Every finding on record at Mount St Rita Health Centre

Based on record review and staff interview, the facility failed to ensure the correct use and ongoing reassessment of bed siderails for one of one resident, Resident ID #1 reviewed for the use of bed siderails. The facility failed to reassess the continued need for and safety of the resident's bed siderails for approximately 15 months, despite the resident's severely impaired cognition, total dependence for bed mobility, and continued use of the device. Consequently, the facility failed to identify that the bed siderails had become unsafe and were no longer clinically appropriate. As a result, Resident ID #1 sustained a traumatic posterior (the back) dislocation of the right shoulder and significant bruising. Following the injury, the facility's bed siderail assessment determined that the bed siderails were no longer indicated because they created a safety hazard for the resident. Findings are as follows:Record review of the Centers for Medicare & Medicaid Services' Resident Assessment Instrument (RAI) 3.0 Manual, dated October 2025, revealed that the use of bed siderails must be assessed prior to implementation and reassessed at least quarterly (every three months), and with any significant change in condition, to determine whether the continued use of the device remains appropriate and safe for the resident.Review of an undated facility policy titled Proper Use of Bed Rails, provided by the Administrator on 6/25/2026, stated in part, .When bed rails are used, perform an ongoing assessment of the patient's physical and mental status; closely monitor high-risk patients . Re-evaluate and revise the patient's treatment program as needed if an episode of entrapment or near-entrapment occurs with or without serious injury .Review of a community reported complaint received by the Rhode Island Department of Health on 6/9/2026 alleged that Resident ID #1 sustained a dislocated right shoulder and bruising to the right upper arm.Record review revealed Resident ID #1 was admitted to the facility in January 2025 with diagnoses including, but not limited to, Alzheimer's disease and polyosteoarthritis (a form of arthritis affecting multiple joints throughout the body).Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. The MDS further revealed the resident was totally dependent on staff for bed mobility.Record review of a nursing progress note dated 6/6/2026 at 11:00 PM, authored by Registered Nurse (RN) Staff A, revealed that a Nursing Assistant reported bruising to the resident's right armpit and right posterior arm. Due to the resident's cognitive impairment, s/he was unable to recall how the injuries occurred.Record review of a nursing progress note dated 6/7/2026 at 11:45 AM, authored by RN Staff B, revealed the resident was transferred to the Emergency Department for evaluation and returned to the facility wearing a sling on the right arm.Record review of the Emergency Department records dated 6/7/2026, revealed the resident was diagnosed with a closed traumatic posterior dislocation of the right shoulder.Record review of the facility's internal investigation revealed a signed statement, authored by the former Director of Nursing Services (DNS), dated 6/9/2026, which stated in part, [Resident ID #1] was found to have a bruise on [his/her] right forearm. The bruise appeared to be shaped like the side rail on [his/her] bed with striations that match the bars on the side rail. [S/he] sleeps on [his/her] right side with [his/her] arm around the side rail. It appears that [his/her] arm got caught in the side rail and when [s/he] rolled over it was stuck, resulting in [his/her] shoulder being dislocated when [s/he] tried to pull it out .Record review failed to reveal evidence Resident ID #1 received the required ongoing reassessments of the continued need for and safety of the bed siderails after 2/4/2025. As a result, the facility failed to reassess whether the bed siderails remained clinically appropriate and safe for Resident ID #1 for approximately 15 months, despite the resident's severely impaired cognition, total dependence for bed mobility, and ongoing use of the device.Further record review revealed a bed siderail assessment completed on 6/8/2026 determined the bed siderails were unsafe for the resident's continued use. The assessment concluded that bed siderails were not indicated because they created an accident hazard for the resident.During a surveyor interview conducted on 6/24/2026 at 2:00 PM, with the Administrator, in the presence of the current DNS, he was unable to provide evidence that the facility completed the required ongoing reassessments to determine whether Resident ID #1's bed siderails remained appropriate and safe.The facility failed to ensure that Resident ID #1's bed siderails were appropriately reassessed, as required, to determine whether their continued use remained clinically appropriate and safe. Despite the resident's severely impaired cognition, total dependence for bed mobility, and continued use of the bed siderails, the facility failed to conduct the required quarterly reassessments for approximately 15 months. Consequently, the facility failed to identify that the bed siderails had become unsafe and no longer appropriate for the resident. As a result, Resident ID #1 sustained a traumatic posterior dislocation of the right shoulder and significant bruising. Following the injury, the facility completed a bed siderail assessment that determined the bed siderails were no longer indicated because they posed a safety hazard.Based on the former Director of Nursing Services' investigation, which concluded that the resident's arm became entrapped in the bed siderail while turning in bed, together with the facility's failure to perform the required ongoing assessments of the continued appropriateness and safety of the bed siderails for approximately 15 months, a reasonable person would conclude that the facility's deficient practice directly contributed to the resident's injury and resulted in actual harm.Cross reference to citations F609 and F610.

Based on clinical record review and staff interview, the facility failed to ensure that an allegation involving an accident resulting in serious injury was reported to the appropriate authorities, including the State Survey Agency, as required by State law. This deficient practice was identified for 1 of 3 residents reviewed, Resident ID #1.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on 6/9/2026 alleged that Resident ID #1 sustained a dislocated right shoulder and bruising to the right upper arm. Additionally, it indicated that the facility was unaware of the cause of the injury.Record review revealed the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, Alzheimer's disease and polyosteoarthritis (a form of arthritis that simultaneously affects multiple joints throughout the body).Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief Interview for Mental Status score of 4 out of 15, indicating severely impaired cognition. The MDS also indicated that the resident is totally dependent on staff for bed mobility.Record review of a nursing progress note dated 6/6/2026 at 11:00 PM authored by Registered Nurse (RN), Staff A, revealed a Nursing Assistant reported bruising to the resident's right armpit and right posterior arm. The resident was unable to recall how s/he sustained the bruising due to his/her cognitive impairment.Record review of a nursing progress note dated 6/7/2026 at 11:45 AM authored by RN, Staff B, revealed the resident was sent to the emergency room (ER) for an evaluation and returned to the facility with a sling on his/her right arm.Record review of the ER hospital progress notes dated 6/7/2026 revealed s/he was diagnosed with a closed traumatic right posterior (the back) dislocation of the shoulder joint.Record review of the facility's internal investigation documents revealed a signed statement authored by the former Director of Nursing Services (DNS) dated 6/9/2026. The statement indicated, in part: [Resident ID #1] was found to have a bruise on [his/her] right forearm. The bruise appeared to be shaped like the side rail on [his/her] bed with striations that match the bars on the side rail. [S/he] sleeps on [his/her] right side with [his/her] arm around the side rail. It appears that [his/her] arm got caught in the side rail and when [s/he] rolled over it was stuck, resulting in [his/her] shoulder being dislocated when [s/he] tried to pull it out.During a surveyor interview on 6/24/2026 at 2:00 PM with the Administrator, in the presence of the current Director of Nursing Services, he acknowledged that the resident sustained a dislocated right shoulder that was not observed by any person, could not be explained by the resident, and was suspicious due to the location of and type of injury. Additionally, he was unable to provide evidence that the facility reported the incident to the appropriate authorities, including the State Survey Agency, as required under applicable State law governing long-term care facilities.Cross reference to citations F610, F689, and F700.

Based on clinical record review and staff interview, the facility failed to ensure that an injury of unknown origin was thoroughly investigated in accordance with federal regulations for 1 of 1 resident reviewed for who was discovered to have bruising to his/her right armpit and was subsequently diagnosed with a closed traumatic right posterior dislocation of the shoulder joint, Resident ID #1.Findings are as follows:Record review revealed the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, Alzheimer's disease and polyosteoarthritis (a form of arthritis that simultaneously affects multiple joints throughout the body).Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief Interview for Mental Status score of 4 out of 15, indicating severely impaired cognition. The MDS also indicated that the resident is totally dependent on staff for bed mobility.Record review of a nursing progress note dated 6/6/2026 at 11:00 PM authored by Registered Nurse (RN), Staff A, revealed a Nursing Assistant reported bruising to the resident's right armpit and right posterior arm. The resident was unable to recall how s/he sustained the bruising.During a surveyor interview on 6/24/2026 at 1:30 PM, Staff A stated that she did not identify any witnesses to the injury and acknowledged that the resident lacked the cognitive capacity to report how it occurred. She revealed that she did not initiate an investigation upon the discovery of the resident's bruising. Furthermore, she stated she was unaware if the incident was ever investigated.Record review of a nursing progress note dated 6/7/2026 at 11:45 AM authored by RN, Staff B, revealed the resident was sent to the emergency room (ER) for evaluation and came back with a sling on his/her right arm.Record review of the ER hospital progress notes dated 6/7/2026 revealed s/he was diagnosed with a closed traumatic right posterior dislocation of the shoulder joint.During a surveyor interview on 6/24/2026 at 11:29 AM, RN Staff B stated she worked the 11:00 PM to 7:00 AM shift on 6/5/2026 and 6/6/2026. Staff B stated the bruising was not present on 6/5/2026 but was noted on 6/6/2026. Staff B revealed that she did not initiate an investigation upon the discovery of the bruise to the resident's right armpit. Furthermore, she revealed that management did not interview or obtain a statement from her regarding the resident's injury.Record review of the internal investigation documents provided by the Administrator on 6/24/2026 at approximately 11:00 AM failed to demonstrate that a complete investigation was conducted, as the record lacked interviews or statements from all direct care staff regarding the resident's injury of unknown source.During a surveyor interview on 6/24/2026 at 2:00 PM, the Administrator, in the presence of the Director of Nursing Services, acknowledged that Resident ID #1 sustained a dislocated right shoulder that was unobserved, could not be explained by the resident, and was suspicious due to its location and type of injury. Additionally, he was unable to provide evidence that the facility completed a thorough investigation regarding this injury of unknown source, to endure no further potential incidents occurred.Cross reference to citations F609, F689, and F700.

Based on surveyor observation, record review, and staff interview, the facility failed to provide a sanitary and comfortable environment for residents, staff and the public relative to stained ceiling tiles observed on 2 of 3 floors in the building.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 2/10/2026 alleges in part, There are serious plumbing issues, and the ceilings leak as do some of the heating systems. There are water stains throughout the building in the ceiling tiles.Surveyor observations of the first floor on 2/17/2026 at approximately 11:45 AM revealed the following: - A ceiling tile with brown staining approximately 6 inches long in the main hallway across from the chapel. - A ceiling tile with brown staining spanning approximately 8 inches directly above the doorway to room [ROOM NUMBER] on the South unit. - A ceiling tile with brown staining approximately 6 to 8 inches long above the doorway to a utility room on the South unit. - Three adjacent ceiling tiles each with a circular, brown stain, 12 to 18 inches in diameter in the hallway leading to the shower rooms on the South unit.Surveyor observations of the second-floor South unit on 2/17/2026 at approximately 12:30 PM revealed a ceiling tile with brown staining, semi-circular in shape, approximately 18 inches wide above the doorway to a shower room.During surveyor observations and interview on 2/17/2026 at 2:40 PM with the Maintenance Director, he acknowledged that the above-mentioned ceiling tiles were stained and needed to be replaced.

Based on surveyor observation, review of the clinical record, and staff interviews, the facility failed to ensure adequate supervision to prevent an accident for 1 of 1 resident reviewed. The resident disengaged the alarm system, exited the facility, remained outside for an unknown period of time, sustained an unwitnessed fall, and was unable to re-enter the building, resulting in hospital admission for treatment of frostbite to the resident's bilateral hands, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/29/2025, states in part, that a resident wandered outside of the facility during a snowstorm, believed to be outside for at least one hour, was found yelling for help while holding onto a metal bar with both hands. S/he had large blisters on both palms, blisters on all 5 digits on the left hand and 3 digits on the right hand. The resident reported to the emergency medical personnel that s/he fell outside after his/her cane fell and that s/he held onto the metal bar for stability and called for help. 1.Record review of a facility policy titled Elopements and wandering Residents states in part, this facility ensures that residents who exhibit wandering behavior and or are at risk of elopement receive adequate supervision to prevent accidents, and receive care in accordance to their person-centered plan of care addressing unique factors contributing wandering or elopement risk.Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit). Record review revealed Resident ID #1 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, type 2 diabetes mellitus, complete traumatic amputation of left foot, and insomnia (inability to sleep). Review of an Annual Minimum Data Set assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Record review of a care plan revised on 9/25/2025 revealed that the resident was at risk of falls, was unsteady on his/her feet, s/he was partial weight bearing to his/her left lower leg and required the use of an orthopedic shoe and rolling walker for ambulation. Record review of a progress note dated 11/26/2025 at 11:48 PM, revealed that the resident had attempted to exit the building from the lobby. S/he indicated that s/he wanted to go home and was waiting for a friend to pick him/her up. The receptionist had called the unit to assist the resident however the resident had refused to return to the unit. A nurse and supervisor went to the lobby, yet the resident continued to refuse. The supervisor reached out to residents family, who revealed that there was not anyone coming to get the resident, however the resident insisted that a friend from out of state was coming. After multiple attempts the resident agreed to return to the unit with the supervisor. Further review of his/her care plan failed to reveal evidence of a focus area for going outdoors without staff notification and wandering prior to 12/26/2025. Record review failed to revealed evidence that an elopement evaluation was completed following the incident on 11/26/2025, when the resident exhibited wandering behavior and potential risk for elopement. Additionally, the care plan was not updated after the 11/26/2025 incident to reflect this change in this residents condition. During a surveyor interview on 12/30/2025 at 3:25 PM with Receptionist, Staff A, she recalled the incident on 11/26/2025 and revealed that when the resident arrived in the lobby independently without a rolling walker or wheelchair, s/he was visibly unsteady when walking. She noted that it was cold and dark outside, and she was concerned that the resident would fall. She then called the nurse on the unit as the resident was insisting on leaving the facility and refusing to return to the unit. She revealed that she had witnessed the resident exit the facility using the emergency exit button, located by the main door, to disengage the alarm on multiple occasions. Additionally, she indicated that the resident would come down the stairs of the lobby without his/her wheelchair or rolling walker as s/he was unable to navigate the stairs with anything other than a cane. During a surveyor interview on 12/30/2025 at 8:22 AM with the Administrator, he revealed that the facility has a receptionist in the lobby daily until 6:00 PM, the front doors automatically lock at approximately 4:30 PM daily and doorbells attached to the building are then used. He revealed that when someone rings the doorbell, a notification and video is sent to a cellular phone that the nursing supervisor has, they can then unlock the door for the individual to enter. When questioned by the surveyor regarding the incident that occurred on 11/26/2025, he stated that he was not aware of the incident until it was brought to her attention by the surveyor. During a surveyor interview on 12/30/2025 at 9:48 AM with the Director of Nursing Services, she revealed that it was not unusual for the resident to go outside for fresh air and that the resident had previously resided in an assisted living facility and was struggling to adjust to a restricted environment. Additionally, she revealed that the resident wakes up early in the morning. When questioned by the surveyor regarding the incident that occurred on 11/26/2025, and the failure to complete an elopement assessment and update his/her care plan, she stated that she was not aware of the incident until it was brought to her attention by the surveyor. 2. Record review of a document titled RI [Rhode Island] EMS [Emergency Medical Services] Patient Report dated 12/27/2025 at 4:27 PM revealed the resident went out for a walk yesterday morning (12/26/2025). Staff were unaware that the resident had left and could not get back into the facility for over an hour. The resident presented with fluid filled blisters on several fingers, and across the palms of both his/her hands. The blisters were described as white and blue in color, waxy and cold to the touch. Record review of a weather report from 12/26/2025 revealed that the temperatures were cold and windy with high temperatures in the upper 20's and overnight lows dropping to around 14 degrees with snow in the morning hours. Review of the emergency department documentation dated 12/27/2025 revealed that the resident presented with blistering to the tips of all fingers on the right hand and the right palm, as well as blistering to the last three fingers of the left hand and the base of the first finger. The resident was subsequently transferred to another hospital for further evaluation and treatment of the injuries. Record review of a hospital document dated 12/28/2025, revealed that the resident was transferred to the hospital from a local medical center with Level C trauma (occurs when a patient is not critically unstable but still needing prompt evaluation by the trauma team) for frostbite. Review of the resident's progress notes revealed the following entries: - 12/26/2025 at 7:29 AM, the resident sustained an unwitnessed fall outside at the ambulance entrance due to ambulating on uneven surfaces without staff assistance. - 12/26/2025 at 3:31 PM, both of the resident's hands were warm however his/her fingers were cold to touch and warmed towels were wrapped around his/her hands earlier that day. At 1:30 PM the resident called a nurse into the room to show that both of his/her hands were red with formed fluid filled blistered. - 12/26/2025 at 4:21 PM the resident is seen by the Nurse Practitioner following a fall. Nursing staff reported that the resident left facility without staff notification at 4:00 AM and now appeared to have frostbite as well as multiple clear fluid filled blisters to palms. - 12/26/2025 at 9:20 PM an elopement evaluation was completed and revealed that the resident did not present with wandering behaviors or an elopement risk, and a wander guard was placed on his/her left wrist. - 12/27/2025 at 11:12 PM both hands and multiple fingers on palm side noted with many large blisters with large red, purple, and greyish areas noted to hands and fingers. Orders were obtained and the resident was sent out emergently for medical evaluation. - 12/28/2025 at 3:36 PM the emergency medical center reported that the resident was transferred to an acute care hospital at 5:30 AM with a diagnosis of frostbite. Record review of the hospital paperwork from the trauma center dated 12/28/2025 revealed that the resident sustained frostbite to bilateral hands consisting of mostly partial and full thickness with hemorrhagic blistering, there was a small dorsal area concerning for narcosis (tissue death). The resident was admitted to the burn unit and treated with daily dressing changes, pain control, antibiotic treatment and debridement (medical process of removing dead, damaged or infected tissue to promote healing). During a surveyor interview on 12/30/2025 at approximately 11:00 AM, with the resident, s/he revealed that on early morning of 12/26/2025, s/he had decided to go for a walk, took the elevator down to the lobby and exited the building. S/he further revealed that while walking, s/he dropped his/her cane, fell and was unable to get up, s/he then grabbed onto the metal rail to stop from slipping. The resident further revealed that s/he was outside for approximately an hour. Record review of a statement obtained from the Nurse Supervisor, Staff B, on 12/26/2025, revealed that at approximately 5:50 AM, while in the 2-north day room he heard someone calling out help me. He looked out the second-floor window and saw the resident on one knee, holding onto the end of the railing located by the driveway at the ambulance turnaround. He then ran down the stairwell to assist the resident. Unable to assist the resident on his own, the nurse went back into the facility to get assistance and a wheelchair. The resident was wearing a spring jacket, hat, and revealed s/he exited the building using the door in the lobby. Record review revealed on 12/26/2025 at 7:33 AM, the resident's external temperature was 96 degrees Fahrenheit. A normal body temperature obtained by external readings ranges between 97-99 degrees Fahrenheit. During a surveyor interview on 12/30/2025 at 9:57 AM, with Nursing Supervisor, Staff B, he revealed that on 12/26/2025, while he was performing rounds on the unit at approximately 4:10 AM, he believed the resident was seated in his/her wheelchair in this/her room. At approximately 5:50 AM Staff B recalled that he sat down in the day room by the window to document and heard someone yelling for help coming from outside. He stood up and looked out the 2nd floor window and saw the resident outside, on the ground, holding onto the railing. During a surveyor interview on 12/30/2025 at 8:43 AM with the Director of Nursing Services, she revealed that following the incident on 12/26/2025, the provider ordered a wander guard for the resident. She indicated that the wander guard will prevent the use of the elevator and sound an alert to staff if the resident attempts to exit. During a surveyor interview on 12/30/2025 at 2:45 PM with the Administrator, he revealed that the resident was alert and oriented, and therefore not an elopement risk, as the resident was able to make his/her choices to exit the building. He revealed the doors are alarmed with emergency security alarms that will sound when opened, and he was aware that Resident ID #1 would exit the building independently using the red emergency exit button, which would disengage the alarm system and allow for an undetected exit from the facility. During a surveyor interview on 12/30/2025 at approximately 3:40 PM with the Administrator, in the presence of the Director of Nursing Services, they acknowledged that Resident ID #1 disengaged the alarm system, exited the facility, remained outside for an unknown period of time, sustained an unwitnessed fall, and was unable to re-enter the building, resulting in frostbite to the resident's bilateral hands.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 1 resident reviewed with a standing physician's order for insulin with special instructions, Resident ID #9, and for 1 of 1 resident reviewed for off-loading heels, Resident ID #47.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing page 314, 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.1. Record review revealed Resident ID #9 was re-admitted to the facility in June of 2025 with a diagnosis including, but not limited to, type two diabetes mellitus with hyperglycemia (high blood sugar).Review of a care plan focus area, last revised 9/22/2025, revealed that Resident ID #9 has diabetes mellitus and is insulin dependent. Interventions include, but are not limited to, administer diabetes medication as ordered by the physician and report any signs or symptoms of hyperglycemia.Record review revealed a physician's order dated 9/19/2025 for Humalog Injection Solution (insulin) 100 unit/milliliter, with instructions to administer 16 units subcutaneously (under the skin) before meals and to call the provider if his/her blood sugar is below 70 or above 350.Review of the November and December 2025 Medication Administration Records revealed on the following dates and times the resident's blood sugar was above 350:- 11/2 at 4:30 PM with a blood sugar of 411- 11/10 at 11:30 AM with a blood sugar of 357- 11/13 at 11:30 AM with a blood sugar of 383- 11/13 at 4:30 PM with a blood sugar of 390- 11/14 at 11:30 AM with a blood sugar of 362- 11/21 at 4:30 PM with a blood sugar of 387- 11/22 at 11:30 AM with a blood sugar of 373- 11/25 at 4:30 PM with a blood sugar of 368- 11/27 at 4:30 PM with a blood sugar of 392- 12/1 at 11:30 AM with a blood sugar of 351Record review of the progress notes failed to reveal evidence that the physician was notified for 7 out of the 10 opportunities in November and December, where his/her blood sugar was above 350: 11/10, 11/13 at 11:30 AM, 11/21, 11/22, 11/25, 11/27, and 12/1/2025.During a surveyor interview on 12/4/2025 at 8:56 AM, with Registered Nurse, Staff A, she acknowledged the blood sugar parameters associated with the resident's Humalog order and revealed that any provider notification should be documented in a progress note. Further, she was unable to provide evidence that the physician was notified for 7 out of 10 opportunities where Resident ID #9's blood sugar was above 350.During surveyor interviews on 12/4/2025 at 10:04 AM and 10:53 AM with the Director of Nursing Services (DNS), she revealed that she would have expected nursing to notify the resident's provider when his/her blood sugar was above the indicated parameter, and was unable to provide evidence that the physician was notified for 7 out of 10 opportunities where Resident ID #9's blood sugar was above 350.During a surveyor interview on 12/4/2025 at 11:30 AM, with the Nurse Practitioner, she revealed that she would expect staff to notify her when the resident's blood sugar is above or below the indicated parameters.2. Record review revealed Resident ID #47 was readmitted to the facility in October of 2024 with a diagnosis including, but not limited to, dementia.Record review revealed a physician's order dated 11/8/2024 to offload the resident's bilateral heels while in bed.During surveyor observations on the following dates and times, the resident was observed in bed, with his/her heels resting directly on the mattress, indicating they were not offloaded:- 12/1/2025 at 11:30 AM- 12/2/2025 at 9:49 AM- 12/3/2025 at 10:30 AMDuring a surveyor interview on 12/3/2025 at 10:42 AM, with Licensed Practical Nurse, Staff B, she acknowledged that Resident ID #47's heels were not offloaded and indicated that they should be.During a surveyor interview on 12/3/2025 at 12:32 PM, with the DNS, she revealed that she would expect Resident ID #47's bilateral heels to be offloaded while in bed, per the physician's order.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that resident records are complete and accurately documented relative to 1 of 1 resident observed for wound care, Resident ID #11, and 1 of 1 resident reviewed for off-loading heels, Resident ID #47.Findings are as follows: 1. Record review revealed Resident ID #11 was readmitted to the facility in September of 2023, with a diagnosis including, but not limited to, stage IV pressure ulcer (the most severe pressure wound that may impact muscle, tendons, ligaments, and bone).Record review revealed the following physician's orders:-10/10/2025: Obtain wound measurements and document in a progress note-10/24/2025: Measure the coccyx (tailbone) wound and document in a progress note-11/7/2025: Measure the coccyx wound and document in a progress note-11/21/2025: Measure the coccyx woundReview of the October and November 2025 Treatment Administration Records (TAR) revealed that the above orders were all documented as completed by Licensed Practical Nurse, Staff B.Although, record review failed to reveal evidence that wound measurements were obtained and documented on 10/10, 10/24, 11/7 and 11/21/2025.During a surveyor interview on 12/3/2025 at approximately 10:50 AM, with Staff B, she acknowledged documenting the above orders as completed, but was unable to provide evidence that wound measurements were obtained, as ordered.2. Record review revealed Resident ID #47 was readmitted to the facility in October of 2024 with a diagnosis including, but not limited to, dementia.Record review revealed a physician's order dated 11/8/2024 to offload the resident's bilateral heels while in bed, every shift.During surveyor observations on the following dates and times, the resident was observed in bed, with his/her heels resting directly on the mattress, indicating they were not offloaded: - 12/1/2025 at 11:30 AM - 12/2/2025 at 9:49 AM - 12/3/2025 at 10:30 AMReview of the December 2025 TAR revealed that the above-mentioned order was documented as completed for all shifts on 12/1 and 12/2.During a surveyor interview on 12/3/2025 at 10:42 AM, with Staff B, she acknowledged that Resident ID #47's heels were not offloaded and indicated that they should be.During a surveyor interview on 12/3/2025 at 12:32 PM, with the Director of Nursing Services, she was unable to provide evidence that resident records are complete and accurately documented.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 of 1 resident observed for wound care, Resident ID #11.Findings are as follows:1. Review of a facility policy titled, Clean Dressing Change states in part, .It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing.remove existing dressing.remove gloves.Wash hands and put on clean gloves.Record review revealed the resident was readmitted to the facility in September of 2023 with a diagnosis including, but not limited to, stage IV pressure ulcer (the most severe pressure wound that may impact muscle, tendons, ligaments, and bone).Review of a care plan focus area, dated 11/10/2020, revealed the resident has a coccyx (tailbone) wound with interventions that include to administer treatments, as ordered, and to measure and document weekly the width, length, depth, type of tissue, and drainage. Additionally, s/he is followed by a wound specialist.Review of a physician's order dated 1/31/2025 revealed, to cleanse his/her coccyx wound with Vashe (a wound cleanser), pat dry, apply skin prep (a skin protectant) to the peri wound, loosely pack calcium alginate with silver (a wound treatment) into the wound bed, and cover with a silicone border dressing daily and as needed.1a. During a surveyor observation of the resident's wound treatment on 12/2/2025 at approximately 1:30 PM, with Licensed Practical Nurse, Staff C, he was observed to have removed the soiled dressing and discarded it, then proceeded to cleanse the wound. Staff C then removed his gloves and discarded them, and donned new gloves, without first performing hand hygiene. Staff C then opened a sealed, sterile package of calcium alginate with silver and cut a circle from the sheet and placed it on top of the packaging, which was not sterile. Staff C then used the small circle of calcium alginate with silver, that was placed on top of the unsterile packaging, to pack the resident's wound. Staff C then completed the wound treatment by covering the wound with an island dressing instead of a silicone dressing, as ordered.During a surveyor interview immediately following the above observation with Staff C, he acknowledged that he did not perform hand hygiene between changing gloves and should have. Additionally, he acknowledged using an island dressing to cover the wound instead of a silicone dressing as ordered and revealed that he always uses the island dressing because the facility does not have the silicone dressing. Further, he could not recall placing the piece of sterile calcium alginate with silver on top of the unsterile packaging prior to packing the resident's wound.During a surveyor interview on 12/2/2025 at 2:08 PM, with the Wound Nurse, she revealed that she would expect Staff C to have performed hand hygiene between changing gloves and utilize the dressing that is ordered. Additionally, she revealed that the facility has silicone dressings specifically for Resident ID #11's wound.1b. Review of a facility policy titled, Documentation of Wound Treatments states in part, .Wound assessments are documented.weekly.The following elements are documented as part of a complete wound assessment.type of wound.stage of wound.Measurements: height, width, depth, undermining, tunneling.Description of wound characteristics.Color of the wound bed.type of tissue.condition of the peri- wound skin.presence, amount, and characteristics of wound drainage.Presence or absence of odor.Presence or absence of pain .Record review failed to reveal evidence of weekly wound measurements and descriptions of wound characteristics for 1 of 4 opportunities between 11/1 and 11/30/2025.Record review revealed a skin assessment dated [DATE] that revealed the resident has a coccyx wound, but the wound was documented as being Not Evaluated.During a subsequent surveyor interview on 12/2/2025 at 3:07 PM, with the Wound Nurse, she revealed that the resident's wound is evaluated weekly when the nurses complete the weekly skin assessment. Additionally, she acknowledged that the wound was not evaluated on 11/22/2025 and revealed it should have been.1c. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Review of the November 2025 Treatment Administration Record failed to reveal evidence that the resident's daily wound treatment was completed, as ordered, on 11/27/2025.During a surveyor interview on 12/3/2025 at approximately 12:30 PM, with the Director of Nursing Services, she revealed that she would expect the resident's wound to be evaluated weekly and wound treatments to be completed as ordered. Additionally, she revealed that she would expect staff to provide wound care consistent with professional standards of practice. Cross reference F 726

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that staff were competent to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as a nurse did not follow proper infection control practices or follow a physician's order during a resident's wound treatment and had not completed a facility provided competency for clean dressing changes, for 1 of 3 Licensed Practical Nurses (LPN) reviewed, LPN, Staff C. Findings are as follows:Review of the Facility Assessment last revised in November of 2025 revealed, that licensed nurses will receive education on topics that include, but are not limited to, skin care.Record review revealed LPN, Staff C, was hired on 9/9/2025.Further record review failed to reveal evidence that Staff C completed a clean dressing change competency. Record review revealed Resident ID #11 was readmitted to the facility in September of 2023 with a diagnosis including, but not limited to, stage IV pressure ulcer (the most severe pressure wound that may impact muscle, tendons, ligaments, and bone).Review of a physician's order dated 1/31/2025 revealed, to cleanse his/her coccyx wound with Vashe (a wound cleanser), pat dry, apply skin prep (a skin protectant) to the peri wound, loosely pack calcium alginate with silver (a wound treatment) into the wound bed, and cover with a silicone border dressing daily and as needed.During a surveyor observation of the resident's wound treatment on 12/2/2025 at approximately 1:30 PM, with Staff C, he was observed to have removed the soiled dressing, discarded it, and proceeded to cleanse the wound. Staff C then removed his gloves and discarded them, and donned new gloves, without first performing hand hygiene. Staff C then opened a sealed, sterile package of calcium alginate with silver and cut a circle from the sheet and placed it on top of the packaging, which was not sterile. Staff C then used the small circle of calcium alginate with silver, that was placed on top of the unsterile packaging, to pack the resident's wound. Staff C then completed the wound treatment by covering the wound with an island dressing instead of a silicone dressing, as ordered.During a surveyor interview immediately following the above observation with Staff C, he acknowledged that he did not perform hand hygiene between changing gloves and should have. Additionally, he acknowledged using an island dressing to cover the wound instead of a silicone dressing that was ordered and revealed that he always uses the island dressing because the facility does not have the silicone dressing. Further, he could not recall placing the piece of sterile calcium alginate with silver on top of the unsterile packaging prior to packing the resident's wound.During a surveyor interview on 12/2/2025 at 2:08 PM with the Wound Nurse, she revealed that she would have expected Staff C to have performed hand hygiene between changing his gloves and utilize the dressing that is ordered. Additionally, she revealed that the facility has silicone dressings specifically for Resident ID #11's wound.During a surveyor interview on 12/3/2025 at 12:10 PM, with the Staff Educator, she acknowledged that Staff C had not completed a clean dressing change competency and revealed that he should have completed it during the most recent education fair that was held in the fall of 2025, as he had attended the fair.During surveyor interviews on 12/3/2025 at 12:30 PM and 1:33 PM and 12/4/2025 at 10:53 AM, with the Director of Nursing Services, she revealed that she was unaware that Staff C had not completed a clean dressing change competency and revealed that he should have completed it during the annual education fair. She further revealed that licensed nurses should complete a clean dressing change competency during orientation but was unable to provide evidence that Staff C had completed the required competency during his orientation in September of 2025. Additionally, she revealed that she would expect staff to provide wound care consistent with professional standards of practice. Cross reference F 686

Based on surveyor observation, clinical record review, and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE), for 1 of 1 resident observed on contact precautions (an infection control measure used in healthcare settings to prevent the spread of germs that can be transmitted by direct or indirect contact with a resident or their environment), Resident ID #18.Findings are as follows:Review of a facility policy titled, Transmission- Based Precautions dated 1/1/2025 to 12/31/2025, states in part, .General Guidelines: Perform hand hygiene upon entering and when exiting the room.Contact Precautions: Isolation gowns and gloves are required.Required personal protective equipment (PPE) should be donned before entering the room and disposed of before exiting the room.Diseases/microorganisms requiring Contact Precautions include but are not limited to.Conjunctivitis [pink eye] .Record review revealed Resident ID #18 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, conjunctivitis. Record review revealed a physician's order dated 11/24/2025 for contact precautions, every shift, due to a bacterial infection of the right eye.During a surveyor observation on 12/2/2025 at 11:10 AM revealed, the resident had signage posted at his/her doorway indicating that s/he was on contact precautions. Additionally, the signage indicated that staff are to wear a gown and gloves prior to entering the room.During a surveyor observation on 12/2/2025 at 11:14 AM, Nursing Assistant, Staff D, was observed entering the resident's room without wearing a gown and gloves, as indicated on the signage posted on the resident's door and the facility policy. Additionally, Staff D exited the room wearing soiled gloves and accessed the clean PPE bin to obtain a gown without performing hand hygiene.During a surveyor interview immediately following the above-mentioned observation with Staff D, she acknowledged that she did not wear a gown and gloves prior to entering the resident's room. Additionally, she was unaware why the resident was on precautions and stated, I'm not sure, maybe Covid. She further acknowledged the signage posted on the outside of the resident's door for contact precautions.During a surveyor interview on 12/2/2025 at 11:20 AM, with Registered Nurse, Staff E, she indicated that the resident is on contact precautions for conjunctivitis.During a surveyor interview on 12/3/2025 at approximately 10:03 AM, with the Infection Preventionist, she indicated that she would expect all staff to wear a gown and gloves each time they enter Resident ID #18's room. During a surveyor interview on 12/3/2025 at approximately 2:40 PM, with the Director of Nursing Services, she was unable to provide evidence the infection control precautions were followed by the staff, as required.

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 1 of 3 medication carts reviewed and 3 of 3 medication rooms. Findings are as follows: Review of a facility policy titled, Medication Storage last revised on ,d+[DATE] states in part, .refrigerators should be kept clean and frost free .Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock . 1. During a surveyor observation of the 1st floor medication cart on [DATE] at 9:40 AM, in the presence of Licensed Practical Nurse (LPN), Staff C, revealed the following: - 1 bottle of vitamin B complex with Vitamin C with a manufacturer's expiration date of ,d+[DATE] - 1 bottle of cranberry supplement with a manufacturer's expiration date of ,d+[DATE] - 1 bottle of ferate 27 milligram (mg) tablets with a manufacturer's expiration date of ,d+[DATE] - 1 bottle of aspirin 81 mg tablets with a manufacturer's expiration date of ,d+[DATE] - 1 bottle of a multivitamin one daily with a manufacturer's expiration date of ,d+[DATE] During a surveyor interview immediately following the observation with Staff C, she acknowledged that the above-mentioned medications were expired and should have been discarded. 2. During a surveyor observation on [DATE] at 10:08 AM of the 2nd floor medication room in the presence of LPN, Staff E, revealed one bottle of liquid Ativan Intensol with a manufacturer's instructions to discard opened bottles after 90 days, with an open date of [DATE] and an expiration date of [DATE]. During a surveyor interview immediately following the above observation with Staff E, she acknowledged that the Ativan Intensol was opened and expired. 3. During a surveyor observation on [DATE] at 10:46 AM of the 3rd floor Medication Room in the presence of LPN, Staff A, revealed one bottle of liquid Ativan Intensol with a manufacturer's instructions to discard opened bottles after 90 days, with an open date of [DATE] and an expiration date of [DATE]. During a surveyor interview immediately following the above observation with Staff A, she acknowledged that the Ativan Intensol was opened and expired. 4. During a surveyor observation on [DATE] at 9:51 AM of the 1st floor medication storage fridge revealed an accumulation of ice in the freezer. During a surveyor interview with Staff C, at the time of the above observation, she acknowledged that there was an accumulation of ice in the freezer. 5. During a surveyor observation on [DATE] at 10:08 AM of the 2nd floor medication storage fridge revealed an accumulation of ice in the freezer During a surveyor interview with Staff E, at the time of the above observation, she acknowledged that there was an accumulation of ice in the freezer. 6. During a surveyor observation on [DATE] at 10:46 AM of the 3rd floor medication storage fridge revealed an accumulation of ice in the freezer. During a surveyor interview with Staff A, at the time of the above observation, she acknowledged that there was an accumulation of ice in the freezer. During a surveyor interview on [DATE] at 12:57 PM with the Director of Nursing Services, she revealed that she would expect the staff to discard medications appropriately when they are expired. Additionally, she revealed that there should not be a accumulation of ice in the freezers and was unsure of the last time they were defrosted.

Based on surveyor observation, record review, resident and staff interviews, 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 the use of a wanderguard bracelet (an electronic device used to alert staff of a potential elopement attempt) for 1 of 1 resident reviewed, Resident ID #56, and 2 of 2 residents reviewed for a change in condition, Resident ID #s 60 and 280. Findings are as follows: 1. Review of a facility policy titled, Elopement Prevention Policy and Procedure states in part, .Residents with cognitive deficits can be at risk for elopement due to certain behaviors which are exit seeking, wandering or curiosity of their surroundings. There are many interventions that are utilized to prevent elopement .If these interventions are not effective the resident could benefit from a wanderguard alert bracelet. This bracelet will prevent the resident from using the elevators and getting out the front lobby doors. Residents with wanderguard bracelets will have .an order in their medical record for the wanderguard bracelet . Record review revealed Resident ID #56 was admitted to the facility in July of 2023 with a diagnosis including, but not limited to, dementia. Additionally, the resident resides on an unsecured unit. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. Review of a care plan focus area initiated on 6/26/2024 and last revised on 9/24/2024 revealed that the resident is at risk for wandering/elopement related to dementia and disorientation with interventions including, but not limited to, ensure wanderguard function weekly and placement to the resident's walker. Review of a document titled, Elopement Evaluation dated 3/20/2024 revealed that the resident is at risk for elopement. Review of the following progress notes revealed that the resident was exhibiting wandering and exit seeking behaviors: - 5/28/2024: Resident with increased confusion and wandering - 6/19/2024: Resident continuously wandering and attempting to access the elevator - 6/20/2024: Resident continuously wandering - 6/21/2024: Resident wandering at the beginning of the shift - 7/2/2024: Resident wandered to another floor and was redirected back to his/her floor - 7/24/2024: Resident continues to remove his/her wanderguard and his/her family continues to encourage the resident to keep his/her wanderguard in place to maximize safety due to his/her wandering and occasional exit-seeking behaviors Record review failed to reveal evidence of an order for a wanderguard per the facility policy or orders to check placement and function of the resident's wanderguard per Resident ID #56's care plan. During a surveyor observation and simultaneous interview on 9/24/2024 at approximately 1:00 PM with Licensed Practical Nurse (LPN), Staff A, she acknowledged that the resident has a wanderguard to his/her walker. She revealed that residents with wanderguards have orders to check the wanderguard placement daily and its function weekly. Additionally, she acknowledged that the resident did not have orders in place for a wanderguard or to check placement or function of the wanderguard. During a surveyor interview on 9/24/2024 at 1:20 PM with Director of Nursing Services (DNS), she revealed that residents with wanderguards should have orders in place for the wanderguard and to check placement every shift and check function every week. 2. Review of a facility policy titled, Physician/Representative Notification of Changes states in part, .Changes in a resident's condition must be reported to the MD [Medical Doctor] and Resident Representative (when applicable) in a timely manner .The nurse on during the shift of the resident's change in condition is responsible to make the attempt to notify MD and Representative. Communication to the oncoming nurse shall include the status of the notification and MD (and Representative) response . a) Record review revealed Resident ID #60 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, Alzheimer's Disease. Record review revealed the following progress notes indicating that the resident had a change in condition: - 9/20/2024: The resident's legs are both noted to have pitting edema (occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, an indentation, will remain). Staff encouraged the resident to elevate his/her legs - 9/22/2024: The resident continues with pitting edema to both of his/her legs and staff continues to encourage him/her to elevate his/her legs Record review failed to reveal evidence that the provider was notified of the resident's pitting edema to his/her legs until brought to the facility's attention by the surveyor. During a surveyor interview on 9/23/2024 at 12:22 PM with the resident, s/he revealed that his/her legs are swollen, and staff continues to encourage the elevation of his/her legs. During a surveyor observation and simultaneous interview on 9/24/2024 at 3:23 PM with LPN, Staff B, he acknowledged that the resident's legs were edematous. He revealed that the resident's legs were not edematous the last time he saw the resident's, which was approximately 2 weeks ago. He further revealed that the edema was a change in condition, and this required a notification to the provider. During a surveyor interview on 9/25/2024 at 9:49 AM with the Physician, he revealed that he would expect staff to have notified him when the edema was first noted. Additionally, he revealed that he implemented new interventions for the resident's edematous legs. During a surveyor interview on 9/25/2024 at 9:25 AM with the DNS, she acknowledged that the resident's leg edema was a change in condition and that the provider should have been notified on 9/20/2024, when the edema was first noted. b) Record review revealed Resident ID #280 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, iron deficiency anemia (a condition when the body lacks healthy red blood cells). Review of a physician's order dated 9/13/2024 indicated to monitor for bleeding every shift and notify the provider if the resident experiences any signs or symptoms of bleeding. Review a progress note dated 9/16/2024 at 12:09 PM authored by the Physician, revealed that the resident had 4 stents (an implanted device in a blood vessel to help restore blood flow) placed (inserted via wrists and groin) and that the resident had .no bleeding, no easy bruisability . Record review revealed the following progress note indicating that the resident had a change in condition: - 9/16/2024 at 3:42 PM: The resident was noted to have bruising all around his/her genitals and groin area and the bruising was monitored throughout the shift and reported to the oncoming nurse. Record review failed to reveal evidence that a provider was notified of the bruising to his/her genital and groin area. During a surveyor interview on 9/26/2024 at 10:46 AM with LPN, Staff C, she revealed that she was aware that the resident had stents placed through his/her groin. She further revealed that a Nursing Assistant noted the bruising to the resident's groin area and the bruising seemed like it was new. She was unable to recall if she contacted the provider. During a surveyor interview on 9/26/2024 at 10:53 AM with the DNS, she revealed that she would have expected staff to notify the provider when the bruising was first noted. During a surveyor interview on 9/26/2024 at 11:54 AM with the Physician, he revealed that he would expect staff to have notified him when the bruising was first noted.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 newly admitted resident reviewed with a pressure ulcer, Resident ID #280. Findings are as follows: 1. Review of a facility document titled, Skin Integrity - Wound Care Protocols states in part, .DOCUMENTATION: 1. A complete wound assessment and documentation will be done weekly on all pressure ulcers until they are healed. The criteria to be included .Site/location .Stage [severity of wound] .Size .Appearance of the wound bed .Undermining/tunneling .Surrounding skin .Drainage . Record review revealed the resident was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, pressure induced deep tissue damage of the left heel (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure). Record review of the hospital discharge paperwork dated 9/13/2024 revealed that the resident was receiving daily wound treatment to his/her left heel wound. Review of the admission progress note dated 9/13/2024 revealed that the resident has a pressure ulcer to his/her left heel. Record review failed to reveal evidence that the resident received any wound care to his/her left heel wound until 9/20/2024, 7 days after the resident was admitted . Further record review failed to reveal evidence that the resident had his/her wound assessed to include the appropriate wound documentation and measurements including, but not limited to, size, appearance, surrounding skin, and drainage until the resident's wound was first assessed by the wound physician on 9/24/2024. During surveyor interviews on 9/25/2024 at 11:49 AM and 12:27 PM with the Unit Manager, Registered Nurse, Staff D, she revealed that the resident did not receive any treatment to his/her left heel pressure wound from 9/13 - 9/20/2024 because the treatment order was transcribed incorrectly. Additionally, she revealed that no wound measurements or wound descriptions were completed for his/her left heel wound until 9/24/2024. Further, she revealed that she is the facility's wound nurse and would expect staff to be measuring and describing the wound upon admission and weekly thereafter. During a surveyor interview on 9/25/2024 at 3:33 PM with the Director of Nursing Services, she revealed that she would have expected that the resident's left heel pressure wound to have been addressed and treated, and staff to be measuring and documenting on the condition of the wound weekly.

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 3 residents reviewed on antibiotics, Resident ID #280. Findings are as follows: Review of a facility policy titled, Antimicrobial Stewardship Program Long Term Care dated 1/1/2024-12/31/2024 states in part, .Nursing staff will receive antibiotic use and infection status information of a patient/resident who is being transferred into the healthcare facility. An antibiotic timeout will be performed within 72 hours of prescribing . Record review revealed that the resident was admitted to the facility in September 2024 with diagnoses including, but not limited to, pressure-induced deep tissue damage of the left heel (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) and peripheral vascular disease (a condition when narrowed arteries reduce blood flow to the arms or legs). Review of a Hospital Discharge Summary dated 9/13/2024 revealed an order for Bactroban 2% (topical antibiotic) topically three times a day for 30 days. Further review failed to reveal evidence on where staff should apply the medication. Review of an Internal Medicine Progress Note dated 9/13/2024 revealed Bactroban 2% ordered for a left heel wound. Review of the September 2024 Treatment Administration Record revealed the Bactroban was signed off as administered to the resident's nares three times a day for 11 days. Record review failed to reveal evidence that the facility performed an antibiotic time out. During a surveyor interview with the Infection Preventionist (IP) on 9/25/2024 at 10:24 AM, she acknowledged that the hospital paperwork revealed that the Bactroban was ordered for a left heel wound. Additionally, she acknowledged that there was no indication to apply the Bactroban to the nares. Further, the IP acknowledged that an antibiotic time out was not completed. During a surveyor interview on 9/25/2024 at 3:33 PM with the Director of Nursing Services she acknowledged that the resident received the antibiotic to the nares and not the left heel wound as ordered. Additionally, she acknowledged an antibiotic timeout was not completed for the resident and the Bactroban use.

Based on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 1 of 2 residents reviewed who were receiving morphine (a medication used to treat pain), Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/21/2024, alleged concerns regarding Resident ID #1's end of life medication. Record review revealed that the resident was readmitted to the facility in February of 2018 with diagnoses including, but not limited to, Alzheimer's disease and diabetes. Further review revealed the resident was receiving end of life care. Record review revealed the resident was assessed by hospice on 5/15/2024 and the resident's morphine was increased from 0.125 milliliters (ml) to 0.25 ml of morphine every 6 hours and every 1 hour as needed shortness of breath or severe pain. Review of a physician's order dated 5/15/2024 revealed Morphine Sulfate (Concentrate) Solution 20 milligrams/milliliters. Give 0.25 milliliters by mouth every 1 hours as needed for shortness of breath or severe pain. Review of the Narcotic logbook for Resident ID #1 revealed, on 5/17/2024 the resident was administered 0.125 ml of morphine at 5 PM and 9 PM, which is half of the ordered dose. Further review failed to reveal evidence in the resident's Medical Record that s/he received 0.125 milliliters (ml) of morphine at 5:00 PM and 9:00 PM on 5/17/2024. During a surveyor interview on 5/21/2024 at 11:14 AM with Licensed Practical Nurse, Staff A, who administered the morphine doses on 5/17/2024 at 5:00 PM and 9:00 pm, he acknowledged that he gave 0.125 ml to the resident on 5/17/2024. During a surveyor interview with the Director of Nursing Services on 5/21/2024 at 1:40 PM and 2:02 PM, she acknowledged that the resident received the incorrect amount of morphine on 5/17/2024 at 5:00 PM and 9:00 PM. Additionally, she revealed that she would have expected that the resident receive the correct amount of morphine, per the physician order.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for the resident's experiences and preferences for 1 of 3 residents reviewed, Resident ID #23. Findings are as follows: Review of the resident record revealed s/he was admitted to the facility in August of 2021, with diagnoses including but not limited to: Alzheimer's disease, need for assistance with personal care, major depressive disorder, and anxiety. Review of a Minimum Data Set (MDS) Assessment, dated 8/23/2023, revealed his/her cognitive skills are severely impaired. Review of the care plan, revised on 4/25/2022, revealed s/he is resistive to care at times related to early trauma and states that s/he is scared and please do not hurt me. Further review revealed interventions including but not limited to: two staff for all personal care interaction to help deescalate aggressive behaviors, when s/he is upset staff are to leave and reapproach later, and to use a soft, stuffed companion dog when providing care for his/her comfort. Further review of the care plan revealed s/he is at risk for harm due to stating s/he wants to die and that s/he bruises easily due to aggressive behavior during care. Review of a Social Services note, dated 11/11/2021, revealed that during a care plan meeting the resident's son stated that the resident's behaviors are exacerbated when s/he soils him/herself and recalled that his/her father was abusive. Further review revealed s/he enjoys holding his/her soft, stuffed companion dog. Review of the October 2023 nursing notes revealed in part: - 10/24/2023: .difficult today with care. Combative. Not easy to redirect . - 10/22/2023: .yelling and screaming during care . - 10/19/2023: .small bruise right arm . - 10/19/2023: .screaming during care today. Punching and pinching . - 10/18/2023: .striking out at staff when giving care today . - 8/13/2023: Resident yelled and appeared irritated a few times, during am/incontinent care. Redirected by staff which was not effective at times. Resident appeared better after being left alone most times . While this surveyor was standing in the corridor on 10/24/2023 from 11:47 AM through 12:00 PM the resident was heard repeatedly yelling out from his/her room, Help me! Surveyor observation upon entering his/her room revealed the resident was not wearing any clothes and was lying in bed on his/her right side, as Nursing Assistant (NA), Staff F, was standing behind him/her cleaning his/her buttocks. Further observation revealed the resident was continuously yelling out Help me! while hitting Staff F's right arm/hand off of his/her hip. Additional observation revealed a few stuffed animals were on the bedside chair in the room. During a surveyor interview with Staff F at the time of the observation, she indicated that the resident needs to be cleaned, then continued to provide care to him/her as the resident yelled and hit her. It was further stated that she is helping on the unit today and the other nursing assistants informed her that the resident has yelling and hitting behaviors with care. When questioned by the surveyor as to what interventions are implemented for the resident when s/he has these behaviors, Staff F indicated that the other nursing assistant working on the unit told her to start care and that she would return later to assist her. Additionally, Staff F was unaware of any interventions that should have been utilized to comfort the resident during care. The surveyor attempted to interview the resident immediately following the above observation but the resident stated No, leave me alone. During a surveyor interview with NA, Staff G, on 10/24/2023 at 12:00 PM, she indicated that the resident .always yells and hits . and that these behaviors have been ongoing for as long as she has known him/her. Additionally, it was indicated that the nurse is aware of the resident's behaviors and has stated to Staff G that the resident is on medication, but nothing further is done. During a surveyor interview with Registered Nurse, Staff H, on 10/24/2023 at approximately 12:30 PM, she indicated that she is aware that the resident exhibits behaviors when staff remove his/her brief and that the resident has experienced trauma in his/her past. Furthermore, she acknowledged not giving report to NA, Staff F, before she started her assignments on the unit. Additionally, she was unaware of the care plan interventions to provide the resident a stuffed companion dog for comfort and two staff for all personal care interactions. During a surveyor interview with the Director of Nursing Services on 10/25/2023 at 2:55 PM, she indicated that she would expect that all staff would follow the resident's care plan and implement the trauma informed care interventions. As the facility did not follow the resident's care plan interventions related to his/her history of trauma and abuse, s/he experienced a witnessed episode of increased agitation and aggression which potentially triggered re-traumatization of the resident. The staff's lack of knowledge as evidenced by the interview with Staff G, who indicated these behaviors have been ongoing with this resident and that s/he always hits. Additionally, Staff F and H, were also unaware of any interventions that could have been utilized to comfort the resident during care, are evidence of the facility's failure. See tag F 949

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 2 out of 4 kitchenettes observed. Findings are as follows: 1. Record review of Rhode Island Food Code, 2018 Edition, Section ,d+[DATE].17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . During a surveyor observation of the main kitchen on [DATE] at approximately 8:30 AM, two packages of raw chicken were in the walk-in refrigerator without identification, use by date, or the date it was removed from the freezer. During a surveyor interview with the Food Safety Director (FSD) immediately following the above observation, he was unable to provide evidence of when the items were placed in the walk-in refrigerator. 2. The Occupational Safety and Health Standards 1910.1030(d)(2)(x) states in part, .Food and drink shall not be kept in refrigerators, freezers .where other potentially infectious materials are present . During a surveyor observation of the 3rd floor kitchenette on [DATE] at 9:49 AM, the following were observed in the freezer food storage: - a red neck wrap - a blue ice wrap - two cold therapy packs During a surveyor interview with the FSD on [DATE] at approximately 2:00 PM, he revealed that nursing has a separate refrigerator for medical items, and that he would expect the kitchenette's refrigerator to contain food contents only. 3. The Rhode Island Food Code 2018 Edition ,d+[DATE].16 states in part, (D) .marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises .or sold . During a surveyor observation of the South 2 kitchenette on [DATE] at 9:11 AM, two burger buns with illegible labels were noted in the freezer. They had a sell by date of [DATE]. During a surveyor interview with the FSD on [DATE] at approximately 2:00 PM, he was unable to provide a reason why the expired burger buns were left in the freezer. 4. The Rhode Island Food Code 2018 Edition ,d+[DATE].11 states in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During a surveyor observation of the 3rd floor lunch meal on [DATE] at 12:14 PM, Dietary Aide, Staff I, was observed wearing her hair restraint covering only her ponytail. The hair restraint did not contain the hair around her face. Further observation of the main kitchen on [DATE] at approximately 11:45 AM revealed Staff I with her hair restraint covering only her ponytail and not containing the hair around her face. During a surveyor interview with Staff I immediately following the above observation, she revealed that she was unaware that hair restraints were supposed to cover all of the hair on her head.

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infection for 1 of 2 residents observed for wound care, Resident ID #57; 1 of 1 resident observed related to glucometer monitoring, Resident ID #223; and 2 of 2 residents observed on transmission based precautions, Resident ID #s 30 and 222. Findings are as follows: Record review of the Centers for Disease Control and Prevention's (CDC) guidelines for infection prevention and control practices for safe healthcare delivery in all settings, last reviewed on November 29, 2022, states in part: .5a. Hand Hygiene .2. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: a. Immediately before touching a patient. b. Before performing an aseptic task or handling invasive medical devices. c. Before moving from work on a soiled body site to a clean body site on the same patient. d. After touching a patient or the patient's immediate environment. e. After contact with blood, body fluids or contaminated surfaces. f. Immediately after glove removal . 5f. Reprocessing of Reusable Medical Equipment .Clean and reprocess (disinfect or sterilize) reusable equipment .blood glucose meters .a. Consult and adhere to manufacturers' instructions for reprocessing . .Maintain separation between clean and soiled equipment to prevent cross contamination . 1. Record review revealed Resident ID #57 was readmitted to the facility in September of 2023 with diagnoses including, but not limited to: peripheral vascular disease (poor blood circulation), and cellulitis (infection of skin). Record review revealed a physician's order dated 10/19/2023 for venous wounds to left and right lower legs, cleanse with NS (normal saline), pat dry, apply Vashe (wound cleansing solution) to 4 x 4 gauze then placed on wound bed for 5 minutes, remove, apply Silver Sulfadiazine to wound bed, cover with wound veil (type of dressing), use thin layer of Zinc ointment around wound bed (approximately 2 cm wide), cover with ABD pad (large, extra thick dressing), wrap with gauze roll (Kerlix) and tape, every day shift for venous wounds. During a surveyor observation of Resident ID #57's left and right lower extremity wound dressing change with Licensed Practical Nurse (LPN), Staff D, on 10/25/2023 at 2:00 PM, revealed the following: -Staff D failed to perform hand hygiene immediately after removal of the used gloves and before putting on new ones, on multiple opportunities. -Staff D failed to clean the scissors she used to cut the dirty dressings off both legs before utilizing it to cut the new clean dressing supplies. -Staff D failed to use two different sets of gauze to clean the resident's 2 left lower extremity wounds separately to prevent cross contamination in between wound beds. -Staff D repeatedly used one Q-tip applicator to apply Silver Sulfadiazine to the resident's multiple bilateral lower extremity wounds, repeatedly dipping the same Q-tip into the tub of ointment after using the Q-tip to apply the medication directly onto the multiple wound beds. During a surveyor interview immediately after the above observation on 10/25/2023 at approximately 2:45 PM, Staff D, acknowledged she did not follow the standard of practice for infection control during the dressing change. During a surveyor interview with the Director of Nursing Services and the Infection Control Nurse on 10/25/2023 at 3:05 PM, they acknowledged that further staff education regarding infection control practices is necessary to provide safe and high-quality patient care. 2. Review of the Centers for Disease Prevention and Control article titled, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, last reviewed March 2, 2011, states in part: .A simple rule for safe care: If shared, blood glucose meters should be cleaned and disinfected after every use . Record review revealed Resident ID #223 was admitted to the facility in October of 2023 with diagnoses including, but not limited to: Type 2 diabetes mellitus. During a surveyor observation on 10/24/2023 at 7:54 AM of Licensed Practical Nurse, Staff C, she obtained Resident ID #223's blood sugar via an Assure Platinum Blood Glucose Monitoring System. Upon completion of obtaining the blood sugar the nurse placed the glucometer back into the medication cart without disinfecting it. During a surveyor observation on 10/24/2023 at 9:22 AM of Staff C, she obtained Resident ID #223's blood sugar via the Assure Platinum Blood Glucose Monitoring System. Upon completion of obtaining the blood sugar the nurse placed the glucometer back into the medication cart without disinfecting it. During a surveyor interview on 10/24/2023 at approximately 9:45 AM, Staff C acknowledged that she failed to disinfect the glucometer after each use. 3. Review of the record for Resident ID #30 revealed s/he was admitted to the facility in October of 2018 with a diagnosis, including but not limited to: urinary tract infection. Further review of the record revealed s/he is currently on precautions due to an Extended Spectrum Beta-Lactamases (ESBL, an infection that is resistant to specific types of antibiotics) infection in the urine. A surveyor observation on 10/23/2023 at approximately 10:25 AM, revealed a contact precaution sign posted outside of the door of Resident ID #30's room; the precaution sign indicated that everyone must clean their hands before entering and when leaving the room. Continued surveyor observation on 10/23/2023 at approximately 10:30 AM, revealed Volunteer #1 entering the room of Resident ID #30, without cleaning her hands first, she then provided the resident with holy communion by placing the Eucharist in his/her mouth. The volunteer was then observed to repeat the process with his/her roommate, Resident ID #32. After exiting the room, the volunteer failed to perform hand hygiene then continued to turn to walk down the corridor. During a surveyor interview immediately following the above-mentioned observations, she acknowledged not performing hand hygiene as indicated on the sign outside of the resident's room. During an interview with the Infection Control Nurse on 10/25/2023 at 10:59 AM, she indicated that she would expect the volunteer to follow the directions provided on the contact precautions sign when entering a transmission-based precaution room. 4. Record review revealed Resident ID #222 was admitted to the facility in September of 2023 with diagnoses including but not limited to the following: Enterocolitis due to clostridium difficile (Multidrug-Resistant Organism causing severe diarrhea). Review of a sign outside the resident's door revealed that staff should be performing hand hygiene, and donning a gown and gloves prior to entering the room. During a surveyor observation on 10/24/2023 at 8:05 AM, Licensed Practical Nurse, Staff C, entered the resident's room without performing hand hygiene, or donning a gown and gloves. She proceeded to touch the bedside table, then without washing her hands came out into the hallway to don gloves and a gown. During a surveyor interview on 10/24/2023 at approximately 9:45 AM, Staff C acknowledged that she failed to perform hand hygiene and put on gloves and a gown before entering the resident's room. During an interview with the Director of Nursing Services on 10/25/2023 at 2:55 PM, she indicated that she would expect the instructions on the contact precaution sign posted outside of the resident's room to be followed. 39496 48928 41720

Based on record review and staff interview, it has been determined that the facility failed to have sufficient staff who provide direct services to residents with the appropriate behavioral health training as determined by the facility assessment. Findings are as follows: Review of a document titled, Facility Wide Resource Assessment, revised on 10/11/2023, revealed in part, .identify the resources needed to provide the necessary care and services the residents require .mental health and behavior .identify and implement interventions to support individuals with issues such as anxiety, care of residents with cognitive impairments, depression, trauma . Record review of a listing of current staff and the staffing schedule during the survey period revealed that the facility has approximately forty-two nursing staff members including nurses, nursing assistants, medication technicians and approximately eighty agency staff. Record review of the facility's staff competencies failed to reveal evidence of a Trauma Informed Care in-service. During a surveyor interview with the Director of Nursing Services on 10/25/2023 at 2:55 PM, she was unable to provide evidence that the Trauma Informed Care in-service was provided to the nursing staff prior to caring for residents with history of trauma and/or post-traumatic stress disorder.

Based on surveyor observation, record review and staff interview it has been determined that the facility failed to respect the residents right to personal privacy for 1 of 2 residents observed during a wound dressing change, Resident ID #222 and 1 of 1 resident observed during blood glucose monitoring and insulin administration, Resident ID #223. Findings are as follows: 1. Record review revealed Resident ID #222 was admitted to the facility September of 2023 with diagnoses including but not limited to: Pressure ulcer of the Sacral Region, Stage 4 (sores caused by pressure that extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments). Surveyor observation on 10/25/2023 at approximately 12:30 PM of Licensed Practical Nurse Staff B performing the dressing change to the resident's sacral pressure ulcer. During the dressing change the resident was rolled onto his/her right side with his/her uncovered buttock facing a large first floor window with an unobstructed view of the parking lot and road, the window blind was wide open. During a surveyor interview on 10/25/2023 immediately following the observation with Staff B, she acknowledged that the window blind was wide open during the dressing change compromising the resident's privacy. 2. Record review revealed Resident ID #223 was admitted to the facility in October of 2023 with diagnoses including but not limited to: Diabetes Mellitus with hyperglycemia (too much sugar in the blood). During a surveyor observation on 10/24/2023 at 9:22 AM of Licensed Practical Nurse, Staff C, revealed the nurse checks the residents blood sugar in his/her room, which is adjacent to the main entrance to the unit. She then administered the resident's ordered insulin into his/her abdomen. The nurse failed to close the privacy curtain or the bedroom door during the above procedures. During a surveyor interview on 10/24/2023 at approximately 9:45 AM with Staff C, she acknowledged that she hadn't closed the privacy curtain when checking the resident's blood sugar and administering his/her insulin. During a surveyor interview on 10/24/2023 at 2:02 PM with the Director of Nursing Services, she revealed that her expectation would be that the residents would be provided privacy during the above procedures.

Based on record review and staff interview, it has been determined that the facility failed to provide the necessary treatment and care in accordance with professional standards of practice relative to monitoring and obtaining orthostatic vital signs per a physician's order and as part of the post fall evaluation assessments, and completing fall risk assessments for 1 of 1 resident reviewed for a fall resulting in death, Resident ID #1. Additionally the facility failed to complete fall risk assessments and failed to complete post fall evaluation assessments relative to obtaining orthostatic blood pressures for 4 of 4 residents reviewed for falls, Resident ID #s 3, 4, 5, & 6. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] alleges in part, The nurse heard a resident [Resident ID #1] moaning. When checked .found resident lying on [his/her] back on the floor .There was blood from the posterior [back] of [his/her] head, swelling and bruising to the right ankle. Resident was non responsive to verbal or tactile stimuli. 911 was called . Record review of a facility policy titled, Policy and Procedure Falls Prevention Program states in part, .Procedure: 1. Fall risk assessments are performed as a part of the admission assessment, as part of the quarterly review, and as an annual and/or significant change in condition process of care plan review . 1) Record review revealed Resident ID #1 was initially admitted to the facility in February of 2020 and readmitted in May of 2021 with diagnoses including, but not limited to, hypertensive heart disease and myocardial infarction (heart attack). Record review revealed that the resident had only one fall risk assessment completed on [DATE] despite the resident residing at the facility for approximately 3 years and 4 months. Record review of a care plan focus area dated [DATE] indicated that the resident is at risk for falls related to poor safety awareness. Record review revealed that the resident was on the following medications prescribed to lower his/her blood pressure that have the potential to increase the likelihood of a fall. - Losartan Potassium 25 milligrams (mg) daily - Metoprolol Succinate Extended Release 50 mg daily Additionally, the resident was also prescribed an antipsychotic medication, Seroquel, which has a common side effect of orthostatic hypotension (a form of low blood pressure that occurs when you stand up from sitting or lying down. Signs and symptoms may include lightheadedness, dizziness, blurry vision, weakness, fainting, and/or confusion). Record review revealed that Resident ID #1 had sustained a fall on [DATE]. As a result of the fall, post fall evaluation assessments were completed for 3 consecutive days after the fall occurred. Record review of the facility's post fall evaluation assessment includes an assessment of the resident for orthostatic blood pressure changes. After the resident had sustained a fall on [DATE], his/her post fall evaluation assessments for orthostatic blood pressure changes were documented as No on the following dates and times: - [DATE] at 1:25 AM - [DATE] at 12:23 PM - [DATE] at 9:36 PM - [DATE] at 1:28 AM - [DATE] at 2:31 PM - [DATE] at 6:28 AM Record review failed to reveal evidence that orthostatic blood pressures were obtained for the resident on the above-mentioned dates and times despite the post fall evaluation assessments indicating that orthostatic blood pressure changes did not occur. Additional record review of a post fall evaluation assessment dated [DATE] at 2:14 PM, revealed the resident's blood pressure was obtained while the resident was seated and was noted to be abnormally low at ,d+[DATE] (normal blood pressure range is ,d+[DATE]). Record review failed to reveal evidence that the facility reassessed the resident's blood pressure in a timely manner to ensure accuracy or reported the abnormally low blood pressure to the physician. Record review of a pharmacy recommendation for the resident dated [DATE] states in part, Resident has an order for Seroquel which may cause orthostatic hypotension. Please consider periodic checks for possible orthostatic hypotension, by taking BP [blood pressure] reclining and then standing. A drop of 20 points in systolic or 10 points in diastolic [systolic is the first number and diastolic is the second number in a blood pressure reading] indicates orthostatic hypotension which may be a cause of falls. If this is detected, suggest reevaluation of Seroquel use . Record review of a Centers for Disease Control and Prevention STEADI (Stopping Elderly Accidents Deaths and Injuries) Assessment tool titled, Measuring Orthostatic Blood Pressure dated 2017 indicates to follow these 4 steps: 1) Have the resident lie down for 5 minutes 2) Measure the blood pressure and pulse rate 3) Have the resident stand 4) Repeat the blood pressure and pulse rate measurements after standing 1 and 3 minutes Further record review of the pharmacy recommendation revealed that the resident's physician agreed with the recommendation and the document was signed and dated on [DATE] by the physician. Additionally, a handwritten order at the bottom of the document indicated that the physician ordered orthostatic blood pressures to be obtained twice a day, twice weekly. Furthermore, there was a check mark next to the handwritten order initialed by Registered Nurse, Staff A. Record review failed to reveal evidence that the order for orthostatic blood pressure monitoring was transcribed as ordered. Additionally, the record failed to reveal evidence that orthostatic blood pressure monitoring for the resident was initiated. Record review of a progress note dated [DATE], authored by Licensed Practical Nurse (LPN), Staff B, states in part, .At 4:15am heard a resident moaning .Noted door to be slightly ajar and noted blood on the floor. Unable to access room and found [Resident ID #1] lying on the floor wrapped in [his/her] blanket on [his/her] back .Noted blood from posterior head and noted swelling and bruising to right ankle .Resident noted to be non responsive to verbal and tactile stimuli .VS [vital signs] ,d+[DATE] . Record review of the hospital documentation dated [DATE] revealed that the resident presented to the emergency department from the nursing facility after being found down and unresponsive on [DATE]. The resident was noted to have significant blood loss from a posterior scalp injury. It further revealed that the resident was hypotensive (blood pressure below ,d+[DATE] which may cause dizziness, blurred vision, and/or fainting) and the resident had a systolic blood pressure in the 60s. Furthermore, the resident's pupils were fixed and dilated (indicative of a traumatic head injury). Additionally, the resident was intubated in the field (at the nursing facility) for airway protection and was noted with scattered bruising to all extremities and had left ankle swelling. Lastly, the resident had an extensive intracranial hemorrhage [brain bleed], was placed on comfort measures, and was to be admitted to hospice care. As a result of the fall, the resident experienced an extensive intracranial hemorrhage and subdural hematoma (brain bleed) and subsequently expired on [DATE], one day after the fall. During a surveyor interview on [DATE] at 10:45 AM with Staff B, she revealed she was the nurse on duty the night the resident was found on the floor on [DATE]. She further revealed at approximately 4:15 AM she heard a moan and noted blood coming from beneath the resident's door into the hall. She indicated she was unable to open the door and had to gain entry through the adjoining bathroom and found the resident wrapped in a blanket and unresponsive on the floor. Additionally, she noted the surrounding floor was wet from the resident being incontinent, which s/he usually is not. During a surveyor interview on [DATE] at 12:38 PM with Staff A, she revealed that the check mark and her initials found on the pharmacy recommendation dated [DATE] indicated that she had reviewed the document. Additionally, she stated that she may have forgotten to transcribe the order for the orthostatic blood pressure monitoring into Resident ID #1's medical record. During a surveyor interview on [DATE] at 12:25 PM with the Director of Nursing Services (DNS), she acknowledged that the resident's fall may have been caused by orthostatic blood pressure changes. She was unable to provide evidence that the order to monitor the resident's blood pressure for orthostatic hypotension was transcribed or completed as ordered. During a surveyor interview on [DATE] at 1:20 PM with LPN, Staff C, she revealed that it is not her usual practice to obtain orthostatic blood pressures for a resident who experiences a fall, which is why she documents No for orthostatic blood pressure changes on post fall evaluation assessments. During a surveyor interview on [DATE] at 1:09 PM with the DNS, she revealed that she would expect that staff would have assessed the resident for orthostatic hypotension as part of the post fall evaluation assessment. She further revealed that documenting No on the post fall evaluation assessment specific to orthostatic blood pressure changes indicates that staff obtained orthostatic blood pressure readings and determined that it was not a potential causative factor of the fall. Additionally, the DNS acknowledged that the blood pressure reading of ,d+[DATE] documented on Resident ID #1's [DATE] post fall assessment evaluation was low and that she would have expected staff to repeat the blood pressure or report the low blood pressure reading to the physician. During a surveyor interview on [DATE] at 1:50 PM with the physician, he revealed that he would expect that staff would repeat the blood pressure and notify him if the blood pressure was found to be abnormally low. During a subsequent surveyor interview on [DATE] at 2:07 PM with the DNS, she revealed she would expect that the fall risk assessments for the resident to have been completed per the facility policy and was unable to explain why the resident had only one fall risk assessment completed since his/her admission to the facility in over three years. As a result of the facility's failure to follow its own fall policy, notify the physician of the resident's abnormally low blood pressure reading on [DATE], monitor the resident for orthostatic blood pressures after falling on [DATE], as ordered by the physician and per the pharmacy recommendation dated [DATE], placed the resident at risk for serious injury, serious harm or death as evidenced by, the resident sustaining a fall on [DATE]. Per the hospital documentation the resident's blood pressure was noted to be low when s/he arrived following his/her fall on [DATE]. S/he was then diagnosed with an extensive intracranial hemorrhage and subdural hematoma, which led to his/her death the following day. 2a) Record review revealed Resident ID #5 was admitted to the facility in January of 2023 and readmitted in May of 2023 with diagnoses including, but not limited to, schizoaffective disorder - bipolar type (mental health disorder), syncope (fainting), and collapse and falls. Record review revealed a significant change Minimum Data Set (MDS) Assessment was completed for the resident on [DATE]. Record review failed to reveal evidence that a fall risk assessment was completed for the resident following the significant change MDS Assessment per the facility policy. Record review of a care plan focus area dated [DATE] indicated that the resident is at risk for falls related to poor safety awareness with an intervention dated [DATE] for orthostatic blood pressures for 2 days. Record review of a progress note dated [DATE] at 10:38 PM revealed in part, the resident had an increase of the medication Flomax (treats symptoms of an enlarged prostate) and to monitor orthostatic blood pressures every shift for 2 days. Record review failed to reveal evidence that orthostatic blood pressures were obtained for the resident. Additional record review revealed that the resident was prescribed Risperidone 0.5 mg twice daily, an antipsychotic medication, which has a common side effect of orthostatic hypotension and may increase the potential for falls. Further record review revealed that the resident sustained falls on the following dates: [DATE], [DATE], [DATE], and [DATE]. Record review of the post fall evaluation assessments following the above-mentioned falls failed to address orthostatic blood pressure changes as a potential causative factor of the falls or was documented as No despite the record lacking evidence that orthostatic blood pressures were obtained for the resident. During a surveyor interview on [DATE] at 2:07 PM with the DNS, she revealed that she would expect the fall risk assessment for the resident to have been completed. She further revealed that orthostatic blood pressures should have been obtained and documented as part of the post fall evaluation assessments. Additionally, she was unable to provide evidence that the facility obtained orthostatic blood pressures as ordered following the increase in Flomax. 2b) Record review revealed Resident ID #6 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, dementia and hypertension. Additionally, the resident was receiving hospice services. Record review of a care plan revealed a focus area dated [DATE] indicating the resident is at risk for falls. Record review revealed that the resident sustained multiple falls in 2023 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Further record review revealed that the resident was started on Seroquel 12.5 mg on [DATE] with a dose increase to 25 mg on [DATE]. Additional record review revealed that the resident sustained two falls after the initiation of Seroquel on [DATE] and [DATE]. Record review of the post fall evaluation assessments following the above-mentioned falls in [DATE] failed to address the recently prescribed medication, Seroquel, indicating in the post fall evaluation assessments that recent changes in the resident's medication did not occur. Additional record review of the post fall assessments following the above-mentioned falls failed to address orthostatic blood pressure changes as a potential causative factor or was documented as No despite the record lacking evidence orthostatic blood pressures were obtained for the resident. 2c) Record review revealed Resident ID #4 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, unsteadiness on feet and history of falling. Record review failed to reveal evidence that a quarterly fall risk assessment was completed for the resident in March of 2023. Further record review revealed that the resident sustained 3 falls in 2023 on the following dates: [DATE], [DATE], and [DATE]. Record review of the post fall evaluation assessments following the above-mentioned falls failed to address orthostatic blood pressure changes as a potential causative factor or was documented as No despite the record lacking evidence orthostatic blood pressures were obtained for the resident. 2d) Record review revealed Resident ID #3 was admitted to the facility in September of 2019 with diagnoses including, but not limited to, Alzheimer's disease and muscle weakness. Record review revealed the resident sustained multiple falls in 2023 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. Record review of the post fall assessments following the above-mentioned falls failed to address orthostatic blood pressure changes as a potential causative factor or was documented as No despite the record lacking evidence orthostatic blood pressures were obtained for the resident. During a surveyor interview on [DATE] at 2:07 PM with the DNS, she revealed that she would expect that orthostatic blood pressures to have been obtained and documented as part of the post fall evaluation assessments, especially if staff is documenting that orthostatic blood pressure changes did not occur. Additionally, she was unable to provide evidence that the facility provided the necessary monitoring and supervision to prevent accidents. 47279

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 2 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 1/17/2023 alleges that Resident ID #1 arrived to the emergency department from this facility on 1/16/2023 after his/her family found him/her in bed with a fever and food left in his/her mouth. Additionally, the complaint alleges the resident had a 23 pound (lb) weight loss since his/her admission to the facility in October of 2022, and there were concerns that the resident was not being fed. Review of the facility's Weight Assessment & Interventions policy states in part: .The nursing staff will measure resident weights on admission and weekly X [times] 4 weeks for our post-acute care residents and monthly for our long term care residents unless otherwise ordered by the physician .Any weight change of 5 lbs. or more from the last weight obtained will be retaken to confirm accuracy. If the weight change is verified, nursing will notify the dietician in writing. Any verbal communication still requires written documentation . Significant weight changes are defined as: - Greater than or equal to 5% weight gain/loss within 30 days. - Greater than or equal to 10% weight gain/loss within 6 months. Significant weight loss or gain will be reported to the physician and the resident or the resident representative . According to State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, a significant weight loss is defined as 5% in one month. A severe weight loss is defined as greater than 5% in one month. Review of the resident's medical record revealed that s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, Alzheimer's Disease and unspecified dementia with agitation. Record review of the resident's Skilled Observation Notes revealed: - 10/29/2022 at 3:23 PM Poor po [by mouth] intake consuming less than 25% of both breakfast and lunch. - 10/30/2022 at 12:34 AM Poor po intake .Fed thickened apple juice with a spoon, tolerated less than 30 ml [milliliters]. - 10/30/2022 at 2:26 PM Poor po intake consuming less than 25% of breakfast but family was able to assist with lunch and had a great intake. - 10/31/2022 at 11:43 PM Spoke with family member, regarding status of resident. Ate less than 25% of meal with 1:1 [one to one] feed. Review of the resident's weight documentation from October 2022 through January 2023 revealed the following, - 10/2022 No admission weight was obtained - 11/3/2022 158.8 lbs. - 11/8/2022 153.5 lbs. - 11/15/2022 152.8 lbs. - 11/22/2022 150.8 lbs. - 11/29/2022 148.5 lbs. - 12/3/2022 147.3 lbs - 1/5/2023 140.5 lbs. - 1/10/2022 136.1 lbs. Record review failed to reveal evidence that the resident was weighed upon admission per facility policy. Further record review revealed that the resident had a 5.3 pound weight loss from 11/3/2022 to 11/8/2022. Further record review failed to reveal evidence that the resident was reweighed after s/he had a weight change of 5 pounds or more. Additional record review reveals that from 11/3/2022 to 12/3/2022 the resident experienced a 11.5 pound weight loss which is a severe weight loss of 7.24%. Record review reveals an order dated 11/4/2022 for Ensure Clear; Two times a day for poor intake. Record review revealed a Nutrition /Dietary Note dated 11/10/2022 at 1:25 PM indicates that the dietician had a discussion with the Administrator regarding appropriate food items such as yogurt, magic cups, pudding, etc. The note further indicates diet and supplement as ordered. Record review failed to reveal evidence that food items such as yogurt, magic cups or pudding were ordered or added to the resident's plan of care. Further record review revealed a dietary note dated 12/1/2022 at 1:39 PM which states in part, WEIGHT WARNING .6.3% wt [weight] loss x 1 mo [month] . Review of a Dietitian note dated 12/12/2022 at 3:12 PM states in part, noted weight loss 7.2% weight loss times one month .will continue to follow po's, wts and labs. Further record review failed to reveal evidence that after the dietician became aware of the resident's severe weight loss on 12/1 and 12/12/2022 that any modifications were made to the resident's plan of care to ensure s/he maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight. Additional record review failed to reveal evidence that the resident's physician was made aware of his/her severe weight loss. During a surveyor interview with the Dietitian on 1/19/2023 at 3:00 PM, she was unable to explain why there were not any modifications made to the dietary interventions for this resident, after s/he experienced a severe weight loss from 11/3/2022 to 12/3/2022. Additionally, she acknowledged that the resident was not reweighed per policy. During an interview with the Administrator on 1/18/2023 at approximately 1:30 PM, she acknowledged that nursing had documented the resident's weight loss and failed to document that they notified physician the resident's representative of the weight loss. Additionally, she revealed that she was unaware of the resident's weight loss until a family member called her on 12/12/2022 with concerns that s/he looked thin. She further indicated that she would have expected the staff to follow the facility's policy and weigh him/her upon admission as well as reweigh the resident when there is a weight change of 5 lbs or more from the previous weight.

Based on record review and staff interview, it has been determined that the facility failed to provide adequate supervision to prevent an accident for 1 of 3 sample residents, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health, dated 7/22/2022, revealed this resident rolled off the bed while a nursing assistant was providing care. Record review revealed the resident was admitted to the facility in June of 2021 with diagnoses which include, but are not limited to; need for assistance with personal care, unspecified lack of coordination, muscle weakness and a nondisplaced fracture of lateral end of left clavicle (a break in the bone connecting the breastbone and shoulder). Record review of the resident's annual minimum data set assessment dated [DATE] revealed s/he is an extensive assist of 2 for bed mobility. Record review of the resident's care plan initiated on 7/20/2022 reveals that the resident has an activity of daily living (ADL) self-care performance deficit. Interventions include, resident to be a 2 person assist with bathing, showering, and bed mobility. Review of the nursing assistant care card, dated 7/20/2022, reveals instructions to provide the resident with assistance of 2 staff for toileting, hygiene, bathing, dressing, and transferring. Record review of the facility's 5-day investigation revealed a statement by Nursing Assistant, Staff A, revealing that the resident fell out of the bed when Staff A was giving the resident a bed bath. Staff A then called for help. During a surveyor interview with the Director of Nursing on 7/28/2022 at 1:52 PM, she acknowledged that Staff A did not use 2 staff members to provide care on 7/22/2022 when the resident rolled out of the bed, resulting in a hospitalization . She further indicated that she would have expected the resident to have 2 staff members present when providing care to him/her.

Based on surveyor observation, record review, staff and family interview, it has been determined that the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder of psychosocial adjustment difficulty, or who has a history of trauma, receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being relative to 1 of 1 resident reviewed for [CONDITION(S)], Resident ID #272. Findings are as follows: Review of the facility policy titled, Suicide Precautions, states in part, When a Resident expresses verbally or through behavioral symptoms, the thought that he/she no longer wishes to live and that he/ she will terminally harm themselves, the facility must initiate suicide precautions . 1. The facility will maintain a one-on-one relationship with the resident. The resident will not be left alone when actively suicidal. 2. The facility will notify the physician and obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . IF the resident is in immediate danger to self or others, the facility will proceed with an emergency transfer (911). 3. The facility will notify the resident's family or legal representative of behavior changes and request them to come in to offer support . 7. The staff will report no less than hourly any observed behavior changes to the charge nurse of the unit. Intervals of greater frequency, such as every 15 minutes, may be required and will be determined by the charge nurse. 8. The charge nurse will chart behaviors in the nursing notes and reassess as needed. 9. The suicide precautions will remain in effect until the physician or psychological consult releases the precautions . Record review for Resident ID #272 revealed that s/he was admitted in April of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS), dated [DATE], reveals that the resident has severe cognitive impairment. Review of the Trauma Informed Care Assessment, dated 4/21/2021, reveals that the resident has had exposure to a warzone and has witnessed the following: a natural disaster, captivity, life-threatening illness or injury, and sudden/violent death. Review of the resident's care plan reveals the following: - Initiated 4/19/2021: Agitation at times related to skilled nursing facility admission and desire to return home. Monitor/record/report to doctor mood patterns of signs/symptoms of depression and anxiety as needed. Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) - Initiated 4/19/2021: Resident was in the Navy and lost many peers while oversees and mentions negative experiences in unrelated conversation. Place referral for consult with psych practitioner, provide 1:1 support as indicated. - Initiated 4/19/2021: the resident continues to [NAME] the loss of friends. S/he is the only one left. Provide 1:1 support as indicated, refer/order consult for psychiatry. - Initiated 4/26/2021: Use of antidepressant medication ([MEDICATION(S)]) related to agitation and restlessness. Monitor/document/report adverse reactions as needed such as suicidal thoughts. During a surveyor interview with the resident's family member/Healthcare Power of Attorney (HPOA) on 5/3/2021 at 1:55 PM, she revealed that she was worried about the resident's depression. Furthermore, she indicated that the resident does not seem to be happy at the nursing home and that s/he has become more agitated/aggressive since his/her admission. Additionally, she revealed that it was reported to her that the resident expressed wanting to jump out of the window, which she found concerning. Review of a progress note, dated 4/19/2021 at 5:00 PM, revealed that upon entering the resident's room s/he stated, I am going to jump out the window and kill everyone . Of note, the resident resides on the second floor of the nursing home. Further record review revealed that the resident was sent out to the hospital on 4/19/2021, after threatening to jump out the window. Review of the hospital discharge instructions, dated 4/19/2021, states in part, the resident came in today because . [s/he] has been reportedly attempting to harm . [himself/herself] by threatening to jump out of the window . Further record review revealed that the resident returned to the nursing home on 4/20/2021. Review of the resident's care plan failed to reveal that interventions were put into place for the [CONDITION(S)] until 5/3/2021. Review of a progress note, dated 4/30/2021 at 2:44 PM, states in part, the resident was found standing in front of the window in . [his/her] room this morning at 7:45 am trying to open the window . Additionally, it indicates that when staff inquired, the resident told staff that s/he tried to open it and jump out. Review of a progress note by Nurse Practitioner (NP), Staff A, dated 4/30/2021 at 3:24 PM, revealed that she was notified by the nurse that the resident was in his/her room by the window attempting to open it and stated that s/he wanted to jump out. The NP ordered a psychiatry evaluation at this time. Further review of a progress note by Nurse, Staff B, dated 4/30/2021 at 10:33 PM, states in part around 10pm . [s/he] became agitated saying . [s/he] was going to kill . [himself/herself] . During a surveyor interview with Nurse, Staff B, on 5/3/2021 at 3:09 PM, she acknowledged that she wrote the progress note above, indicating that the resident stated that s/he was going to kill himself/herself. Additionally, she revealed that the resident was not put on one-to-one supervision and she was unaware of the facility's Suicide Precautions policy. Furthermore, she acknowledged that the physician was not notified of the resident's [CONDITION(S)]. Record review failed to reveal evidence that the resident's physician or family were notified of the suicidal ideation statement made by the resident on 4/30/2021 at approximately 10:00 PM. During multiple surveyor observations on both 5/2/2021 and 5/3/2021, the resident was sitting in his/her room with no staff present. During further surveyor observations on 5/3/2021 at 3:00 PM and 5/4/2021 at 8:47 AM, there were multiple cords noted in the resident's room. Additionally, on 5/4/2021 at 8:34 AM, the resident was noted to have regular silverware with breakfast. During a surveyor interview with Nursing Assistant, Staff C, on 5/3/2021 at 3:01 PM, she indicated that the resident has mentioned wanting to kill himself/herself previously; however, she acknowledged that the resident is not provided one-on-one supervision and that they do not document when they check on the resident. Review of a progress note by the social worker, dated 5/2/2021 at 10:41 AM, revealed the social worker was aware of the resident's statement and attempt to open the bedroom window. Additionally, it indicates that the resident was placed on the list for a psychiatry consult and that she would contact psychiatry services to obtain an emergent consult. Further record review failed to reveal evidence that the facility attempted to obtain a psychiatry consult on 4/30/2021 or 5/1/2021, after the resident presented with [CONDITION(S)] on 4/30/2021. Additionally, there is no evidence that the resident was seen by psychiatry services at the facility since admission. Review of the progress note by the social worker, dated 5/3/2021 at 7:33 PM, revealed that she spoke with psychiatry services who Requested implementation of 15 minute safety checks until psych [psychiatry] consult on 5/5. Recommended . [resident] is sent out for eval [evaluation] if bx's [behaviors] worsen and presents an immediate threat to self and others . There is no evidence that the facility implemented scheduled checks for this resident from 4/30/2021 at 10:00 PM, upon resident's statement that s/he was going to kill himself/herself until 5/3/2021 at 4:30 PM, when recommended by psychiatry services. Review of a progress note, dated 5/3/2021 at 11:08 PM, revealed that the resident refused dinner saying that s/he wanted to die. Additionally, it reveals that the resident got very combative and told one staff member that s/he was going to shoot her. Further record review revealed that the resident was medicated with [MEDICATION(S)] and remained in the facility. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] started for restlessness and anxiety. Likely needs baseline antidepressant. Psych services has not seen . [him/her] . Further review revealed that the resident was started on [MEDICATION(S)] (an antidepressant medication). The facility failed to implement their Suicide Precautions policy which includes notification of the physician and one-on-one supervision until cleared by a physician or psychological consult. Record review revealed that the resident was not seen by the physician until 5/4/2021 and a psychological consult did not occur until 5/5/2021, putting the resident at immediate risk related to his/her [CONDITION(S)]. During a surveyor interview with the Director of Nursing Services and the Administrator on 5/4/2021 at 1:55 PM, they could not provide evidence that the resident received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being when the resident presented with [CONDITION(S)] on 4/30/2021.

Based on surveyor record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision and assistance to prevent accidents for 3 of 3 residents reviewed relative to ADLs (Activities of Daily Living) (Resident ID #'s 1, 6, and 7). Findings are as follows: 1. Review of a facility reported incident revealed that Resident ID #1 rolled out of bed while being provided care on 08/03/2020. Resident ID #1 was sent to the emergency room (ER) for evaluation after hitting the side of the forehead. Resident ID #1 was admitted to the facility in August of 2016 and has [DIAGNOSES REDACTED]. wrist and left hand, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS), dated [DATE] and 08/18/2020, reveals that the resident requires two or more staff for assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Review of the care plan interventions, dated 07/20/2020, 08/13/2020, and 10/19/2020, reveals that the resident requires the help of 2 staff for repositioning in bed, transfers, toilet use, dressing, and bathing. Review of the nursing assistant care card, dated 07/20/2020, reveals instructions to provide the resident with assistance by 2 staff for positioning when in bed. Further review reveals an updated care card, dated 08/11/2020, to provide 2 staff for bed mobility and assistance with positioning when in bed. Review of the fall note, dated 08/24/2020, regarding the incident on 08/03/2020 indicates that at 2130 (9:30 PM) cna (certified nursing assistant) called for help because patient fell out of bed during care. Pt (patient) was rolled to the left and fell to the floor, was found laying on .right side with a bruise to .forehead. 911 was called and pt was sent to . the hospital. The fall note further reveals that the resident had red or reddish blue bruising to the right forehead. Review of the statement, dated 08/04/2020, from Nursing Assistant (NA), Staff A (staff who was providing resident care at the time of the incident), reveals that she rolled the resident onto his/her right side while attempting to pull the clean sheets from under the resident. The resident started to fall onto his/her right side. Staff A attempted to slow down the fall by leaning over the bed and grabbing his/her head and side. The resident proceeded to fall onto the floor and Staff A called for Nurse, Staff B. Review of the statement, dated 08/03/2020, from the nurse, Staff B, states in part, cna was changing pt when .fell out of bed, hit R (right) side of forehead. Said ow when tried to turn . or c (with) any movement . Review of the hospital discharge summary, dated 08/11/2020, states in part, Patient fell at SNF (Skilled Nursing Facility), reportedly accidentally dropped during repositioning with positive head strike resulting in hematoma to forehead. En route with EMS (Emergency Medical Service) .became hypotensive (low blood pressure), requiring 2 doses of [MEDICATION NAME] (medication used to treat serious reactions to substances) and transition to [MEDICATION NAME] drip (medication used to treat low blood pressure) . Review of the nursing progress notes revealed a note, dated 08/11/2020, which states in part, Resident readmitted to the facility via stretcher from acute care hospital r/t (related to) fall that occurred a week prior. No new orders or changes to current orders .Bruising on right side of face and right arm from fall . During a surveyor interview with the Director of Nursing Services (DNS) on 12/04/2020 at 3:04 PM, she acknowledged that Staff A did not use 2 staff members to provide care on 08/03/2020 when the resident rolled out of bed, resulting in hospitalization . Record review revealed that staff education was provided, after the incident, relative to providing Resident ID #1 with a two-person assist with ADLs and transfers. Further review revealed that the facility continued to provide ADL care to the resident with assistance by only 1 nursing assistant, despite nursing staff being re-educated on the need for 2 people to assist with ADL care. Review of the nursing assistants' ADL documentation for the resident from 08/11/2020 (the day the resident returned from the hospital) to 08/14/2020 revealed the following: - 08/11/2020 at 11:22 PM: Hygiene performed with 1-person assist - 08/12/2020 at 2:42 PM: Hygiene performed with 1-person assist - 08/13/2020 at 2:46 AM: Toileting performed with 1-person assist - 08/13/2020 at 2:46 AM: Bed mobility performed with 1-person assist - 08/13/2020 at 11:40 AM: Toileting and hygiene performed with 1-person assist - 08/13/2020 at 11:42 AM: Bed mobility performed with 1-person assist - 08/13/2020 at 10:44 PM: Hygiene performed with 1-person assist - 08/14/2020 at 1:19 AM: Toileting performed with 1-person assist - 08/14/2020 at 1:19 AM: Bed Mobility performed with 1-person assist - 08/14/2020 at 3:17 PM: Dressing and hygiene performed with 1-person assist - 08/14/2020 at 3:18 PM: Bed Mobility performed with 1-person assist Review of the nursing assistants' ADL documentation for the resident from 11/01/2020-11/30/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bathing: 51 out of 57 opportunities - Bed Mobility: 57 out of 81 opportunities - Dressing: 51 out of 58 opportunities - Personal Hygiene: 60 out of 78 opportunities - Toilet Use: 57 out of 68 opportunities Review of the nursing assistants' ADL documentation for the resident from 12/01/2020-12/03/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bathing: 6 out of 6 opportunities - Bed Mobility: 5 out of 8 opportunities - Dressing: 5 out of 5 opportunities - Personal Hygiene: 6 out of 6 opportunities - Toilet Use: 3 out of 5 opportunities During a surveyor interview with Staff C, NA, on 12/04/2020 at 2:26 PM, she indicated that the resident requires complete care. Additionally, she revealed that she uses common knowledge of what care is needed for the resident and at times will provide care by herself, depending on the day. During a surveyor interview with Staff D, NA, on 12/04/2020 at 2:30 PM, she indicated that she can provide care to the resident by herself, such as toileting, dressing, etc., if she does not have to roll the resident. During a surveyor interview with Staff E, RN Supervisor, on 12/04/2020 at 10:45 AM, she revealed that the resident requires 2 nursing assistants for care. During a surveyor interview with the Director of Nursing Services (DNS) on 12/04/2020 at 3:04 PM, she revealed that staff should be using two people to provide care to Resident ID #1. 2. Resident ID #6 was admitted to the facility in June of 2020 with [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment, dated 06/26/2020, reveals that the resident is at a high risk for falls. Review of the initial MDS, dated [DATE], reveals that the resident requires two or more staff for assistance with bed mobility and transfers. Review of the care plan interventions, dated 10/19/2020, reveals that the resident requires the assistance of 2 staff for repositioning when in bed and transfers. Review of the updated care plan interventions, dated 12/04/2020, reveals that the resident requires the assistance of 2 staff for bed mobility and transfers. Review of the nursing assistant care card, dated 06/26/2020, reveals that the resident requires assistance by 1 staff for positioning when in bed and bed mobility. The facility failed to update the care card to be consistent with the updated care plan interventions and MDS, indicating that the resident requires a 2-person assist for bed mobility and transfers. Review of the nursing assistants' ADL documentation for the resident from 11/01/2020-11/30/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bed Mobility: 51 out of 73 opportunities - Transfers: 17 out of 22 opportunities Review of the nursing assistants' ADL documentation for the resident from 12/01/2020-12/07/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bed Mobility: 18 out of 22 opportunities - Transfers: 5 out of 11 opportunities During a surveyor interview with Staff F, NA, on 12/08/2020 at 9:15 AM, she indicated that she can transfer the resident on her own if the resident does not need to be transferred by a mechanical lift. During a surveyor interview with Staff G, NA, on 12/08/2020 at 10:15 AM, she indicated that if the resident is feeling stronger that day and they do not have to use a mechanical lift, it is up to the nursing assistant's judgment whether to transfer the resident using an assist of 1 or 2 staff. During a surveyor interview with the DNS on 12/08/2020 at approximately 12:30 PM, she indicated that the nursing assistants should be following the care plan. 3. Resident ID #7 was admitted to the facility in June of 2015 and has [DIAGNOSES REDACTED]. Review of the quarterly MDS, dated [DATE], reveals that the resident requires two or more staff for assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Review of the care plan interventions, dated 07/24/2020, reveals that the resident requires assistance of 2 staff for repositioning in bed, transfers, toilet use, dressing, and bathing. Review of the nursing assistant care card, dated 07/25/2020, reveals instructions to provide the resident with assistance by 2 staff for bed mobility, positioning when in and out of bed, dressing, bathing/daily washing, toilet use and transfers. Review of the nursing assistants' ADL documentation for the resident from 11/01/2020-11/30/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bathing: 40 out of 56 opportunities - Bed Mobility: 35 out of 83 opportunities - Dressing: 43 out of 59 opportunities - Personal Hygiene: 43 out of 52 opportunities - Toilet Use: 28 out of 62 opportunities - Transfer: 3 out of 35 opportunities Review of the nursing assistants' ADL documentation for the resident from 12/01/2020-12/07/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bathing: 6 out of 12 opportunities - Bed Mobility: 6 out of 19 opportunities - Dressing: 6 out of 12 opportunities - Personal Hygiene: 8 out of 10 opportunities - Toilet Use: 4 out of 15 opportunities - Transfer: 2 out of 6 opportunities During a surveyor interview with the DNS on 12/08/2020 at approximately 12:30 PM, she indicated that the nursing staff should be following the interventions that were put in place in the care plan and care card. Additionally, she was unaware that the above residents were not provided assistance with ADLs in accordance with their plan of care.

Based on surveyor record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 3 of 3 residents reviewed relative to ADLs (Activities of Daily Living) (Resident ID #'s 1, 6, and 7). Findings are as follows: 1. Review of a facility reported incident revealed that Resident ID #1 rolled out of bed while being provided care on 08/03/2020. Resident ID #1 was sent to the emergency room (ER) for evaluation after hitting the side of the forehead. Resident ID #1 was admitted to the facility in August of 2016 and has [DIAGNOSES REDACTED]. wrist and left hand, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS), dated [DATE] and 08/18/2020, reveals that the resident requires two or more staff for assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Review of the care plan interventions, dated 07/20/2020, 08/13/2020, and 10/19/2020, reveals that the resident requires the help of 2 staff for repositioning in bed, transfers, toilet use, dressing, and bathing. Review of the nursing assistant care card, dated 07/20/2020, reveals instructions to provide the resident with assistance by 2 staff for positioning when in bed. Further review reveals an updated care card, dated 08/11/2020, to provide 2 staff for bed mobility and assistance with positioning when in bed. Review of the statement, dated 08/04/2020, from Nursing Assistant (NA), Staff A (staff who was providing resident care at time of the incident), reveals that she rolled the resident onto his/her right side while attempting to pull the clean sheets from under the resident. The resident started to fall onto his/her right side. The resident proceeded to fall onto the floor. Review of the hospital discharge summary, dated 08/11/2020, states in part, Patient fell at SNF (Skilled Nursing Facility), reportedly accidentally dropped during repositioning with positive head strike resulting in hematoma to forehead. En route with EMS (Emergency Medical Service) .became hypotensive (low blood pressure), requiring 2 doses of [MEDICATION NAME] (medication used to treat serious reactions to substances) and transition to [MEDICATION NAME] drip (medication used to treat low blood pressure) . During a surveyor interview with the Director of Nursing Services (DNS) on 12/04/2020 at 3:04 PM, she acknowledged that Staff A did not use 2 staff members to provide care on 08/03/2020 when the resident rolled out of bed, resulting in hospitalization . Review of the nursing assistants' ADL documentation for the resident from 08/11/2020 (the day the resident returned from the hospital) to 08/14/2020 revealed the following: - 08/11/2020 at 11:22 PM: Hygiene performed with 1-person assist - 08/12/2020 at 2:42 PM: Hygiene performed with 1-person assist - 08/13/2020 at 2:46 AM: Toileting performed with 1-person assist - 08/13/2020 at 2:46 AM: Bed mobility performed with 1-person assist - 08/13/2020 at 11:40 AM: Toileting and hygiene performed with 1-person assist - 08/13/2020 at 11:42 AM: Bed mobility performed with 1-person assist - 08/13/2020 at 10:44 PM: Hygiene performed with 1-person assist - 08/14/2020 at 1:19 AM: Toileting performed with 1-person assist - 08/14/2020 at 1:19 AM: Bed Mobility performed with 1-person assist - 08/14/2020 at 3:17 PM: Dressing and hygiene performed with 1-person assist - 08/14/2020 at 3:18 PM: Bed Mobility performed with 1-person assist Review of the nursing assistants' ADL documentation for the resident from 11/01/2020-11/30/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bathing: 51 out of 57 opportunities - Bed Mobility: 57 out of 81 opportunities - Dressing: 51 out of 58 opportunities - Personal Hygiene: 60 out of 78 opportunities - Toilet Use: 57 out of 68 opportunities Review of the nursing assistants' ADL documentation for the resident from 12/01/2020-12/03/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bathing: 6 out of 6 opportunities - Bed Mobility: 5 out of 8 opportunities - Dressing: 5 out of 5 opportunities - Personal Hygiene: 6 out of 6 opportunities - Toilet Use: 3 out of 5 opportunities During a surveyor interview with Staff C, NA, on 12/04/2020 at 2:26 PM, she revealed that she uses common knowledge of what care is needed for the resident and at times will provide care by herself, depending on the day. During a surveyor interview with Staff D, NA, on 12/04/2020 at 2:30 PM, she indicated that she can provide care to the resident by herself, such as toileting, dressing, etc., if she does not have to roll the resident. During a surveyor interview with the Director of Nursing Services (DNS) on 12/04/2020 at 3:04 PM, she acknowledged that the resident's plan or care requires two staff to provide care to Resident ID #1. 2. Resident ID #6 was admitted to the facility in June of 2020 with [DIAGNOSES REDACTED]. Review of the initial MDS, dated [DATE], reveals that the resident requires two or more staff for assistance with bed mobility and transfers. Review of the care plan interventions, dated 10/19/2020, reveals that the resident requires the assistance of 2 staff for repositioning when in bed and transfers. Review of the updated care plan interventions, dated 12/04/2020, reveals that the resident requires the assistance of 2 staff for bed mobility and transfers. Review of the nursing assistants' ADL documentation for the resident from 11/01/2020-11/30/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bed Mobility: 51 out of 73 opportunities - Transfers: 17 out of 22 opportunities Review of the nursing assistants' ADL documentation for the resident from 12/01/2020-12/07/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bed Mobility: 18 out of 22 opportunities - Transfers: 5 out of 11 opportunities During a surveyor interview with Staff F, NA, on 12/08/2020 at 9:15 AM, she indicated that she can transfer the resident on her own if the resident does not need to be transferred by a mechanical lift. During a surveyor interview with Staff G, NA, on 12/08/2020 at 10:15 AM, she indicated that if the resident is feeling stronger that day and they do not have to use a mechanical lift, it is up to the nursing assistant's judgment whether to transfer the resident using an assist of 1 or 2 staff. During a surveyor interview with the DNS on 12/08/2020 at approximately 12:30 PM, she indicated that the nursing assistants should be following the care plan. 3. Resident ID #7 was admitted to the facility in June of 2015 and has [DIAGNOSES REDACTED]. Review of the quarterly MDS, dated [DATE], reveals that the resident requires two or more staff for assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Review of the care plan interventions, dated 07/24/2020, reveals that the resident requires assistance of 2 staff for repositioning in bed, transfers, toilet use, dressing, and bathing. Review of the nursing assistant care card, dated 07/25/2020, reveals instructions to provide the resident with assistance by 2 staff for bed mobility, positioning when in and out of bed, dressing, bathing/daily washing, toilet use and transfers. Review of the nursing assistants' ADL documentation for the resident from 11/01/2020-11/30/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bathing: 40 out of 56 opportunities - Bed Mobility: 35 out of 83 opportunities - Dressing: 43 out of 59 opportunities - Personal Hygiene: 43 out of 52 opportunities - Toilet Use: 28 out of 62 opportunities - Transfer: 3 out of 35 opportunities Review of the nursing assistants' ADL documentation for the resident from 12/01/2020-12/07/2020 reveals that the resident was provided with only a 1 person assist on the following opportunities: - Bathing: 6 out of 12 opportunities - Bed Mobility: 6 out of 19 opportunities - Dressing: 6 out of 12 opportunities - Personal Hygiene: 8 out of 10 opportunities - Toilet Use: 4 out of 15 opportunities - Transfer: 2 out of 6 opportunities During a surveyor interview with the DNS on 12/08/2020 at approximately 12:30 PM, she indicated that the nursing staff should be following the interventions that were put in place in the care plan.