.

Based on surveyor observation, record review and staff interviews, it has been determined that the facility failed to properly prevent and contain the potential spread and transmission of COVID-19 relative to its screening system failure that allowed staff to work while symptomatic for 55 sample staff reviewed (Staff ID's A-X). Findings are as follows: According to the 10/23/2020 Centers for Disease Control and Prevention (CDC) document titled, Considerations for Use of [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] Testing in Nursing Homes it states in part, .Testing of symptomatic residents or HCP (HealthCare Personnel) .Symptomatic residents and HCP should be kept in transmission-based precautions or excluded from work until RT-PCR (reverse-transcriptase polymerase chain reaction test) results return .[MEDICATION NAME] tests (point of care diagnostics with a rapid turnaround time) should not be utilized to determine the duration of Transmission Based Precautions nor when HCP can return to work. Test-based strategies are not generally recommended to determine duration of transmission-based precautions, nor to determine when HCP may return to work. If used, test-based strategies should rely only on RT-PCR . According to the 11/20/2020 CDC document titled, Coronavirus Disease 2019 (Covid-19) Healthcare Workers Preparing for COVID-19 in Nursing Homes . it states in part, .Screen all HCP .and document absence of symptoms consistent with COVID-19 . ( .Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea .) Review of the facility policy titled, General Screening and Health Care Personnel (HCP)/Visitor Response, reads in part, Procedure .HCP-Health Care Personnel .The facility staff member conducting the screening, will sign off on this form, indicating if the person is allowed to enter the facility or not . Review of the facility protocol for staff screening revealed, .Another staff member is to take the temperature, do a visual observation .sign staff person in .Do not leave until you have been screened in by another staff member. Review of a November 2020 Covid-19 nursing home screening form and timecard documentation for Cook/Staff A revealed the following: - On 11/12/2020 she documented symptoms of muscle or body aches, fatigue and headache and was permitted to enter the facility by Staff R - On 11/14/2020 she documented symptoms of muscle or body aches, fatigue and headache, with no documentation of a 2nd staff for screening - On 11/15/2020 she documented symptoms of muscle or body aches and fatigue and was permitted to enter the facility by Staff W - On 11/16/2020 she documented fatigue and was permitted to enter the facility by Staff M - On 11/21/2020 she documented symptoms of muscle or body aches, fatigue and headache and was permitted to enter the facility by Staff S - On 11/22/2020 she documented symptoms of muscle or body aches, fatigue, diarrhea and headache and was permitted to enter the facility by Staff T - 11/23/2020 she documented symptoms of SOB (shortness of breath) or difficulty breathing, muscle or body aches and fatigue and was permitted to enter the facility by Staff X - On 11/24/2020 she documented symptoms of muscle or body aches, fatigue and headache and was permitted to enter the facility by Staff U During an interview with the Staff R on 11/25/2020 at 9:29 AM, it was revealed that she did not review what Staff A documented prior to signing. During an interview with the Staff M on 11/27/2020 at 4:25 PM, it was revealed that she did not review what Staff A documented prior to signing. During an interview with the Staff S on 11/27/2020 at 1:31 PM, it was revealed that she did not review what Staff A documented prior to signing. During an interview with the Staff T on 11/25/2020 at 2:00 PM, it was revealed that she did not review Staff A symptoms prior to signing the screening form allowing Staff A to enter the facility and work. During an interview with the Staff U on 11/27/2020 at 4:44 PM, it was revealed that she did not review what Staff A documented prior to signing and was not in-serviced on screening procedures. During an interview with the Staff A on 11/25/2020 at 4:34 PM, it was revealed that on the 11/12/2020, she had an early morning conversation (prior to coming to work) via text messages with the Administrator notifying her that she was symptomatic and was told to come to the facility to be tested . Staff A then stated that she donned PPE (personal protective equipment) and waited for Staff V to arrive and was tested in the green room of the facility utilizing the [MEDICATION NAME] rapid test. She further stated that each time after this when she was tested with both the RT-PCR and [MEDICATION NAME] rapid tests the results were negative, so she continued working. Review of the additional screening records for Staff A from August through November 24, 2020 revealed that on 9/19/2020 Staff A signed herself in without a second staff verification. Review of a line list of Covid-19 test results using the BD Veritor (a system for rapid detection of Covid-19) and obtained via the [MEDICATION NAME] test revealed that Staff A was tested on [DATE], 11/21/2020 and 11/24/2020. Further record review revealed this employee was tested because she stated that she was, .Tired not feeling well . This employee subsequently tested positive for Covid-19 on 11/24/2020, after working symptomatic on 8 separate occasions. Expanded sample review of screening records from August through November 24, 2020 revealed that on 11/21/2020 Staff O, P and Q signed themselves in without a second staff verification. Furthermore, Staff N also signed himself in without a second staff verification on 11/21/2020 and 11/23/2020. Additional expanded sample record review of the Covid-19 nursing home screening forms from August through November 24, 2020 revealed the following documented temperatures (normal temperature range is between 97-99 Fahrenheit): - 93.3 recorded by Staff B on 8/1/2020 - 94.4 recorded by Staff C on 8/12/2020 - 90.8 recorded by Staff D on 8/13/2020 - 90.6 recorded by Staff E on 8/17/2020 - 93.3 recorded by Staff C and 94.4 recorded by Staff F on 8/18/2020 - 89.4 recorded by Staff G and 89 recorded by Staff H on 8/20/2020 - 90.8 recorded by Staff H on 8/22/2020 - 94.6 recorded by Staff F on 8/24/2020 - 93.3 recorded by Staff I on 8/26/2020 - 91 recorded by Staff H on 8/28/2020 twice (documented on two different entries) - 94.8 recorded by Staff J on 8/31/2020 - 94.2 recorded by Staff G and 90.1 recorded by Staff I on 9/2/2020 - 92.3 recorded by Staff I on 9/5/2020 - 94.6 recorded by Staff H and 92 recorded by Staff K on 10/31/2020 - 91.5 recorded by Staff H on 11/1/2020 - 90.8 recorded by Staff L on 11/4/2020 - 93 recorded by Staff M on 11/20/2020 - 94.8 recorded by Staff N and 92 recorded by Staff M on 11/23/2020 Further review of the expanded sample Covid-19 nursing home screening forms revealed the following: - From 8/1/2020 through 8/17/2020, no documentation to the question: Have you traveled to RI from any hotspot state by any mode of transportation? Staff were cleared to enter the facility for 31 of 59 opportunities - From 10/1/2020 through 10/31/2020, no documentation to symptom and quarantine questions, .runny or stuffy nose .fatigue .loss of taste and smell and Has anyone in your household been diagnosed with [REDACTED]. - From 10/27/2020 through 10/31/2020, no documentation to the question regarding muscle or body aches for 8 of 53 opportunities During a phone interview with the Infection Control Nurse and the DNS on 11/27/2020 at 1:43 PM, it was revealed that both the Infection Control Nurse and the DNS are responsible for monitoring screening forms and both failed to notice any of the errors with the screening forms. However, the DNS stated that a rapid test is done when a person is symptomatic. The DNS stated as she Since both Staff A's bi-weekly surveillance swabs (RT-PCR) and the [MEDICATION NAME] rapid tests were negative, she was not advised to leave the facility but instead was permitted stay and work despite continuing with symptoms. During a phone interview with the Administrator on 11/27/2020 at 11:14 AM, it was revealed that she was notified through a text message received from Staff A on 11/12/2020 that she was, .feeling achy and malaise . and advised her to come to the facility for [MEDICATION NAME] rapid testing. The Administrator then stated that on 11/20/2020 Staff A sent her a text notifying her that a member of her household had tested positive. Staff A was advised to come to the facility for [MEDICATION NAME] testing and was negative, so the Administrator told her to return for the regular swab (RT-PCR). It was further stated that on 11/23/2020 Staff A again notified her via text that she felt rotten since last week and on 11/25/2020 she advised Staff A to again be tested utilizing the [MEDICATION NAME] test. This test resulted in a Covid-19 positive result.