Every finding on record at Morgan Health Center

Based on clinical record review and staff interview, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed, who had nausea and vomiting for approximately 21 days and was later transferred and admitted to the hospital with renal failure (a condition in which the kidneys lose their ability to effectively filter waste products, excess fluids, and toxins from the blood. Common signs and symptoms of renal failure may include nausea, vomiting, abdominal pain and weight loss), Resident ID #1. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/5/2026 alleged that the resident experienced nausea and vomiting for weeks prior to hospitalization. The complaint further, alleged the family requested a hospital transfer, but the facility staff stated the hospital would send [him/her] back without doing anything. The complaint indicated that the resident continued to suffer nausea, vomiting and mouth sores through 4/30/2026, despite consults ordered on 4/16/2026. The resident was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, heart failure and gastro-esophageal reflux (involuntary backflow of stomach acid into the esophagus).Record review of a care plan initiated on 5/11/2023 revealed the resident has altered cardiovascular status related to heart failure with an intervention to monitor him/her for nausea and vomiting.Record review revealed the following:A physician's order dated 1/12/2026 for Ondansetron (a medication used to treat nausea and vomiting) oral tablet 4 milligrams (mg) every 6 hours, as needed. 4/10/2026- The Registered Dietician (RD), saw the resident and identified that s/he had a weight loss despite eating excellent. The resident reported to the RD that s/he was having nausea with vomiting over the past month and is being treated with Ondansetron (a medication prescribed to treat nausea).4/16/2026- The resident had lab work completed today which contained a Blood Urea Nitrogen level (BUN- helps assess how well the kidneys are filtering waste) of 70 Milligram per Deciliter (MG/DL). The normal range 8 - 23 MG/DL and a Creatinine level (used to assess kidney function) of 3.41 MG/DL. The normal range 0.8 - 1. 40 MG/DL. 4/16/2026- A nursing note authored by the Nurse Practitioner at 10:26 PM revealed that the resident was experiencing daily vomiting, has a canker sore in his/her mouth and has experienced weight loss with referrals to nephrology (a medical doctor who specializes in the diagnosis and treatment of kidney conditions and diseases) and gastrointestinal (a medical doctor who specializes in the digestive system). The note further indicates that the resident's family member wants him/her to be sent to the emergency room for an endoscopy (a medical procedure that examines the esophagus, stomach, and first part of the small intestine). The NP indicated in her note that this will be managed by outpatient GI and hospitalization is not needed at this time. 4/16/2026- A nursing note authored by Registered Nurse (RN), Staff B, at 11:02 PM, revealed that the nephrology and gastroenterology consults were faxed to the Veterans Hospital. 4/20/2026- A nursing note authored by the Nurse Practitioner at 3:09 PM, revealed that the resident was seen for ongoing nausea with occasional vomiting and left upper quadrant abdominal pain. The note further indicated that the resident experienced pain upon abdominal palpation by the Nurse Practitioner. Additionally, the resident reported not feeling well overall and agreed with the plan to obtain an abdominal ultrasound (an abdominal ultrasound is a non-invasive imaging test that uses sound waves to create pictures of the organs in the abdomen. It is commonly used to evaluate structures such as the liver, gallbladder, pancreas, kidneys, and spleen, and to help identify causes of pain, nausea, or other abdominal symptoms) and laboratory testing for amylase and lipase (blood tests that help evaluate pancreas function). She also wrote a new order to increase his/her Pantoprazole Sodium Oral Tablet Delayed Release 20 milligrams (mg) twice daily. 4/21/2026- A nursing note authored by RN, Staff C, revealed that the Nurse Practitioner reviewed the abdominal ultrasound results with an order to please refer to Urology [a medical doctor is a medical doctor who specializes in conditions that affect the urinary and reproductive systems] and Nephrology. Record review of a document titled Radiology Result Report dated 4/21/2026 for the abdominal ultrasound revealed the resident has bilateral hydronephrosis (the swelling of both kidneys caused by a backup of urine) and left renal cysts (a fluid-filled pouch that develops on or inside the kidney). 4/27/2026- A progress note dated 4/27/2026 authored by the Transport Coordinator stated that multiple messages were left at the VA hospital for the nephrology consult and she is waiting for a call back. 4/30/2026- A nurses note authored by RN, Staff B at 5:31 PM which revealed that the nephrology and gastrointestinal consults had been faxed to the VA hospital as ordered by the provider two weeks prior. However, the facility is still waiting for a response. Record review failed to reveal evidence that the provider was notified that the nephrology and gastroenterology appointments were not arranged.4/30/2026 authored by Staff B revealed that the resident has a history of nausea and vomiting with recent abnormal BUN and creatinine levels. Additionally, the note stated that nephrology and gastrointestinal consults have been faxed to the VA hospital as ordered by the provider two weeks prior, however, the facility is still waiting for a response.During a surveyor interview on 5/21/2026 at 12:38 PM with the Transport Coordinator, she revealed that she faxed the gastrointestinal and the nephrology consult referrals to the VA hospital and was waiting for a call back for approximately 2 weeks. During a surveyor interview on 5/21/2026 at 1:19 PM with Staff B, he revealed that he faxed the GI and the nephrology consults referrals to the VA hospital on 4/16/2026 as ordered following the episodes of nausea, vomiting and abnormal laboratory results. Additionally, Staff B acknowledged that he did not follow up on the status of the referral as the resident continued to experience nausea and vomiting. During a surveyor interview on 5/21/2026 at 1:39 PM with the Nurse Practitioner, she revealed that the order to refer the resident to nephrology and gastroenterology was provided on 4/16/2026. She further revealed that she was unaware that an appointment had not been scheduled for Resident ID #1.

Based on clinical record review and staff interview, the facility failed to ensure that residents received care and services in accordance with professional standards of practice, resulting in Immediate Jeopardy. Specifically, for 3 of 3 residents reviewed who were prescribed anticoagulant (blood-thinning) medications and experienced falls, the facility failed to implement physician orders for post-fall care. This included failure to conduct timely and frequent neurological monitoring (e.g., every 15 minutes for the first hour) and/or the failure to transfer residents to the hospital as ordered. This deficient practice placed Resident IDs #1, #2, and #3 at risk for serious harm, serious impairment, serious injury or death. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/27/2026 alleged that Resident ID #1 was transferred to the hospital on 4/24/2026 following a fall at the facility on 4/20/2026 with noted head bruising and a last known well date of 4/21/2026. The complaint further alleged that a family member reported prior falls at the facility without hospital evaluation.Record review of a facility policy titled, Falls - Clinical Protocol states in part, .The staff with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma [a type of bleeding that occurs between the brain and its outer protective layer, usually after a head injury, which can press on the brain and be life-threatening] have been ruled out or resolved. A. Record review revealed Resident ID #1 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, atrial fibrillation (A-fib; is a condition that causes an irregular heartbeat which puts a person at risk of developing blood clots).Record review revealed a physician's order with a start date of 3/18/2026 for Xarelto (a blood thinning medication) 15 milligrams (mg) to be given every evening for A-fib.Record review of a Change in Condition Evaluation form dated 4/5/2026, completed by Licensed Practical Nurse (LPN), Staff A, revealed that at 2:45 AM, the on-call provider was notified of the resident's unwitnessed fall, which resulted in a small laceration to the top of the scalp. The documentation further indicated that the on-call provider recommended hospital evaluation.Review of the provider's progress note dated 4/5/2026 at 3:27 AM revealed the resident underwent a video telehealth evaluation due to falling from bed with findings including a lump on the top of the head with some oozing from the site, left arm pain, and difficulty assessing his/her mental status. Additionally, the note indicates that because the resident hit his/her head, is on blood thinners, and was difficult to assess if s/he has had a further change in his/her mental status. An order was given to transfer the resident to the Emergency Department (ED) for an evaluation.Further record review identified a physician's order document scanned into the Electronic Medical Record (EMR), dated 4/5/2026 at 1:30 AM, directing that Resident ID #1 be transferred to the ED.Further record review failed to reveal evidence that the order was implemented.Additional record review revealed a physician's order dated 4/5/2026 for the resident's vital signs and neuro checks to be completed every shift for 72 hours following a fall.Further record review revealed that the order was not completed as ordered on 4/7/2026 during the 7:00 AM to 3:00 PM shift.During a surveyor interview on 4/29/2026 at 8:53 AM, with LPN, Staff A, she acknowledged that she was the nurse assigned to care for Resident ID #1 during the 11:00 PM to 7:00 AM shift on 4/4/2026 into 4/5/2026. Additionally, she stated that she notified the on-call provider of the resident's fall with a head strike and that s/he was prescribed a blood thinning medication. Staff A further revealed that the provider ordered the resident to be transferred to the ED for an evaluation and indicated that she did not send him/her to the ED for an evaluation, because the facility administrative staff have instructed nurses many times to call a supervisor prior to sending a resident out to the hospital. She further revealed that she was not able to speak with the nursing supervisor, Registered Nurse (RN)/Staff Development Coordinator, Staff B, during the 11:00 PM to 7:00 AM shift on 4/5/2026, as she unable to be located in the facility so she sent her a text message indicating the provider's orders, to which Staff B never responded to before the end of her shift. Staff A acknowledged that she did not send Resident ID #1 to the hospital, as ordered by the provider.B. Record review revealed that Resident ID #2 was readmitted to the facility in August of 2025 with a diagnosis including, but not limited to, A-fib.Record review revealed a physician's order dated 8/8/2025 for Xarelto 15 mg to be given every evening for A-fib.Further record review revealed a progress note dated 3/22/2026 at 10:57 AM, authored by RN, Staff C, which indicates that the resident receives blood thinning medication and had an unwitnessed fall at approximately 10:50 AM. Additionally, the note indicates that an on-call provider was notified and gave an order for neurological assessments to be completed every shift for 72 hours.Review of the on-call provider's progress note dated 3/22/2026 at 1:30 PM, indicates the resident had an unwitnessed fall with injury, denies hitting his/her head, and receives blood thinning medication. The note further indicates that s/he refused to be transferred to the hospital and orders were given for neuro checks to be completed every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours.Additional record review revealed a physician's order scanned into the EMR dated 3/22/2026 for the neuro checks to be completed every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours.Further record review failed to reveal evidence that the neuro checks were completed as ordered as the neuro checks were only completed once a shift for 72 hours. During a surveyor telephone interview on 4/29/2026 at 12:44 PM, with Staff C, she stated that she could not remember why she did not transcribe and complete the neuro checks as the on-call provider ordered.Record review revealed Resident ID #3 was admitted to the facility in November of 2023 with a diagnosis including, but not limited to, A-fib.Record review revealed a physician's order dated 12/24/2024, for Apixaban (a blood thinning medication) 2.5 mg every 12 hours for anticoagulant use.Record review revealed a progress note dated 2/15/2026 at 6:19 AM, authored by LPN, Staff D, which revealed that the resident was found on the floor after attempting to walk independently. The note further indicated that the on-call provider was notified with orders given for neuro checks.Review of the on-call provider's progress note dated 2/15/2026 at 5:19 AM, indicates the resident had a non-injury fall and receives blood thinning medication. The note further indicates that an order was given for neuro checks to be completed every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and every four hours for an additional 24 hours.Additional record review revealed a physician's order scanned into the EMR dated 2/15/2026 to complete neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours.Further record review failed to reveal evidence that the neuro checks were completed as ordered as the neuro checks were only completed once a shift for 72 hours. A surveyor interview with the Staff D, was attempted but unsuccessful, as she did not return the surveyor's call.During a surveyor interview on 4/28/2026 at 1:11 PM, with the Medical Director, he stated that he would have expected Resident ID #1 to be transferred to the ED as ordered. Additionally, he stated that the facility should not override a provider's order.During surveyor interviews with the Director of Nursing Services on 4/28/2026 at approximately 3:00 PM and 4/30/2026 at 10:56 AM, she acknowledged that Resident ID #1 was not transferred to the hospital as ordered, and that the order for monitoring vitals and conducting neurological assessments every shift for 72 hours after the fall was not completed as ordered on 4/7/2026 during the 7:00 AM to 3:00 PM shift. She indicated that her expectation is for the nurses to follow physician's orders. Additionally, she acknowledged that Resident ID #s 2 and 3, sustained falls, were both prescribed blood thinning medications and the facility staff were provided with orders to monitor their neurological signs frequently and were instead provided with neurological monitoring once a shift for 72 hours. The facility's failure to implement physician orders for post-fall care including timely transfer to the ED and frequent neurological monitoring for residents receiving anticoagulant therapy represents a serious and systemic breakdown in care. For Resident ID #1, the failure to carry out a direct physician order for hospital transfer following a head injury while on a blood thinner significantly delayed necessary medical evaluation. For Resident IDs #2 and #3, the failure to perform neurological assessments at the ordered frequency following falls resulted in inadequate monitoring for potential delayed complications, including intracranial bleeding. The facility's actions placed residents at risk for serious harm, serious impairment, serious injury, or death. Cross reference: State tag 1.16.6.C

Based on clinical record review and staff interview, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 2 residents reviewed with a pressure ulcer (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #1. Findings are as follows:The Rhode Island Department of Health received a community reported complaint on 12/11/2025 alleging that the facility did not have any hygiene supplies for patients and that Resident ID #1 developed bed sores and s/he was re-admitted to the hospital on [DATE] with a pressure ulcer that was not present when s/he was initially discharged from the hospital 11/25/2025. Record review revealed the resident was admitted to the facility in November of 2025 with diagnoses including, but not limited to, laminectomy (back surgery), diabetes mellitus (a chronic condition where the body is unable to regulate blood sugar) and obesity. Record review of an admission skin assessment dated [DATE] revealed the resident had a Stage 2 pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer with a red-pink wound bed and may also present as an intact or open/ ruptured blister) to his/her coccyx and popped blisters surrounding the coccyx (tailbone). Further review of the assessment failed to reveal evidence of any measurements or a description of the wound. Record review of the physician's orders failed to reveal evidence that a treatment order was implemented for the resident's coccyx wound or popped blisters until 12/2/2025, indicating that the resident's wound was not treated for 6 days. During a surveyor interview on 12/18/2025 at 1:52 PM with the admitting nurse, Licensed Practical Nurse, Staff A, she indicated the resident was admitted with a Stage 2 wound to his/her coccyx and popped blisters surrounding the coccyx. Additionally, she acknowledged that she failed to obtain a treatment order for the resident's wound upon admission. During a surveyor interview on 12/18/2025 at 3:09 PM with the Wound Nurse, Staff B, she revealed that nurses are expected to complete a skin assessment, including measurements and a description of the wound, contact the provider to obtain a treatment order, and implement the treatment order for an identified wound. Additionally, she was unable to provide evidence that the resident received a treatment to his/her coccyx wound from when the wound was first identified on 11/25/2025, until 12/2/2025.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 3 residents reviewed, Resident ID #3. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/16/2025, alleged in part that Resident ID #3's medications were not administered according to the physician's orders.According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed that Resident ID #3 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, hypertension. Record review revealed the following physician's orders:-Metoprolol Succinate (a medication prescribed to treat hypertension) ER 50 milligram (mg) one time daily. Hold if Systolic Blood Pressure (SBP) is less than 100. Hold if Apical Pulse (AP) is less than 60. This order had a start date of 4/26/2025 and was discontinued on 7/7/2025.-Metoprolol Succinate ER 50 mg one time daily. Hold if SBP is less than 100. Hold if AP is less than 50. This order had a start date of 7/8/2025 and was discontinued on 7/11/2025.Record review of the Medication Administration Records (MAR) for April, May, June, and July 2025, failed to reveal documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication.During a surveyor interview on 7/23/2025 at approximately 10:15 AM, with Registered Nurse, Staff A, she acknowledged the resident's MAR failed to reveal evidence that the resident's blood pressure and pulse were obtained prior to the administration of the Metoprolol.During a surveyor interview on 7/23/2025 at approximately 11:00 AM with the Director of Nursing Services, she could not provide evidence that the resident's blood pressure and pulse were obtained prior to administering the Metoprolol, per the physician's order.

Based on record review and staff interview, it has been determined that the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 3 residents reviewed, Resident ID #3. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/16/2025, alleged in part that Resident ID #3's medications were not administered according to the physician's orders.Record review of a facility policy titled, Medication Regimen Reviews [MRR] states in part, .A licensed pharmacist reviews the medication regimen of each resident at least monthly.The MRR includes a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities, for example, the use of medication.administered without adequate monitoring or in the presence of adverse consequences. ‘Irregularities' may also include.other medication errors, including those related to documentation.Record review revealed that Resident ID #3 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, hypertension. Record review revealed the following physician's orders:-Metoprolol Succinate (a medication prescribed to treat hypertension) ER 50 milligram (mg) one time daily. Hold if Systolic Blood Pressure (SBP) is less than 100. Hold if Apical Pulse (AP) is less than 60. This order had a start date of 4/26/2025 and was discontinued on 7/7/2025.-Metoprolol Succinate ER 50 mg one time daily. Hold if SBP is less than 100. Hold if AP is less than 50. This order had a start date of 7/8/2025 and was discontinued on 7/11/2025.Record review of the Medication Administration Records for April, May, June, and July 2025 failed to reveal documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication.Record review of the progress notes revealed, the pharmacy had reviewed the resident's medications on 4/27/2025, 5/30/2025, and 6/26/2025. It further revealed that the pharmacist had failed to identify that the monitoring of the resident's blood pressure and pulse were not documented to ensure adequate monitoring of the medication.During a surveyor interview on 7/23/2025 at approximately 12:15 PM with the Consultant Pharmacist, she acknowledged that she had completed the resident's medication reviews on 4/27/2025, 5/30/2025, and 6/26/2025. She further acknowledged that she failed to identify the above irregularity.During a surveyor interview on 7/23/2025 at approximately 11:00 AM with the Director of Nursing Services, she acknowledged that the Consultant Pharmacist had not identified the above irregularity.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 3 units observed and for 1 of 1 resident observed with medications stored in their room, Resident ID #309. Findings are as follows: Review of a facility policy titled Medication Labeling and Storage dated 2021 states in part, .Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents . 1a. During the medication storage and labeling task on 5/20/2025 at 5:12 PM, in the presence of Certified Medication Technician (CMT), Staff F, observations of the 3rd Floor CMT medication cart revealed 17 medication cups labeled with residents' last names. Further observation revealed the medication cups containing multiple medications in each, were stacked on top of one another in two different drawers. During a surveyor interview at the time of the above observation with Staff F, she indicated that she pre-poured the resident's evening and night time medications. She further indicated that she does this because she struggles with passing medications to all of the residents. During a surveyor interview and observation on 5/20/2025 at 5:26 PM with Registered Nurse (RN), Staff C, she indicated that medications should never be pre-poured and that education was recently provided to staff regarding this. Additionally, she acknowledged the pre-poured medications in the CMT cart and stated that the medications needed to be disposed of. During a surveyor interview and observation on 5/20/2025 at 5:32 PM with the Director of Nursing Services (DNS), she acknowledged the pre-poured medications and indicated that pre-pouring medications is against the facility's policy. Additionally, she disposed of the medications. 1b. During a surveyor observation of the 2nd Floor east side CMT medication cart on 5/20/2025 at 5:49 PM, in the presence of CMT, Staff G, revealed a medication cup, labeled with a resident's room number, containing medications in a drawer of the cart. During a surveyor interview at the time of the above observation with Staff G, she indicated that she previously poured the medication but the nurse was in the resident's room so she did not administer it, and put it in the cart to be given at a later time. During a surveyor interview on 5/20/2025 at 5:52 PM with RN, Staff H, s/he acknowledged the medications in the medication cup and disposed of the medications. During a surveyor interview on 5/20/2025 at 5:57 PM with the DNS, she indicated that she would've expected the CMT to dispose of the medications if she could not administer them to the resident immediately. 2. Review of a facility policy titled Medication Labeling and Storage states in part, .The facility stores all medications and biologicals in locked compartments .The nursing staff is responsible for maintaining medication storage . Record review reveled that Resident ID #309 was readmitted to the facility in May of 2025 with a diagnosis including, but not limited to, pain of the right shoulder. Record review revealed a physician's order initiated on 5/13/2025 to apply Diclofenac Sodium External Gel 1 % (a nonsteroidal anti-inflammatory topical gel prescribed to relieve pain and inflammation) to both shoulders every shift. During a surveyor observation of Resident ID #309's room on 5/20/2025 at 9:44 AM and at 10:25 AM revealed a tube of Diclofenac Sodium Gel 1% on top of the bedside table. During a surveyor interview on 5/20/2025 at 10:25 AM with Resident ID #309, in the presence of Staff I, s/he revealed that s/he brought the medication from the hospital and has kept in his/her room since readmission. The resident further indicated that the night nurse had been applying it. During a surveyor interview on 5/20/2025 at approximately 10:30 AM with RN Staff I, she acknowledged that the Diclofenac Sodium Gel 1% was on Resident ID #309's bedside table. Additionally, Staff I acknowledged that the medication was not supposed to be left in the resident's room. During a surveyor interview on 5/21/2025 at 4:54 PM with the DNS, she indicated that she was made aware that the medication was stored in the resident's room. Additionally, she indicated that she would expect medications to be properly stored in the medication cart.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are prescribed psychotropic medications (medications prescribed to affect behavior, mood, thoughts, or perception) receive gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these medications, for 1 of 2 residents reviewed with a recommendation for a GDR, Resident ID #84. Findings are as follows: Record review of the policy titled Psychotropic Medication Use dated 2/2025 states in part, Gradual Dose Reduction .Residents on psychotropic medication receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication . Record review revealed the resident has a physician's order for quetiapine (a psychotropic medication) 25 milligrams (mg) two times a day. Record review of the document titled Psychiatric Evaluation & Consultation with a service date of 5/6/2025 revealed that the resident was seen for an evaluation for a GDR. Further review revealed the quetiapine should be decreased to 25 mg once daily at bedtime. Record review on 5/21/2025 failed to reveal evidence that this GDR recommendation was acted upon by the facility, therefore the resident continued to receive quetiapine 25 mg twice daily. During a surveyor interview on 5/21/2025 at 11:49 AM with Registered Nurse, Staff C, she was unable to provide evidence that the above GDR recommendation had been acted upon by the facility. During a surveyor interview on 5/21/2025 at 12:21 PM with the Nurse Practitioner, Staff D, she revealed that she was not notified of the GDR recommendation to decrease the quetiapine. Additionally, she revealed that the resident did not have any disqualifying conditions that would prevent the GDR from being implemented. During a surveyor interview on 5/21/2025 at 12:28 PM with the Director of Nursing Services, she was unable to provide evidence that the GDR recommendation to decrease the quetiapine had been acted upon, as required.

Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident related to antibiotic administration for 1 of 2 residents reviewed, Resident ID #49. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, pneumonia. Record review revealed the following physician's orders: -Amoxicillin-Potassium Clavulanate (Augmentin-an antibiotic) 875-125 milligrams (mg) give one tablet every twelve hours for ten days. This order had a start date of 5/1/2025 and it was discontinued on 5/1/2025. -Amoxicillin-Potassium Clavulanate (Augmentin) 875-125 mg give one tablet every twelve hours for seven days. This order had a start date of 5/1/2025. Record review of the May 2025 Medication Administration Record revealed the Augmentin was not administered per the order, because it was not available, on the following dates and times: -5/4/2025 at 9:00 PM -5/5/2025 at 9:00 AM Record review of a progress note written on 5/5/2025 at 8:01 PM by Nurse Practioner, Staff D, revealed that the resident missed two doses of the Augmentin due to the pharmacy not delivering the medication. During an interview on 5/22/2025 at 1:07 PM with the Director of Nursing Services, she revealed that when an order is put into the electronic medical record it is sent automatically to the pharmacy to be filled. She further revealed that the expectation would be that the medication would be delivered to the facility by the next day. She further revealed that the Augmentin was unable to be administered to the resident because it was not delivered by the pharmacy and there was no Augmentin left in the facility's emergency medication supply. Record review of the pharmacy delivery slip revealed that the resident's prescription for Augmentin was delivered on 5/5/2025 at 6:53 PM, 4 days after it was ordered from the pharmacy. Record review of an email sent to the surveyor on 5/22/2025 at 2:09 PM from the [NAME] President of Operations of the pharmacy, revealed that an order was received on 5/1/2025 at 4:28 PM for Augmentin with the directions to administer every twelve hours for ten days. While this order was being processed, another order was received on 5/1/2025 at 5:51 PM that changed the directions to every twelve hours for seven days. When the second order for Augmentin was received, it replaced the first order. However, before the first order was discontinued, the second order was thought to be a duplicate and it was moved to the refill too soon section. This is why the medication was not filled and delivered as expected from the pharmacy. Further review of the email revealed that the facility's emergency medication supply of Augmentin ran out on 5/4/2025, and a new supply wasn't delivered by the pharmacy until 5/5/2025 at 8:35 PM. The lack of availability of the Augmentin from the pharmacy caused the resident to miss two doses of the prescribed medication.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 27 opportunities for errors observed during the medication administration task, there were 2 errors resulting in an error rate of 7.41%, involving Resident ID #359. Findings are as follows: Review of the facility policy titled, Administering Oral Medications last revised October 2010, states in part, .Prepare the correct dose of medication .For liquid medication .Place cup on a level surface and read the poured amount at eye level to check accuracy . Record review revealed the following physician's orders: - Amantadine (a medication prescribed to treat stiffness or tremors) oral solution 50 milligrams (mg) per 5 milliliters (mL), administer 10 mL via G-tube (gastrostomy tube - a medical device inserted through the abdomen into the stomach to provide nutrition, fluids, and nutrients to residents) two times a day. - Cholecalciferol (Vitamin D3) 1000 units, administer 2 tablets via G-tube daily. During a surveyor observation of the medication administration task on 5/22/2025 at 9:22 AM with Licensed Practical Nurse, Staff E, she poured the Amantadine into the liquid measuring cup and failed to measure the amount of medication on a level surface and at eye level. Additionally, she prepared two tablets of vitamin B-12 1000 mcg (micrograms) instead of the vitamin D3 1000 units, as ordered. Subsequently, after Staff E revealed that she was ready to administer the medication to the resident, the surveyor intervened and the incorrect dose was not administered. During a surveyor interview with Staff E immediately following the above observation and after the surveyor intervened, she acknowledged that she failed to measure the Amantadine liquid medication dose on a level surface and at eye level. After putting the medication on a level surface and measuring at eye level, she acknowledged that the medication was over the ordered dose of 10 mL and proceeded to remove approximately 2 mL of liquid medication from the mediation cup. Additionally, Staff E discarded the 2 tablets of vitamin B-12 1000 mcg, acknowledged that she prepared the wrong vitamins, and prepared 2 tablets of vitamin D3 1000 units, per the physician's order. During a surveyor interview on 5/22/2025 at 10:22 AM with the Director of Nursing Services, she was unable to provide evidence that the facility ensured each resident's medication regimen is free from a medication error rate of 5% or greater.

Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical well-being for 2 of 3 residents reviewed relative to follow up appointments, Resident ID #s 1 and 2. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/7/2025 alleges that Resident ID #s 1 and 2 have been trying to get to appointments for his/her hernia (an abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides) and a neurologist. Additionally, the report alleges that the facility did not get these appointments and that the residents had to schedule the appointments themselves after waiting almost a year. 1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, spinal stenosis and diabetes. Review of the progress notes revealed the following: - 9/20/2024: Per the Nurse Practitioner, order for an ultrasound to rule out a hernia. - 9/22/2024: Abdominal ultrasound report sent for review, significant for small right inguinal hernia. Completed for resident's right sided pain and swelling. -10/4/2024: NP [Nurse Practitioner] wants to assure that a GI [Gastrointestinal] surgical consult is being scheduled, we will check w/transport/scheduler. Record review failed to reveal evidence of a GI surgical consult. During a surveyor interview on 4/8/2025 at 10:32 AM with Resident ID #1, s/he revealed that s/he has a hernia and requires a surgical consult. S/he stated, I asked the nurse and transport person several times over the past several months and they did nothing. So, I just called and got one for myself. Additionally, s/he revealed that s/he went to this appointment in March and provided the nurse with the paperwork from the appointment. During a surveyor interview on 4/8/2025 at 10:32 AM with the Transport Aide, she revealed that once a consultation is ordered, an appointment slip is filled out and given to her to set up the appointment. She further revealed that she had no documentation for a GI consult for Resident ID #1 and she was unaware that s/he had recently scheduled and went to the appointment in March. During a surveyor interview on 4/8/2025 at 11:09 AM with the outpatient GI provider's receptionist, she revealed that Resident ID #1 had an appointment in March and left with orders for the facility to obtain cardiac clearance for Resident ID #1 to have surgery to repair his/her hernia. During a surveyor interview on 4/8/2025 at 11:42 AM with Licensed Practical Nurse, Staff A, she revealed that she was aware that Resident ID #1 had scheduled their own GI appointment and provided him/her with a Continuity of Care Form. Additionally, she revealed that she was unaware if the form was returned or what the outcome of the appointment was. During a surveyor interview on 4/8/2025 at 11:46 AM with the NP, she revealed that she recently took over his/her care and was unaware that Resident ID #1 went to a GI specialist. Additionally, she was unaware that s/he was waiting on cardiac clearance for surgery. Record review failed to reveal evidence of the March GI appointment or information regarding the outcome of the appointment. During a surveyor interview on 4/8/2025 at 12:15 PM with Resident ID #1's Physician, he revealed that Resident ID #1 recently changed Nurse Practitioners, and it would have been his expectation that the facility would have scheduled and followed up on the order for a GI consult. 2. Record review revealed Resident ID #2 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, diabetes and chronic obstructive pulmonary disease. Review of the progress notes revealed the following: -1/28/2025: lab work ordered by Nurse Practitioner, required for neuro referral. A computed tomography scan (CT scan) and a magnetic resonance imaging (MRI) also required, will schedule. -1/30/2025: Faxed Vitamin B12 result to Neurology, part of referral packet. -1/31/2025: B12 results reviewed with Nurse Practitioner and were advised to fax to Neurology. During a surveyor interview on 4/8/2025 at 10:32 AM with Resident ID #s 1 and 2, they revealed that Resident ID #2 was ordered to have a Neurology consult months ago and when they asked the Transport Aide and nurse, no one could give them any information about the appointment. Additionally, Resident ID #1 stated, After we waited two months, I just called one and made the appointment for April. Record review failed to reveal evidence that Resident ID #2 was receiving care from a neurologist. Record review failed to reveal evidence that the CT/MRI had been scheduled as required. During a surveyor interview on 4/8/2025 at 10:32 AM with the Transport Aide, she indicated that she did receive a referral for a neurology but the nurses do not list where to contact and was unable to complete the appointment. Additionally, she revealed that she had no appointment scheduled for a CT, MRI and there was no follow-up documentation for the neurology referral from January. During a surveyor interview on 4/8/2025 at 11:42 AM with Licensed Practical Nurse, Staff A, she revealed that the appointment was scheduled by the resident's spouse recently. Record review of a nursing progress note dated 3/17/2025, states in part, New Neurohealth appointment 04/25/25 .Res [resident] has own ride provided . During a surveyor interview on 4/8/2025 at 12:15 PM with Resident ID #2's Physician, he revealed that Resident ID #2 recently changed Nurse Practitioners, and it would have been his expectation that the facility would have scheduled and followed up on the order for a neurology referral. During a surveyor interview on 4/8/2025 at approximately 1:00 PM with the Director of Nursing Services in the presence of the Administrator, she was unable to provide evidence that the facility followed up and scheduled the appointments as ordered by the provider.

Based on record review, staff and resident interview, it has been determined that the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of facility reported incident submitted to the Rhode Island Department of Health on 8/28/2024 indicates that Resident ID #2 was witnessed by staff with his/her hand under the blanket of Resident ID #1 rubbing between his/her legs asking him/her do you like that? When staff approached to separate the residents, Resident ID #2 moved his/her hand away quickly. Record review revealed that Resident ID #1, the victim, was admitted to the facility in August of 2024 with diagnoses including but not limited to dementia, difficulty in walking, weakness, and lack of coordination. Further review revealed a Minimum Data Set (MDS) Assessment for Resident ID #1 dated 8/28/2024 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. A surveyor interview with Resident ID #1 was unable to be conducted as s/he had been discharged home prior to this survey. Record review revealed that Resident ID #2, the perpertrator, was admitted to the facility in July of 2024 with diagnoses including but not limited to muscle wasting, epilepsy, and difficulty in walking. Further review of Resident ID #2's medical record revealed a MDS dated [DATE] that revealed a BIMS score of 13 out of 15, indicating intact cognition. A surveyor interview with Resident ID #2 was unable to be conducted as, due to this incident, s/he had been discharged from the facility to an acute care hospital. During a surveyor interview with the Administrator and the Director of Nursing Services (DON) on 9/9/2024 at approximately 10:05 AM, the Administrator revealed that this incident was witnessed by staff. Additionally, he revealed that Resident ID #2 had a history of using inappropriate language towards others. Record review of a written statement authored by Activities Staff, Staff A, dated 8/31/2024 states in part, I saw [Resident ID #2's] hand under [Resident ID #1's] blanket. [Resident ID #2] was moving [his/her] hand saying 'do you like that' on [Resident ID #1's] private parts . During a surveyor interview with the MDS Coordinator, on 9/9/2024 at approximately 11:20 AM, she revealed that she was working at the time of the incident and that she was notified by another staff member of what had occurred between Resident ID #s 1 and 2. Additionally, she indicated that, because Resident ID #2 had a BIMS score of 13 out of 15, she believed s/he was well aware of what s/he was doing. She further revealed that because Resident ID #1 had a BIMS score of 3 out of 15, s/he would not have the cognitive ability to consent. During a surveyor interview on 9/9/2024 at approximately 2:00 PM with the Administrator and the DON, they acknowledged that Resident ID #2 was observed touching Resident ID #1 inappropriately.

Based on record review and staff interview, it has been determined that the facility failed to promptly notify the ordering physician or a provider of laboratory results that fall outside of clinical reference ranges for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on [DATE] alleges in part, .I was called by the nurse at [facility] .told that [resident] was having a hard time breathing and there was some blood in [his/her] stool so they were going to call an ambulance and have [him/her] transported to the hospital .the attending and a surgeon informed us that [resident] had a ruptured intestine and had sepsis [a life threatening complication of an infection] .[s/he] died shortly after . Record review revealed the resident was admitted to the facility in January of 2022 with a diagnosis including, but not limited to, alcoholic cirrhosis of liver without ascites (abnormal build up of fluid in the abdomen). Record review revealed a physician's order with a start date of [DATE] for a basic metabolic panel (common blood test that measures kidney function, blood sugar, and electrolyte balance) and a complete blood count (common blood test that screens for disorders affecting your blood cell counts) every 6 months on the 23rd of each month for labs. Review of a document titled, Lab Results Report dated [DATE] revealed the following abnormal lab results including, but not limited to: - [NAME] Blood Cells (WBC, part of your immune system that protects your body from infection): 13.0 K/uL (thousands per cubic milliliter). Normal range is 4.0 - 10.0 K/uL. An elevated WBC count may be indicative of an infection. - Monocytes (a type of WBC that fight infections): 1.35 K/uL. Normal range is 0.2 - 1.0 K/uL. An elevated monocyte count may be indicative of an infection, inflammation, and other health issues. - Hemoglobin (a protein found in red blood cells that carries oxygen to your tissues): 11.1 g/dL (grams per deciliter). Normal range is 14.0 - 18.0 g/dL. A low hemoglobin level may occur from blood loss. Record review failed to reveal evidence that a provider was notified of the lab results from [DATE]. Record review of a progress note dated [DATE] at 10:03 AM revealed that the resident was noted to have trouble breathing, a bloated abdomen, and rectal bleeding, and was subsequently transferred to the hospital via rescue. During a surveyor interview on [DATE] at 9:33 AM with the Unit Manager, Registered Nurse, Staff A, she revealed that when they recieve lab results, staff will report them to the provider and document in the progress notes that the labs were reported and if there are any new orders or not. During a surveyor interview on [DATE] at 10:39 AM with the Nurse Practitioner, Staff B, she revealed that she was away during that time, therefore she was unaware of the lab results. She further revealed that the labs should have been reported to another provider in her absence. She would have expected the labs to have been reported that same day to a provider. Additionally, she indicated that she would have ordered follow up lab work based on the lab results including, encouraging fluid intake, a chest X-Ray, possibly a urine culture, and to repeat the same labs in ,d+[DATE] days and include a procalcitonin (a blood test to help diagnose or rule out a bacterial infection or sepsis). During a surveyor interview on [DATE] at 11:56 AM with the Director of Nursing Services, she revealed that she would expect staff to have reported the labs and document in a progress note. She was unable to provide evidence that a provider reviewed or acted upon the resident's labs.

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 implementing a water management program based upon industry standards and/or the Centers for Disease Control and Prevention (CDC) toolkit. Findings are as follows: Record review of the CDC document titled, Developing a Water Management Program to Reduce Legionella [a bacteria that may cause a very serious type of lung infection] Growth & Spread in Buildings, dated June 2021, version 1.1 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. Common issues that contribute to water stagnation include .reduced building occupancy .Stagnation can also occur when fixtures go unused, like a rarely used shower . A. Record review of the facility's water management binder failed to reveal evidence that the water flow assessment identified areas where legionella could grow and spread. B. During surveyor observations on 6/5/2024 at approximately 12:10 PM with the Maintenance Director and the Regional Plant Operations Director, the second and fourth floor tubs were observed being used as storage. During a surveyor interview with the Maintenance Director and the Regional Plant Operations Director following the above observation, they acknowledged that both tubs were still functioning. They were unable to provide evidence that both tubs have been flushed regularly to maintain the water quality. Further record review failed to reveal evidence that the facility was monitoring and flushing infrequently used fixtures including, but not limited to, the second and fourth floor tubs. During a surveyor interview with the Regional Plant Operations Director and Administrator on 6/5/2024 at approximately 2:00 PM, they were unable to provide evidence that the facility had a water flow assessment that identified areas where legionella could grow and that the second and fourth floor tubs were flushed regularly to prevent the growth of legionella. Additionally, the facility was unable to provide evidence that they maintained or implemented a water management program based upon industry standards and the CDC toolkit for the prevention of Legionella, as required. 41542

Based on surveyor observations, record review, staff, resident and resident representative interviews, it has been determined that the facility failed to treat each resident with respect and dignity, and is cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with toileting and communication with a resident whose primary language is not the dominant language of the facility, Resident ID #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 3/25/2024 alleges that a Nursing Assistant (NA) punched the resident in his/her leg. Review of an undated facility policy titled, Translation and/or Interpretation Services states in part, .This facility will ensure that individuals who are non-English speaking or have a communication disability will have access to translation and/or interpretation methods . 1. The facility will determine a means to communicate with any resident admitted who is non-English speaking . 2. The facility utilizes Interactive Voice Response (IVR) to connect to an interpreter for limited English proficient resident. 3. The facility utilizes Cue Cards (Communication Boards) to assist health professionals and residents who have English language difficulties or communication difficulties to communicate . Record review revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, hemiplegia (paralysis on one side of the body) and fracture of the lateral malleolus of the left fibula (ankle fracture). Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Additionally, the MDS revealed that the resident's preferred language is not English, and s/he wants or needs an interpreter to communicate with health care staff. Record review of a care plan dated 1/3/2024 revealed a focus area indicating that the resident requires the services of an interpreter because English is not his/her primary language. Interventions include, but are not limited to the following: - Monitor the resident for signs of withdrawing from attempts to communicate such as symptoms of anger or feelings of frustration. - Provide him/her with a communication board including common words in English and the resident's preferred language to aide in communication for simple daily needs. - Use the Language Line [which includes Video Remote Interpretation Services] as needed to provide adequate communication with the resident. During a surveyor interview on 3/28/2024 at 1:02 PM with the resident and the resident's representative via telephone, the representative translated the following. It was revealed that at some time during the 11:00 PM - 7:00 AM shift on 3/23/2024 into 3/24/2024, the NA (Staff B) assigned to the resident did not assist him/her with transferring from bed to the bathroom as s/he requested and preferred. The resident's representative indicated that the resident wanted to use the bathroom however the NA gave him/her the bedpan instead. Additionally, they indicated that physical therapy had recently cleared the resident for transferring out of bed. Prior to that s/he was not able to bear weight on his/her lower extremity. Staff B was the only staff member present in the room. The resident's representative further revealed that the resident urinated in the bedpan because s/he had no other choice. The NA did not respond to his/her requests to use the bathroom. It was further revealed that at some point the bedpan was filled with urine and the urine had spilled. The resident believes this caused the staff member to become upset and hit him/her on the right leg with a closed fist. During a surveyor observation at the time of the above-mentioned interview, a communication board was observed pinned on the wall near the resident's bed. The communication board contained pictures of common items labeled in the resident's preferred language. Additionally, the resident's bathroom is approximately 10 feet from his/her bed. During a surveyor telephone interview on 3/28/2024 at 3:08 PM, with Staff B, she revealed that she was the NA assigned to provide care to Resident ID #2 during the 11:00 PM - 7:00 AM shift on 3/23/2024 into 3/24/2024. Additionally, Staff B revealed that she entered the resident's room at some time during the shift to provide the resident with care. She further indicated that the resident was speaking in his/her primary language and appeared furious and began throwing things. Staff B indicated that she does not speak the resident's primary language and acknowledged that she did not utilize an interpreter or the communication board and acknowledged she should have. Furthermore, Staff B indicated that she got the nurse to assist her due to the resident's frustrations and indicated that she did not assist the resident to the bathroom. During a surveyor telephone interview on 3/29/2024 at 1:22 PM, with Licensed Practical Nurse (LPN) Staff C, she revealed that she was Resident ID #2's assigned nurse on the 11:00 PM -7:00 AM shift on 3/23/2024 into 3/24/2024. Staff C further indicated that Staff B asked her to go into the resident's room towards the end of care because Staff B was having an issue with the him/her. Staff C indicated that the resident pointed to his/her leg and said something in his/her primary language. She further revealed that she does not speak or understand the resident's primary language. Staff C acknowledged that she did not utilize an interpreter, the communication board or the Language Line to communicate with the resident and acknowledged she should have. Staff C further revealed that Staff B does not usually work on the resident's unit and does not believe that she knew the resident goes into the bathroom instead of using the bedpan. Staff C acknowledged that she did not provide Staff B with that information in shift report and acknowledged she should have. During a surveyor interview on 3/29/2024 at 2:43 PM with the Director of Nursing Services (DNS), she revealed that she would expect staff to utilize an interpreter, the communication board, or the Language Line when assisting Resident ID #2 with care to facilitate communication with him/her. Additionally, the DNS was unable to provide evidence that Resident ID #2 was provided with respect and dignity.

Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Rhode Island Department of Health;RIDOH), in accordance with State law, for 1 of 1 resident reviewed for an allegation of abuse, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the RIDOH on 3/21/2024, alleges that the facility failed to follow up on an allegation of staff to resident sexual abuse. Record review of a facility policy last revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, states in part, .All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) . During a surveyor interview with the complainant on 3/22/2024 at 11:36 AM, s/he revealed that the resident reported an allegation that a male staff member inserted their finger in the resident's rectum during care. Additionally, s/he indicated the facility was made aware of this allegation sometime in January or February of 2024 and indicated the facility failed to follow up on this allegation. Record review revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, diabetes, cerebrovascular accident (stroke) and depression. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. Surveyor interviews with the resident and his/her family member were attempted, however, unsuccessful throughout the duration of the investigation. During a surveyor interview on 3/22/2024 at 1:00 PM, with the Director of Nursing Services (DNS), she indicated that she was not aware of Resident ID #1's allegation of sexual abuse. During a surveyor telephone interview on 3/22/2024 at 2:10 PM with the Social Services Director (SSD), she revealed that she participated in a telephone care conference held with the resident, the resident's family member, Staff A, and the facility's Wound Nurse in February of 2024. She was unable recall the date. Additionally, the SSD revealed that during the conference, the resident reported that a male staff member inserted their finger in his/her rectum. The SSD further indicated that she immediately reported the allegation to the Administrator. During a surveyor interview with the Administrator on 3/22/2024 at approximately 3:00 PM, in the presence of the DNS and the Regional Director of Clinical Services, he acknowledged that he was made aware of Resident ID #1's allegation of staff to resident sexual abuse on 2/19/2024 after it was reported to staff during a care conference. Furthermore, the Administrator acknowledged that he did not report the allegation to RIDOH or other officials in accordance with State and Federal law and per the facility's policy, until the surveyor questioned him, which was approximately four weeks after he was made aware of the resident's allegation of staff to resident sexual abuse.

Based on record review and staff interview, it has been determined that the facility failed to provide evidence that all alleged violations are thoroughly investigated for 1 of 1 resident reviewed for allegations of abuse, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 3/21/2024, alleges that the facility failed to follow up on an allegation of staff to resident sexual abuse. Record review of a facility policy last revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, states in part, .All reports of resident abuse .are .thoroughly investigated by facility management .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report . During a surveyor interview with the complainant on 3/22/2024 at 11:36 AM, s/he revealed that the resident reported an allegation that a male staff member inserted their finger in the resident's rectum during care. Additionally, s/he indicated the facility was made aware of this allegation some time in January or February of 2024 and indicated the facility failed to follow up on this allegation. Record review revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, diabetes, cerebrovascular accident (stroke) and depression. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. During a surveyor telephone interview on 3/22/2024 at 2:10 PM with the Social Services Director (SSD), she revealed that she participated in a telephone care conference held with the resident, the resident's family member, Staff A, and the facility's Wound Nurse in February of 2024. She was unable recall the specific date. Additionally, the SSD revealed that during the conference, the resident reported that a male staff member inserted their finger in his/her rectum. The SSD further indicated that she immediately reported the allegation to the Administrator. During a surveyor interview with the Administrator on 3/22/2024 at approximately 3:00 PM, in the presence of the DNS and the Regional Director of Clinical Services, he acknowledged that he was made aware of Resident ID #1's allegation of staff to resident sexual abuse on 2/19/2024 after it was reported to staff during a care conference. Furthermore, the Administrator acknowledged that the facility did not conduct a thorough investigation as required.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility in May of 2023 with diagnoses including, but not limited to chronic diastolic heart failure and atherosclerotic heart disease (thickening or hardening of the arteries). Record review of the order summary revealed the following physician orders: - Hydralazine HCL 25 milligrams (mg) give two times daily for hypertension. Hold if Systolic Blood Pressure (SBP) is less than 110 or - Heart rate (HR) is less than 60. The order start date was 1/31/2024 and the discontinue date was 2/18/2024. Record review of the February 2024 Medication Administration Record (MAR) revealed the Hydralazine was given outside of parameters on the following dates and times: 2/1/2024 at 9:00 AM with a documented HR of 59 2/9/2024 at 9:00 AM with a documented HR of 57 2/12/2024 at 9:00 AM with a documented HR of 54 2/13/2024 at 5:00 PM with a documented HR of 57 Additional record review revealed a physician's order for Metoprolol Succinate extended release 25 mg give 1/2 tablet once daily for hypertension. Hold for heart rate less than 60. The order start date was 12/30/2023 and the discontinue date was 1/29/2024. Record review of the January 2024 MAR revealed the Metoprolol Succinate was given outside of parameters on the following dates and times: 1/1/2024 at 9:00 AM with a documented HR of 56 1/3/2024 at 9:00 AM with a documented HR of 56 1/4/2024 at 9:00 AM with a documented HR of 58 1/16/2024 at 9:00 AM with a documented HR of 57 1/20/2024 at 9:00 AM with a documented HR of 54 1/24/2024 at 9:00 AM with a documented HR of 55 2. Record review revealed Resident ID #2 was admitted to the facility in November of 2023 with diagnoses including, but not limited to orthostatic hypotension (dizziness when standing after sitting or lying down) and hypertension. Record review of the order summary revealed the following physician orders: Amlodipine besylate 2.5mg give once daily for hypertension. Hold if SBP is less than 110 and if HR is less than 60. Order start date of 11/21/2023. Losartan Potassium 50 mg once daily for hypertension. Hold if SBP is less than 110 and if HR is less than 60. Order start date is 11/21/2023. Record review of the February 2024 MAR revealed the Amlodipine Besylate, and the Losartan Potassium were given outside of parameters on the following dates and times: 2/12/2024 at 9:00 AM with a documented HR of 55 2/19/2024 at 9:00 AM with a documented HR of 58 Record review of the January 2024 MAR revealed the Amlodipine Besylate, and the Losartan Potassium were given outside of parameters on the following dates and times: 1/6/2024 at 9:00 AM with a documented HR of 50 1/24/2024 at 9:00 AM with a documented HR of 59 During a surveyor interview on 2/20/2024 at 12:59 PM with the Director of Nursing Services, she acknowledged the above medications were administered outside of the ordered parameters.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident received incontinence care as per the resident's plan of care for 1 of 1 resident observed, Resident ID #1. Findings are as follows: Record review of the community reported complaint sent to the Department of Health (DOH) on 2/5/2024 alleged that .someone from DOH needs to pay attention to these poor, vulnerable residents, They sit all day in 1 position at table . Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including but not limited to; Alzheimer's disease, impaired visual function and lack of coordination. A review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 6 out of 15, indicating severe cognitive loss. Additionally, the MDS indicates the resident required extensive assistance from staff for transfers, hygiene and toileting. Record review of the resident's current plan of care revealed the resident has self care performance deficits related to cognitive impairment and decreased mobility. This care plan also indicates the resident has a communication deficit related to Alzheimer's disease. Record review revealed a care plan dated 5/28/2023 for .I have urinary incontinent r/t [related to] cognitive impairment . with interventions including but not limited to .Establish voiding pattern .Check resident at regular intervals and provide incontinence care as needed . Surveyor observation of the resident on 2/7/2024 from 9:00 AM through 1:55 PM (approximately 5 hours) revealed the resident sitting in his/her wheelchair in the dining room. During this observation period, incontinence care was not provided to this resident. During a surveyor interview with a nursing assistant, Staff A on 2/7/2024 at 11:02 AM, she revealed that she is a primary nursing assistant for the resident and she has been caring for the resident for approximately 8 months. During an additional surveyor interview with Staff A on 2/7/2024 at 1:50 PM, she revealed she did not take the resident to the bathroom and she only stood [him/her] up quick from the wheelchair from 9:00 AM through 1:55 PM while the resident was in the dining room. During a surveyor observation in the presence of Staff A, of the resident on 2/7/2024 at 1:55 PM revealed the resident's incontinence pad was wet with urine and soiled with brown matter. During a surveyor interview with the Director of Nursing Services (DNS) on 2/8/2024 at 8:50 AM, she revealed they do not have policy and procedure relative to incontinence care. The DNS revealed staff should provide incontinence care to the resident at regular intervals, between breakfast and lunch and then after lunch. The DNS further revealed standing the resident up is not adequate way to check for incontinence. Additionally, the DNS further revealed her expectation is that Resident ID #1 would be taken to bathroom for toileting and checking for incontinence.

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases for 1 of 3 residents reviewed who tested positive for Influenza A, Resident ID #1. Findings are as follows: Record review of an undated facility's policy and procedure for Influenza Outbreak, states in part .2. Contact and droplet precautions are implemented during care of a resident with suspected or confirmed influenza, in addition to standard precautions used with all residents regardless of symptoms. 3. Contact and droplet precautions are continued for seven (7) days after illness onset or until after 24 hours the resolution of fever and respiratory symptoms, whichever is longer. Precaution may continue for longer periods based on clinical judgement . During a surveyor interview with the Infection Control Nurse on 2/7/2024 at 11:20 AM, she revealed they have 40 residents on the third floor unit and 16 residents had tested positive for Influenza A since 1/28/2024. Record review revealed Resident ID #1 was admitted to the facility in November of 2022 with diagnoses including but not limited to Alzheimer's disease. Further record review revealed the resident tested positive for Influenza A on 2/1/2024. Surveyor observation on 2/6/2024 at 12:05 PM revealed signs posted on the wall near the resident's room door. One sign was for Droplet Precautions which indicates .Clean their hands including before entering and when leaving the room. Make sure their eyes nose and mouth are fully covered before room entry . Another sign was for Contact Precautions which indicates EVERYONE MUST: Clean their hands including before entering and when leaving the room. PROVIDER AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . Surveyor observation on 2/7/2024 at 8:55 AM revealed two nursing assistants, Staff A and B assisting the resident with transferring him/her to the wheelchair. The surveyor noted that both Staff A and B were wearing only surgical masks. Both staff members failed to wear eye protection, gowns and gloves as per the signs posted near the door. During an additional observation on 2/7/2024 at 1:55 PM, revealed Staff A and B taking the resident back into his/her room for toileting. Upon entering the room, the two staff were observed wearing only a surgical mask. Staff A and B failed to apply eye protection, gowns and gloves. When questioned by the surveyor as to why they did not don eye protection, gowns and gloves before entering the room, Staff A revealed the resident has the Flu and staff only need to wear a mask. The surveyor then asked her to read the signs posted near the door. After reading the signs, Staff A revealed she was not aware that she needed to wear the eye protection, gown and gloves upon entering the room. Additionally, surveyor observation on 2/8/2024 at 9:05 AM revealed an Activity Staff, Staff C standing next to the resident's bed, wearing only a surgical mask. The surveyor noted that Staff C's clothing was touching the resident's blanket and bed while talking to the resident. Furthermore, the surveyor noted that Staff C walked towards the resident's roommate (Resident ID #3) and moved his/her bedside table and spoke with Resident ID #3. Staff C then exited the room and failed to performed hand hygiene. During a surveyor interview after the observation with Staff C on 2/8/2024 at 9:10 AM, Staff C acknowledged that she failed to apply eye protection, gown, and gloves before entering the room and perform hand hygiene upon leaving the room. During a surveyor interview with the Infection Control Nurse on 2/8/2024 at 9:45 AM, she revealed residents who test positive for Influenza A will be placed on isolation for at least a 7 full days. The Infection Control Nurse further revealed that Resident ID #1 tested positive for Influenza on 2/1/024. Additionally, she stated that her expectation is for staff to wear the appropriate PPE (personal protective equipment) and perform hand hygiene as indicated. During a surveyor interview with the Director of Nursing Services on 2/8/2024 at approximately 11:00 AM, she was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of Influenza A.

Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to staff entering a COVID-19 (SARS-CoV-2) positive room without wearing personal protective equipment (PPE) for 1 of 3 residents reviewed for COVID-19, Resident ID #4. Findings are as follows: According to the Centers for Disease Control and Prevention guidance, last updated on May 8, 2023, the recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection include the following: .Personal Protective Equipment- Health Care Personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . Review of a facility provided document titled Covid-19 Infection Control Facility Management Interventions states in part, .source control will be instituted to ONLY the areas affected (resident room, unit) based on the facility review, under the following situation .a. If staff or resident have suspected or confirmed SARS-CoV-2 infection .b. If staff or residents had close contact or higher risk exposure with someone with SARS-CoV-2 infection, for 10 days after their exposure; or c. if residents reside or staff work on a unit/area of the facility experiencing a SARS-CoV-2 outbreak .the facility will implement universal use of personal protective equipment (PPE). Including the implementation of NIOSH-approved N 95 or equivalent, eye protection for HC [health care worker] during such resident encounter . Record review of a community reported complaint sent to the Rhode Island Department of Health on 10/13/2023 alleges that Resident ID #3 is concerned that staff are not wearing PPE when they are caring for his/her roommate, Resident ID #4, who is positive for COVID-19. Review of Resident ID #4's record revealed s/he was admitted to the facility in October of 2023 with diagnoses including, but are not limited to, generalized anxiety disorder, depression, and muscle weakness. Additional record review revealed a physician's order dated 10/13/2023 which indicated that the resident is on droplet precautions (prevention of the spread of pathogens that are passed through respiratory secretions) for COVID-19 through 10/23/2023. During a surveyor observation on 10/17/2023 at 9:55 AM, Registered Nurse, Staff A was observed entering the room of Resident ID #s 3 and 4 without wearing a gown, face shield or goggles. During a surveyor interview following the above observation with Staff A, she acknowledged that she was not wearing a gown or eye protection when she entered a COVID-19 positive room. She further revealed that she only went in the room to answer the resident's call light and didn't physically care for the resident. Additionally, she indicated that she was not aware that she needed to wear a gown and eye protection when entering a COVID-19 positive room. During a surveyor interview on 10/17/2023 at 10:00 AM with Resident ID #3 s/he revealed that most staff do not wear PPE when entering his/her room even though his/her roommate tested positive for COVID-19. During a surveyor interview on 10/17/2023 at 1:36 PM with the Infection Control Nurse, she revealed that everyone should don an N 95 mask, gown, gloves, and eye protection before entering a COVID-19 positive room. She acknowledged that Staff A should have been wearing a gown and eye protection prior to entering Resident ID # 3 and 4's room.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration for 2 of 4 residents reviewed, Resident ID #s 1 and 3. Additionally, the facility failed to ensure residents maintain acceptable parameters of nutritional status, such a usual body weight or desirable body weight and failed to follow their policy relative to weights, for 2 of 4 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: Record review of a community report complaint received at the Rhode Island Department of Health on 3/2/2023 alleges that Resident ID #1 arrived at the hospital with sunken eyes, severely dehydrated, scaly, flaky, and inflamed skin. Additionally, the report revealed the patient developed a pressure wound to his/her buttocks and had an unkempt appearance. According to Brunner & Suddarth's Textbook, Medical and Surgical Nursing, 10th Edition, Volume 2, page 262 states signs/symptoms and laboratory findings of hypernatremia (excess amounts of sodium in the blood) include, but are not limited to lethargy, restlessness, and twitching. According to Brunner & Suddarth's Textbook, Medical and Surgical Nursing, 10th Edition, Volume 2, page 2131 states the patient with moderate dehydration exhibit signs and symptoms including, but not limited to, sunken eyes and loss of skin turgor, and patients with severe dehydration show signs and symptoms of shock, such as lethargy and coma. 1A. Record review for Resident ID #1 revealed the resident was admitted to the facility in June of 2022 with diagnoses including, but not limited to, adult failure to thrive, chronic kidney disease, pemphigus foliaceus [autoimmune blistering of the skin] and major depressive disorder. Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored a 15 out of 15 during a Brief Interview for Mental Status assessment, indicating s/he has intact cognition. Additionally, the assessment revealed that s/he did not have any pressure injuries. Further review of the assessment revealed under the heading Weight Gain- Gain of 5% or more in the last month or gain of 10% or more in the last 6 months, is coded as Yes, not on a physician-prescribed weight-gain regimen. Record review of the resident's baseline admission care plan, edited on 12/13/2022 revealed a care plan which states in part, .for Dehydration Risk/ Nutrition. History of FTT [failure to thrive] and poor oral intake . with interventions including, but not limited to, Diet as ordered; Monitor for signs and symptoms of dehydration Labs per MD orders; Dietary consult as indicated . Record review of the resident's documented daily fluid intake from 2/10/2023 through 2/27/2023 revealed the following: -2/10/2023 720 milliliters (ml) -2/11/2023 360 ml -2/12/2023 720 ml -2/13/2023 1560 ml -2/14/2023 1080 ml -2/15/2023 840 ml -2/16/2023 900 ml -2/17/2023 1560 ml -2/18/2023 120 ml -2/19/2023 720 ml -2/20/2023 720 ml -2/21/2023 1450 ml -2/22/2023 360 ml -2/23/2023 720 ml -2/24/2023 1040 ml -2/25/2023 240 ml -2/26/2023 1080 ml -2/27/2023 960 ml During a surveyor interview with the Director of Nursing Services (DNS) and the Administrator on 3/2/2023 at approximately 4:00 PM, the DNS revealed the Registered Dietician (RD) and the physician review the resident's intake. Additionally, during a review of Resident ID #1's fluid intake, the Administrator acknowledged the fluid intake totals. Record review of the nursing progress notes revealed the following: -2/22/2023 .poor po [by mouth] intake . -2/25/2023 2:21 AM Res [resident] with some confusion .res appears irritated and restless .shaking [his/her] legs .Drinks encouraged . -2/27/2023 at 6:30 AM .Continues to have full body shakes . -2/27/2023 at 4:10 PM Previous RN reported .that resident had body shakes overnight, but mild tremors present this shift .Poor PO intake this shift .Around 1500, CNA reported to this RN that resident was shaking. On assessment resident laying in bed with whole body tremors, lethargic but arousable .second shift to report to MD [medical doctor]. -2/27/2023 at 8:54 PM Res [resident] alert, verbal, continues with full body shakes .MD notified, new order obtained for Benadryl .labs .will monitor. -2/28/2023 at 7:55 AM .Resident noted to be shaking in bed this shift .7-3 nurse notify of resident status during shift change. -2/28/2023 at 10:16 AM .On assessment this morning resident with whole body tremors .Resident alert but lethargic .resident agreeable to hospital transfer .Reported to [resident's MD] . -2/28/2023 at 3:14 PM Resident is being admitted at [hospital] with hypernatremia and dehydration, Na [Sodium, normal lab value range 135-145 mmo (milliequivalents)/l (liter)] 170. Record review of the Hospital History & Physical documentation for Resident ID #1 states in part, .Currently residing at [facility]. Presented confused, clinically very dehydrated .Labs showed severe hypernatremia with a sodium of 176 . Acute renal failure with a BUN [Blood Urea Nitrogen] of 56 [normal lab value range 6-24 mg (milligram/dl (deciliter)] and creatinine of 2.9 [normal lab value 0.74 to 1.35 mg/dl]. Lactic acidosis of 6.0 [normal lab value 2-4 mmo/l]. Elevated troponin at 0.045 [normal lab value 0 to 0.04 nanograms per milliliter]. Leukocytosis [elevated white blood cell count] .Additional information from [residents] facility. Apparently has been declining rather rapidly over the last few weeks. Refusing medications. Not taking in a reasonable amount of fluids and daily meals . Record review of the Hospital Discharge Summary document states in part, .Patient was admitted to [hospital] from [facility] with severe hyponatremia [sic], acute renal failure, severe sepsis in the setting of failure to thrive. [S/He] was extremely dehydrated on presentation, IVF [intravenous fluid] hydration was initiated. Broad spectrum antibiotics were given although infectious etiology was unclear; uti [urinary tract infection] vs. skin with extensive pemphigus foliaceus. Unfortunately, despite hydration, renal function worsened. Serum sodium slightly improved to 169 .[S/He] was seen by [Dr.] of [Hospice] service who discussed goals of care with niece .who wished for transition to inpatient hospice given tenuous status . 1B. Record review of the resident's nutritional care plan dated 2/8/2023 states in part, .therapeutic diet. (02/2023) Weight with recent significant gain/and loss-was on Prednisone, excellent intake, skin with tx [treatment]. Interventions include, but are not limited to, .Monitor and record meal intakes - Monitor and record weights per schedule . Record review of a progress note authored by the RD dated 2/8/2023 at 7:50 AM states in part, Quarterly nutritional review: Most current weight (2/6) 162.5# (pounds)-history of gain/loss, now back to baseline in the 160's. Peaked at 178# in January and will trigger for a significant, yet planned loss on MDS .excellent PO intake, 75-100%. Able to take meals independently . Record review of the resident's meal intake during the month of February revealed his/her documented meal intake was recorded as 76-100% consistently. Further review of the record revealed the resident's meal intake started to decrease on 2/24/2023. Findings below are the meals documented: 2/24/2023 no intake documented 2/24/2023 51-75% for dinner 2/25/2023 no intake documented 2/26/2023 26-50% for breakfast 2/26/2023 26-50% for lunch 2/26/2023 26-50% for dinner 2/27/2023 1-25% for breakfast 2/27/2023 26-50% for lunch 2/27/2023 None for dinner 2/28/2023 None for breakfast Review of the physician's orders revealed the resident has an order for weekly weights and to reweigh if weight is < or > 3 pounds. Record review of the resident's documented weights in January 2023 revealed the following: -1/9/2023 164 pounds (lbs.) -1/16/2023 Resident refused -1/23/2023 178.2 lbs. -1/30/2023 162 lbs. Record review revealed the resident had a 14.2 lb. weight gain which was documented on 1/23/2023 from his/her previous weight of 164 lbs. Further record review failed to reveal a reweigh was obtained as ordered. Additional record review revealed the resident had a 16.2 lb. weight loss which was documented on 1/30/2023 from his/her previous weight of 178 lbs. Further record review failed to reveal a reweigh was obtained as ordered. Record review of the resident's documented weights in February 2023 revealed the following: -2/6/2023 162.5 lbs. -2/13/2023 163.5 lbs. -2/20/2023 156.4 lbs. Record review revealed the resident had a 7.1 lb. weight loss which was documented on 2/20/2023 from his/her previous weight of 163.5 lbs. Further record review failed to reveal a reweigh was obtained as ordered. During a surveyor interview with the Director of Nursing Services (DNS) and the Administrator on 3/2/2023 at approximately 4:00 PM, the DNS revealed the RD and the physician review the resident's intake. Additionally, they revealed the resident's weights are obtained on a Monday and reviewed on a Wednesday, indicating a reweigh would be obtained by Wednesday. Lastly, the DNS was unable to provide evidence of a reweigh for the weights noted above as indicated. During a surveyor interview with Resident ID #1's physician on 3/3/2023 at 12:36 PM, revealed that he was unaware of the resident's weight loss and was was not made aware of his/her tremors and decrease in po intake until 2/27/2023. 2. Record review for Resident ID #2 revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, dysphagia following cerebral infarction and dementia. Record review of the resident's nutritional care plan dated 2/15/2023 states in part, .[Resident] has impaired swallowing with texture modified diet, weight loss prior to admission, fair intake, dependent with meals . interventions include, but are not limited to, Diet: pureed/nectar thickened liquids .Magic cup supplements .Provide additional foods/supplements if PO <50%. Record review of a progress note dated 2/15/2023 at 9:11 AM authored by the RD states in part, Initial nutritional assessment .diet with intake 25-50% .Skin: stage 2 wound [partial thickness loss to the skin presenting as a shallow open ulcer] to coccyx and right heel .Weight (2/10): 135#-daughter reports a 10# loss prior to hospitalization . Ht [height] 67in [inches], BMI [body mass index] = 21.1/within desirable range Will rec [recommend] to add magic cup supplements 120ml 2x/day to promote wound healing, help meet needs . Record review of a progress note dated 2/15/2023 at 9:11 AM authored by the RD states in part, Magic cup added 120ml 2x/day as previously recommended for weight loss and skin integrity .notify RD with any nutritional concerns . Record review of the physician's orders revealed an order dated 2/16/2023 for Magic cup twice a day in the morning and evening. Record review of the February and March 2023 Medications Administration History revealed that the resident missed 24 our of 29 opportunities to receive the Magic cup as ordered. Further review of the records revealed the Magic cup order. During a surveyor interview with the DNS on 3/2/2023 at approximately 5:00 PM, she revealed the magic cup order for Resident ID #2 was to be provided by the kitchen during his/her meals and that the Magic cup order did not transfer to the kitchen orders for it to be delivered to the resident. 3. Record review of a community report complaint received at the Rhode Island Department of Health on 2/19/2023 alleges that Resident ID #3 had two falls and became dehydrated. Per the complaint the resident fell while attempting to get out of bed to get a drink. Review of facility policy titled, Resident Hydration and Prevention of Dehydration, revealed in part, .If potential inadequate intake and/ or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan .the physician will be notified .Orders may be written for extra fluids to be encouraged between meals and/or with medication passes .a specific minimum amount should be included in the order .encouraging fluids is not an adequate order .nursing will monitor and document fluid intake and the dietician will be kept informed of status .the interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved . Record review for Resident ID #3 revealed s/he was admitted to the facility in February of 2023 with diagnoses including, but not limited to, subdural hematoma (a condition due to bleeding under the membrane covering the brain), Fahr's disease (a condition where calcium builds up in the part of the brain that controls movement), Acute encephalopathy (a term for any disease of the brain that alters brain function) and acute cystitis (infection or inflammation of the urinary bladder). Record review of a quarterly Minimum Data Set Assessment, dated 2/19/2023, revealed under the heading Weight Loss- Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, is coded as Yes, not on a physician-prescribed weight-loss regimen. Record review of the resident's baseline admission care plan, revealed a care plan which states in part, .for Dehydration Risk/ Nutrition .resident will show no signs or symptoms of dehydration or malnutrition over the next 21 days .with interventions including, but not limited to, Diet as ordered; Monitor for signs and symptoms of dehydration Labs per MD orders; Dietary consult as indicated . Record review of the resident's documented daily fluid intake from 2/9/2023 through 2/18/2023 revealed the following: -2/9/2023 960 milliliters (ml) -2/10/2023 720 ml -2/11/2023 0 ml -2/12/2023 720 ml -2/13/2023 1,560 ml -2/14/2023 1,320 ml -2/15/2023 960 ml -2/16/2023 2,100 ml -2/17/2023 1,080 ml -2/18/2023 420 ml Record review of the nursing progress notes revealed the following: -2/11/2023 at 2:43 AM .resident had an unwitnessed fall @ [at] 2:30 am. Was found crawling on the floor . -2/12/2023 at 11:12 PM .Resident is confused at baseline, had unwitnessed fall at 2245 [10:45 PM]. Resident found on the floor, stated 'slid off the bed' . -2/15/2023 at 8:22 AM .initial nutritional assessment .Estimated needs: 1200-1400ML fluids [per day] . authored by the Registered Dietician. -2/15/2023 at 5:55 PM Lab results reported to [resident's physician's assistant] .with new orders to Encourage PO [by mouth] fluids, repeat BMP [basic metabolic panel, a type of lab] on Friday 2/17/2023 .New dietary recommendation add house supplement 120ml/2x [times] a day related to weight loss. -2/16/2023 at 7:22 PM .res[ident] is restless and not able to stay in bed safely .will continue to monitor. -2/19/2023 at 1:41 AM .resident was found lying next to [his/her] bed by C.N.A.[Certified nursing Assistant] .This writer was unable to get this resident VS [vital signs] because [s/he] was being behavioral and [s/he] kept crawling on the floor .This writer called [resident's MD] .Resident left the facility at approx .1:20AM to go to [acute care hospital] . -2/20/2023 at 3:46 PM admitted to [acute care hospital] with hypernatremia diagnosis of dehydration. Record review of the following BUN [blood urea nitrogen test used to determine how well your kidneys are working] and creatinine [a waste product that comes from the normal wear and tear on muscles of the body] laboratory results reveals the following: -2/10/2023 The day after the resident was admitted to the facility, Bun (normal range 8-23 mg/dl), 13 and creatinine (normal range 0.60-1.30 mg/dl), 0.80 -2/13/2023 Bun 37 and creatinine 1.59 -2/14/2023 Bun 38 and creatinine 1.51 -2/15/2023 Bun 52 and creatinine 2.36 -2/17/2023 Bun 47 and creatinine 1.59 Record review revealed the resident had a physician's order dated for 2/15/2023 to encourage fluids every shift by mouth. Record review of the Medication Administration Record from 2/15/2023 through 2/19/2023 revealed the following documentation entries for the order to encourage fluids every shift: -2/15/2023 480 ml -2/16/2023 1,140 ml -2/17/2023 540 ml -2/18/2023 360 ml Record review of the Hospital History & Physical documentation, dated 2/19/2023 for the resident revealed in part, .past medical history of .who was brought in via EMS [emergency medical services] from NH [nursing home] after sustaining 2 mechanical fall and dehydration .initial labs showed cr [creatinine] of 2.3 mg/dl vs [versus] 0.7 mg/dl on 2/5/23 .Pt [patient] admitted for further eval[evaluation] for placement and AMS [Altered Mental Status] and AKI [acute kidney injury] . During a surveyor interview with the Director of Nursing Services (DNS) on 3/10/2023 at approximately 12:00 PM, she acknowledged that the order to encourage fluids did not include a specific minimum amount as indicated in the policy. Additionally, the DNS could not provide evidence that the amount of fluid intake on the MAR was or was not reflected in the resident's total daily fluid intake. During a surveyor interview with the Registered Dietician on 3/10/2023 at approximately 2:00 PM, she indicated that the minimum daily fluid intake for this resident is 1,200 ml. She further indicated she was not made aware of the above fluid intakes for this resident. Additionally, she inicated that the documented amount of fluid intake was lower than estimated daily fluid needs of this resident. During a surveyor interview with the Medical Director on 3/10/2023 at approximately 3:50 PM, he indicated that the above-mentioned laboratory values reflected AKI and he would have expected the resident to have received IV hydration or Clysis [an infusion of fluid into a subcutaneous space] at the facility. 47939

Based on observation, record review, and staff interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 resident reviewed for pain management, Resident ID #63. Findings are as follows: Record review for the resident revealed s/he was readmitted to the facility after being evaluated at an acute care facility in December of 2021 due to a fracture to his/her right femur. The resident has other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's annual Minimum Data Set (MDS), dated [DATE], reveals that the resident has severe cognitive impairment. The MDS also revealed that the resident had a pain interview which revealed that the resident had experienced occasional pain in the last 5 days and that the pain limited his/her day-to-day activity. Review of the resident's care plan for pain dated 2/8/2022 states, [the resident] is potential for Opioid Complications due to use of [MEDICATION(S)] for fracture pain management. Interventions include, Monitor for potential constipation. Follow up facility bowel protocol and report to Provider if not effective Monitor for respiratory depression (shallow breathing) 8 or less. Observe for pinpoint pupils. Observe for increased lethargy/drowsiness. Follow up, document and report to Provider. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -1/25/2022: [MEDICATION(S)] (medication used to relieve pain) 5 mg for pain of 6 out of 10 (0 being no pain and 10 being the worst pain), twice a day PRN (as needed) -1/25/2022: [MEDICATION(S)] (medication to relieve pain) 7.5 mg once a day at 12:00 PM -12/20/2021: Acetaminophen (medication to relieve pain) 975 mg for symptoms of pain and fever every 8 hours. -12/20/2021: [MEDICATION(S)] 5% adhesive medicated patch, 1 patch topical to right hip daily -2/7/2022 .Foot buddy Abductor pillow when in or OOB as tolerated LR for positioning . -12/21/2021 to 2/16/2022: PT (physical therapy) tx (treatment) 3-5x/wk x 4 weeks to address thera (therapy) ex (exercises), thera (therapy) acts (activities), neuro (neurological) re-ed (re-education), w/c (wheelchair) mgt (management) and training, group tx (treatment) and POC (plan of care) as indicated -12/22/2021 to 2/2/2022: OT (occupational therapy) services 3-5 x week x 4 weeks for there (therapy) ex (exercises), there (therapy) acts (activities), neuro (neurological) re-ed (re-education), adl (activities of daily living) retraining and group tx (treatment) at indicated During surveyor observations of the resident on the following dates and times, s/he was observed with his/her right leg internally rotated and without wearing the abductor pillow as ordered: 2/14/2022 at 12:49 PM, 1:15 PM, 1:27 PM, and 1:40 PM 2/15/2022 at 8:36 AM, 9:40 AM, and 1:55 PM 2/16/2022 at 8:31 AM and 8:37 AM Record review of the Physical Therapy notes revealed the following dates that the resident was in pain during therapy: -12/21/2021 states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: Facial grimacing during bed mobility task ; Does pain limit patient's functional activities? = Yes; Pain limits the following functional activities: functional mobility; bed mobility; What relieves pain? = Remaining Prescribed Medications; What exacerbates pain? = Other (movements involving R LE [right lower extremity]) .Patient has increased difficulty in bed mobility task .appears to be in great pain every time [his/her] R LE is being moved . -12/22/2021 states in part, Pain= Present .Complexities/Barriers Impacting Session: Cognitive status and Pain levels . -12/23/2021 states in part, Pain= Present .Complexities/Barriers Impacting Session: Cognitive status and Pain levels . -12/25/2021 states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: Crying, Moaning, Facial grimacing and Protective behaviors to area of pain.; Does pain limit patient's functional activities? = Yes; Pain limits the following functional activities:: functional mobility; What relieves pain? = Remaining still,Change in body position; What exacerbates pain? = Sitting, Prolonged Activity .Complexities/Barriers Impacting Session: Cognitive status and Pain levels. -12/27/2021 states in part, Pain = Present, assessment indicated; Pain Assessment Method =Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: Patient demonstrated facial grimacing when [resident] R LE [right lower extremity] is being moved. ; Does pain limit patient's functional activities? = Yes; Pain limits the following functional activities:: Movements involving R LE -12/28/2021 states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: Facial grimacing . -12/29/2021, states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: Facial grimacing when R LE is being moved .Complexities/Barriers Impacting Session: Cognitive status., pain levels, patient impulsive and weight bearing restrictions . -12/30/2021, states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: (+) Facial grimacing when R LE is being moved .Complexities/Barriers Impacting Session: Cognitive status., pain levels, patient impulsivity . -1/2/2022, states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited :wincing during RLE movement . -1/4/2022, states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: occasional facial grimacing when R LE is being moved .Complexities/Barriers Impacting Session: Cognitive status. and pain levels . -1/20/2022, states in part, Complexities/Barriers Impacting Session: Cognitive status. and pain levels . -1/21/2022, states in part, Complexities/Barriers Impacting Session: Cognitive status. and pain levels . -1/24/2022, states in part, Complexities/Barriers Impacting Session: Cognitive status. and pain levels . -1/27/2022, states in part, Complexities/Barriers Impacting Session: Cognitive status. and pain levels . -1/31/2022, states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: (+) facial grimacing when R LE is repositioned .unable to tolerate any weight bearing on R LE .Complexities/Barriers Impacting Session: Cognitive status. and pain levels . -2/2/2022, states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: (+) facial grimacing when R LE is being moved .Complexities/Barriers Impacting Session: Cognitive status. and pain levels . -2/7/2022, states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: Patient is crying out during attempts for range of motion .Complexities/Barriers Impacting Session: Cognitive status. and pain levels . -2/8/2022, states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: Patient cries during attempts to perform ROM .Complexities/Barriers Impacting Session: Cognitive status. and pain levels . -2/10/2022, states in part, Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient.; Behaviors Exhibited: Patient cries/moans every time an attempt is made to move RLE .Complexities/Barriers Impacting Session: Cognitive status. and pain levels . Record review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review failed to reveal evidence of pain tracking or a pain assessment. Additional record review failed to reveal evidence that the physician was notified of the resident complaining of pain and not being able to tolerate the therapy sessions as indicated in the therapist progress notes. During a surveyor interview with the Registered Nurse Practitioner, Staff G, on 2/17/2022 at 10:13 AM, she indicated that she was unaware of the resident reporting pain within the last couple of weeks and was unaware that the PRN [MEDICATION(S)] was not administered as ordered. During a surveyor interview on 2/17/2022 at 8:04 AM with the Director of Nursing Services, she indicated that she was unaware of the resident reporting of pain during his/her therapy sessions and could not provide evidence that the resident's pain was addressed.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a cognitively impaired resident received adequate supervision to prevent elopement from the facility for 1 of 6 sample residents reviewed for elopement Resident ID #1. Findings are as follows: On 10/25/2021, the facility reported an incident of elopement by Resident ID #1, which occurred on 10/24/2021 at approximately 6:45 PM. The facility is in a suburban setting within a short distance of a heavily traveled street. On 10/24/2021 at 6:45 PM it was dark outside. A review of the facility's policy and procedure titled Elopement Procedure states in part, .Policy: It is the policy of this facility to provide a safe and secure environment for all residents. In order to achieve this goal, residents are to be monitored at all times. Their presence within (or absence from) the facility is to be accounted for. The charge nurse on each unit is responsible to know the whereabouts of residents on his/her unit . Record review for the resident revealed that s/he was admitted to the secure dementia unit in the facility in September of 2021 with diagnoses which include but are limited to, dementia with behavioral disturbance, [CONDITION(S)], need for assistance with personal care, unsteadiness on feet, unspecified abnormalities of gait and mobility, and [CONDITION(S)] of hip. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating severe cognitive impairment. Additionally, the MDS revealed that s/he required extensive assistance of one assist with Activities of Daily Living (ADLs) including, transfers, ambulation, dressing, and hygiene/bathing. Further, the MDS revealed that s/he requires the use of a walker for ambulation. Review of the document Police Dispatch Report dated 10/24/2021 revealed a call was received on 10/24/2021 at 6:09 PM from a concerned citizen regarding an elderly person wearing a blue hat and gray jacket walking down the street. An officer was dispatched for a wellness check at 6:11 PM and arrived at 6:22 PM. S/he reported to the officer that s/he was going for a walk. S/he was transported back to the facility at 6:35 PM by the local fire department. Review of a nursing progress note written by Registered Nurse (RN), Staff A, on 10/25/2021 at 12:08 AM states, At about 1845 hours, rec'd [received] a call from . police officer who asked this writer to: (1) identify somebody (2) verify [his/her] date of birth After providing the above information the officer said he would be at [the facility] with the person in 5 minutes. He came in at 1650pm with [Resident ID #1] whom he said he picked up from Plainfield Pike. Resident verbalizes adequately and states, I just wanted to buy some cigarettes and then head home, and I almost made it. Asked how [s/he] opened the door, [s/he] replied, I just followed the instructions. I pushed the door for a short time, and it opened for me.Resident was last seen by this writer during and after supper at about 1800 hours. Per CNA's [Certified Nursing Assistant's] statement she took resident to [his/her] room per [his/her] request. Thereafter all the CNAs were busy giving care to other residents while this writer was busy administering medication to some residents. Staff denies hearing the alarm sound when resident left the unit. Resident did not have a wander guard on [him/her] prior to exiting the building. One has been placed on [his/her] (L) [left] ankle after the elopement assessment. Resident immediately called the [spouse] and informed [him/her] I 've bad news . I escaped from the building. This writer later explained the incident to the [spouse] via phone. Paperwork (Reportable) faxed to (1) Department of Health and (2) Ombudsman . Record review of hospital documentation titled Patient Inquiry dated 9/3/2021 states in part, .Brief focused history: .hx [history] of dementia w/ [with] behavioral disturbance presents via . ambulance from [facility] for psych eval [psychiatric evaluation]. Per report pt. [patient] attempted to elope from facility by breaking window and tying sheets together to climb down from 3rd floor . Review of a baseline care plan dated 9/11/2021 revealed, [Resident ID #1] is at risk for elopement/wondering due to: attempts at previous facility. [S/he] tied bed sheets together, broke window and was going to climb out the window. Voicing wanting to go to home depot per nursing notes . will wander safety within specified boundaries without harm to self or others . will not have no successful elopement attempts over the next review . Interventions include, placing resident on a secured unit, redirecting from elevators or doorways if resident is exit seeking, engage in diversional activities and reassurance, encourage rest periods, psych consult if agitation or change in behavior occurs. Review of the comprehensive care plan dated 9/30/2021 revealed, .[Resident] has a history of falling r/t [related to] poor safety awareness and poor insights to own personal limitations r/t Dementia process and history of cerebral infarction . interventions include but are not limited to, .SPH: [Safe Patient Handling] Ambulation: AX1 [Assist times one] with gait belt and RW [rolling walker] . During a surveyor interview with the Director of Nursing Services and the Assistant Director of Nursing Services on 10/26/2021 at approximately 9:00 AM, they revealed the resident was last seen by staff on the unit on 10/24/2021 at approximately 6:00 PM following dinner. They stated staff were not aware the resident was missing until the nurse received a phone call at approximately 6:30 PM from the local police department informing them they had found the resident walking down the road. They further revealed the resident resides on a secured unit. Additionally, they were unable to determine exactly how the resident was able to get out as staff did not hear an alarm sounding. During a surveyor interview with RN, Staff A, on 10/26/2021 at 11:30 AM he revealed he had received a phone call from a police officer on 10/24/2021 at 6:45 PM informing him they had found the resident walking down the street. He revealed he was not aware the resident was missing prior to receiving this phone call. He stated the resident was returned to the facility by the police at 6:50 PM. He stated he had last seen the resident at approximately 6:00 PM sitting at a table socializing with other residents in the common area nearby the outside patio exit. He stated after he saw this resident, he was busy passing medication and CNAs were busy providing PM care to residents. He indicated he had never heard an alarm sounding and was unsure how the resident left the facility. He further indicated approximately one month ago the resident had asked him on two separate occasions to take him/her to Home Depot to go site seeing. He stated he had informed the residents spouse and s/he informed him that the resident had attempted to elope from a nursing home in the past and s/he would try again. He further stated the resident had not asked to go to Home Depot again until that day prior to him/her eloping. During a surveyor interview with Licensed Practical Nurse (LPN), Staff B, on 10/26/2021 at approximately 11:00 AM she revealed that the resident exhibits exit seeking behaviors. She indicated that s/he is always looking at the elevator and trying to get on. Also, s/he attempts to open exit doors setting the alarms off. She further indicated that staff monitor and redirect him/her as needed. During a surveyor interview with Activities/CNA, Staff C, on 10/26/2021 at approximately 11:05 AM she revealed that she was working the evening of 10/24/2021 when the resident eloped. She denied hearing an alarm sounding that evening. She did not know how the resident left the building. She revealed she had also worked the day shift on 10/24/2021 and that the resident had been exhibiting exit seeking behaviors during the shift. She revealed she had reported these behaviors to Staff Nurse A during change of shift. She further revealed that she had witnessed the resident approach Staff Nurse A informing him that s/he wanted to leave the facility prior to him/her eloping. Additionally, she revealed that it is common for the resident to exhibit exit seeking behaviors and that staff redirect him/her as needed. During a surveyor interview with CNA Staff D, on 10/26/2021 at approximately 12:06 PM she revealed she was assigned to care for the resident on the evening of 10/24/2021. She stated s/he had eating dinner between 5:00 PM and 5:45 PM in the common area located near the back patio door. She stated she had last seen him/her walking back to his/her room at approximately 5:45 PM prior to him/her eloping. She further indicated that she did not hear any alarms sounding as she was busy providing care to other residents she was assigned to. Additionally, she was not aware the resident had left prior to the police calling the facility and was unaware how s/he got out of the building. During a surveyor interview with Human Resources, Staff E, on 10/26/2021 at approximately 11:45 AM and on 10/28/2021 at approximately 3:15 PM she revealed that on 10/24/2021 at approximately 6:30 PM she met the ambulance at the front entrance of the building. The EMTs informed her they had found one of the residents walking down the street. She stated the resident was on the stretcher but, was able to get off and ambulate into the building and onto the elevator. She revealed she then went onto the elevator with the resident and brought him/her back to the 2nd floor secured unit. She stated when she entered the unit, she did not hear any alarms sounding on the unit. She stated the resident informed her s/he was walking to the store to purchase cigarettes. She further revealed the resident did not have his/her walker with him/her when s/he returned to the facility. Additionally, she revealed following the residents return she had found the first-floor south side exit door alarm was sounding. During a surveyor interview on 10/29/2021 at 10:48 AM with the concerned citizen who called the police on 10/24/2021 she revealed she had first seen the resident walking on the sidewalk at approximately 6:00 PM on 10/24/2021. She stated s/he appeared to be struggling to walk as s/he was stumbling and wobbling from side to side. She stated s/he then walked off the sidewalk and into the street, then back onto the sidewalk without a walker. The resident approached the concerned citizen and asked where s/he was. She indicated as she talked to him/her she realized s/he was very confused. She stated s/he walked away and continued to walk up the street. She stated she immediately went into her house and called the police. When she came back out, she could still see him/her walking up the road. She stated s/he then turned and began to walk back and forth while looking around. She further indicated she was very concerned as it was dark outside and there is always a lot of traffic on the street. She stated she had called the police approximately 10 minutes after she had first seen him/her, and they arrived approximately 10 minutes later. She stated they were there for approximately 10-15 minutes. The location where the resident was found was noted to be approximately a 15-minute walk, a half mile away (give or take depending on route taken). It is located on a heavily traveled street. The facility failed to provide adequate supervision to a cognitively impaired resident resulting in the resident eloping from the facility on 10/24/2021, during the evening, while it was dark outside. This delay and lack of supervision placed the resident in immediate jeopardy for serious harm, injury, or death due to his/her diagnoses, cognitive impairment, and decreased functional abilities.