Every finding on record at Overlook Nursing and Rehabilitation Center

Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that a resident's environment remains as free of accident hazards as possible for 1 of 1 resident reviewed who sustained a burn, Resident ID #27. Findings are as follows: Review of an article published by the Journal of Food Science, dated July 11, 2019, titled A Review of Hot Beverage Temperatures-Satisfying Consumer Preference and Safety states in part, .An appropriate range for service temperatures is 130 to 160 °Fahrenheit (F) .This recommendation balances a range of consumer preferences and safety . Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, chronic kidney disease, dependence on renal dialysis, and diabetes. Record review of a Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status score of 14 out of 15, indicating intact cognitive function. Record review a progress note dated 3/26/2025 revealed that at approximately 7:00 PM, the resident spilled hot chocolate on him/herself. His/her skin was assessed at approximately 8:00 PM and revealed redness with an intact blister on the outside of the left thigh. Skin prep and a border gauze was applied. Record review of a progress notes dated 3/31/2025 at 12:08 PM states in part, .left thigh with a new area measuring 7.7 x 13.5 x 0.1 [centimeters] 30% dermis [middle layer of skin], 70% epithelial [outer layer of skin] no drainage or signs of infection. The resident stated [s/he] spilled hot cocoa on [him/herself] during a meal [s/he] was having with a friend who was visiting over the weekend . Record review of a document titled, Integrated Wound Care dated 4/14/2025, revealed the resident had a left thigh burn measuring 7 by 12 centimeters (cm) and 0.1 cm deep noted with 30% scabbing. Additionally, the burn was noted as a second-degree burn (damage to the outer layer of skin and some of the underlying layer of skin). During a surveyor interview with the resident on 5/1/2025 at 8:37 AM, s/he revealed that on the evening of 3/26/2025, a Nursing Assistant made him/her a cup of hot chocolate using a Keurig brand coffee maker located on the 1st floor kitchenette. Resident ID #27 indicated s/he had put the cup of hot chocolate on the edge of table, and it spilled onto his/her leg. S/he further revealed that the spilled hot chocolate on his/her thigh was very painful. During a surveyor observation of the 1st floor kitchenette on at 5/1/2025 at 10:27 AM, revealed Nursing Assistant (NA) Staff F, warming a plated breakfast meal for a resident using the facility provided microwave. During a surveyor interview with Staff F immediately following the observation, she revealed that she had been a NA at the facility for approximately 6 months and during this time she had not been provided education on safe temperatures when reheating meals for residents or serving hot beverages. She further revealed she was not aware of what temperatures are too hot and may be harmful. During a surveyor interview on 5/5/2025 at 9:17 AM with the Staff Educator, she revealed that education of reheating or serving food and beverages was not provided to any staff member. During a surveyor observation on 5/5/2025 at 1:47 PM in the presence of Licensed Practical Nurse, Staff A, an 8-ounce (oz) cup of hot water was obtained from the available Keurig brand coffee maker located in the first-floor kitchenette. The water temperature in the 8 oz cup was 180.3 F. Additionally, Staff A indicated the water was too hot to touch and acknowledged it would cause injury to skin. During a surveyor interview on 5/5/2025 at 2:37 PM with the Administrator in the presence of the Director of Nursing Services, she acknowledged that Resident ID #27 had sustained a second degree burn from hot chocolate provided to him/her by the facility. She further indicated that she was aware that education had not been provided to reduce the risk of accidents associated with hot liquids.

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 of 2 kitchenettes observed. Findings are as follows: Record review of Rhode Island Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and help 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 . Record review of the Rhode Island Food Code 2022 edition, section 4-602.11 states in part, .(C) NON_ FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . 1) During the initial tour of the kitchen in the presence of the Food Service Director (FSD), on 4/30/2025 at 9:55 AM, the following was observed in the main kitchen: - a bag containing approximately one dozen pieces of fried chicken without a label or discard date - a bag containing approximately 15-20 pieces of chicken patties in the freezer without a label or discard date - package containing 5 frozen hamburger patties in the freezer without a label or discard date - 3 bags of 2-3 pancakes wrapped in saran wrap in the freezer, without a label or discard date - a large zip lock style bag in the freezer, containing approximately 3-4 pounds of shaved beef without a label or discard date, with ice formed on the inside of the bag. During a surveyor interview on 4/30/2025 at 10:04 AM with the Food Service Director (FSD), he acknowledged the above-mentioned items did not have labels and or discard dates per the regulations. 2) Record review of the facility policy titled Use and Storage of Food Brought in by Visitors revised on 4/18/2024, states in part .food for residents .is to be labeled with the resident's name and date .discard those perishable items that appear unsafe or are older than 3 days . During a surveyor observation on 5/1/2025 at 10:02 AM, of the 1st floor kitchenette, in the presence of the FSD, the following was observed: - a container in the refrigerator labeled with only a resident's name, without a discard date - a brown box in the freezer labeled with only a resident's name, without a discard date During a subsequent interview with the FSD, he indicated that he would expect the above items to be labeled, dated or discarded date per the facility policy. 3) During a surveyor observation on 5/1/2025 at 10:13 AM, of the 2nd floor kitchenette, in the presence of the FSD, the following was observed: - a large Ziplock style bag containing what appeared to be tacos without a label or discard date - the refrigerator contained a clear plastic container containing an unidentified food substance that was thick, dark orange in color with a pasty texture without a label or discard date - the oven was observed with residual burnt matter on the inside, dark in color scattered on the bottom During a surveyor interview on 5/1/2025 at 10:16 AM with the FSD, he acknowledged the above observations. Additionally, he was unable to provide a cleaning schedule for the oven. During a surveyor interview on 5/1/2025 at 11:06 AM with the Administrator, she revealed that it was her expectation that the above-mentioned items would have been labeled, dated or discarded as indicated per the regulations and per the facility policy.

Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 3 of 5 residents reviewed, Resident ID #s 21, 32, and 37. Findings are follows: According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or 65 years or older who have only received PPSV23 [type of pneumococcal conjugate vaccination], the PCV15 [type of pneumococcal conjugate vaccine] or PCV20 [type of pneumococcal conjugate vaccine] dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical indications who have only received PCV13 [type of pneumococcal conjugate vaccine], give 1 dose of the PCV20 at least 1 year after PCV13 or give 1 dose of PPSV23 at least 8 weeks after PCV13. For adults 65 years or older who have only received PCV13, give PPSV23 or PCV20 as previously recommended. Together, with the patient, vaccine providers may choose to administer PCV20 or PCV21 to adults greater than or equal to [AGE] years old who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. 1. Record review for Resident ID #21 revealed the resident was admitted to the facility in November of 2018. Record review of the resident's immunization records revealed that the resident completed his/her initial series including PCV13 and PPSV23. Record review failed to reveal evidence that resident was offered, received, or declined the PCV20 or PCV21. 2. Record review for Resident ID #32 revealed the resident was admitted to the facility in April of 2018. Record review revealed that the resident consented to the Pneumococcal vaccination in May of 2023. Record review of the resident's immunization records failed to reveal evidence that the PPSV23, or PCV20 was received or declined. 3. Record review for Resident ID #37 revealed the resident was admitted to the facility in March of 2019. Record review of the resident's immunization records revealed that the resident completed his/her initial series including PCV13 and PPSV23. Record review failed to reveal evidence that the resident was offered, received, or declined the PCV20 or PCV21. During a surveyor interview on 5/1/2025 at 11:31 AM, with the Director of Nursing Services, she revealed that she contacted the Medical Director and those who have completed the pneumococcal vaccination series should be offered the PCV20 or PCV21. Additionally, she was unable to provide evidence that Resident ID #s 21, 32, and 37's medical records included documentation that indicates, at a minimum, if the residents either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal, until brought to the facility's attention by the surveyor.

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 which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 3 of 3 residents reviewed for antibiotic use, Resident ID #s 1, 12, and 343. Additionally, the facility failed to develop or maintain and Antibiotic Stewardship Team. Findings are as follows: 1. According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, .Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians .Requires prescriber's to document a dose, duration, and indication for all antibiotic prescriptions . Review of a facility policy titled, Antibiotic Stewardship states in part, .The antibiotic stewardship program is directed toward the correct use of antibiotic- the five D's -right diagnosis, the right medication, the right dose, the right duration, and the right deceleration . 1a. Record review revealed that Resident ID #1 was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, acute bronchiolitis due to respiratory syncytial virus (an acute viral infection of the lower respiratory tract). Record review revealed a physician's order dated 4/29/2025 for ciprofloxacin suspension (antibiotic) 500 milligram (mg) per 5 milliliters (ml), administer 5 ml twice a day. Review of the physician's order for ciprofloxacin suspension, failed to reveal evidence of the indication of use for the antibiotic per the CDC and the facility policy. 1b. Record review revealed that Resident ID #12 was readmitted to the facility in April of 2025 with a diagnosis including, but not limited to, aftercare following surgical amputation. Record review revealed a physician's order dated 4/29/2025 for sulfamethoxazole-trimethoprim (antibiotic) 800-160 mg, administer 1 tablet twice a day. Review of the physician's order for sulfamethoxazole-trimethoprim, failed to reveal evidence of the indication of use for the antibiotic per the CDC and the facility policy. 1c. Record review revealed that Resident ID #343 was readmitted to the facility in April of 2025 with a diagnosis including, but not limited to, pneumonia. Record review revealed a physician's order dated 4/29/2025 for amoxicillin-pot clavulanate (antibiotic) 875-125 mg, administer 1 tablet twice a day. Review of the physician's order for amoxicillin-pot clavulanate, failed to reveal evidence of the indication of use for the antibiotic per the CDC and the facility policy. During surveyor interviews on 5/1/2025 at 9:25 AM and 11:40 AM, with the Director of Nursing Services (DNS), she revealed that all antibiotics should have the indication for use in the physician's orders. Additionally, she acknowledged the above-mentioned orders for Resident ID #s 1, 12, and 343, failed to list an indication for the use of the antibiotics. Furthermore, the physician's orders were updated after it was brought to the facility's attention by the surveyor. 2. Further review of a facility policy titled, Antibiotic Stewardship states in part, .the Antibiotic Stewardship Team as outlined below, will meet on a regular scheduled basis. Minutes will be recorded and maintained for review. The efficacy of work of program will be analyzed at least annually and goals re-established each year based on the annual analysis . During a surveyor interview on 5/1/2025 at 9:20 AM, with the DNS, when asked about the antibiotic stewardship team and meeting minutes, the DNS revealed that the facility does not have an antibiotic stewardship team. Additionally, she acknowledged the policy states that the facility has an active antibiotic stewardship team and that they do not have one.

Based on record review, staff, resident, and resident representative interview, it has been determined that the facility failed to inform the resident and/or resident's representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering of, and administration of, a medication prescribed to treat high blood pressure for 1 of 1 resident reviewed for the use of amlodipine, Resident ID #84. Findings are as follows: Review of the manufacturer's insert for amlodipine last revised in May of 2011, revealed the following possible side effects: - Headache - Swelling of the legs or ankles - Tiredness, extreme sleepiness - Stomach pain, nausea - Dizziness - Arrhythmia (irregular heartbeat) - Heart palpitations (very fast heartbeat) Additional review of the insert revealed that there is a potential risk of having a heart attack when first taking amlodipine. Record review revealed the resident was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, hypertension (high blood pressure). Record review revealed the following progress notes: - 4/18/2025 at 12:17 PM, authored by the resident's Physician, revealed that the resident was started on amlodipine 5 milligrams (mg) once daily for blood pressure control. - 4/18/2025 at 1:40 PM, authored by Licensed Practical Nurse, Staff A, revealed that the resident's Physician reviewed his/her blood pressures and gave a new order for amlodipine 5 mg once daily. Additionally, the above-mentioned notes failed to indicate that the resident, and/or his/her representative, was informed, in advance, of the addition of the amlodipine, the risks and benefits associated with the amlodipine, or the treatment alternatives prior to prescribing and administering the medication. Review of a physician's order with a start date of 4/18/2025 and a disocontinue date of 4/28/2025 revealed to administer amlodipine 5 mg daily. Review of the April 2025 Medication Administration Record (MAR) revealed that the resident was administered amlodipine 5 mg daily from 4/19 through 4/28. Review of a progress note dated 4/26/2025 at 9:42 PM revealed that the resident's family member, who is listed as his/her emergency contact, expressed concerns to the staff that the resident is dizzy and requested to know what medication the resident was receiving. Additionally, it revealed that the resident's family member was unaware of the addition of the amlodipine and the family member would contact the resident's physician. During a surveyor interview on 4/30/2025 at 12:59 PM with the resident and his/her representative, they revealed that neither of them were informed of the addition of the amlodipine to the resident's treatment plan. During a surveyor interview on 5/1/2025 at 11:18 AM with Staff A, she revealed that she did not notify the resident or his/her representative regarding the amlodipine and indicated that she should have. During a surveyor interview on 5/1/2025 at 4:33 PM with the Director of Nursing Services, she revealed that she would have expected the nurse to discuss the addition of the amlodipine to the resident's treatment plan with the resident and/or resident's representative prior to initiating treatment.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 2 of 2 residents reviewed for skin tears, Resident ID #s 19 and 27. Findings are as follows: Review of a facility policy titled, Abuse prohibition states in part, .Injuries of unknown origin .the source of the injury was not observed or the source cannot be explained by the resident .Investigations .obtain statements from witnesses, notify the appropriate administrative personnel so that a comprehensive internal facility investigation can be carried out . 1. Record review revealed that Resident ID #19 was readmitted to the facility in July of 2024 with a diagnosis including, but not limited to, Alzheimer's Disease. Review of a progress note dated 4/26/2025 at 1:04 PM revealed that the resident presented with two new skin tears to his/her left upper extremity and s/he was unable to explain the origin of the skin tears. Further record review failed to reveal evidence that an investigation had been conducted to determine the origin of the two skin tears. During a surveyor interview on 5/1/2025 at 4:21 PM with the Director of Nursing Services (DNS), she acknowledged that the resident sustained an injury of unknown origin and was unable to provide evidence that an investigation was initiated and revealed that one should have been conducted. 2. Record review revealed that Resident ID #27 was readmitted to the facility in December of 2024 with a diagnosis including, but not limited to, chronic kidney disease. Review of a progress note dated 4/28/2025 revealed that the resident sustained a 1 centimeter skin tear to his/her left knee and the area was cleansed and two steri strips were applied. Additionally, the note failed to indicate the origin of the skin tear. Further record review failed to reveal evidence that an investigation had been conducted to determine the origin of the resident's skin tear to his/her left knee. During a surveyor interview on 5/5/2025 at 9:09 AM with Licensed Practical Nurse, Staff A, she acknowledged the progress note on 4/28/2025 did not contain an origin for the resident's skin tear. During a surveyor interview on 5/5/2025 at 2:37 PM with the DNS, she was unable to provide evidence that an investigation had been conducted to determine the origin of the resident's skin tear.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality and practices relative to 1 of 2 residents reviewed for Abnormal Involuntary Movement Scale (AIMS) Assessments, Resident ID #23, and 1 of 1 resident reviewed that receives insulin without blood sugar monitoring in place, Resident ID #48. 1. Record review revealed Resident ID #23 was readmitted to the facility in August of 2022 with diagnoses including, but not limited to, anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), and panic disorder. Review of the resident's care plan revealed a focus area dated 6/1/2022 for psychotropic medication (a medication that affects behavior, mood, thoughts, or perception) use and to complete an AIMS Assessment as directed. Review of a physician's order dated 5/17/2024 revealed to complete an AIMS Assessment on the 13th of every March, June, September, and December. Record review revealed the last AIMS Assessment for the resident was completed on 8/12/2024. Additionally, record review failed to reveal evidence that an AIMS Assessment was completed on 9/13/2024, 12/13/2024, or 3/13/2025, as ordered. During a surveyor interview on 5/6/2025 at 11:29 AM with the resident's Nurse Practitioner, she revealed that she would expect staff to complete the AIMS Assessments as ordered. During a surveyor interview on 5/6/2025 at 12:27 PM with the Director of Nursing Services (DNS), she acknowledged that an AIMS Assessment had not been completed since 8/12/2024 and would expect the assessments to be completed as ordered. 2. Record review revealed Resident ID #48 was readmitted to the facility in November of 2024 with a diagnosis including, but not limited to, diabetes mellitus due to an underlying condition with hyperglycemia (high blood sugar). Review of the resident's care plan revealed a focus area dated 2/18/2025 indicating that s/he is at risk for potential complications related to diabetes and potential adverse effects of receiving insulin. Review of a physician's order dated 1/27/2025 revealed to administer Semglee (insulin glargine-yfgn) 5 units subcutaneously (under the skin) once daily. Review of a progress note dated 11/5/2024 at 2:06 PM revealed that the resident's hemoglobin A1C (a blood test that measures a person's average blood sugar levels over the past 3 months and provides insight in diagnosing and managing diabetes) was to be repeated in 3 months. Record review failed to reveal evidence that the resident's hemoglobin A1C had been drawn following the above-mentioned progress note. Review of progress notes dated 5/5/2025 at 11:50 AM and 12:44 PM, authored by the DNS, revealed that the resident had his/her hemoglobin A1C drawn on 11/1/2024 and his/her provider ordered a follow up hemoglobin A1C to be completed in 3 months. Additionally, new orders for labs were obtained and to be completed on 5/12/2025. Record review revealed that a physician's order for a hemoglobin A1C test was entered for 5/12/2025, after it was brought to the facility's attention by the surveyor. During a surveyor interview on 5/5/2025 at 11:37 AM with the DNS, she acknowledged that the last hemoglobin A1C completed for the resident was in November of 2024 and was unable to provide evidence that the resident's repeat hemoglobin A1C had been completed. Cross reference F 842

Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 2 residents reviewed for orthostatic blood pressures (a form of low blood pressure that happens when standing after sitting or lying down that may cause dizziness, lightheadedness, and fainting), Resident ID #23, and for 1 of 2 residents reviewed for physician referrals for appointments, Resident ID #52. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1. According to [NAME] JJ. Antipsychotic pharmacotherapy and orthostatic hypotension: identification and management. CNS Drugs. 2011 Aug;25(8):659-71, states that, .Orthostatic hypotension is a common adverse effect of antipsychotics .monitoring for changes in postural blood pressure is important . Record review revealed Resident ID #23 was readmitted to the facility in August of 2022 with Parkinson's disease with dyskinesia (involuntary, uncontrolled movements), dizziness and giddiness, bipolar disorder, and a history of falling. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Review of the resident's care plan revealed that s/he is at risk for falls related to dizziness, potential medication side effects, effects of Parkinson's Disease, and the need for assistance with ambulation and transfers with interventions that includes to report changes in vital signs and complaints of dizziness. Additional review of the resident's care plan revealed a focus area dated 6/1/2022 for psychotropic medications (medication that affects behavior, mood, thoughts, or perception). Record review revealed the following physician's orders: - 5/17/2024 Orthostatic vital signs every 3 months - 8/22/2024 Seroquel (an antipsychotic medication) 25 milligrams (mg) give 25 mg at bedtime - 10/3/2024 Seroquel 25 mg give 12.5 mg once daily Review of the progress notes revealed the following: - 12/15/2024: The resident had an unwitnessed fall in the bathroom - 1/9/2025: The resident complained of dizziness after ambulating from bathroom - 3/3/2025: The resident sustained a fall from his/her chair - 3/10/2025: The resident stated that s/he was too dizzy to walk to the bathroom Record review revealed that the resident had a change in orthostatic blood pressures as evidenced by the following quarterly fall assessments: - 12/14/2024 No noted drop in blood pressure between lying and standing - 3/14/2025 A drop of more than 20 mm/hg (millimeter of mercury; units of pressure for measuring blood pressure) Record review failed to reveal evidence that the provider was made aware of the resident's change in orthostatic blood pressures. During a surveyor interview on 5/1/2025 at 11:08 AM with the resident, s/he was asked if s/he gets dizzy when attempting to stand from a sitting or lying position and s/he replied, Oh, yeah. During a surveyor interview on 5/6/2025 at 11:04 AM with Licensed Practical Nurse, Staff A, she revealed that the resident has a history of falls and dizziness. She further revealed that if the resident had a change in orthostatic blood pressures noted between the quarterly fall assessments, she would document it and notify the provider. During a surveyor interview on 5/6/2025 at 11:29 AM with the resident's Nurse Practitioner, she revealed that she would expect to be notified of the change in orthostatic blood pressures and she would then review his/her blood pressures, medications, and fluid intake to ensure it is adequate, and reassess the resident. During a surveyor interview on 5/6/2025 at 12:27 PM with the Director of Nursing Services (DNS), she revealed that she would expect the provider to be notified if the resident had a change in orthostatic blood pressures and was unable to provide evidence that the provider was made aware. 2. Record review revealed Resident ID #52, was admitted to the facility in March of 2023 with diagnoses including, but not limited to, spinal stenosis (a condition in which your spinal canal narrows, causing back pain and other nerve-related problems) and neurogenic bladder dysfunction (a urinary bladder condition caused by damage to the nerves that control bladder function). Record review revealed the following physician's orders: - Urology consult for possible suprapubic tube (SP tube, a medical device that drains urine from the bladder through a small incision in the abdomen) insertion due to history of difficulty maintaining indwelling catheter initiated on 3/19/2025 - MRI (a medical imaging technique) of the spine without contrast related to chronic back pain, initiated on 3/19/2025 Review of a progress note dated 3/19/2025, revealed the resident was seen by his/her physician and expressed interest in having an SP tube placed. Additionally, the note indicates the Physician educated the resident on risks and benefits of the SP tube and further indicated an appointment should be scheduled. Review of a progress note dated 4/17/2025 revealed a continued need to schedule an MRI for chronic back pain. Record review failed to reveal evidence of an appointment with urology for the placement of an SP catheter or an MRI for chronic back pain had been scheduled for Resident ID #52. During a surveyor interview on 5/1/2025 at 2:36 PM with the facility's Appointment Scheduler, Staff C, she revealed that she was unaware of the resident's need for a urology appointment or an MRI until it was brought to her attention by the surveyor. During a surveyor interview on 5/1/2025 at 2:46 PM with Licensed Practical Nurse, Staff D, she revealed that an appointment for urology or an MRI had not been made. Additionally, she revealed that if the resident refused to go to an appointment, then a note would be put in his/her medical record. During a surveyor interview on 5/5/2025 at 11:21 AM with the DNS, she was unable to provide evidence that appointments for a urology consult or an MRI had been scheduled as ordered.

Based on surveyor observation, record review and staff interview, it has been determined that 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, prevent infection and prevent new ulcers from developing for 1 of 1 resident observed for wound care, Resident ID #52. Findings are as follows: Record review revealed the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, spinal stenosis (a condition in which your spinal canal narrows, causing back pain and other nerve-related problems) and stage 4 pressure ulcer (the most severe pressure wound that may impact muscle, tendons, ligaments, and bone). Review of a progress note dated 4/28/2025 revealed the resident has the following wounds: - Stage 4 pressure ulcer to his/her coccyx (tailbone) measuring 3.5 centimeters (cm) X 2.5 cm X 1 cm. - Stage 4 pressure ulcer to his/her right gluteal fold (visible crease that separates the gluteal region from the upper thigh) measuring 3.3 cm X 2 cm X 2 cm. Record review revealed the following physician's orders for wound care: - Coccyx stage 4 pressure ulcer, vashe soak (wound cleanser) for 10 minutes, apply collagen with silver and calcium alginate (absorbent wound treatment) to wound bed, pack with kerlix (highly absorbent wound dressing) and cover with super absorbent dressing daily. - Right gluteal fold stage 4 pressure ulcer, vashe soak for 10 minutes, apply collagen powder to the wound bed then pack with calcium alginate and cover with silicone super absorbent dressing daily. During a surveyor observation of wound care on 5/1/2025 at 10:24 AM with Registered Nurse (RN), Staff E, she applied the collagen powder on top of the calcium alginate and packed it into the resident's coccyx wound with her gloved fingers. She then was observed to pack a ball of kerlix into the wound with her gloved fingers and not an applicator. Directly following the application to the coccyx wound, Staff E was observed to apply collagen powder on top of the calcium alginate and then pack into the wound to the right gluteal fold with her fingers and not an applicator. Staff E did not change her gloves between packing the coccyx wound and the gluteal fold wound. During a surveyor interview on 5/1/2025 at 10:50 AM with, Staff E, she acknowledged that she did not utilize an applicator to pack the wounds. Additionally, she acknowledged she did not change her gloves after applying the coccyx wound dressing and before applying the right gluteal fold wound dressing. During a surveyor interview on 5/1/2025 at 11:02 AM with the Director of Nursing Services (DNS), she acknowledged that Staff E should have utilized an applicator to pack the wound and should have changed her gloves between wound treatments. Additionally, the DNS was unable to provide evidence that the facility provided wound care consistent with professional standards of practice, to promote healing, and prevent infection for Resident ID #52.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to provide appropriate treatment and services for 1 of 3 residents reviewed with a foley catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #35, and for 1 of 2 residents with a suprapubic catheter (SP tube, a medical device that drains urine from the bladder through a small incision in the abdomen) Resident ID #45. Additionally, the facility failed to assess for the removal of a urinary catheter for 1 of 1 resident reviewed requiring a trial void, Resident ID #39. Findings are as follows: Review of a facility policy titled, Foley Catheters dated 1/16/2024 states in part, It is the policy of this facility to ensure that the resident (s) with a foley catheter (or SP tube) have the proper documentation in place to support the usage and proper care of the foley catheter .A resident with a foley catheter (or SP tube) must have a physician order in place for the foley catheter. The order must include the size of the catheter and the balloon .The order must also include the diagnosis to support the reason for the foley catheter . 1. Record review revealed that Resident ID #35 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, obstructive uropathy (a blockage that prevents urine from flowing naturally through the urinary system). Review of a care plan dated 1/22/2025 revealed that Resident ID #35 has urinary retention with an intervention including, but not limited to, foley catheter care every shift. During a surveyor observation on 5/1/2025 at 9:29 AM of Resident ID #35 revealed a foley catheter hanging from the left side of his/her bed. Record review failed to reveal a physician's order for the foley catheter including the size of the catheter, the balloon size, or the diagnosis to support the use, per the facility policy. During a surveyor interview on 5/1/2025 at 1:50 PM with Licensed Practical Nurse (LPN), Staff D, she acknowledged that there was not an order in place for Resident ID #35's foley catheter. During a surveyor interview on 5/1/2025 at 1:56 PM with the Director of Nursing Services (DNS), she acknowledged that there was not an order in place for the foley catheter including the catheter size and balloon size, and/or a diagnosis for its use, per the facility policy. 2. Record review revealed that Resident ID #45 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, urinary tract infection and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems). Review of a care plan dated 3/15/2021 revealed that Resident ID #45 utilizes an SP catheter for urinary retention and is at high risk for recurrent urinary tract infections. Record review failed to reveal an order for the SP catheter including the size of the catheter, the balloon size, or the diagnosis to support its use, per the facility policy. During a surveyor interview on 5/1/2025 at 4:20 PM with the DNS she acknowledged that there is not an order for use of the SP catheter including the catheter and balloon size and a diagnosis for its use, per the facility policy. 3. Record review revealed that Resident ID #39 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, obstructive uropathy and urinary retention. Record review revealed a physician order dated 11/21/2024 for a foley catheter. Review of a progress note dated 1/14/2025 revealed that Resident ID #39 saw a urologist who provided a recommendation to have a trial void in one week. Record review revealed a physician's order with a start date of 1/22/2025 to remove the foley catheter for a trial void and if s/he does not void in 8 hours to reinsert the foley catheter. Record review failed to reveal evidence that a trial void was attempted or failed. During a surveyor interview on 5/5/2025 at 2:18 PM with the DNS, she was unable to provide evidence that a trial void was attempted for Resident ID #39 as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed for oxygen use, Resident ID #7. Findings are as follows: According to Lippincott Nursing Procedure Ninth Edition 2023, page 621, states in part, .Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed . Record review revealed the resident was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypercapnia (a condition where there are abnormally high levels of carbon dioxide in the blood that could be caused by conditions like COPD). Review of the care plan revealed that the resident utilizes oxygen at 2 liters per minute (LPM). Review of a physician's order dated 6/10/2024 revealed an order for oxygen 2 LPM every shift. Review of the resident's carbon dioxide levels revealed that the s/he had increasingly elevated levels which can be attributed to COPD, as well as, individuals that utilize supplemental oxygen, as evidenced by the following: - 12/12/2024 Carbon dioxide level (normal range 19-32): 31 - 2/19/2025 Carbon dioxide level: 33 - 4/4/2025 Carbon dioxide level: 35 Surveyor observations revealed the resident was not receiving the 2 liters of oxygen as ordered on the following dates and times: - 4/30/2025 at 11:54 AM, noted at approximately 3.5 LPM - 5/1/2025 at 9:22 AM, 2:33 PM, and 2:39 PM, noted at approximately 3.5 LPM During a surveyor interview immediately following the above observation at 2:39 PM with Registered Nurse, Staff G, she acknowledged that the resident was not receiving the 2 liters of oxygen as ordered. During a surveyor interview on 5/1/2025 at 4:30 PM with the Director of Nursing Services, she indicated that she would have expected the resident to receive oxygen at 2 LPM, as ordered. Cross reference F 842

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 2 residents reviewed for a urinary tract infection (UTI), Resident ID #45. Findings are as follows: Record review revealed the resident was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, UTI. Record review revealed the following progress notes: -3/12/2025 at 12:43 PM: The resident was seen by the provider and is to start Bactrim (an antibiotic) 800 milligrams (mg) twice daily for 7 days (to equal 14 total doses) -3/13/2025 at 10:48 PM: The resident continues Bactrim for a UTI Review of a physician's order dated 3/12/2025 revealed Bactrim DS 800-160 mg administer 1 tablet twice daily for 7 days (to equal 14 total doses). Review of the March 2025 Medication Administration Record revealed that the resident received a total of 17 doses of Bactrim from 3/12 through 3/20, thus receiving an additional 3 doses more than what the provider had prescribed. During a surveyor interview on 5/5/2025 at 11:37 AM with the Director of Nursing Services, she revealed that she would have expected the resident to have received only 14 doses of Bactrim, as prescribed.

Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices for 1 of 1 resident reviewed for oxygen use, Resident ID #7, and 1 of 2 residents reviewed for Abnormal Involuntary Movement Scale (AIMS) Assessments, Resident ID #23. Findings are as follows: 1. Record review revealed Resident ID #7 was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD). Review of the care plan revealed that the resident utilizes oxygen at 2 liters per minute (LPM). Review of a physician's order dated 6/10/2024 revealed oxygen at 2 LPM every shift. Surveyor observations revealed the resident was not receiving the 2 liters of oxygen as ordered on the following dates and times: - 4/30/2025 at 11:54 AM, noted at approximately 3.5 LPM - 5/1/2025 at 9:22 AM, 2:33 PM, and 2:39 PM, noted at approximately 3.5 LPM Review of the April and May 2025 Medication Administration Records (MARs) revealed that the resident was documented as receiving oxygen at 2 LPM on the above-mentioned dates and times, although the resident was observed by the surveyor receiving approximately 3.5 liters of oxygen. Additional review of the May 2025 MAR revealed that Registered Nurse, Staff G, documented the resident as receiving oxygen at 2 LPM on 5/1/2025 on the 7:00 AM to 3:00 PM shift. During a surveyor interview on 5/1/2025 at 2:39 PM with Staff G, she revealed that she noted that the resident was receiving oxygen at 3 LPM earlier that morning, and was unable to explain why she documented the resident as receiving oxygen at 2 LPM. 2. Record review revealed Resident ID #23 was readmitted to the facility in August of 2022 with diagnoses including, but not limited to, anxiety, bipolar disorder, post traumatic stress disorder (PTSD), and panic disorder. Review of the resident's care plan revealed a focus area dated 6/1/2022 for psychotropic medications (medications that affects behavior, mood, thoughts, or perception) use and to complete an AIMS Assessment as directed. Review of a physician's order dated 5/17/2024 revealed to complete an AIMS assessment on the 13th of every March, June, September, and December. Record review revealed that an AIMS Assessment was documented as completed on the following dates: - 9/13/2024 - 12/13/2024 - 3/13/2025 Further record review revealed the last AIMS Assessment was completed on 8/12/2024. Additionally, record review failed to reveal evidence that an AIMS Assessment was completed on 9/13/2024, 12/13/2024, or 3/13/2025, as documented. During a surveyor interview on 5/1/2025 at 4:30 PM with the Director of Nursing Services, she was unable to provide evidence that the facility maintained medical records that are accurate and would expect such. Cross reference F 695 and F 658

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to a post fall transfer for 1 of 1 resident reviewed for injury, Resident ID #1. Findings are as follows: Record review of a facility provided document titled Fall Protocol states in part, A fall is an unintentional CHANGE IN POSITION COMING TO REST ON THE GROUND, FLOOR OR ON THE NEXT LEVEL SURFACE .Assess ROM [Range of motion] of all extremities for changes .Once you are sure the PT [patient] is stable you may move the patient If the PT is not able to get up on their own, you will use the hoyer lift [a mechanical device used to transfer] and two assist to get back into bed . Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/28/2025 alleges in part, the resident often fell because [s/he] had been incontinent .so when [s/he] would stand up to walk [him/herself] to the bathroom [s/he] would have falls . Review of a facility reported incident resulting in hospitalization received by the Rhode Island Department of Health on 3/28/2025 revealed that on 3/25/2025 at 10:50 PM, the resident experienced a fall with complaints of right hip pain. Additionally, the report revealed an x-ray was obtained on 3/27/2025 which showed a right hip fracture, and the resident was subsequently transferred to the hospital. Record review revealed that the resident was admitted to the facility in October of 2024 with diagnoses including, but not limited to, severe dementia with behavioral disturbance, muscle weakness, numerous falls, and abnormalities of gait and mobility. Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 4 out of 15, indicating the resident has severe cognitive impairment. Additionally, it revealed that the resident requires supervision/touching assistance of one staff to transfer from a sitting to a standing position. Review of a progress note dated 3/26/2025 at 12:12 AM, authored by Registered Nurse (RN), Staff A, revealed the resident was observed in his/her doorway laying on the floor. Additionally, the progress note indicated that the resident was guarding his/her right leg and complaining of right hip and leg pain. Further, the progress note indicated the resident required staff assistance to stand. Record review of a Safety events fall SBAR [Situation Background Assessment Recommendation] form completed on 3/26/2025 revealed the resident experienced a pain level of 7-severe pain-horrible, intense with painful and limited ROM at the time of his/her fall. Record review revealed that a portable x-ray was completed at the facility on 3/26/2025 which resulted in a right hip fracture. The resident was subsequently transferred to the emergency roiagnom on [DATE] due to his/her fracture. Review of the hospital emergency room visit notes dated 3/27/2025, revealed that the resident was diagnosed with a right femur (thigh bone) fracture. During a surveyor interview on 3/31/2025 at 2:54 PM, with RN, Staff A, she acknowledged that the resident experienced an unwitnessed fall on 3/25/2025 and upon assessment the resident was guarding his/her right extremity and was complaining of right hip and leg pain. Additionally, she revealed that the resident was assisted to a standing position from the floor with two staff members. Additionally, she revealed she was not aware of the facility's fall protocol to utilize a Hoyer lift if the resident is not able to stand independently. During a surveyor interview with the Assistant Director of Nursing Services on 3/31/2025 at 2:47 PM she revealed that it would be her expectation that staff would utilize a Hoyer lift to assist a resident off the floor that is unable to get up on their own. Additionally, she acknowledged that the resident was experiencing severe pain and sustained a fracture to his/her right femur.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following physician's orders for 1 of 1 resident with waffle boots (an off-loading device), Resident ID #60 and 1 of 1 resident receiving Nystatin powder (antifungal treatment), Resident ID #3. Findings are as follows: 1. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #60 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, weakness and the need for assistance with personal care. Record review revealed a physician's order dated 3/14/2024 for bilateral waffle boots as tolerated, remove and reapply for care. During a surveyor observation on 6/14/2024 at 10:29 AM, in the presence of Licensed Practical Nurse, Staff C, revealed the resident was lying in his/her bed without his/her waffle boots applied. Additionally, Staff C acknowledged that the resident's waffle boots had not been applied and she was unable to locate the resident's waffle boots. Record review of the Treatment Administration Record (TAR) from 6/1/2024 to 6/13/2024 revealed the waffle boots were documented as unavailable for 18 out of 39 opportunities. During a surveyor interview on 6/14/2024 at approximately 1:00 PM with the Director of Nursing Services (DNS), she was unable to explain why the waffle boots were not applied as ordered and had been documented as unavailable, as the resident's waffle boots were located in the laundry room after it was brought to the facility's attention. 2. According to Mosby's Fundamentals of Nursing Concepts, Process and Practice, 4th Edition, page 809, states in part, .a Registered Nurse checks all transcribed orders against the original order for accuracy and thoroughness . Record review revealed Resident ID #3 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, cerebral infarction (stroke) and diabetes mellitus. Record review of an admission skin assessment dated [DATE], revealed skin alterations of dermatitis and moisture associated skin damage. Further review of the assessment revealed a description of the skin integrity conditions including, but not limited to, nystatin powder to his/her bilateral groin. Record review revealed a physician's order dated 5/21/2024 for Nystatin powder to fungal rash twice daily for 30 days. Further review of the order failed to indicate the affected area for the treatment. Record review of the May and June 2024 TARs revealed the treatment was signed off as administered, without an affected area indicated for treatment. During a surveyor interview on 6/14/2024 at 2:16 PM with Licensed Practical Nurse, Staff A, when asked where she applies the resident's Nystatin powder, she revealed she applies the powder to the reddened areas under the resident's chest folds. During a surveyor interview on 6/14/2024 at approximately 1:00 PM with the DNS, she acknowledged that the Nystatin powder order was incomplete and that the order should have indicated the affected area to apply the treatment. 41542

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide food that accommodates resident allergies for 1 of 1 resident reviewed, Resident ID #29. Findings are as follows: Record review revealed the resident was readmitted to the facility in March of 2023 with diagnoses including, but not limited to, dementia and anxiety. Review of the resident's listed allergies revealed s/he has an allergy to blueberries. During a surveyor observation on 6/11/2024 at approximately 8:15 AM, revealed a breakfast tray on Resident ID #29's bedside table with Resident ID #41's name on the diet ticket. Further surveyor observation revealed Resident ID #29 consumed all of the food on the tray that was given to him/her. Review of the diet ticket revealed the following food was served to Resident ID #29: .blueberry coffeecake . During a surveyor interview on 6/11/2024 at 8:16 AM with Certified Medication Technician (CMT), Staff D, she acknowledged that Resident ID #29 was given the wrong breakfast tray and was served blueberry coffeecake, and that s/he has an allergy to blueberries. During a surveyor interview on 6/11/2024 at 9:20 AM with the Cook, Staff E, in the presence of the Food Service Director, she revealed that if blueberry coffeecake was listed on the meal ticket, then that is what the resident received. During a surveyor interview on 6/11/2024 at 9:23 AM with Nursing Assistant, Staff F, she acknowledged that she served the resident the incorrect breakfast tray. During a surveyor interview on 6/11/2024 at 9:31 AM with the Director of Nursing Services, she acknowledged that the resident has an allergy to blueberries. Additionally, she revealed that Resident ID #29 should not have received another resident's breakfast tray.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents' advance directives were consistent with the residents' electronic medical record (EMR) for 3 of 19 residents reviewed, Resident ID #s 2, 68 and 398. Additionally, the facility failed to ensure that the resident's advance directive was formulated for 1 of 4 new admissions reviewed, Resident ID #3. Findings are as follows: Review of a facility policy dated [DATE], titled, Advance Directives, states in part, .This facility is required to comply with state and federal regulations .including the right to formulate Advance Directives .to see that the resident's wishes are properly documented and carried out . 1. All residents (or their responsible party) shall, upon admission, shall be asked about their advanced directives/wishes and educational materials which explain the right of the individual to make decisions concerning medical care including .the right to make advance directives which are to be carried out when and if the resident becomes incapable of making his/her wishes known . 5. If the resident does not have an advance directive, the resident or his/her responsible party will be asked as soon as possible after admission, to indicate the resident's code status by completing the code status form . 7. In the absence of a specified code status, or/an advance directive, the resident is to be considered a full code .all residents in cardiac arrest should receive resuscitation unless the resident has a valid 'Do Not Resuscitate (DNR) order . 10. A copy of the advance directive is to be maintained in the resident's record . 1. Record review for Resident ID #2 revealed s/he was readmitted to the facility in May of 2024. Record review revealed a MOLST (Medical Orders for Life Sustaining Treatment) dated [DATE] which indicates, Cardiopulmonary Resuscitation (CPR) Full Code. Record review revealed a physician's order dated [DATE], indicating a code status of DNR. Record review revealed the EMR code status banner, derived from the data entered onto the resident's face sheet, identified the resident as a DNR. Additional, record review revealed an advance directive document, dated [DATE] from a previous admission, which indicated DNR. During a surveyor interview on [DATE] at 2:52 PM with Licensed Practical Nurse (LPN), Staff A, when reviewing the above resident's record with her, she was unable to determine if the resident was truly a Full Code and further revealed she would refer to the MOLST for his/her code status. 2. Record review for Resident ID #3 revealed s/he was readmitted to the facility in May of 2024. Record review failed to reveal evidence of an advance directive or any indication of the resident's code status. Record review revealed a physician's order dated [DATE] for Code Status with no further instructions. Additional, record revealed an Advance Directive document dated [DATE] from a previous admission, which indicated DNR. During a surveyor interview on [DATE] at 2:52 PM with LPN, Staff A, after reviewing the above resident's record with her, she was unable to provide evidence that upon admission the resident was able to formulate his/her advance directives. Further, she acknowledged the resident's advance directive from his/her previous admitted d [DATE], indicating a DNR. Additionally, she revealed that she would treat the resident as if s/he was a full code as she has nothing to verify his/her code status. 3. Record review for Resident ID #68 revealed s/he was admitted to the facility in May of 2024. Record review revealed a MOLST dated [DATE], unsigned by the resident's healthcare provider, indicating Do Not Attempt Resuscitation/DNR. Further review of the MOLST indicated Do Not Intubate [DNI]. Record review of the EMR banner only identified the resident as a DNR and not DNI. Additional, record review revealed a physician's order dated [DATE] for Code Status with no further instructions. 4. Record review for Resident ID #398 revealed s/he was admitted to the facility in July of 2024. Record review revealed a MOLST dated [DATE], unsigned by the resident's healthcare provider, indicating Do Not Attempt Resuscitation/DNR and Comfort Measures Only. Further review of the MOLST did not indicate DNI. Record review of the EMR banner identified the resident as a DNR/DNI. Additional, record review revealed a physician's order dated [DATE] for Code Status with no further instructions. During a surveyor interview on [DATE] at 2:52 PM with LPN, Staff A, when asked what she would refer to for the resident's code status in the event of an emergency, she revealed she would refer to the resident's MOLST. During a surveyor interview with Registered Nurse, Staff B, on [DATE] at 2:33 PM, when asked what she would refer to for a resident's code status in the event of an emergency, she revealed she would refer to the resident's EMR banner. During an interview on [DATE] at 10:30 AM with the Director of Nursing Services, she acknowledged that Resident ID #s 2 and 3 had an advance directive from a previous admission. However, it is expected that an updated advance directive would have been completed upon their re-admission. She also acknowledged that Resident ID #3 did not have documentation of an advance directive from their current admission. Furthermore, she was unable to explain why Resident ID #s 68 and 398 did not have a signed MOLST document. Additionally, she was unable to explain the above-mentioned inconsistencies between the MOLST documents, orders and EMR banners. Lastly, she revealed staff should always refer to the resident's paper document for code status instructions.

Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan relative to 1 of 3 residents reviewed for falls, Resident ID #3. Findings are as follows: Record review revealed Resident ID #3 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, unspecified fracture of upper left end of humerus. Record review of a document titled Events revealed the resident had fallen on 7/8/2023, 7/29/2023, and 8/30/2023. Record review revealed the resident had a 'ADLs Functional Status care plan that was implemented on 5/31/2023 relative to fall prevention. This care plan failed to reveal evidence that the care plan was reviewed and revised after the resident experienced actual falls on 7/8, 7/29 and 8/30/2023. During a surveyor interview on 9/14/2023 at approximately 2:15 PM with the Minimum Data Set Coordinator, she acknowledged the care plan was not reviewed and revised for Resident ID #3 after s/he experienced actual falls. Additionally, she indicated that care plans should be updated by nursing staff after a resident experiences a fall. During a surveyor interview on 9/14/2023 at approximately 2:45 PM with the Director of Nurses, she was unable to provide evidence of care plan updates and revisions for Resident ID #3.

46241 Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality relative to following physician's orders for 3 of 18 residents reviewed, Resident ID #s 41, 60, and 282. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1. Record review revealed Resident ID #41 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, fusion of spine in lumbar region and peripheral vascular disease (narrowing, blockage, or spasms in a blood vessel). Record review revealed a physician's order with a start date of 4/19/2023 for heparin solution (medication that prevents formation of blood clots) 5,000 unit/milliliter subcutaneously (injection) every 8 hours. Record review of the May 2023 Medication Administration Record (MAR) revealed the resident refused his/her 5:00 AM dose of heparin on 5/23 and 5/24. Record review of the progress notes failed to reveal evidence that the physician was notified of the resident's refusals of the medication. During a surveyor interview with the Director of Nursing Services (DNS) on 5/25/2023 at 2:21 PM, she acknowledged that the physician should be notified when a resident refuses a medication. 2. According to the facility policy titled, Medication Administration states in part, .16. If the medication was not administered because the medication was not available, the nurse MUST take steps to ensure timely delivery of the medication and document all steps taken in progress notes . Record review revealed Resident ID #60 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, type 2 diabetes mellitus and morbid obesity. Record review revealed a physician's order with a start date of 3/10/2023 for Ozempic (medication that helps control blood sugar for people with type 2 diabetes) pen injector 2 milligram/dose subcutaneously once a week every Saturday. Record review of the April and May 2023 MARs failed to reveal evidence that the resident was administered the Ozempic injection weekly, due to the medication being unavailable, on the following dates: -4/22/2023 -4/29/2023 -5/6/2023 -5/13/2023 -5/20/2023 Record review of the nursing progress notes failed to reveal evidence that steps were taken to ensure timely administration of the medication. Additionally, the record failed to reveal evidence that the physician was notified after the medication doses were not administered on the above-mentioned dates. During a surveyor interview with the DNS on 5/24/2023 at 3:02 PM, she was unable to provide evidence that the physician was notified that the medication was unavailable for administration and not administered as ordered. 3. According to the facility policy titled, Weight Loss/Gain Protocol states in part .a significant weight discrepancy is defined as: 1. A weight change of 3 pounds or more in one week .significant weight loss/gain, nursing must notify; Physician, Dietician, DNS, Family/Responsible Party . Record review revealed Resident ID #282 was admitted to the facility in April of 2023 with diagnosis including, but not limited to, alcoholic cirrhosis of liver with ascites (severe scarring of the liver that causes fluid buildup in the abdomen). Record review revealed the following physician's orders with a start date of 4/28/2023: -Weigh daily and call the physician for gain of 3 pounds or more in 1 day or 5 pounds in 1 week. -Re-weigh the resident as needed if discrepancy of 3 pounds (gain or loss) were found and notify the physician. Record review failed to reveal evidence that the resident's weight was obtained for 3 days on 5/20, 5/21, and 5/23/2023. Record review of the progress notes failed to reveal evidence that the resident refused to be weighed or that the physician was notified of the weights that were not obtained on the above-mentioned dates. During a surveyor interview with the DNS on 5/25/2023 at 11:26 AM, she was unable to provide evidence that the resident's weights were obtained on the above mentioned dates or that the physician was notified.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care plan was implemented for each resident, consistent with the residents rights set forth and includes measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment, for 1 of 1 residents reviewed for suicidal ideations, Resident ID #55. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2022 with diagnoses including, but not limited to, cerebral infarction (stroke), major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. Record review of a nursing progress note dated 4/24/2023 revealed the Consultant Psychiatric Registered Nurse (RNP) was notified of the resident's comments to his/her sister regarding wanting to die. Record review of the 5/3/2023 consultant psychiatric RNP document states in part, .Pt [patient] believes [s/he] would be better off dead, states how [s/he] would attempt-cuts arteries in legs; past attempt x 1 in [his/her] 50's .[S/he] would use a sharp object to cut blood vessels in legs . Review of the record revealed the resident was sent out to the hospital for an psychiatric evaluation on 5/3/2023. Record review of the hospital continuity of care document, dated 5/3/2023, states in part, .Source: patient, EMS [emergency medical services] .presenting today for evaluation of suicidal statements. Patient reportedly telling staff at [his/her] SNF [skilled nursing facility] that [s/he] would like to hurt [him/herself], stating that [s/he] would cut [him/herself] with a knife if [s/he] could .have access to 1. Stating that [s/he] would do this in an effort to hurt [him/herself] . Record review of the care plan, updated on 5/23/2023, revealed an intervention to restrict access to potentially harmful items, including but not limited to, knives. During a surveyor observation of the lunch meal pass on 5/25/2023 at 12:25 PM, revealed Nursing Assistant, Staff A, carrying a meal tray that included a metal butter knife, into the resident's room and placed the tray on his/her bedside table. After assisting the resident with cutting his/her food, the NA left the room. Continuous surveyor observation of the resident during his/her meal revealed the resident had access to the knife until his/her meal tray was removed by staff, which was at 1:08 PM. During a surveyor interview on 5/25/2023 at 12:30 PM with Licensed Practical Nurse, Staff B, she revealed she was unaware of a care plan indicating that the resident should not have access to potentially harmful items, such as knives. During a surveyor interview on 5/25/2023 at 1:35 PM with the Social Worker, she indicated that she developed the care plan to include restrictions of potentially harmful items due to his/her recent threat to harm his/her self. Additionally, attempts were made to contact the consultant psychiatric RNP for an interview on 5/25/2023, but she was unable to be reached, and a return phone call has yet to be received. During a surveyor interview on 5/25/2023 at 1:00 PM with the Director of Nursing Services, she was unable to provide evidence that the interventions in the care plan to maintain Resident ID #55's safety were implemented.

Based on record review and staff interview, it has been determined that the facility failed to follow its own policy relative to investigating and reporting an allegation of inappropriate touching for 1 resident (ID #7). The facility also failed to protect resident ID #2 and other vulnerable residents from potential abuse/harm by resident ID#1 during an investigation of inappropriate touching . Findings are as follows; As defined by the United States, Equal Employment Opportunity Commission (EE[NAME]), states in part; .Harassment can include sexual harassment or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. I. The facility's policy for Abuse, under reporting states, in part ; .When an alleged or suspected case of mistreatment, . or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident; 1. RI Department of Health . 4. Incidents of patient to patient abuse .Residents involved in patient to patient abuse cases should be separated and monitored closely to prevent any further incidents . 6. Definition of abuse are provided: . c. sexual abuse is defined as, but is not limited to, sexual harassment . 9.An immediate investigation will be made and a copy of findings of such investigation will be provided to the administrator within five (5) working days of the occurrence of such incidents. The administrator will send results of investigation to agencies listed above . Clinical record review revealed resident ID#7 has a [DIAGNOSES REDACTED]. A review of a nurse's note dated 5/29/2017 revealed resident ID #7 reported to the third shift nurse (staff D) that resident ID #1 came into his/her room and made inappropriate sexual comments and advances toward him. Resident ID #7 told resident ID #1 to leave his room. Resident ID #1 left through the bathroom door but kept going back to the bathroom opening the door to the room and staring at him which made him uncomfortable and nervous. During a phone interview on 4/5/2018 at 8:05 AM, staff D told the surveyor that resident ID #7 had reported to her that resident ID #1 came in to his room while he was sleeping and touched his private area, which was under the cover. Staff D stated the resident was very upset. He was going to knock his head off and he was crying. Surveyors requested that staff D provide a written statement about the 5/29/2017 incident. Consequently, staff D provided a written statement, dated 4/6/2018, which revealed that resident ID #7 alleged that resident ID #1 came in and was trying to touch him. Staff D stated the resident was very upset and nervous. During an interview with the Director of Nursing Services (DNS) on 4/5/2018 at 3:55 PM, she stated after the above allegation, she spoke with resident ID #7 and staff but did not write anything down. She did not report the incident to the Department of Health because she was unaware that resident ID #7 told staff that resident ID #1 touched his private area. The DNS stated resident ID #1 just made resident ID #7 uncomfortable. Although in the nurse's note written on 5/29/2017 at 1:51 AM by staff D, the behavior described fits within the definition of sexual harassment as defined by the EE[NAME] (see above definition). The DNS was unable to produce evidence that the incident was thoroughly investigated and reported. II. The facility's policy for Abuse, under protection states, in part -The facility will protect the resident from harm during an investigation . Surveyor observation on 4/4/2018 at 2:30 PM revealed resident ID#1's room and resident ID# 2's room are approximately 75 feet from the nursing station. Each room has 2 beds and the rooms are connected by a bathroom which allows a resident to go between rooms without being noticed from the hallway. Clinical record review revealed resident ID#2 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 5/29/2017 care plan indicates the resident has both short and long term memory impairment. The resident requires extensive assistance from staff with ADLs and a Hoyer (total lift) for transferring in and out of bed. The resident moved into his room on 1/13/2018 and presently resides there. Review of the 4/3/2018 nurse's note, documented at 10:25 PM, revealed that resident ID #2 was noted to be uncovered, his penis was removed from inside the still-closed brief and the resident was very agitated- appearing very easy startled; .appeared very afraid. The NAs reported the situation to the unit nurse (staff A). Staff A then asked the resident why he was uncovered. The resident stated The man did it to me. When the nurse asked where the man came from, the resident stated he came from that room and the resident pointed toward the bathroom which was adjoining his room to resident ID #1's room. When the nurse asked if the man had touched him. The resident stated yes he did and the resident became very agitated and crying out OH and putting his arms together across his body as if to hide himself. I am sorry the resident stated. The nurse documented that the resident was unable to answer any further questions. The nurse further documented that it was noted that the man in the neighboring room (resident ID #1), had just gotten back into his bed from a trip to the bathroom. On 4/4/2018 at 3:45 PM, an interview was conducted with a second shift NA (staff F) who found the resident uncovered on 4/3/2018. Staff F stated her and another NA found resident ID #2 uncovered with his penis exposed, his johnny was pull up to his chest and his brief was pulled down to his knees and the blanket was down to the end of the bed, covering only his feet. She further stated that she found him this way 2 to 3 times over the past several weeks and reported it to the nurse. She believed the resident is unable to pull his brief down or pull his blanket down to the end of the bed. Interview with staff A on 4/3/2018 at 3:55 PM, revealed she was in resident ID #2's room approximately 45 minutes before the incident, at that time, the resident was lying in bed, wearing a johnny and covered with a blanket. Staff A stated that she has been working at the facility for years and the resident prefers to be covered and she has never seen him reaching toward his brief/private area. She believed the resident is unable to pull his brief down or pull his blanket down to the end of the bed. Staff A further indicated that, when she was called back to the room, she found the resident uncovered and his penis was removed from his brief and his brief was tied. The resident told her that the man came from there, pointing to the bathroom, he further indicated that the man touched him. When she asked if the man touched his private the resident nodded and got anxious. Record review of ID #1's care plan revealed after the 11/16/2017 incident of inappropriate touching of another resident, an approach was added for behavior symptoms which indicates initiate 15 min checks as needed if behavior changes are noted (going through other residents' belongings, inappropriate behaviors/touching of staff, etc). Record review lacked evidence that the 15 minute checks had been done after the incident on 4/3/2018 at approximately 10:30 PM, until 3:00 PM on 4/4/2018. During a phone interview with a third shift NA (staff E) on 4/5/2018 at 2:45 PM, she stated she has observed resident ID #1 had gone through the bathroom and was trying to get into resident ID# 2's room. She asked him what he was doing and he stated just looking. Interview with the first shift unit nurse (staff B) on 4/4/2018 at 3:30 PM, revealed that she checked on the resident at least every 1/2 hour. She stated she told NAs at the morning report to check on the resident frequently. During an interview with unit nurse (staff B) on 4/4/2018 at 2:35 PM, she revealed staff put a bedside table in front of the bathroom door in resident ID #2's room (both residents in that room do not use the bathroom at night) as a barrier so they could hear if resident ID #1 came through the bathroom door. Interview with a first shift NA (staff C) on 4/4/2018 at 2:45 PM, revealed that she was unaware of any recent incident with inappropriate behavior involving resident ID #1. She further stated that she was not aware that resident ID #1 is on 15 minute checks. An interview with the unit nurse (staff B) on 4/4/2018 on 2:35 PM, revealed that resident ID#'s 1, 2, and 8 slept in their respective beds throughout the previous night. This could potentially allow further access of resident ID #1 to his roommate, or to his alleged victim, and his roommate through the bathroom which connects the two rooms. During an interview with the DNS on 4/4/2018 at 3:20 PM, she stated she was not aware of the above allegation until 7:40 AM on 4/4/2018. She then reported the incident to the assistant administrator, who called the police. During an interview with the DNS on 4/5/2018 at 3:45 PM, she revealed that she would have expected to have them to call her that night, she would have told them to call the police. She also indicated that she would have expected them to do 15 minute checks or put someone outside the door, sitting where the staff member could see him. She indicated that staff has the form available but was unable to produce evidence that staff completed the 15 minute check form until 3:00 PM on 4/4/2018. During an interview with the Administrator and the DNS on 4/4/2018 at 5:00 PM, they were unable to produce evidence that a plan has been implemented to protect resident ID #2 and other residents from further potential abuse by resident ID #1. The facility failed to prevent resident ID #1 from having access to the alleged victims and/or other vulnerable residents.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to protect the resident's right to be free from abuse. Findings are as follows; On 4/4/2018, the facility reported to the Department of Health that resident ID #2 had been found exposed and distraught, alleging that he had been touched in his genital area by another resident without his consent. Investigation of this allegation by a surveyor on 4/4 & 4/5/2018 revealed the following: 1. Clinical record review revealed that resident ID #2 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 5/29/2017 care plan indicates that the resident has both short and long term memory impairment. The resident requires extensive assistance from staff with ADLs and uses a (mechanical) Hoyer lift for transferring in and out of bed. A nurse's note on 4/3/2018 at 10:25 PM documented that resident ID #2 was found by a nursing assistant (NA) uncovered and with his penis removed from inside his still-closed brief. The resident was very agitated- appearing, and very easy startled; he appeared very afraid. The NA reported the situation to the unit nurse (staff A). Staff A then questioned the resident as to why he was uncovered. The resident stated The man did it to me. When the nurse asked where the man came from, the resident stated he came from that room, and the resident pointed toward the bathroom which connects his room and the room where resident ID #1 resides. When the nurse asked if the man had touched him. The resident stated yes he did and the resident became very agitated and crying out OH and putting his arms together across his body as if to hide himself. I am sorry the resident stated. The nurse documented that the resident was unable to answer any further questions. The nurse further documented that it was noted that the man in the neighboring room (resident ID #1), had just gotten back into his bed from a trip to the bathroom. On 4/4/2018 at 3:45 PM, an interview was conducted with a second shift NA (staff F) who found the resident uncovered on 4/3/2018. Staff F stated that she and another NA found resident ID #2 uncovered with his penis exposed, his johnny pulled up to his chest, his brief pulled down to his knees and his blanket pulled down to the end of the bed, covering only his feet. She further stated that she found him this way 2 to 3 times over the past several weeks and had reported it to the nurse. She believed the resident is unable to pull his brief down or pull his blanket down to the end of the bed. Interview with staff A on 4/3/2018 at 3:55 PM, revealed she was in resident ID #2's room approximately 45 minutes before the incident, at which time the resident was lying in bed, wearing a johnny and covered with a blanket. Staff A stated that she has been working at the facility for years and the resident prefers to be covered and she has never seen him reaching toward his brief/private area. She believed the resident is unable to pull his brief down or pull his blanket down to the end of the bed. Staff A further indicated that, when she was called back to the room, she found the resident uncovered, his penis removed from his brief and his brief was tied. The resident told her that the man came from there, pointing to the bathroom, and he further indicated that the man touched him. When she asked if the man touched his privates the resident nodded and became anxious. Surveyor observation on 4/4/2018 at 2:30 PM revealed resident ID # 1's room and ID # 2's room are approximately 75 feet from the nursing station. Each room has 2 beds and the rooms are connected by a bathroom which allows a resident to go between rooms without being seen from the hallway. During an interview with the DNS on 4/4/2018 at 3:20 PM, she stated she was not aware of the allegation by resident ID # 2 until 7:40 AM on 4/4/2018. She then reported the incident to the assistant administrator, who called the police. Clinical record review revealed resident ID# 1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He is independent with ambulating and using the bathroom. Further record review revealed a nurse note dated 3/27/2018 at 11:01 PM, which stated that during 10 PM rounds, resident ID #2 was found with johnny off and penis outside the depends and the depends was lowered to the hip area. Additionally a 3/20/2018 nurse note indicates that at 4:30 AM resident ID #2 was found sitting on the side of the bed with the call light clipped to his johnny. He asked staff Is this a gay establishment? Staff documentation at 11:08 PM indicates after 5 attempts to get out of bed unassisted, the resident was brought to the nursing station. Staff indicated he is . easily startled, and crying at times. When asked whether he was sad, he became more weepy, stating that he did not know why he was crying, and felt ashamed to be so upset. During a phone interview with a third shift NA (staff E) on 4/5/2018 at 2:45 PM, she stated she had observed resident ID #1 going through the bathroom and trying to get into the room of resident ID # 2. When asked what he was doing, resident ID # 1 stated he was, just looking. Interview with the first shift unit nurse (staff B) on 4/4/2018 at 3:30 PM, revealed that she checked on the resident at least every 1/2 hour. She stated she told NAs at the morning report to check on the resident frequently. Interview with a first shift NA (staff C) on 4/4/2018 at 2:45 PM, revealed that she was unaware of any recent incident with inappropriate behavior involving resident ID #1. She further stated that she was not aware that resident ID #1 is on 15 minute checks. Although resident ID #1 had a revised care plan for behavioral symptoms with an approach start date of 11/22/2017 for initiate 15 min checks as needed if behavior changes are noted . Further record review revealed 3 separate residents had made allegations against resident ID #1. Resident ID #'s 2 and 3 alleged that resident ID #1 touched them in their private, and ID #7 alleged that ID #1 was trying to touch him. Each of the residents making the allegations were, at the time of the reported incidents, occupying the same bed which is currently occupied by resident ID # 2. 2. Clinical record review revealed resident ID #3 was admitted to the facility with [DIAGNOSES REDACTED]. A MDS dated [DATE] indicates a BIMS score of 8 of 15, indicating moderate cognitive impairment. He required extensive assistance with Activities of Daily Living (ADL). On 10/3/2017, resident ID #3 moved into the same bed presently occupied by resident ID # 2. A nurse's note on 11/16/2017 at 1:49 AM documented that resident ID #3 rang the call light and told a NA something which made the NA get the nurse on duty (staff A). When staff A asked the resident to repeat what he had told the NA, he stated that man next door came in here and touched me. When staff A asked the resident to point to where he had been touched, he pointed to his perineum and stated he touched me in the private. He then pointed to the adjoining bathroom door and said the man that is in there right now is the one who touched me. Per this nurse's note, the resident then asked for a sleeping pill and stated he was feeling very anxious and was afraid not to be able to sleep. Subsequently, the resident moved to another floor. Record review of ID #1's care plan revealed that after the 11/16/2017 incident of inappropriately touching of resident ID #3, ID #1's plan of care was modified to include an approach for behavior symptoms. The care plan states, initiate 15 min checks as needed if behavior changes are noted (going through other residents' belongings, inappropriate behaviors/touching of staff, etc). Record review lacked evidence that the 15 minute checks had been done after the incident on 4/3/2018 PM. 3. Clinical record review revealed resident ID#7 had a [DIAGNOSES REDACTED]. His 5/26/2017 BIMS score was 15 of 15, which indicates no cognitive impairment. Between 5/19/2017 to 9/29/2017, resident ID # 7 occupied the same room and bed which were subsequently occupied by resident ID #'s 2 & 3 . A nurse's note on 5/ 29 /2017 at 1:51 AM, revealed resident ID #7 reported to the third shift nurse (staff D) that resident ID #1 came into his room and made inappropriate sexual comments and advances toward him. Resident ID #7 reportedly told resident ID #1 to leave his room. Resident ID #1 left through the bathroom door but kept going back to the bathroom opening the door to his room and staring at him which made him very uncomfortable and nervous. Staff D spoke to resident ID #1 and asked him not to go into resident's ID #7 's room and resident ID #1 agreed not to do it anymore. A review of staff D's written statement, dated 4/6/2018, revealed that resident ID #7 told her that resident ID #1 came in and was trying to touch him. Staff D stated the resident was very upset and nervous. During an interview with the Director of Nursing Services (DNS) on 4/5/2018 at 3:55 PM, she stated that after the above allegation, she spoke with resident ID #7 and staff, but did not write anything down. She did not report the incident to the Department of Health because resident ID #1 just made resident ID #7 uncomfortable. The DNS was unable to produce evidence that this allegation was thoroughly investigated and reported to the Department of Health, or that a plan of care was implemented to protect ID #7, or other residents from further potential abuse by resident ID #1. 4. Record review revealed resident ID #8 has been sharing a room with resident ID #1. The resident has [DIAGNOSES REDACTED]. A MDS dated [DATE] indicates a BIMS score of 11 of 15, indicating moderate cognitive impairment. He requires extensive assistance with ADL. A nurse's note dated 04/01/2018 at 7:54 PM, revealed staff found resident ID #1 .at the roommate's (bed) with both hands on top of the roommate's bed. When staff asked what he was doing he wouldn't answer and walked to his bed and went under his blanket without saying anything. During an interview with a NA (staff F) on 4/4/2018 at 4:10 PM, she stated resident ID #8 has cognitive impairment and needs total assistance from staff. She has observed resident ID #1 standing over resident ID #8's bed or touching his bed. The facility failed to prevent resident ID #1 from having access to the alleged victims and/or other vulnerable residents following allegations of inappropriate sexual behavior in (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). There was no indication that a new approach was added on the care plan of resident ID #1 after the alleged incident on 5/29/2017. Although an approach was added to resident ID #1's care plan on 11/22/2017 after the second alleged incident was reported, documentation of 15 minute checks was noted in the nurse's notes on only 11/16 and 11/18/2017. Then on 11/20/2017 at 10:27 AM, there was documentation in a nurse's note by unit nurse (Staff B) Q 15 min. checks d/c'd for behavioral monitoring. Additionally, after the alleged incident on 4/3/2018, there was no evidence of 15 minute checks being completed until 3:00 PM on 4/4/2018 despite the fact that this was an alleged pattern of behavior for resident ID #1. Furthermore there lacked evidence that resident ID #'s 2 & 3, who alleged sexual contact, had been evaluated for either physical or emotional injury by a qualified healthcare professional, and that care plan's had been developed for resident ID #'s 2, 3 and 7 after they alleged sexual abuse by resident ID #1. During an interview with the Administrator and the DNS on 4/4/2018 at 5:00 PM, they were unable to produce evidence that a plan has been implemented to protect resident ID #2 and other residents from further potential abuse by resident ID #1. During interview with the DNS on 4/5/2018 at 3:45 PM, it was revealed she would expect the 15 minutes check to be done and she indicated that staff has the form available but was unable to produce evidence that staff completed the form until 3:00 PM on 4/4/2018.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to prevent further potential for abuse while an investigation is in progress for resident ID# 2, and provide evidence that all alleged violations are thoroughly investigated and reported to the State Survey Agency (Department of Health) for resident ID #7 Findings are as follows; The facility's policy for Abuse Reporting, under Policy Interpretation and Implementation states, in part 4. Incidents of patient to patient abuse . Residents involved in patient to patient abuse cases should be separated and monitored closely to prevent any further incidents. 1. Clinical record review revealed resident ID #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating the resident has severe cognitive impairment. Surveyor observation on 4/4/2018 at 2:30 PM revealed resident ID #1's room and resident ID # 2's rooms are approximately 75 feet from the nursing station. Each room has 2 beds and the rooms are connected by a bathroom which allows a resident to go between rooms without being seen from the hallway. Clinical record review revealed resident ID #2 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 5/29/2017 care plan indicates the resident has both short and long term memory impairment. The resident requires extensive assistance from staff with ADLs and a Hoyer (total lift) for transferring in and out of bed. The resident moved into his room on 1/13/2018 and presently resides there. Review of the 4/3/2018 nurse's note, documented at 10:25 PM, revealed the resident ID #2 was noted to be uncovered, his penis was removed from inside the still-closed brief and the resident was very agitated- appearing very easy startled; .appeared very afraid. The NAs reported it to the unit nurse (staff A). Staff A then asked the resident why he was uncovered. The resident stated The man did it to me. When the nurse asked where the man came from, the resident stated he came from that room and the resident pointed toward the bathroom which was adjoining his room to resident ID #1's room. When the nurse asked if the man had touched him. The resident stated yes he did and the resident became very agitated and crying out OH and putting his arms together across his body as if to hide himself. I am sorry the resident stated. The nurse documented that the resident was unable to answer any further questions. The nurse further documented that it was noted that the man in the neighboring room (resident ID #1), had just gotten back into his bed from a trip to the bathroom. On 4/4/2018 at 3:45 PM, an interview was conducted with a second shift NA (staff F) who found the resident uncovered on 4/3/2018. Staff F stated her and another NA found resident ID #2 uncovered with his penis exposed, his johnny was pulled up to his chest and his brief was pulled down to his knees and the blanket was down to the end of the bed, covering only his feet. She further stated that she found him this way 2 to 3 times over the past several weeks and reported it to the nurse. She believed the resident is unable to pull his brief down or pull his blanket down to the end of the bed. Interview with staff A on 4/3/2018 at 3:55 PM, revealed she was in resident ID #2's room approximately 45 minutes before the incident, at that time, the resident was lying in bed, wearing a johnny and covered with a blanket. Staff A stated that she has been working at the facility for years and the resident prefers to be covered and she has never seen him reaching toward his brief/private area. She believed the resident is unable to pull his brief down or pull his blanket down to the end of the bed. Staff A further indicated that, when she was called back to the room, she found the resident uncovered and his penis was removed from his brief and his brief was tied. The resident told her that the man came from there, pointing to the bathroom, he further indicated that the man touched him. When she asked if the man touched his private the resident nodded and got anxious. Record review of ID #1's care plan revealed after the 11/16/2017 alleged incident of inappropriate touching of another resident, an approach was added for behavior symptoms which indicates initiate 15 min checks as needed if behavior changes are noted (going through other residents' belongings, inappropriate behaviors/touching of staff, etc). Record review lacked evidence that the 15 minute checks had been done after the incident on 4/3/2018 at approximately 10:30 PM, until 3:00 PM on 4/4/2018. During a phone interview with a third shift NA (staff E) on 4/5/2018 at 2:45 PM, she stated she has observed resident ID #1 had gone through the bathroom and was trying to get into resident ID #2's room. She asked him what he was doing and he stated just looking. During an interview with unit nurse (staff B) on 4/4/2018 at 2:35 PM, she revealed staff put a bedside table in front of the bathroom door in Resident ID# 2's room (both residents in that room do not use the bathroom at night) as a barrier so they could hear if resident ID #1 came through the bathroom door. Interview with the first shift unit nurse (staff B) on 4/4/2018 at 3:30 PM, revealed that she checked on the resident at least every 1/2 hour. She stated she told NAs at the morning report to check on the resident frequently. Interview with a first shift NA (staff C) on 4/4/2018 at 2:45 PM, revealed that she was unaware of any recent incident with inappropriate behavior involving resident ID #1. She further stated that she was not aware that resident ID #1 is on 15 minute checks. An interview with the unit nurse (staff B) on 4/4/2018 on 2:35 PM, revealed that resident ID#'s 1, 2, and 8 slept in their respective beds throughout the previous night. This could potentially allow further access of resident ID #1 to his roommate, and to his alleged victim and his roommate through the bathroom connecting the two rooms. During an interview with the DNS on 4/4/2018 at 3:20 PM, she stated she was not aware of the above allegation until 7:40 AM on 4/4/2018. She then reported the incident to the assistant administrator, who called the police. During an interview with the DNS on 4/5/2018 at 3:45 PM, she revealed that she would have expected have them to call her that night, she would have told them to call the police. She also indicated that she would have expected them to do 15 minute checks or put someone outside the door, sitting where the staff member could see him. She indicated that staff has the form available but was unable to produce evidence that staff documented on the form until 3:00 PM on 4/4/2018. During an interview with the Administrator and the DNS on 4/4/2018 at 5:00 PM, they were unable to produce evidence that a plan has been implemented to protect resident ID# 2 and other residents from further potential abuse by resident ID #1. The facility failed to prevent resident ID #1 from having access to the alleged victims and/or other vulnerable residents. The facility's policy for Abuse,under Policy Interpretation and Implementation, states, in part 7. The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the charge nurse .8. Upon receiving reports .the charge nurse shall immediately examine the resident .9 .An immediate investigation will be made and a copy of the findings .will be provided to the administrator within five (5) working days of the occurrence of such incidents. The administrator will send results of investigation to the agencies listed above .11. Upon receiving information concerning a report of abuse, the director of nursing services will request that a representative of the social services department monitor the resident's feelings concerning the incident . 2. Clinical record review revealed resident ID #7 has a [DIAGNOSES REDACTED]. Record review of the list received from the social worker,revealed that resident ID #7 resided in the room adjoining resident ID #1's room from 5/19/2017 to 9/29/2017 A review of a nurse's note dated 5/29/2017 revealed resident ID #7 reported to the third shift nurse (staff D) that resident ID #1 came into his room and made inappropriate sexual comments and advances toward him. Resident ID #7 told resident ID #1 to leave his room. Resident ID #1 left through the bathroom door but kept going back to the bathroom opening the door to the room and staring at him which made him uncomfortable and nervous. Staff D spoke to resident ID #1 and asked him not to go into resident's ID #7's room and resident ID #1 agreed not to do it anymore. During a phone interview on 4/5/2018 at 8:05 AM, staff D told the surveyor that resident ID #7 had reported to her that resident ID #1 came in to his room while he was sleeping and touched his private area, which was under the cover. Staff D stated the resident was very upset. He was going to knock his head of and he was crying. Surveyors requested that staff D provide a statement about the 5/29/2017 incident. Consequently, staff D provided a written statement, dated 4/6/2018, which revealed that resident ID #7 alleged that resident ID #1 came in and was trying to touch him. Staff D stated the resident was very upset and nervous. During an interview with the Director of Nursing Services (DNS) on 4/5/2018 at 3:55 PM, she stated after the above allegation, she spoke with resident ID #7 and staff but did not write anything down. She did not report the incident to the Department of Health or police because she was unaware that resident ID #7 told staff that resident ID #1 touched his/her private area. The DNS stated resident ID #1 just made resident ID #7 uncomfortable. Although in the nurse's note written on 5/29/2017 at 1:51 AM by staff D, the behavior described fits within the definition of sexual harassment as defined by the EE[NAME] (see above definition). The DNS was unable to produce evidence that the incident was thoroughly investigated and that a plan was developed to address the above allegation. Refer to details in F 600. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions.