Every finding on record at Pawtucket Falls Healthcare Center

Based on record review and staff interview, the facility failed to meet professional standards of quality relative to not following physician's orders for behavior monitoring for 2 of 4 resident's reviewed, Resident ID #s 2 and 6.Findings are as follows: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 client.1. Record review revealed Resident ID #2 was admitted to the facility in April of 2026 with diagnoses which included, but were not limited to, Alzheimer's Disease and anxiety disorder.Record review revealed a physician's order, dated 4/15/2026 to monitor the resident's mood, behavior and agitation every shift. It contains instructions to document the number of occurrences and the interventions utilized.Record review of the June 2026 Medication Administration Record (MAR) failed to reveal documentation of the number of occurrences or the interventions utilized.Further review of the resident's record failed to reveal that the resident's mood, behavior and agitation, including the number of occurrences and interventions utilized, were being documented every shift, as per the physician's order.2. Record review revealed Resident ID #6 was admitted to the facility in June of 2026 with diagnosis which included, but were not limited to, dementia with agitation.Record review revealed a physician's order, dated 4/3/2026 to monitor the resident's mood, behavior, and agitation every shift. It contains instructions to document the number of occurrences and the interventions utilized.Record review of the July 2026 MAR failed to reveal documentation of the number of occurrences or the interventions utilized.Further review of the resident's record failed to reveal that the resident's mood, behavior and agitation, including the number of occurrences and interventions utilized, were being documented every shift, as per the physician's order.During a surveyor interview on 7/16/2026 at approximately 2:30 PM with the Director of Nursing Services, she could not provide evidence that Resident ID #s 2 and 6 had behavior monitoring related to mood, behavior, or anxiety, including the number of occurrences and interventions utilized, every shift per the physician's order.

Based on record review and staff interview, the facility failed to ensure that the comprehensive care plan was revised by the interdisciplinary team after changes of condition for 5 of 6 residents reviewed, Resident ID #s 1, 3, 4, 5, and 6.Findings are as follows:Record review of a Facility policy titled, Care Plan Revisions Upon Status Change revealed in part, The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.The MDS coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.The care plan will be updated with the new or modified interventions.1. Review of a facility reported incident submitted to the Rhode Island Department of Health on 7/8/2026, revealed in part, that on 7/8/2026 Resident ID #6 smacked Resident ID #1 on the shoulder.1a. Record review revealed Resident ID #1 was admitted to the facility in January of 2026 with diagnoses which include, but are not limited to, dementia with agitation and depression.Record review of a care plan dated 6/8/2026 revealed that the resident has the potential to be physically aggressive and combative. This care plan was updated on 7/9/2026 to include that on 7/8/2026 there was a resident-to-resident incident, where Resident ID #1 was originally the victim, but retaliated and became the aggressor.Further record review of the care plan failed to reveal evidence that the care plan was revised to include the addition of new interventions after the 7/8/2026 incident.1b. Record review revealed Resident ID #6 was admitted to the facility in June of 2026 with diagnosis including, but not limited to, dementia with agitation.Record review of a care plan dated 1/7/2026 revealed that the resident is verbally and physically aggressive to others, difficult to redirect, and refuses medications and care. This care plan was updated on 7/9/2026 to include that on 7/8/2026 there was a resident-to-resident incident, and Resident ID #6 was the aggressor.Further record review of the care plan failed to reveal evidence that the care plan was revised to include the addition of new interventions after the 7/8/2026 incident.2. Review of a facility reported incident submitted to the Rhode Island Department of Health on 6/23/2026, revealed in part, that on 6/23/2026 Resident ID #3 arm was grabbed by another resident who attempted to drag him/her out of his/her room.Record review revealed Resident ID #3's was admitted to the facility in June of 2026 with diagnoses including, but not limited to, dementia with behavioral disturbance and adjustment disorder.Record review of a care plan dated 6/8/2026 revealed that the resident has the potential to be physically/verbally aggressive. This care plan was updated on 7/16/2026 to include that on 6/23/2026 there was a resident-to-resident incident, and Resident ID #3 was the victim.Further record review of the care plan failed to reveal evidence that the care plan was revised to include the addition of new interventions after the 6/232026 incident.3. Review of a facility reported incident submitted to the Rhode Island Department of Health on 6/23/2026, revealed in part, that on 6/23/2026 Resident ID #4 had another resident attempt to pull him/her out of his/her room in an aggressive manor. The facility reported incident further revealed that the same resident also attempted to pull Resident ID #5 out of his/her room in an aggressive manner.3a. Record review revealed Resident ID #4 was admitted to the facility in April of 2026 with diagnoses including, but not limited to, dementia, generalized anxiety, and adjustment disorder.Record review failed to reveal evidence that the resident's care plan was revised to include the resident-to-resident incident that took place on 6/23/2026, where s/he was the victim, or new interventions to prevent further incidents.3b. Record review revealed Resident ID #5 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, dementia, major depressive disorder, and adjustment disorder.Record review failed to reveal evidence that the resident's care plan was revised to include the resident-to-resident incident that took place on 6/23/2026, where s/he was the victim, or new interventions to prevent further incidents.During a surveyor interview on 7/16/2026 at 1:54 PM with Licensed Practical Nurse, Staff A, she revealed that the care plan should have been revised with new interventions after the above incidents. She acknowledged that the care plans for Resident ID #s 1, 3, 4, 5, and 6 failed to be revised with new interventions.During a surveyor interview on 7/17/2026 at approximately 2:30 PM, the Director of Nursing Services acknowledged that the care plans for Resident ID #s 1, 3, 4, 5, and 6 failed to be revised, with new interventions after the above resident- to-resident Incidents.

Based on surveyor observation, clinical record review, and resident and staff interview, the facility failed to provide or obtain from an outside resource, emergency dental services for 2 of 2 residents reviewed, who were experiencing mouth pain, Resident ID #s 13 and 77. Findings are as follows:1. Record review revealed Resident ID #13 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, diabetes and major depression.Record review revealed the following physician's orders:- 7/30/2025: Regular texture diet with thin liquids- 4/9/2026: Dentist referral for the left front lower teeth.- 4/10/2026: Orajel Toothache & Gum Gel every six hours as needed. Record review of a nursing progress note dated 4/9/2026 revealed that the resident complained of a tooth ache. The provider was in to assess the resident and ordered a referral to a dentist.Record review failed to reveal evidence that a dental consultation was obtained or that the facility attempted to obtain a dental appointment for the resident.During a surveyor interview on 5/7/2026 at approximately 1:30 PM with the resident s/he revealed that s/he has had mouth pain and has been receiving medication for approximately one month but would like to go to a dentist to have his/her tooth pulled. Additionally, s/he revealed that this was discussed with his/her provider and s/he is waiting for an appointment.During a surveyor observation on 5/8/2026 at approximately 9:30 AM of the resident's oral cavity his/her teeth were observed to be dark and discolored with a buildup of plaque. Additionally, his/her gums appeared to be swollen and red.During surveyor interviews on 5/8/2026 at 9:57 AM and 5/11/2026 at 1:30 PM with the Director of Nursing Services, she revealed that it would be her expectation that a dental appointment would be made as soon as possible for a resident who is experiencing mouth pain. She further revealed that the facility obtained a dental appointment for the resident on 5/11/2026, after the concern was brought to the facility's attention by the surveyor.2. Record review revealed Resident ID #77 was readmitted to the facility in April of 2022 with a diagnosis including, but not limited to, diabetes mellitus.During a surveyor interview with the resident on 5/6/2026 at approximately 9:00 AM, s/he stated his/her mouth was so painful to the touch and that the pain had been going on for a while. Record review of a document titled Health Drive Dental Group dated 3/2/2026 revealed, the resident required an extraction and an evaluation by an outside oral surgeon if pain or swelling occurs. Record review of a provider order and a corresponding nursing progress note dated 4/7/2026 revealed an order for an oral surgeon consultation related to needing an extraction due to complaints of gum and mouth pain.Further record review failed to reveal evidence that the facility scheduled an appointment for an evaluation with an oral surgeon.During a surveyor interview on 5/7/2026 at approximately 12:00 PM with the Nurse Practitioner, Staff K, she acknowledged that she had approved the recommendation for the oral surgeon, but she was not aware if it was completed.During a surveyor interview on 5/7/2026 at approximately 1:30 PM with the DNS, she stated that she was unaware of the recommendation for the oral surgeon consult for Resident ID #77. Additionally, she stated that she would expect the staff to forward such recommendations to the transport coordinator to ensure appointments are arranged.During a surveyor interview on 5/7/2026 at approximately 2:00 PM with the Transportation Coordinator, she revealed that an appointment has been scheduled after it was brought to her attention that an appointment was never made.The facility's failure to secure timely dental and oral surgeon consultations for these residents represents a serious breakdown in the provision of necessary care and services. As a result, both residents endured unnecessary pain, unresolved dental conditions, and delays in clinically indicated treatment. The facility's inaction placed the residents at increased risk for worsening oral deterioration, infection, compromised nutritional status, and further decline in overall health and well-being.

Based on record review and staff interview, the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances, at least quarterly for 5 of 5 residents reviewed, Resident ID #s 21, 81, 85, 103, and 131.Findings are as follows:Review of a facility document titled, Trial Balance dated 5/7/2026 revealed that the facility holds funds for Resident ID #s 21, 81, 85, 103, and 131.Record review failed to reveal evidence that quarterly statements were provided to the residents or their representatives.During a surveyor interview on 5/7/2026 at 10:02 AM, with the Business Office Manager, he revealed that he was unaware that the facility must provide individual accounting of the residents' financial records through quarterly statements.

Based on clinical record review and staff interview, the facility failed to ensure the resident's record is accurate, complete, and readily accessible for 1 of 1 resident reviewed with an order for a permacath (a type of central venous catheter that is inserted into a large vein, typically in the chest, to provide long-term vascular access) Resident ID #8. Findings are as follows:Record review revealed the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, end stage renal disease (when the kidneys are no longer functioning to meet the body's needs) and is dialysis dependent (a life-sustaining medical treatment that performs the natural filtering functions of the kidneys when they can no longer function to filter waste and excess fluid from the body).Record review revealed an order dated 5/1/2025 to monitor right chest wall permacath for signs and symptoms of dislodgement or drainage each shift. Record review revealed a progress note dated 9/22/2025 indicating the resident's permacath was removed on this date.Review of the Medication Administration Records for January, February, March, April, and May through 5/7/2026 revealed, staff continued to inaccurately sign off on the order to monitor the right chest wall Permacath, despite documentation that the Permacath had been removed.During a surveyor interview on 5/7/2026 at 12:47 PM, the Director of Nursing Services stated that the resident's Permacath had been removed on 9/22/2025. She further stated she would not expect staff to sign off on an order that was no longer accurate.

Based on clinical record review and staff interview, the facility failed to ensure that residents are free from any significant medication errors for 3 of 3 residents reviewed for significant medication irregularities identified by the Consultant Pharmacist during the Medication Regimen Review (MRR), including the omission of an antibiotic and the failure to discontinue insulin for Resident ID #48, for a change in medication to manage excess fluids for Resident ID #70, and for an inhaler to manage a chronic lung disease for Resident ID #111. Additionally, the facility failed to ensure that residents are kept free from any significant medication errors for 1 of 1 resident reviewed for vascepa (a medication prescribed for cardiovascular health) and stiolto respimat (an inhaled medication prescribed to treat chronic obstructive pulmonary disease, COPD), Resident ID #73.Findings are as follows:1. Record review revealed Resident ID #48 was readmitted to the facility in April of 2026 with diagnoses including, but not limited to, dementia and type II diabetes mellitus.Record review revealed the resident was readmitted to the facility following a brief hospitalization for acute cystitis (bladder infection) on 4/10/2026.Review of a pharmacy MRR document titled, New Admission/re-admission Review dated 4/16/2026, revealed the following significant medication recommendations that required attention:- Insulin glargine (a long-acting insulin) was indicated on the hospital continuity of care (COC) form to be discontinued, however the resident continued to receive it.- Cefpodoxime (an antibiotic) 100 milligrams (mg) was ordered on the hospital COC to be administered twice daily, and to clarify the order and determine an appropriate end date, however, the resident was not currently receiving it.Record review failed to reveal evidence that the above-mentioned pharmacy recommendations were addressed by the facility.Review of the hospital COC form dated 4/10/2026 revealed for the resident to start taking cefpodoxime 100 mg every 12 hours and to discontinue his/her insulin glargine.Review of a progress note dated 4/10/2026 at 11:43 PM revealed that a provider had reviewed and approved the resident's medication list.Record review failed to reveal evidence that the resident received cefpodoxime following his/her readmission to the facility after the provider had reviewed and approved the resident's medication list upon readmission to the facility.Review of the April 2026 Medication Administration Record (MAR) revealed that the resident continued to receive insulin glargine 22 units daily from 4/11 through 4/21/2026 until s/he was transferred back to the hospital on 4/21/2026.During a surveyor interview on 5/11/2026 at 12:46 PM with the Director of Nursing Services (DNS) and the Administrator, they were unable to provide evidence that the cefpodoxime and insulin glargine orders were addressed per the hospital COC after it was reviewed and approved by the provider. Further, they were unable to provide evidence that the pharmacy recommendations that identified the irregularities for the above-mentioned medications were addressed.2. Record review revealed Resident ID #111 was readmitted to the facility in January of 2026 with a diagnosis including, but not limited to, chronic obstructive pulmonary disorder (COPD) exacerbation.Record review revealed a pharmacy MRR document titled, NURSING RECOMMENDATIONS/NURSE MANAGER REPORT dated 2/11-2/12/2026 states in part, .Repeated rec [recommendation] from January. Please review and correct the following orders that were not transcribed correctly: Anoro ellipta [a daily inhalation powder prescribed for the long term maintenance treatment of COPD that relaxes airway muscles and improve breathing] ordered on [hospital] COC, not entered.Please clarify if this order should be in place. ***Patient on no maintenance inhalers, and has had worsening SOB [shortness of breath]****.Record review failed to reveal evidence that the pharmacy MRR regarding the Anoro ellipta inhaler was addressed when the irregularity was initially identified in January 2026 or when the irregularity was readdressed on the above-mentioned pharmacy MRR from February 2026.During a surveyor interview on 5/8/2026 at approximately 11:30 AM with the DNS, she was unable to provide evidence that Resident ID #111's pharmacy MRR recommendation regarding the Anoro ellipta inhaler was addressed by a provider until after it was brought to the facility's attention by the surveyor on 5/11/2026.During a surveyor interview on 5/11/2026 at approximately 10:30 AM with the Physician Assistant, she revealed that she was unaware of the January and February pharmacy MRRs for the Anoro ellipta inhaler and would have ordered it for the resident beginning in January of 2026 if she had been notified. Additionally, she revealed that she will re-instate the resident's Anoro ellipta inhaler that was previously prescribed for the resident prior to his/her readmission to the facility.Record review revealed that the Anoro ellipta inhaler was reinstated on 5/11/2026 after it was brought to the facility's attention by the surveyor.3. Record review revealed Resident ID #70 was readmitted to the facility on [DATE] with a diagnosis including, but not limited to, ascites (an abnormal buildup of fluid in the abdomen) after a brief hospitalization.Review of a pharmacy MRR document titled, New Admission/re-admission Review dated 5/7/2026 revealed the following significant medication recommendation that required attention:- Furosemide (a medication prescribed to treat excess fluids) is documented on the hospital COC form to administer 20 mg daily, however, the resident is currently receiving 40 mg daily. Additionally, the pharmacy MRR document had a handwritten check mark on the line next to agree with a handwritten note that indicated to change to 20 mg per the hospital COC form.Review of a progress note dated 5/5/2026 at 4:22 PM revealed that a provider reviewed the hospital COC form medication list and discharge paperwork, and that orders were received and initiated as prescribed.Record review failed to reveal evidence that the furosemide order was changed from 40 mg to 20 mg daily.Review of the May 2026 MAR revealed that the resident continued receiving furosemide 40 mg daily from 5/6 through 5/11/2026.Record review revealed a provider's order was entered for the resident to start furosemide 20 mg daily to begin on 5/12/2026, after it was brought the facility's attention by the surveyor on 5/11/2026.During a surveyor interview on 5/11/2026 at 12:46 PM with the DNS and the Administrator, they revealed they would have expected the furosemide medication order to have been transcribed correctly per the hospital COC form after it was reviewed and approved by the provider. Additionally, they would have expected that the pharmacy MRR document regarding the furosemide medication order to have been addressed immediately.4. Record review revealed Resident ID #73 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and congestive heart failure.Record review revealed the following physician's orders:- 9/10/2025: tiotropium bromide-olodaterol 2.5 - 2.5 micrograms inhale two puffs daily for COPD- 6/28/2025: vascepa administer two grams in the morning and evening for cardiac healthReview of the March 2026 MAR revealed his/her vascepa was not administered, as ordered, on the following dates and times:- 3/16 morning and evening- 3/17 evening- 3/18 morning- 3/19 morning and evening- 3/20 morning and evening- 3/29 morning and evening- 3/30 morning and evening- 3/31/2026 eveningReview of the April 2026 MAR revealed his/her tiotropium bromide was not administered, as ordered, on the following dates:- 4/3- 4/4- 4/5- 4/9- 4/11- 4/12- 4/13- 4/14- 4/15/2026Record review failed to reveal evidence that the provider was notified that the resident did not receive the above-mentioned medications, as ordered.During a surveyor interview on 5/7/2026 at approximately 11:30 AM with the Nurse Practitioner, she revealed that she was unaware that the resident did not receive the above-mentioned medications and would expect staff to notify her.During a surveyor interview on 5/7/2026 at approximately 12:00 PM with the DNS, she was unable to provide evidence that the resident was kept free from significant medication errors.

Based on clinical record review and staff interview, the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 2 of 2 residents reviewed with medication recommendations identified by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR), Resident ID #s 75 and 111. Findings are as follows:1. Record review revealed Resident ID #75 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, history of nicotine dependence. Record review revealed a document titled, New Admission/re-admission Review, dated 3/24/2026, with a recommendation to continue the nicotine patch daily for two weeks and then discontinue. Further review of this document revealed that the physician agreed to continue the nicotine patch daily for two weeks and then discontinue. Additionally, it revealed a handwritten note that states, RB [Initials] may d/c [discontinue] per [physician] 3/24/26.Review of the April 2026 Medication Administration Record revealed that the resident's nicotine patch was not discontinued after the two-week period, resulting in the resident receiving four additional administrations of the nicotine patch.During a surveyor interview on 5/11/2026 at 12:46 PM with the Assistant Director of Nursing Services, she acknowledged that she initialed the pharmacy recommendation on 3/24/2026 but was unable to provide evidence the nicotine patch order was discontinued after the two-week time period, as ordered by the physician.2. Record review revealed Resident ID #111 was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, vertigo (dizziness) and anxiety.Record review of a hospital Discharge summary dated [DATE], revealed an order for Meclizine (a medication prescribed to treat dizziness) 12.5 milligrams (mg) two times a day, as needed for dizziness.Record review revealed a document titled, New Admission/re-admission Review, dated 2/12/2026, indicates to review the Meclizine as it was entered incorrectly as standing and should have been entered as needed. Record review revealed a physician's order dated 1/13/2026 for Meclizine 12.5 mg two times daily. Further record review revealed that the resident has received this medication two times daily since 1/13/2026.Record review failed to reveal evidence that the New Admission/ re-admission Review completed by the Consultant Pharmacist on 2/12//2026 was addressed by the facility. During a surveyor interview on 5/8/2026 at approximately 11:30 AM with the Director of Nursing Services, she was unable to provide evidence that the recommendation for Resident ID #111 was acted upon until after it was brought to the facility's attention by the surveyor.

Based on clinical record review and staff interview, the facility failed to ensure that irregularities identified by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR) were acted upon for 3 of 3 residents reviewed with outstanding pharmacy recommendations related to medication monitoring, Resident ID #s 10, 43, and 48.Findings are as follows:1. Record review revealed that Resident ID #10 was admitted to the facility in February of 2026 with a diagnosis including, but not limited to, dementia. Record review revealed a pharmacy MRR document titled, NURSING RECOMMENDATIONS/NURSE MANAGER REPORT dated 2/13/2026, revealed the following recommendation for his/her high-risk medication monitoring:- Furosemide (a diuretic medication that is prescribed to remove excess fluid in the body), monitor for signs and symptoms of dehydration, electrolytes, acute kidney injury, monitor for edema (swelling), congestion, and weight changesRecord review failed to reveal evidence that the above-mentioned medication monitoring recommendation was implemented.During a surveyor interview on 5/8/2026 at approximately 11:30 AM with the Director of Nursing Services (DNS), she was unable to provide evidence that Resident ID #10's pharmacy MRR recommendation was acted upon by the provider until after it was brought to the facility's attention by the surveyor.2. Record review revealed Resident ID #43 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, major depressive disorder and anxiety.Record review revealed a pharmacy MRR document titled, NURSING RECOMMENDATIONS/NURSE MANAGER REPORT dated 3/13/2026, revealed the following recommendations for his/her high-risk medication monitoring:- Hydrochlorothiazide (a diuretic medication), monitor for signs and symptoms of dehydration, electrolytes, acute kidney injury, monitor for edema, congestion, weight changes - Gabapentin (an anticonvulsant medication), monitor for signs of seizures, pain assessment, changes in behaviors, therapeutic drug levels, rash, fever and dizzinessRecord review failed to reveal evidence that the above-mentioned medication monitoring recommendations were implemented until after it was brought to the facility's attention on 5/7/2026, when the surveyor had requested to review the resident's pharmacy MRR document, that the provider signed in agreement with the above-mentioned recommendations.During a surveyor interview on 5/8/2026 at approximately 11:30 AM with the DNS, she was unable to provide evidence that Resident ID #43's pharmacy MRR recommendations were acted upon by the provider until after it was brought to the facility's attention by the surveyor. 3. Record review revealed Resident ID #48 was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, dementia. Record review revealed a pharmacy MRR document titled, NURSING RECOMMENDATIONS/NURSE MANAGER REPORT dated 3/13/2026, revealed the following medication recommendations:- Bisphosphonate (a medication prescribed to strengthen bones), is to be administered in the morning with a full glass of water (6-8 ounces) at least 30 minutes before the first food, beverage, or medication. To avoid esophageal (throat) irritation, patients should not lie down for at least 30 minutes post dose- The resident has an order to crush medications, and the above medication cannot be crushed, and to review with a provider for an alternativeRecord review failed to reveal evidence that the above-mentioned recommendations were implemented.During a surveyor interview on 5/8/2026 at approximately 11:30 AM with the DNS, she was unable to provide evidence that Resident ID #48's pharmacy MRR recommendations were acted upon by the provider until after it was brought to the facility's attention by the surveyor. During a surveyor interview on 5/11/2026 at 12:19 PM with the Administrator in the presence of the DNS, he revealed that he would have expected the above-mentioned pharmacy recommendations to have been addressed immediately.Cross reference F 760 and F 757

Based on surveyor observation, clinical record review, and resident and staff interviews, the facility failed to provide necessary services to residents who are unable to carry out activities of daily living (ADLs) relative to scheduled showers for 2 of 2 residents reviewed who did not receive their scheduled weekly showers on 5/8/2026, Resident ID #s 3 and 122, and for 1 of 1 resident reviewed for nail care, Resident ID #8.Findings are as follows:Review of a facility policy titled Activities of Daily Living states in part, .A resident who is unable to carry out activities of daily living (ADL) will receive necessary services to maintain .grooming and personal hygiene .1. Record review revealed Resident ID #122 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, morbid obesity (a chronic disease defined by a body mass higher than 40) and urinary incontinence (the involuntary loss or leakage of urine due to an inability to control bladder function).Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition is intact. The MDS assessment revealed that the resident is dependent on staff for toileting and requires extensive assistance for bathing/hygiene and dressing and that the resident is always incontinent of bowel and bladder. Further review of the MDS revealed that the resident's preference to receive shower is very important.Record review of a document titled Assignment for Aides 7-3, Assignment 3 revealed, the resident is scheduled to receive showers twice weekly on Tuesday and Friday.Review of the document titled Task: ADL - Shower/Bathing revealed, the resident is scheduled to receive showers twice weekly on the 7:00 AM to 3:00 PM shift. Review of shower documentation for the previous 30 days revealed the resident received only one documented shower on 4/23/2026. Further review revealed the resident missed seven scheduled showers during this time period. During a surveyor observation on 5/5/2026 at 11:40 AM, the resident was observed in bed with greasy hair. During an interview conducted at that time, the resident stated showers were not being provided as scheduled and reported that the staff frequently state there is not enough staff to provide showers. During a surveyor observation and interview with the resident on 5/8/2026 at 11:36 AM, the resident was observed lying in bed and stated that s/he had not yet received morning care. The resident further stated that s/he had experienced a bowel movement approximately one hour earlier and was uncomfortable lying in his/her feces. The resident reported activating the call light at the time of the bowel movement; however, staff did not respond. Additionally, the resident stated that s/he was scheduled to receive a shower that day but was informed by staff that the shower could not be provided due to staffing shortages. During a surveyor interview on 5/8/2026 at approximately 12:00 PM with the resident, in the presence of the Director of Nursing Services (DNS), the resident reiterated the above concerns. At that time, the resident had received a bed bath and incontinent care but had not received the preferred scheduled shower. During this interview, Nursing Assistants (NA), Staff L and M who were in the resident's room stated that they were unable to provide the resident with his/her scheduled shower due to insufficient aides assigned on the unit. 2. Record review revealed Resident #3 was admitted to the facility in May of 2024 with diagnoses including but not limited to, type 2 diabetes mellitus, and anxiety disorder.Record review of Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15, indicating the resident's cognition is moderately impaired, that the resident is dependent on staff for transfers, requires extensive assistance for bathing/hygiene and dressing, and that the resident is always incontinent of bowel and bladder. Further review of the MDS revealed that the resident's preference to receive showers is very important.Review of the care plan last revised on 9/19/2025, identified the resident as dependent on staff for physical and social needs related to impaired mobility and change in health status, with interventions to provide required physical care throughout the resident's stay.Record review of the document titled, Assignment for Aides 7-3, Assignment 1 revealed, the resident was scheduled to receive showers twice weekly on Monday and Friday.Review of the document titled Task: ADL - shower/bathing revealed, the resident was scheduled for showers twice weekly on the 7:00 AM-3:00 PM shift. This documentation indicated only one shower was provided on 5/1/2026 within the previous 30 days, indicating the resident missed seven scheduled showers in 30 days.During a surveyor observation and interview on 5/8/2026 at 12:11 PM, the resident was observed up, dressed, and sitting in the Geri-chair. S/he stated that s/he had not received his/her scheduled shower for that day.During a surveyor interview on 5/8/2026 at 12:15 PM with NA, Staff L, she acknowledged that the resident had not received his/her scheduled shower prior to ADL care on this date. During a surveyor interview on 5/8/2026 at approximately 1:00 PM with the DNS, she indicated that she would expect the staff to provide showers as scheduled. 3. Record review revealed Resident ID #8 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, hemiplegia (a form of paralysis that affects only one side of the body) and hemiparesis (weakness on one side of the body) to the left side.Record review of a Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident's cognition is intact. Additionally, the assessment revealed the resident requires substantial to maximum staff assistance with personal hygiene and grooming.Record review of a care plan dated 3/26/2025 revealed, the resident has self-care performance deficits related to decreased mobility and a history of a stroke requiring staff to assist with ADLs. Staff interventions include, but are not limited to, check nail length, trim and clean on bath days, and as necessary.During a surveyor interview and observation on 5/6/2026 at 11:45 AM, the resident's left-hand fingernails were observed to be approximately 1/2 inch in length. The resident stated that s/he would like his/her fingernails trimmed but is unable to do so independently. During a surveyor observation on 5/7/2026 at 9:06 AM, in the presence of Unit Manager, Staff N, she acknowledged the resident's fingernails were long and needed to be trimmed.During a surveyor interview on 5/7/2026 at 12:49 PM with the DNS, she was unable to provide evidence that Resident ID #8 had received assistance with nail care, as required. Cross Reference F 725

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide services that meet professional standards of quality relative to 1 of 1 resident reviewed with an arterial wound (a skin injury caused by poor blood flow), Resident ID #30. Additionally, the facility failed to follow the physician's orders for 1 of 1 resident reviewed with an order to obtain a T4 laboratory test (a blood test that measures the levels of the hormone produced by the thyroid gland) for Resident ID #74, and for 1 of 1 resident reviewed for Thrombo-Embolism Deterrent (TED) stockings (a compression sock used to prevent blood clots in immobile, bedridden, or post-surgical patients), Resident ID #142.Findings are as follows: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 that the orders are in error or would harm the clients.1. Record review revealed Resident ID #30 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, congestive heart failure (a condition in which the heart muscle is too weak to pump, causing back flow of blood into the lungs and other tissues).Review of a physician's order revealed a treatment initiated on 4/28/2026 to cleanse the right foot second toe ulcer with normal saline, apply skin prep (a protective liquid applied to the skin that forms a barrier), and leave open to air.Record review revealed a wound care specialist began following the resident for his/her toe ulcer, and s/he was first evaluated on 5/1/2026. Review of a wound care document dated 5/1/2026 revealed the wound care specialist made recommendations to change the frequency of the skin prep wound treatment from daily to twice daily.Record review failed to reveal evidence that the wound care specialist's recommendation was addressed until after it was brought to the facility's attention by the surveyor on 5/6/2026.Further record review revealed a physician's order was initiated on 5/6/2026 to apply skin prep to the resident's right foot second toe ulcer, twice daily.During a surveyor interview on 5/7/2026 at 1:22 PM with the resident's physician, he revealed that he would expect the facility to follow the wound specialist's recommendations for wound care.During a surveyor interview on 5/7/2026 at approximately 1:35 PM with the Director of Nursing Services (DNS), she stated that she would expect the wound specialist's recommendations to be addressed immediately. 2. Record revealed Resident ID #74 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, hypothyroidism (a condition in which the thyroid gland fails to produce enough hormones to meet the body's needs).Record review of the physician's notes revealed an entry dated 3/26/2026 to check the free T4 the following day.Review of the laboratory reports failed to reveal evidence that the free T4 laboratory test had been completed, as ordered, until it was brought to the facility's attention by the surveyor on 5/7/2026.Review of the laboratory results dated [DATE] revealed an elevated T4 level of 2.7 nanograms per deciliter (ng/dL), exceeding the normal reference range of 0.8-1.9 ng/dL.Record review of the progress notes dated 5/8/2026 revealed that the provider decreased the resident's Levothyroxine (a medication prescribed to treat low thyroid hormone levels) from 150 microgram (mcg) to 125 mcg daily, as a result of the elevated T4 level obtained on 5/8/2026.During a surveyor interview on 5/11/2026 at 12:19 PM with the DNS, she stated that she would have expected the T4 laboratory testing to have been completed on 3/27/2026, as indicated in the provider's progress notes.3. Record revealed Resident ID #142 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, nondisplaced fracture of the lateral condyle of right tibia (a crack or break on the outer, upper portion of the right shinbone at the knee joint).Record review of the physician's orders dated 5/24/2025 revealed, TED stockings to be applied in the morning and removed during the evening.Surveyor observations on the following dates and times, Resident ID #142 was observed not wearing the TED stockings as ordered:- 5/5/2026 at 11:08 AM and 11:14 AM- 5/6/2026 at 12:10 PM- 5/8/2026 at 10:18 AM and at 11:00 AMDuring a surveyor interview on 5/8/2026 at 11:03 AM with Nursing Assistant, Staff I, she acknowledged that she had provided care to the resident on 5/5/2026, 5/6/2026 and 5/8/2026, and did not put the TED stockings on the resident, as ordered.During a surveyor interview on 5/8/2026 at 11:13 AM with the Assistant Director of Nursing, she was unable to provide evidence that the resident's order for the TED stocking was being followed, as ordered.Cross reference F 842

Based on surveyor observation, clinical record review, and resident and staff interview, the facility failed to have sufficient nursing staff to assure resident safety and attain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 2 of 2 residents reviewed who failed to receive their scheduled shower due to staffing shortages, Residents ID #s 3 and 122.Findings are as follows:Review of the FACILITY ASSESSMENT dated 2/23/2026 states in part .the residents' daily needs, preferences, and routines in order to help each resident attain or maintain the highest practicable physical, mental, and psychosocial wellbeing.Direct Care Staff .7-8 residents for days (CNA) .Review of an undated policy titled Activities of Daily Living (ADLs) states in part, .that residents unable to carry out ADLs will receive necessary services to maintain grooming and personal hygiene .1. Record review revealed Resident ID #122 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, morbid obesity (a chronic disease defined by a body mass higher than 40) and urinary incontinence (involuntary loss of bladder control in accidental leakage of urine).Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition is intact. It further revealed that the resident is dependent on staff for transfers, requires extensive assistance for bathing/hygiene and dressing, and that the resident is always incontinent of bowel and bladder. Further review of the MDS revealed that the resident's preference to receive shower is very important.Record review of a document titled Assignment for Aides 7-3, Assignment 3 revealed, the resident is scheduled to receive showers twice weekly on Tuesday and Friday.Review of the document titled Task: ADL - Shower/Bathing revealed, the resident is scheduled to receive showers twice weekly on the 7:00 AM to 3:00 PM shift. Review of the shower documentation for the previous 30 days revealed the resident received only one documented shower on 4/23/2026. Further review revealed the resident missed seven scheduled showers during this time period. During a surveyor observation on 5/5/2026 at 11:40 AM, the resident was observed in bed with greasy hair. During an interview conducted at that time, the resident stated showers were not being provided as scheduled and reported that the staff frequently state there are insufficient staff to provide showers. During a surveyor observation and interview with the resident on 5/8/2026 at 11:36 AM, the resident was observed lying in bed and stated that s/he had not yet received morning care. The resident further stated that s/he had experienced a bowel movement approximately one hour earlier and was uncomfortable lying in feces. The resident reported activating the call light at the time of the bowel movement; however, staff did not respond. Additionally, the resident stated that s/he was scheduled to receive a shower that day but was informed by staff that the shower could not be provided due to staffing shortages. During a surveyor interview on 5/8/2026 at 11:40 AM with Licensed Practical Nurse, Staff J, she stated there is no Nursing Assistant (NA) assigned to Resident #122 due to a staffing shortage on the unit. Staff J further indicated that the residents that are scheduled to receive a shower have not been provided one due to insufficient staffing.During a surveyor interview on 5/8/2026 at approximately 12:00 PM with the resident, in the presence of the Director of Nursing Services (DNS), the resident reiterated the above concerns. At that time, the resident had received a bed bath and incontinent care but had not received their preferred scheduled shower. During this interview, NAs, Staff L and Staff M who were in the resident's room stated that they were unable to provide the resident his/her scheduled shower due to insufficient aides assigned on the unit. 2. Record review revealed that Resident #3 was admitted to the facility in May of 2024 with a diagnosis including but not limited to, type 2 diabetes mellitus.Record review of Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 indicating the resident's cognition is moderately impaired. It further revealed that the resident is dependent on staff for transfers, requires extensive assistance for bathing/hygiene and dressing, and that the resident is always incontinent of bowel and bladder. Further review of the assessment revealed that the resident 's preference to receive shower is very important.Record review of the document titled, Assignment for Aides 7-3 Assignment 1 revealed, the resident was scheduled to receive showers twice weekly on Mondays and Fridays.Review of the document titled, Task: ADL - shower/bathing revealed, the resident was scheduled for showers twice weekly on the 7:00 AM-3:00 PM shift. This documentation indicated only one shower was provided on 5/1/2026 within the previous 30 days, indicating that the resident missed seven scheduled showers in 30 days.During a surveyor observation concurrent to the resident interview on 5/8/2026 at 12:11 PM, s/he was observed up, dressed, and sitting in the Geri-chair. S/he stated that s/he had not received his/her scheduled shower for that day.Review of the posted schedule on 5/8/2026 did not reveal evidence that the facility was staffed in accordance with the facility assessment, which indicated a staffing ratio of 7-8 residents per NA. Instead, there were approximately 16 residents assigned to each NA. During a surveyor interview on 5/8/2026 at approximately 1:00 PM with the DNS, she was unable to provide evidence that the unit was adequately staffed and that the residents were receiving care as indicated in the facility assessment.Cross reference F 677

Based on clinical record review, and staff and resident interview, the facility failed to ensure that residents who requires dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services consistent with professional standards of practice for 1 of 1 resident reviewed, Resident ID #8.Findings are as follows:Review of a facility policy titled Hemodialysis dated 10/8/2024, states in part, .The facility will coordinate and collaborate with the dialysis facility to assure that the resident's needs related to dialysis treatments are met.Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist [a medical doctor who specializes in diagnosing, treating, and managing diseases and conditions affecting the kidneys], attending practitioner, and dialysis team.The nurse will ensure that the dialysis site .AV fistula [a surgically created connection between an artery and a vein, usually in the forearm or upper arm, designed for long-term hemodialysis access] is checked before and after dialysis treatment every shift for patency by auscultating for a bruit [a swooshing sound that is heard through a stethoscope indicating blood flow in an artery] and palpating for a thrill [a vibration felt on the skin over the access site, indicating blood is flowing properly] .Record review revealed the resident was admitted to the facility in November of 2024 with a diagnosis including, but not limited to, dependence on renal dialysis.Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief interview for Mental Status score of 15 out of 15, indicating the resident's cognition is intact.Record review revealed a physician's order dated 2/21/2026 indicating the resident receives outpatient dialysis three times a week on Tuesday, Thursday, and Saturday, and s/he is picked up from the facility at 10:00 AM to go to dialysis. A. Record review revealed a physician's order dated 8/30/2025 for lidocaine external cream 4% (a medication prescribed as a local anesthetic to numb specific areas of the body, providing temporary relief from pain) apply to the dialysis access site daily on Tuesday, Thursday, and Saturday at 4:30 AM before dialysis.Record review of the April 2026 Medication Administration Record (MAR) failed to reveal evidence that the resident had received the lidocaine cream on 4/2, 4/4, 4/7, 4/11, 4/14, 4/18, 4/21, 4/23, 4/25, and 4/30/2026, as ordered.Record review of the May 2026 MAR failed to reveal evidence that the resident had received the lidocaine cream on 5/2, 5/5, and 5/7/2026, as ordered.During a surveyor interview on 5/7/2026 at 12:23 PM with Registered Nurse, Staff C, she acknowledged that she did not administer the resident his/her lidocaine cream on 4/30, 5/2, 5/5, and 5/7/2026 and had signed off the order as being administered.B. Record review of a document titled Hemodialysis Communication Record dated 4/4/2026 states in, .New orders: per [nephrologist].restart nepro [a high-calorie nutrition supplement prescribed for patients on dialysis] one daily.pt [patient]agreeable.Record review failed to reveal evidence that the above-mentioned recommendation was collaborated with the attending physician at the facility and instituted as per the facility policy.C. Additional record review failed to reveal evidence that the resident's dialysis access site is being assessed by the nurse for a bruit and thrill before and after dialysis treatment, every shift, per the facility's policy.During surveyor interviews on 5/6/2026 at 12:05 PM and on 5/11/2026 at 11:00 AM with the resident, s/he stated that he has an AV fistula on his/her left upper arm that is used for his/her dialysis treatment. The resident further stated that the staff does not apply the lidocaine cream to his/her dialysis site as ordered. Additionally, the resident acknowledged that s/he has not received the nepro for months since it was ordered by the nephrologist.During a surveyor interview on 5/7/2026 at 12:49 PM with the Director of Nursing Services, she was unable to provide evidence the lidocaine cream was administered on the above-mentioned dates, as ordered. During a subsequent interview on 5/11/2026 at 12:08 PM, she stated that she would expect the staff to assess the resident's AV fistula for a bruit and thrill each shift and acknowledged that the recommendation for the nepro had not been addressed by the facility. During a surveyor interview on 5/11/2026 at 1:55 PM with the Physician Assistant, she acknowledged that she was not aware of the recommendation from the dialysis center on 4/4/2026 for nepro and would have expected the staff to notify her within, at least, 24 hours of when the recommendation was received. Additionally, she stated that she would have approved the recommendation if she had been made aware.

Based on clinical record review, and resident and staff interview, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 3 of 3 residents reviewed, who experienced actual weight loss, Resident ID #s 1, 11, and 111.Findings are as follows:Record review of an undated facility policy titled, Nutrition states in part, .it is the policy of this facility to assess all residents/patients and identify those residents/patients at risk for weight loss and provide appropriate interventions according to the physical and mental abilities and his/her wishes.All weight loss/gain of 5 # [pounds] or more if the resident is over 100 #'s, or weight loss/gain of 2 # if the resident is less than 100 # requires a re-weight for verification. If significant weight loss/gain is identified (greater than 5% in 30 days or greater than 10% in 6 months), the IDT [interdisciplinary team], Dietician, Physician and Family are notified. All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly.1. Record review revealed that Resident ID #1 was admitted to the facility in April of 2026, with diagnoses including, but not limited to, adult failure to thrive and dysphagia (difficulty swallowing).Record review revealed the following physician's orders:-4/10/2026: Diet order for a regular texture diet with thin liquids-4/10/2026: 1 to 1 feeding assistance due to dysphagia and aspiration-4/10/2026: Remeron 15 milligrams (MG) related to anorexia (an eating disorder)Record review of the resident's care plan initiated on 4/13/2026 revealed that the resident is at risk for weight loss related to a diagnosis of diabetes and s/he refuses to eat related to a history of mental illness. Interventions include, but not limited to, monitoring and reporting weight loss.Record review revealed the following weights:-4/10/2026 178.2 pounds (lbs.)-4/30/2026 162.5 lbs.-5/2/2026 162.5 lbs.Record review revealed that the resident experienced a significant weight loss of 8.81% (15.7 lbs.) from 4/10/2026 to 5/2/2026.Further record review failed to reveal evidence that a re-weight was obtained, or that the weight loss was reported to the Registered Dietician (RD) or the provider on 4/30/2026 or 5/2/2026.During a surveyor interview on 5/7/2026 at 2:17 PM with the RD, she revealed that she was not made aware of the weight loss for Resident ID 1. She indicated she was unaware of the facility's process for nursing to report weight discrepancies. She further revealed that it would be her expectation that a re-weight would have been obtained per the facility's policy.2. Record review revealed that Resident ID #11 was admitted to the facility in September of 2024, with diagnoses including, but not limited to, cerebral infarction (stroke) and dysphagia.Record review revealed the following physician's orders:-4/14/2026: Diet order for a regular texture diet with thin liquids. Chopped meat, weighted utensils, and a scoop plate-4/6/2026: Mirtazapine 7.5 MG for an appetite stimulantRecord review of the resident's care plan last revised on 3/9/2026 revealed that the resident has a nutritional problem. Interventions include, but are not limited to, monitoring and reporting weight loss to provider, significant weight loss includes greater than 5% in 1 month, 7.5% in 3 months, 10% in 6 months.Record review revealed the following weights:-2/4/2026 143.2 lbs.-4/6/2026 144.4 lbs.-4/27/2026 129.6 lbs.Record review revealed that the resident experienced a significant weight loss of 9.5% (13.6lbs.) from 2/4/2026 to 4/27/2026.Further record review failed to reveal evidence that a re-weight was obtained, or that the weight loss was reported to the RD or the provider on 4/6/2026 on 4/27/2026.During a surveyor interview on 5/7/2026 at 2:17 PM with the RD, she revealed that she was not made aware of the weight loss for Resident ID 11. She indicated she was unaware of the facility's process for nursing to report weight discrepancies. She further revealed that it would be her expectation that a re-weight would have been obtained per the facility's policy.Record review of a progress note dated 5/8/2026 authored by the Physician Assistant, states in part, .Unexplained weight loss Assessment: Patient has unexplained and undesired weight loss with bilateral temporal wasting noted on examination. CT [computed tomogram] scan has been ordered to evaluate underlying cause.3. Record review revealed that Resident ID #111 was admitted to the facility in March of 2021, with diagnoses including, but not limited to, heart failure and dysphagia.Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, indicating the resident has moderately impaired cognition.During a surveyor interview on 5/6/2026 at 11:06 AM, with the resident s/he stated that the food texture provided by the facility revolts and turns his/her stomach. S/he further revealed that s/he believes s/he had some weight loss related to not eating at times.Record review revealed a physician's order dated 1/15/2026 for a minced and moist texture and thin consistency liquids.Record review of the resident's care plan last revised on 3/27/2026 revealed that the resident has a nutritional problem. Interventions include, but are not limited to, monitoring and reporting weight loss to provider, significant weight loss includes greater than 5% in 1 month, 7.5% in 3 months, 10% in 6 months.Record review revealed the following weights:-3/1/2026 210.0 lbs.-3/18/2026 199.2 lbs.-4/1/2026 194.0 lbs.-5/1/2026 190.0 lbs.Record review revealed that the resident experienced a 7.62% (16 lb.) significant weight loss in one month from 3/1/2026 to 4/1/2026.Record review revealed that the resident experienced a 9.52% (20 lbs.) significant weight loss in three months from 3/1/2026 to 5/1/2026.Further record review failed to reveal evidence that a re-weight was obtained, or that the weight loss was reported to the RD or the provider on 3/18, 4/1, or 5/1/2026.During a surveyor interview on 5/7/2026 at 2:17 PM with the RD, she revealed that she was not made aware of the weight loss for Resident ID 111. She indicated she was unaware of the facility's process for nursing to report weight discrepancies. She further revealed that it would be her expectation that a re-weight would have been obtained per the facility's policy.During a surveyor interview on 5/7/2026 at approximately 3:18 PM with the DNS, she revealed that she would have expected a re-weight to be obtained immediately after the weight loss was identified for resident ID's 1, 11, and 111. If the weight loss was verified, the RD and provider should have immediately been notified.Record review of a progress note dated 5/10/2026 authored by the RD states in part, .Resident triggered for significant weight loss. Diet: *Regular diet, *Minced and Moist (Level 5) texture, *Thin consistency Supplement: Health Shake - No Sugar Added 1x daily Resident has had reduced PO [by mouth] intake, which varies. order noted for ST consult. 5/6/2026 Speech Therapy (ST) clarification orders: Recommend S.T. services for 12 visits x 4wks [weeks] to address dysphagia management, diet modification and safe swallow protocol. Reweigh x1 for 5/11/2026.

Based on surveyor observation, clinical record review, and staff and resident interviews, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice. This included failure to ensure staff completed and documented required weekly skin assessments, reported changes in skin condition to the provider, and initiating timely treatment interventions for 1 of 1 resident observed with a skin impairment, Resident ID #8. Findings are as follows:Review of a facility policy titled, Weekly Body Audit states, in part, .If an alteration in skin integrity, rash, reddened area, or other skin issue is discovered, it will be documented on the weekly skin audit form as soon as the nurse observes the area.the charge nurse is responsible for initiating appropriate documentation, notifying the Unit Manager or Supervisor, and adding this information to the 24-hour report.Record review revealed the resident was admitted to the facility in November of 2024 with diagnoses including, but not limited to, hemiplegia (a form of paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) affecting the left side.Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident's cognition is intact. Additionally, the assessment revealed the resident required substantial to maximum staff assistance with personal hygiene and grooming.Record review of a care plan dated 3/26/2025 revealed the resident is at risk for altered skin integrity related to decreased and impaired mobility. Staff interventions include, but are not limited to, completing weekly skin condition checks.Record review revealed a physician's order dated 1/8/2025 for a weekly skin check to be completed every Wednesday, with findings to be documented in the skin observation assessment.Record review of the May 2026 Medication Administration Record (MAR) revealed that on 5/6/2026, Registered Nurse, Staff P, signed the above-mentioned order as completed.Record review of the weekly skin observation/audit document failed to reveal evidence that Staff P documented findings from the skin assessment completed on 5/6/2026, as ordered and required by the facility policy.Further record review revealed the last documented skin observation/audit was completed on 4/29/2026 and contained no evidence of skin impairment.During a surveyor observation and interview with the resident on 5/6/2026 at 12:05 PM, the resident stated that s/he has had wounds on his/her buttocks for a while that were not being treated by the facility. The resident then lifted his/her left pant leg, revealing two red patches on his/her shin. The resident stated the area was itchy and that s/he was also not receiving treatment for those areas.During a surveyor observation of the resident on 5/7/2026 at 9:12 AM, in the presence of the Unit Manager, Staff N, the resident was observed to have three reddened papules areas (small, solid, raised, inflamed skin bumps) on the left buttock.During an interview immediately following the above observation, Staff N acknowledged the resident's skin impairment and stated she had not previously been aware of it. She further stated she would expect staff to document any skin impairment when identified, notify her of any changes in the resident's skin condition, and notify the provider.During a surveyor interview on 5/7/2026 at 9:51 AM with Rn, Staff P, she acknowledged that she completed the resident's skin check on 5/6/2026 and observed the skin impairment on the resident's left buttock but failed to document the findings. Staff P stated the rash was not newly identified and further acknowledged that she applied lotion to the area but did not notify the Unit Manager or provider.During a surveyor interview on 5/7/2026 at 9:43 AM with the Director of Nursing Services, she was unable to provide evidence that the resident's skin condition had been documented or treated prior to the surveyor bringing it to the facility's attention on 5/7/2026.Record review of a progress note dated 5/8/2026 states, in part, .On exam, several areas of red, flaky, raised rash extending from facial area, navel, to BLE [bilateral lower extremities]. Resident reports feeling very itchy throughout, more prominent to left buttocks.referral to dermatology [skin doctor].agents ordered to relieve symptoms including Clobetasol propionate [a topical medication prescribed to reduce inflammation, redness, itching, and swelling associated with certain skin conditions] 0.05% twice daily for 10 days, and triamcinolone [a medication prescribed to reduce the inflammation, redness, itching, and swelling in various conditions] 0.1% to the navel region and left posterior knee twice daily for 10 days.During a surveyor interview on 5/8/2026 at 11:50 AM with the Physician Assistant, she stated she was unaware the resident had a skin impairment until it was brought to her attention on 5/7/2026, after the surveyor brought it to the attention of the facility.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure residents were free from misappropriation of property for 2 of 2 residents reviewed during the medication administration task, when medications intended for Residents ID #18 and #115 were administered to Resident ID #90.Findings are as follows:1. Record review revealed that Resident ID #18 was admitted to the facility in May of 2022 with diagnoses including, but not limited to, essential hypertension and type 2 diabetes mellitus.Additional record review revealed a physician's order dated 8/4/2023 for Metformin HCL (a medication prescribed to treat diabetes) oral tablet 1000 milligrams (MG) by mouth twice a day.2. Record review revealed that Resident ID #115 was admitted to the facility in May of 2022 with a diagnosis including, but not limited to, hypercholesterolemia (high levels of cholesterol in the blood).Additional record review revealed a physician's order dated 5/14/2025 for Amlodipine Besylate (a medication prescribed to treat high blood pressure) oral tablet 5 MG by mouth daily.3. Record review revealed Resident ID #90 was admitted to the facility in November 2025 with diagnoses including, but not limited to, essential hypertension and type 2 diabetes mellitus.Additional record review revealed a physician order dated 11/18/2025 for Metformin HCL 1000 mg by mouth twice daily and an order dated 11/19/2025 for Amlodipine Besylate 5 mg by mouth daily.During the medication administration task conducted on 5/7/2026 at 9:03 AM with Certified Medication Technician, Staff O, Resident ID #90 was scheduled to receive Metformin 1000 mg and Amlodipine Besylate 5 mg. When the medications were not available for administration, Staff O obtained Metformin 1000 mg from Resident ID #18 and Amlodipine 5 mg from Resident ID #115 for administration to Resident ID #90 until the surveyor intervened.During a surveyor interview following the above observations, Staff O stated that Resident ID #90 had run out of both medications and acknowledged borrowing the medications from Residents ID #18 and #115. Staff O further stated that borrowing medications from one resident to administer to another was her normal practice.During a surveyor interview on 5/7/2026 at 9:58 AM, with the Director of Nursing Services, she stated that staff should not borrow medications from one resident for administration to another resident. She further stated the above-mentioned medications were available in the emergency medication supply and staff would be expected to obtain the medications from that source.

Based on record review and staff interview, the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 2 of 2 residents reviewed who required notification, Resident ID #s 21 and 103. Additionally, the facility failed, upon a resident's death, to convey within 30 days the resident's funds and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate, in accordance with state law for 1 of 1 resident reviewed for personal needs funds handled by the facility that had expired, Resident ID #148.Findings are as follows:1. Record review of Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS) under section 2.4 (G) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities . states in part, .The nursing facility must notify the resident in writing when his/her balance reaches $200.00 less than the resource eligibility guideline, that Medicaid eligibility is jeopardized if the account exceeds the guideline [$4,000] .Review of a facility document titled, Trial Balance dated [DATE] revealed the following:-Resident ID #21 has a current balance of $4,028.86-Resident ID #103 has a current balance of $3,817.69During a surveyor interview on [DATE] at 10:02 AM, with the Business Office Manager, he revealed that he was unaware that the facility is required to provide written notification to a resident receiving Medicaid benefits or their resident representative when their account balance reached $200 less than the SSI Medicaid eligibility resource limit ($4,000).2. According to Rhode Island State Regulation, Section 2.4 (H) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities. states in part, .(c) Upon the death of a Medicaid resident, a facility shall, within 10 days, transmit a notarized statement .indicating the amount of personal needs money on hand after funeral expenses. Funeral expenses are designated to be the first paid. Copies of receipts obtained either from the funeral home or the relative responsible for the funeral should be included .(e) If there is a balance in the Medicaid resident's personal needs account, after payment of the above noted disbursements, a check payable to EOHHS in that amount shall be sent along with the copy of the notarized statement and receipts to EOHHS .Record review revealed Resident ID #148 expired in October of 2025 with a remaining balance of $106.11. Additionally, as of [DATE], his/her personal needs account balance was $106.11.Record review failed to reveal evidence that resident's funds being held by the facility were conveyed, as required, upon his/her death.During a surveyor interview on [DATE] at 10:02 AM with the Business Office Manager, he acknowledged that the facility still held funds for Resident ID #148.

Based on record review, and staff and resident interview, the facility failed to ensure a resident was free from verbal abuse for 1 of 5 residents reviewed, Resident ID #1.Findings are as follows:Record review of a facility-reported incident received by the Rhode Island Department of Health on 3/13/2026 revealed that Nursing Assistant, Staff A, was reported to have been verbally abusive towards Resident ID #1.Record review of a facility policy titled Abuse prohibition revealed in part, .Verbal Abuse = Oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident/patient or their families, or within their hearing distance, to describe resident/patient, regardless of their age, ability to comprehend or disability.Record review revealed the resident was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, hypertension (high blood pressure).Record review of the admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.During a surveyor interview with the resident on 3/25/2026 at 10:20 AM, s/he stated that after using the call light for toileting assistance, Staff A entered the room yelling, I'm not playing games with you tonight, you keep pressing the call light, and I told you to wait. The resident reported being upset.During a surveyor interview on 3/25/2026 at 1:30 PM with Nursing Supervisor, Staff B, she revealed that she was the supervisor who was working the afternoon of 3/11/2026 when the incident happened. She stated that she responded to the resident's room after hearing Staff A yelling at the resident. She observed the resident being visibly upset.Record review of a written statement dated 3/13/2026 authored by Licensed Practical Nuse, Staff C, revealed that she heard Staff A being very rude in her tone, yelling at the resident, I told you to wait, I was with another resident.Record review of a written statement dated 3/13/2026 authored by Staff A, it revealed that she acknowledged speaking back to the resident loudly.During a surveyor interview on 3/25/2026 at 3:20 PM, with the Administrator and Director of Nursing Services, they acknowledged the findings and were unable to provide evidence that the resident was free from verbal abuse during the incident 3/11/2026.

Based on record review, staff, and resident interview, it has been determined that the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 2 residents reviewed who alleged staff to resident abuse, Resident ID #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/14/2024 revealed a verbal altercation occurred between Resident ID #2 and a staff member regarding his/her roommate's care. Further review revealed the staff member was suspended pending the facility's investigation and removed from the resident's roommate's assignment. Record review revealed Resident ID #2 was admitted to the facility in December of 2019 with diagnoses including, but not limited to, anxiety disorder and major depressive disorder. Review of a Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident's cognition was intact. During a surveyor interview on 12/23/2024 at 10:02 AM with Nursing Assistant (NA), Staff A, she indicated that while she was in the resident's room assisting his/her roommate, she and Resident #2 began arguing related to oral care. She further indicated that Resident ID #2 told her to shut up and she responded with make me! Additionally, she indicated that Resident #2 frequently yells at her and she lost her cool at that time. Furthermore, she indicated that the nurse removed her from the resident's room. During a surveyor interview on 12/23/2024 at 10:33 AM with Licensed Practical Nurse, Staff B, she indicated that she was the unit nursing during the time of the altercation and heard the staff member and resident yelling at each other. She further indicated that she told Staff A to leave the room, notified the nursing supervisor and returned to passing medications. During a surveyor interview on 12/23/2024 at approximately 12:15 PM with Resident ID #2, s/he indicated that a NA had began yelling at him/her while she was in the room caring for his/her roommate. The resident further indicated that s/he told the NA to shut up and the NA responded with make me! Additionally, the resident indicated that s/he felt physically threatened by the NA, as she was walking towards him/her. During a surveyor interview on 12/23/2024 at approximately 12:30 PM with the Social Worker (SW), Staff C, she indicated that she was aware of the incident that had recently occurred between Staff A and Resident ID #2. She further indicated that she spoke with the resident following the incident however, did not document the conversation. Additionally, she indicated that she did not follow up with the resident following the altercation. During a surveyor interview on 12/23/2024 at 12:55 PM and 1:20 PM with the Director of Nursing Services, she indicated that the alleged staff to resident altercation had been substantiated by the facility and that Staff A had been re-educated and disciplined. Additionally, she indicated that she would expect the SW to update the resident's care plan and document that she followed up with the resident.

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure a resident with limited range of motion (ROM) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 1 of 2 residents reviewed with contractures, Resident ID #13. Findings are as follows: Review of the facility's policy titled Splints/Orthotics/Prosthetics [medical devices used to assist when physical impairments or limitations are present] states in part, Residents will receive splint/orthotics/prosthetics as deemed appropriate by the physician and rehabilitation services .Nursing staff will apply/remove the designated splint/orthotics/prosthetic device during scheduled wearing times . Record review revealed the resident was readmitted to the facility in November of 2024 with diagnosis including, but not limited to, Parkinson disease (a progressive neurological disorder that causes nerve cells in the brain to die which affects movement including stiffness, and loss of balance). Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 10 out of 15 indicating a moderate cognitive impairment. Record review of a Quarterly MDS assessment dated [DATE] revealed the resident has upper extremities impairments on both sides. Further review of this assessment revealed the resident is totally dependent on staff for all activities of daily living, including transfers, eating, dressing, toileting, and bed mobility. Record review of a care plan with revision dates of 3/5/2024 and 6/12/2024 revealed the resident is at risk for a decline in physical function. Staff interventions include, but are not limited to, provide carrot (a device used to prevent contractures) to left hand and bilateral palm guards (devices that are used as a barrier between the fingers and the palm to prevent injury to the palm from severe finger contractures). Record review revealed a physician's order initiated on 8/7/2023 to place the carrot in the resident's left hand every shift, as tolerated. During surveyor observations of the resident on 12/10/2024 at 9:08 AM, 10:46 AM, 11:37 AM, and 2:01 PM, s/he was observed in bed with bilateral hands contracted and the carrot was not applied to his/her left hand, as ordered. Further record review of the Treatment Administration Record for December 2024 revealed the order for the carrot was signed off by Licensed Practical Nurse (LPN), Staff C as being completed on 12/10/2024, although the carrot was not observed to be in his/her left hand. Additionally, the record failed to reveal evidence the resident had refused the carrot. Additional surveyor observations on the following dates and times revealed that the bilateral palm guards were not applied as indicated in his/her care plan: - 12/09/2024 9:48 AM - 12/10/2024 9:08 AM - 12/10/2024 10:46 AM - 12/10/2024 11:20 AM - 12/10/2024 11:37 AM - 12/10/2024 02:01 PM - 12/10/2024 03:01 PM - 12/11/2024 08:15 AM - 12/11/2024 09:59 AM During a surveyor interview with the resident on 12/10/2024 at 2:05 PM, s/he indicated that s/he was not utilizing the carrot or bilateral palm guards and stated that s/he had not been offered these devices by the staff on this date. During a surveyor interview with LPN, Staff C, on 12/11/2024 at 9:16 AM, she indicated that she is responsible for applying the carrot to the resident's left hand as ordered. She indicated that she was not aware that the resident should have been wearing bilateral palm guards. Additionally, Staff C could not provide evidence the resident was using the carrot as ordered though she had signed off the carrot was in place on 12/10/2024. During a surveyor interview with the Director of Nursing Services (DNS) on 12/11/2024 at 11:47 AM, she could not provide evidence as to why the resident's bilateral contractures were not being addressed. The DNS indicated that she would expect the staff to apply the carrot to the resident's left hand as ordered and the bilateral palm guards as indicated in the care plan. Additionally, the DNS indicated that if the resident refuses either of these devices, the staff should document the refusals in the resident's record.

Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice for 1 of 2 residents reviewed for fluid restrictions, Resident ID #30. Findings are as follows: Record review of a facility policy titled Fluid Restrictions states in part, .The fluid restriction breakdown should be documented in the Medication Administration Record (MAR), as well as dietary or tray card . Record review revealed the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and cerebral infarction (a condition when blood flow to the brain is blocked, causing brain cells to die). Further record review revealed the resident receives outpatient dialysis three times a week on Monday, Wednesday, and Fridays. Review of a Quarterly Minimum Data Set assessment dated [DATE], revealed the resident has a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognitive function. Record review of a care plan revised on 12/8/2024 included an intervention for fluid restrictions per the physician's order. Record review revealed the resident has a physician's order that was initiated on 10/25/2024 for a fluid restriction of 1000 milliliters (mL) daily. Record review of the Medication Administration Records (MAR) for November 2024 and December 2024 failed to reveal evidence that the resident's 1000 mL daily fluid restriction was documented per the facility's policy. During a surveyor observation of the resident on 12/9/2024 at approximately 10:00 AM, revealed s/he was waiting to be picked up for dialysis and had received a 240 mL cup of coffee provided to him/her by Activities Aide, Staff D. During a surveyor interview on 12/9/2024, following the above observation with Staff D, she indicated that she was unaware of Resident ID #30's fluid restriction order. During a surveyor interview with the resident on 12/10/2024 at 2:36 PM, s/he indicated that s/he was unaware of the physician's order for a fluid restriction. Additionally, s/he was observed to be drinking from a 480 mL travel mug. During a surveyor interview on 12/11/2024 at 9:23 AM with Nursing Assistant, Staff E, she revealed that she was unaware that Resident ID #30 had an order for a fluid restriction. During a surveyor interview on 12/11/2024 at 9:48 AM with Unit Manager, Staff F, she acknowledged that Resident ID #30 has a physician's order for a 1000 ml daily fluid restriction. Staff F was unable to provide evidence that the resident's daily fluid intake was being monitored. During a surveyor interview on 12/11/2024 at 11:59 AM with the Director of Nursing Services she indicated it was her expectation that the staff would be aware of all residents with orders for a daily fluid restriction, that the resident's daily total fluid intake would be monitored, documented in the MAR. Record review failed to reveal evidence that the facility was monitoring Resident ID #30's total daily fluid intake from 10/25/2024 per the physician's order, until after it was brought to the facility's attention by the surveyor, on 12/11/2024.

Based on record review and staff interview, it has been determined that the facility was not being administered in a manner that enabled it to utilize resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident related to infection control. This failure resulted in immediate jeopardy for F 880. Additionally, the Administrator directed an employee, who did not have a Food Safety Manager Certification, to work as the only cook in the main kitchen for all of the facility's residents. Findings are as follows: As a result of the survey investigation, it was determined that the Director of Housekeeping, Staff A, who tested positive for COVID-19 on 7/31/2024, was directed by the Administrator to report to the facility and work as the [NAME] on 8/3/2024 and 8/4/2024. Additionally, Staff A does not have a Food Safety Manager Certification to work as a cook. During a surveyor interview on 8/7/2024 at 10:24 AM with Staff A, she indicated that she was directed by the Administrator on 8/3/2024 to come into work on 8/3/2024 and 8/4/2024 as the Cook, due to no other certified dietary staff members being available during those shifts. Staff A revealed that she did work on those dates, while COVID-19 positive. Record review failed to reveal evidence that Staff A has a Food Safety Manager Certification. Record review revealed there were 13 residents who tested positive for COVID-19 on 8/6/2024 and another 13 residents tested positive on 8/8/2024, indicating a total of 26 residents were now positive for COVID-19. Of note, there were no COVID-19 positive residents prior to this COVID-19 positive staff member working. Record review of the text messages exchanged between Staff A and the Administrator dated 8/3/2024 revealed the Administrator was aware that Staff A had tested positive for COVID-19 and ordered her to cover the open shifts in the kitchen as the cook for 8/3 and 8/42024. During a surveyor interview on 8/7/2024 at 11:40 AM with the Administrator, she acknowledged that Staff A was COVID-19 positive and worked on 8/3/2024 and 8/4/2024. The Administrator further acknowledged that it is not the expectation for staff, who are COVID-19 positive, to report to work during their COVID-19 quarantine period. Cross reference F 812 and F 880

Based on record review and staff interview, it has been determined that the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by allowing a staff member who tested positive for COVID-19 on 7/31/2024, to work as the cook in the kitchen during the evening shift on 8/3/2024 and during the morning and evening shifts on 8/4/2024. Findings are as follows: Record review of the current guidance from the Center for Disease Control (CDC) titled, Interim Guidance for Managing Healthcare Personnel [HCP] with SARS-CoV-2 [COVID-19] Infection or Exposure to SARS-COV-2 states in part, Return to Work Criteria for HCP with SARS-CoV-2 Infection .HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: - At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and - At least 24 hours have passed since last fever without the use of fever-reducing medications, and - Symptoms (e.g., cough, shortness of breath) have improved. *Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later . Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/5/2024 alleges in part, that the Housekeeping Director, Staff A, is positive for COVID-19; and the Administrator forced Staff A to come to the building and cook for the residents because there are no cooks, for two days while positive for COVID-19. Record review of a laboratory report dated 7/31/2024, revealed that Staff A tested positive for COVID-19 via an antigen-based test. Record review of Staff A's employee time sheets revealed that she was working in the facility on the following dates: - Saturday, 8/3/2024, 3:20 PM through 6:00 PM - Sunday, 8/4/2024, 5:23 AM through 5:49 PM During surveyor interviews with Staff A on 8/6/2024 at 2:01 PM and on 8/7/2024 at 10:25 AM, she revealed that she started to become symptomatic for COVID-19 on Tuesday, 7/30/2024 with body aches and congestion, but tested negative for COVID-19 on a home antigen-based test. She further revealed she had taken another test at the facility, on 7/31/2024, which revealed a positive result for COVID-19. She indicated she informed the facility's Infection Preventionist, who instructed her to leave the facility and that she would be able to return to work on Wednesday, 8/7/2024 if she tested negative for COVID-19 on Sunday, 8/4/2024. Additionally, Staff A revealed she had been helping oversee the kitchen with scheduling and ordering food since 7/16/2024 and was responsible for ensuring that there was coverage of at least one cook for the preparation of all meals. On 8/1/2024, she made the Administrator aware that there was not a cook scheduled to work in the kitchen for the evening of 8/3 and both the morning and evening of 8/4. Additionally, Staff A indicated that she was directed by the Administrator on Saturday, 8/3/2024 to report to work and cover the kitchen as it was her responsibility. She further revealed that she was worked in the kitchen the evening of 8/3/2024 and on 8/4/2024 for 12 hours, while she was positive for COVID-19. Staff A further revealed that while she was preparing dinner on 8/3 and all three of the meals on 8/4, she did not wear a surgical or a N95 (respirator) mask. During a surveyor interview with the Infection Preventionist (IP) on 8/6/2024 at 1:41 PM, she revealed that she follows the CDC guidance regarding staff returning to work after testing positive for COVID-19. She acknowledged that Staff A tested positive for COVID-19 on 7/31/2024 and left the facility immediately after receiving the positive result. She revealed she had instructed Staff A to take a test on Sunday, 8/4/2024 (Day 5) and she would be able to return to work on Wednesday, 8/7/2024 if her test on 8/4 was negative. The IP revealed she was unaware that Staff A was in the facility, working in the kitchen, on 8/3/2024 and 8/4/2024, during her 7-day isolation period. During a surveyor interview with the Administrator on 8/7/2024 at 11:40 AM, she revealed that she was aware that Staff A had tested positive for COVID-19, and was working in the kitchen on Saturday, 8/3/2024 and on Sunday, 8/4/2024. She further revealed that she would not expect staff to return to work in the facility while still in their 7-day isolation period for COVID-19. Record review of surveillance testing for residents on 8/6/2024 revealed 13 residents tested positive for COVID-19 and another 13 residents tested positive on 8/8/2024, indicating a total of 26 residents were now positive for COVID-19. Of note, there were no COVID-19 positive residents in the facility prior to this staff member working while COVID-19 positive. Cross reference F 812 and F 835.

Based on record review and staff interview it has been determined that the facility failed to keep a resident free from sexual abuse for 1 of 6 residents reviewed, Resident ID #2. The facility also failed to screen newly admitted residents upon admission for their sex offender status (as required by the facility assessment) for 2 of 2 newly admitted residents from June 2023 through September of 2023, Resident ID #s 1 and 7, resulting in Resident ID #1 touching a vulnerable resident in a sexual manner, Resident ID #2. Findings are as follows: 1. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .sexual contact is nonconsensual if the resident .lacks the cognitive ability to consent . Review of a facility policy titled, Abuse Prevention, dated October 2022, states in part, .The facility prohibits the .abuse of residents/patients .by anyone including staff, family, friends, etc . Record review of the facility assessment dated [DATE] revealed known sex offenders would be denied admission to the facility. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/30/2023 indicates that Resident ID #1 was observed grabbing Resident ID #2's chest in the hallway. Record review revealed Resident ID #2, the alleged victim, was admitted to the facility in September of 2022 with a diagnosis that includes, but is not limited to, dementia. Record review of a Comprehensive Minimum Data Set (MDS) Assessment for Resident ID #2 dated 7/20/2023 revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severely impaired cognition. Record review revealed Resident ID #1, the alleged perpetrator, was admitted to the facility on [DATE]th, 2023, with diagnoses including, but not limited to, altered mental status, and cognitive communication deficit. Record review of a Quarterly MDS Assessment for Resident ID #1 dated 9/13/2023, revealed a BIMS score of 12 out of 15, indicating moderately impaired cognition. Record review of the initial psychosocial care plan for Resident ID #1 dated 9/8/2023, revealed s/he was admitted for short term rehabilitation and medical monitoring and was to return to the community shelter when appropriate for discharge from the facility. Record review of a nursing note authored by Licensed Practical Nurse (LPN) Staff B, dated 10/28/2023 states in part .was touched inappropriately by another resident [Resident ID #1] .daughter notified and was very upset over the phone .was very concerned for [Resident ID #2 's] safety . Record review of the police report dated 10/28/2023 indicated that the Officer met with Staff B who stated she witnessed the assault occur and Resident ID #1 touched Resident ID #2 on the inside of both of his/her thighs and then grabbed his/her breasts. During a surveyor interview on 11/2/2023 at 8:38 AM with the Administrator she revealed that on 9/8/2023 the facility received a call from a person who identified herself as the Probation Officer for Resident ID #1. The Probation Officer communicated to the facility that Resident ID #1 was a Level III Sex Offender. Record review revealed that the facility conducted a search for Resident ID #1 on 9/8/2023 at 9:52 AM in the National Sex Offender Public Website and found that s/he was a Level III Sex Offender (a high risk of repeatable behavior and a threat to public safety). Additional record review failed to reveal interventions to mitigate the risk of his/her behaviors to other residents in the facility or interventions for staff to implement/utilize to ensure the safety of the other residents residing in the facility after they were informed of his/her criminal history on 9/8/2023. The care plan was updated on 9/18/2023, 10 days after the facility learned that Resident ID # 1 was a Level III Sex Offender and has a Probation Officer. Interventions only included; is not allowed to be within 300 feet of a daycare or school, to be provided with psych services as needed and to place weekly counseling sessions on hold while the resident resides in the facility. The care plan failed to implement any interventions for the vulnerable residents that currently reside in the facility who were placed at risk for serious harm by Resident ID #1. Record review of a progress note dated 10/1/2023 authored by Licensed Practical Nurse, Staff B, revealed that Resident ID #1 touched her inappropriately on the buttock on 10/1/2023. During a surveyor interview on 11/2/2023 at 9:13 AM, with Staff B, she indicated that on 10/1/2023 Resident ID #1 smacked her buttocks inappropriately and stated, oh and it's nice and soft. Staff B further revealed that she told the Social Worker, Staff D, about the above incident and she was told to keep her distance and not turn around in front of him/her. She also indicated that she was unaware of Resident ID #1's criminal history until she spoke to Staff D. During a surveyor interview on 10/31/2023 at 11:15 AM, with Nursing Assistant (NA), Staff A, she revealed that on 10/28/2023, she witnessed Resident ID #s 1 and 2 in the dining room together. She indicated that she saw Resident ID #1 touch Resident ID #2's upper thighs and breasts with both hands in an inappropriate manner. During a surveyor interview on 10/31/2023 at 11:25 AM, with Staff B, she revealed that on 10/28/2023 she witnessed Resident ID #s 1 and 2 sitting together in the dining room. She indicated that she saw Resident ID #1 touch Resident ID #2's thighs and breasts in an inappropriate manner. She immediately separated both residents and stated to Resident ID #1 you can't touch [him/her] like that. Additionally, Staff B revealed that she had communicated her concerns to the facility's Social Worker, Staff D, regarding Resident ID #1 going into a cognitively impaired resident's room, Resident ID #3. She indicated that Resident ID #3 believed Resident ID #1 was his/her spouse. Further, Staff B, indicated that on 10/1/2023 Resident ID #1 touched her buttocks inappropriately. Staff A further revealed that she was unaware of Resident ID #1's criminal history until after she was inappropriately touched on her buttocks on 10/1/2023, 3 weeks following his/her admission. During a surveyor interview on 10/31/2023 at approximately 12:26 PM, with the Unit Manager, LPN, Staff C, she acknowledged that the facility has denial criteria for sex offenders on the facility assessment. She further revealed that Resident ID #1 was not identified as a Level III Sex Offender prior to his/her admission. Staff C was unable to provide evidence that the staff had been educated regarding Resident ID #1 being a Level III Sex Offender or on interventions to mitigate the risk s/he placed for other residents. Additionally, when the surveyor asked what the facility plan should have been once they knew of his/her history, she indicated that staff should have been constantly watching this resident. Record review failed to reveal evidence that Resident ID #1 was constantly watched. During a surveyor interview on 11/2/2023 at 8:48 AM, with the Social Worker, Staff D, she acknowledged that the facility had been made aware of Resident ID #1 being a Level III Sex Offender by his/her Probation Officer. Additionally, she revealed that Staff A, had made her aware that Resident ID #1 would sit outside of other resident rooms, and she indicated to Staff A, we had to have eyes on [him/her]. When questioned by the surveyor as to what have eyes on a resident is, Staff D was unable to explain her expectations and stated, just general like anyone else. Record review failed to reveal evidence that staff were educated to have eyes on Resident ID #1. During a surveyor interview on 11/2/2023 at 4:00 PM with the Facility Manager, Registered Nurse, Staff E, she acknowledged that the facility should not have admitted Resident ID #1 as s/he was a Level III Sex Offender which is contrary to the Facility Assessment. Additionally, she was unable to provide evidence that Resident ID #2 was kept free from abuse. 2. Record review of the Facility assessment dated [DATE] revealed known sex offenders would be denied admission to the facility. Record review revealed that Resident ID #1 was admitted to the facility in September of 2023. Further record review failed to reveal evidence that the National Sex Offender Public Website was checked prior to his/her admission. Additional record review revealed that Resident ID #1 was a Level III Sex Offender. Record review revealed Resident ID #7 was admitted to the facility in August of 2023 and was discharged in September of 2023. Further record review failed to reveal evidence that the National Sex Offender Public Website was checked prior to his/her admission or at any time while s/he was a resident. During a surveyor interview on 11/2/2023 at 10:20 AM with Staff E, she acknowledged that the facility had not checked the National Sex Offender Public Website for all admissions since June of 2023. Additionally, she was unable to provide evidence that the facility kept all residents free from abuse by admitting a Level III Sex Offender, Resident ID #1. After the facility was made aware of Resident ID #1's history on 9/8/2023 they failed to implement any safety measures to protect the vulnerable residents that were residing in the facility. On 10/1/2023 Resident ID #1 inappropriately touched a staff member on the buttocks. Although the facility had Resident ID #1 seen by psych services, they again failed to implement any safety measures to protect the vulnerable residing in the facility. Then on 10/28/2023 Resident ID #1 touched a severely cognitively impaired resident inappropriately on the breasts and thighs. This continued failure had the potential to place all resident in the facility at risk for serious harm.

Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receives adequate supervision based on the risks and current professional standards of practice relative to preventing an incident by a known sex offender, Resident #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/30/2023 indicates that Resident ID #1 was observed grabbing Resident ID #2's chest in the hallway. Review of a facility policy titled, Abuse Prevention, dated October 2022, states in part, .Protocol 5. Implementation and ongoing monitoring consist of the following: Screening, Training, prevention, identification, protection, investigation, and reporting . Record review of the facility assessment dated [DATE] revealed that known sex offenders would be denied admission to the facility. Record review revealed Resident ID #1, the alleged perpetrator, was admitted to the facility in September of 2023 with diagnoses including, but not limited to, altered mental status and cognitive communication deficit. Record review for Resident ID #1 revealed a quarterly MDS assessment dated [DATE], with a BIMS score of 12 out of 15 indicating moderately impaired cognition. During a surveyor interview on 11/2/2023 at 8:38 AM with the Administrator, she revealed that on 9/8/2023 the facility received a telephone call from a person who identified herself as the Probation Officer for Resident ID #1. The Probation Officer communicated to the facility that Resident ID #1 was a Level III Sex Offender. Record review revealed that the facility conducted a search for Resident ID #1 on 9/8/2023 at 9:52 AM in the National Sex Offender Public Website and found that s/he was a Level III Sex Offender (a high risk of repeatable behavior and a threat to public safety). Record review for Resident ID #1 revealed a care plan dated 9/18/2023, developed 10 days after they became aware of his/her criminal history, indicating the resident is registered as a level three sex offender and s/he has a probation officer. Further review of the care plan revealed interventions including to alert his/her parole officer and assigned detective to be informed of all resident whereabouts, resident may not reside within 300 feet of a daycare establishment or public or private school property. Further review of the care plan failed to reveal evidence of interventions to reduce the risks to other residents such as, supervision to mitigate the risk of his/her behaviors to other residents in the facility or interventions for staff to implement/utilize to provide supervision to ensure the safety of the other residents residing in the facility after they were informed of his/her history on 9/8/2023. Record review of a progress note dated 10/1/2023 authored by Licensed Practical Nurse, Staff B, revealed that Resident ID #1 touched her inappropriately on the buttock on 10/1/2023. During a surveyor interview on 11/2/2023 at 9:13 AM, with Staff B, she indicated that on 10/1/2023 Resident ID #1 smacked her buttocks inappropriately and stated, oh and it's nice and soft. Staff B further revealed that she told the Social Worker, Staff D, about the above incident and she was told to keep her distance and not turn around in front of him/her. She also indicated that she was unaware of Resident ID #1's criminal history until she spoke to Staff D. Record review failed to reveal evidence of any interventions that were put into place related to the supervision of Resident #1 after s/he touched Staff B inappropriately and knowing that Resident ID # 1 was a Level III Sex Offender. Record review of a progress note authored by Staff B, dated 10/28/2023 states in part [Resident ID #2] was touched inappropriately by another resident [Resident ID #1] .[Resident ID #2's] daughter notified and was very upset over the phone .was very concerned for [Resident ID #2 's] safety . Record review of the police report dated 10/28/2023 indicated that the Officer met with Staff B who stated she witnessed an assault occur between Resident ID #1 and 2. Resident ID #1 touched Resident ID #2 on the inside of both of his/her thighs and then grabbed his/her breasts. Record review revealed Resident ID #2 was admitted to the facility in September of 2022 with a diagnosis that includes, but is not limited to, dementia. Record review for Resident ID #2 revealed a comprehensive Minimum Data Set (MDS) assessment dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severely impaired cognition. During a surveyor interview on 10/31/2023 at 11:15 AM, with Nursing Assistant, Staff A, she revealed that on 10/28/2023, she witnessed Resident ID #1 touch Resident ID #2's upper thighs and breasts with both of his/her hands. Additionally, she revealed that she was not provided education from anyone in the facility regarding interventions that were in place for the supervision of Resident ID #1. She further revealed that she was made aware of Resident ID #1's criminal history by Staff B, only after Staff B was inappropriately touched on her buttocks by Resident ID #1. During a surveyor interview on 10/31/2023 at 11:25 AM, with Staff B, she revealed that on 10/28/2023 she witnessed Resident ID #1 touch Resident ID #2's thighs and breasts in an inappropriate manner. She immediately separated both residents and stated to Resident ID #1 you can't touch [him/her] like that. Additionally, Staff B revealed that she had communicated her concerns to the facility's Social Worker, Staff D, regarding Resident ID #1 going into a cognitively impaired resident's room, Resident ID #3. She indicated that Resident ID #3 believed Resident ID #1 was his/her spouse. Record review revealed Resident ID #3 was admitted to the facility in November of 2020 with a diagnosis that includes, but is not limited to, Alzheimer's disease. Record review for Resident ID #3 revealed a Quarterly MDS assessment dated [DATE] with a BIMS score of 4 out of 15 indicating severely impaired cognition. During a surveyor interview on 11/2/2023 at 9:13 AM, with Staff B, she acknowledged that Resident ID #1 would enter Resident ID #3's room unsupervised, and that Resident ID #3 would state oh that's my husband. Staff B indicated that she was told to keep an eye on him/her and that no-one ever told me that [s/he] shouldn't go into the room additionally, they didn't want [him\her] to think [s/he] was a predator. Staff B also revealed that there are gaps in the staff's ability to supervise the resident, such as when they are passing medications or providing care to other residents. Staff B was unable to provide evidence that Resident ID #1 was under adequate supervision. During a surveyor interview on 10/31/2023 at 11:51 AM, with Staff D, she revealed that Staff A, made her aware that Resident ID #1 would also sit outside of another cognitively impaired resident's room, Resident ID #4. Record review for Resident ID #4 revealed a Quarterly MDS assessment dated [DATE] with a BIMS score of 6 out of 15 indicating severely impaired cognition. During a surveyor interview on 11/2/2023 at 8:48 AM with Staff D, she revealed that her expectation is that the staff would monitor Resident ID #1 to ensure that s/he is never in another resident's room alone and that another resident is not alone with him/her in his/her room. During a surveyor interview on 11/2/2023 at approximately 8:45 AM with the Administrator and the Social Worker, they were unable to provide evidence that the facility provided appropriate supervision to prevent an incident by a known registered sex offender. After the facility was made aware of Resident ID #1's history on 9/8/2023 they failed to ensure that Resident ID #1 received adequate supervision to prevent an incident from occurring as evidenced by him/her touching Resident ID #2 inappropriately on the breasts and thighs. The facility had multiple opportunities to implement safety measures to protect the other vulnerable residents that reside in the facility, such as Resident ID #3 and 4. This continued failure to implement interventions to supervise Resident ID #1 to prevent incidents had the potential to place all residents in the facility at risk for serious harm. 47939

Based on surveyor observations, record review, staff and resident interview, it has been determined that the facility failed to ensure that a resident's environment remains as free from accident hazards as possible for 1 of 3 residents reviewed, resulting in a burn, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Department of Health on 3/8/2023 revealed the resident was seen by rehab on 3/4/2023, .was treated with a hydrocollator pack and sustained a burn as a result . Review of the Hydrocollator Heating Units Service/User Manual revealed The hydrocollator Heating Unit is equipped with an immersion type heating element and a hydraulic capillary-type thermostat which evenly maintains the HotPac temperature in the water and provides a ready supply of heated packs. Further review revealed the recommended operating temperature is 160 -165 degrees Fahrenheit (a temperature hot enough to cause skin injury). Review of the policy last updated 10/28/2022 titled Policy: 8.25 - Physical Agent Modalities revealed .Hot Packs Procedure Screen for precautions or contraindications to hot pack use. Ensure skin is clean and dry. Remove topical analgesics, if applicable, prior to applying hot packs. Fold 4 towels in half, width-wise .forming 8 layers of toweling .If using a [NAME] cloth hot pack cover, the [NAME] cloth acts as two layers .When using a hot pack, clinicians must document .a pre/post skin assessment . Record review revealed that the resident was admitted to the facility in August of 2022 with diagnoses including, but not limited to, diabetes mellitus type 2, muscle weakness and pain in left shoulder. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed s/he has a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. Review of the March 2023 Medication Administration Record (MAR) revealed a physician's order dated 2/18/2023 for Voltaren External Gel 1% (a topical analgesic) .Apply to shoulders topically four times a day for pain. Further review revealed this medication was applied to the resident's shoulders on 3/4/2023 at 8 AM, prior to receiving therapy at approximately 10 AM. Review of an Occupational Therapy Treatment Encounter Note(s) with the date of service of 3/4/2023 states in part, .placement of hot pack on L [left] shoulder for 15 minutes prior to deep tissue massage to L shoulder deltoid area . Further review failed to reveal documentation of a skin assessment before or after the application of the hot pack, per the facility policy. Additional review of the March 2023 MAR revealed the resident reported a pain level of 10 on 3/4/2023 at 4:00 PM following the application of the hot pack. Review of a progress note dated 3/4/2023 at 9:39 PM revealed a new skin alteration was discovered to the resident's left shoulder. Further review revealed .First degree burn .7.5cm [centimeter] x[by] 4cm. Resident states burn happened during therapy with warm compress. Area cleansed with normal saline, then covered with xeroform [a sterile petroleum gauze] and bordered foam dressing. Review of an initial wound evaluation and management summary from VOHRA Wound Physicians (an outpatient wound specialty group) dated 3/8/2023 revealed the resident had a focused wound exam to a burn wound of the left, posterior shoulder. Further review revealed the wound was described as partial thickness (a second degree burn that affects the top two layers of skin and can continue to evolve to a full thickness burn, even after initial treatment), with light serous exudate (draining of liquid from an open wound) measuring 7.2 cm in length, 3.6 cm in width and an unmeasurable depth. Additional review revealed a dressing treatment plan including Silver sulfadiazine [a treatment for significant second and third degree burns]. Record review of the OT [Occupational Therapy] Evaluation & Plan of Treatment for the resident's OT certification period of 2/22/2023-4/22/2023 does not specify the use of a physical modality such as a hot pack. During a surveyor interview on 3/9/2023 at 12:04 PM with the Certified Occupational Therapist Assistant (COTA), Staff A, she revealed she did not cleanse the resident's skin or remove the topical analgesic prior to administering the hot pack for approximately 15 minutes. She further revealed the temperature of the hydrocollator that she obtained prior to use was approximately 165 degrees Fahrenheit. She revealed that she used 2 towels folded to make 4 layers and the hot pack cover totaling only 6 layers between the resident's skin and the hot pack. Additionally, she could not provide evidence that a pre/post skin assessment was completed. During a surveyor observation on 3/9/2023 at 1:18 PM in the presence of Licensed Practical Nurse (LPN) Staff B, the resident's left shoulder wound was observed to have an open area with a red and yellow wound bed. The resident was observed to wince when the wound dressing was removed by the LPN at that time. During a surveyor interview on 3/9/2023 at 2:25 PM with a telephone interpreter and the resident, s/he revealed the burn was sustained on 3/4/2023 during therapy after a staff member applied wet hot cloths on my shoulder. During a surveyor interview on 3/9/2023 at approximately 1:30 PM with the Occupational Therapist, Staff C, he indicated that a hot pack is considered a physical modality. Additionally, he acknowledged that the use of a hydrocollator hot pack was not part of the resident's plan of treatment.

Based on record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such a usual body weight or desirable body weight and failed to follow their policy relative to weight loss, for 1 of 12 residents reviewed, Resident ID #4. Findings are as follows: Review of the facility policy titled, Weight Assessment and Intervention, state in part, .The nursing staff will measure resident weights on admission and weekly for four weeks thereafter .Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - [minus] 5% weight loss is significant; greater than [>] 5% is severe . Record review revealed the resident was admitted to the facility in October of 2022 and was readmitted in January of 2023, with diagnoses including, but not limited to, acute posthemorrhagic anemia (a condition that develops when you lose a large amount of blood quickly) and moderate protein-calorie malnutrition. Review of the resident's care plan revealed a focus initiated on 11/10/2022 and revised on 2/15/2023, that states in part, The resident has nutritional problem or potential nutritional problem .hx [history] of sig wt [significant weight] changes .Interventions .Monitor/record/report to MD [medical doctor] PRN [as needed] s/sx [signs and symptoms] of malnutrition .significant weight loss .>5% in 1 month . Further record review revealed the resident was admitted to the hospital in January 2023 for 4 days with a diagnosis of anemia (deficiency of healthy red blood cells in blood). On 1/17/2023, the resident underwent a thoracentesis (procedure to remove excess fluid accumulated in the chest cavity), removing 1 L (liter) of fluid. Additionally, the resident's weight was obtained at the hospital on 1/19/2023 after the thoracentesis and was documented at 197 lbs. (pounds) and 1.5 oz (ounces). Review of a documents titled Weights and Vitals Summary, revealed the following weights documented in 2023: - 1/5/2023 205 lbs. - 2/10/2023 163.6 lbs. - 2/11/2023 158.8 lbs. - 2/15/2023 158.2 lbs. - 2/16/2023 160.6 lbs. - 2/17/2023 158.8 lbs. - 2/22/2023 155.8 lbs. Additional review of the document titled, Weights and Vitals Summary revealed the resident's weight was documented at 200 lbs. on the day of his/her readmission to the facility but was struck out by the Registered Dietician (RD) on 2/14/2023 with a note that revealed it was a mistaken entry. Record review failed to reveal evidence of an accurate weight documented upon the resident's readmission to the facility. Additional record review revealed the resident lost 33.4 lbs. from 1/19/2023 to 2/10/2023, indicating a severe weight loss of 16.95%. Review of the resident's January 2023 Medication Administration Record (MAR) revealed a physician's order with a start date of 1/21/2023 and an end date of 1/22/2023 to Obtain weight every day shift x 4 weeks then monthly every day shift every 7 day(s) for 4 Weeks, which was signed off as being completed. Review of the resident's documented weights failed to reveal evidence that a weight was obtained on 1/21/2023, per the physician's order. Additional review of the resident's January 2023 MAR revealed a physician's order with a start date of 1/23/2023 and an end date of 2/14/2023 to Obtain weight every day shift x 4 weeks then monthly every day shift every 7 day(s) for 4 Weeks, which was signed off as being completed on 1/23/2023 and 1/30/2023. Review of the resident's documented weights failed to reveal evidence that the weights were obtained on 1/23/2023 and 1/30/2023, per the physician's order. Review of the resident's February 2023 MAR revealed a physician's order with a start date of 2/3/2023 and an end date of 2/14/2023 to Obtain weight every day shift x 4 weeks then monthly every day shift every 1 month(s) starting on the 3rd for 1 day(s) for monthly weight, which was signed off as being completed on 2/3/2023. Review of the resident's documented weights failed to reveal evidence that a weight was obtained on 2/3/2023, per the physician's order. Additional review of the February MAR revealed a physician's order with a start date of 1/23/2023 and an end date of 2/14/2023 to Obtain weight every day shift x 4 weeks then monthly every day shift every 7 day(s) for 4 Weeks, which was signed off as being completed on 2/6/2023 and 2/13/2023. Review of the resident's documented weights failed to reveal evidence that the weights were obtained on 2/6/2023 and 2/13/2023, per the physician's order. During a surveyor interview on 2/24/2023 at 8:41 AM, with the RD, she acknowledged that a weight was entered into the system upon the resident readmission to the facility, but indicated she struck it out, 3 weeks later, because it was an error. She revealed the resident's weight was not obtained until 2/10/2023, and at which time, the severe weight loss was identified. She further indicated intervention were then put in place following the identification of the resident's weight loss. Record review failed to reveal evidence of interventions put in place until 2/14/2023, four days after the severe weight loss was identified. During a surveyor interview on 2/24/2023 at 12:45 PM, with the Director of Nursing Services, she was unable to provide evidence that the resident's weights were obtained on the above-mentioned dates, per the physician orders. During an additional surveyor interview on 2/28/2023 at 10:45 AM, with the DNS and Administrator, they were unable to provide evidence that the RD was notified in writing, on 2/10/2023 regarding the resident's severe weight loss, per facility policy. Furthermore, they were unable to provide evidence of any interventions that were put in place on 2/10/2023 when the resident's severe weight loss was identified.

46338 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for falls, Resident ID #4. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 12/28/2022 states in part, CNA [Nursing Assistant] .reported to this writer today that on 12/25/2022 .[Resident ID #4] had a fall at the nurse's station and states that patient was not attended to by nurses that were at the nurse's station for 20 minutes. Record review of a policy titled Falls-Clinical Protocol states in part .In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion .; d. Change in cognition or level of consciousness; e. Neurological status; f. Pain . Record review revealed the resident was admitted to the facility in May of 2021 with diagnoses including, but not limited to, cognitive communication deficit, unspecified dementia, anxiety disorder and mood disturbance. Record review of a progress note dated 12/25/2022 at 3:28 PM authored by Registered Nurse, Staff D, revealed Resident was sitting in the w/c [wheelchair] at nurse' station, while counting narcotics, resident attempted to get up out of bed and fell to the floor at nurses' station, Resident claims [s/he] did hit [his/her] head. Additional review of the progress notes revealed an entry authored by Staff D on 12/25/2022 at 3:49 PM which states in part, Supervisor on floor and aware. Voicemail left with [family member] and TrueCare on call [on call provider]. During a surveyor interview with Staff D on 1/6/2023 at approximately 10:00 AM she acknowledged working at the facility on 12/25/2022 on the unit in question although she could not recall a fall that occurred on 12/25/2022 at the change of shifts. The surveyor read her the progress notes she had entered into the resident's record on 12/25/2022 and she again she stated, I don't know that resident .there were no falls on Christmas day .I don't remember writing those notes or assessing anyone that fell . The surveyor then asked Staff D if she had given her username and password to the electronic medical system (EMAR) to anyone else and she replied that she had not. Additionally, she was unable to explain how those notes were entered into the system under her name. During an interview on 12/30/2022 at approximately 10:00 AM with Licensed Practical Nurse, Staff F, she indicated that she was the supervisor on call on 12/25/2022 and did not receive any phone calls regarding Resident ID #4. She indicated if she had received the phone call concerning the resident sustaining a fall, she would have ensured that the facility spoke to the resident's physician so they could direct care for the resident. During a surveyor interview with the Nurse Practitioner (NP) on 1/3/2023 at 10:15 AM, she indicated that she was not notified about the fall or any injuries until 12/28/2022, despite her being in the facility on 12/27/2022. Additionally, she revealed that she would expect the nurse to follow the facility's fall protocols following a resident's fall. She also revealed that if a resident was known to have hit their head, she would have ordered neurological checks on the resident. During a surveyor interview with the Medical Director on 1/6/2023 at approximately 1:00 PM he revealed that he did not receive any phone calls or voice messages regarding the resident's fall or injury on 12/25/2022. He revealed his NP was made aware of the fall on 12/28/2022 and she ordered an x-ray of his/her clavicle. He indicated that he would expect that if a nurse had called him and left a message and no one called back that the nurse would attempt to call the physician again for orders etc. During an interview on 12/30/2022 at approximately 9:00 AM with the Director of Nursing (DON), she revealed that the facility utilizes Point Click Care (PCC) as their EMAR. She then went into the resident's record in PCC to the Assessment tab and she was unable to find an assessment for Resident ID #4 relative to his/her fall on 12/25/2022. Although there were nursing notes indicating the resident's vital signs were stable and that the resident was alert and responsive with no visible injuries on 12/26 and 12/27/2022, the record failed to reveal evidence that a full body assessment was completed, including musculoskeletal function, observing for a changes in range of motion and neurological status had been completed for the resident. During a surveyor interview with NA, Staff E on 12/29/2022 at 11:23 AM he revealed he was the resident's primary NA and that he was present at the time the resident fell on [DATE]. He indicated that the resident was on the floor for 10 to 15 minutes before any of the licensed nurses responded to the resident. He indicated that he had not cared for the resident since his/her fall on 12/25/2022 until he returned to work on 12/28/2022, which is when he observed a large bruise on the resident's shoulder. He further revealed that he reported this bruise to the unit manager and at that point he questioned what had been done for this resident after s/he had fallen on 12/25/2022. Additional record review failed to reveal evidence that any interventions, assessments including musculoskeletal function, observing for change in range of motion and neurological status, or treatments were provided to Resident ID #4, prior to Staff E's return to work on 12/28/2022. Review of a Radiology report dated 12/28/2022 revealed Nondisplaced fracture of the clavicle (collarbone) laterally .acute fracture . During a surveyor observation on 12/29/2022 at 1:53 PM in the presence of Registered Nurse Staff A, the resident was observed in bed with a large bruise covering his/her left shoulder. During an additional surveyor observation on 12/30/2022 at approximately 9:30 AM the resident was observed in bed, difficult to arouse and had a large yellow, green, purple, and blue bruise covering his/her left shoulder, left chest wall, and extending down to his/her left shoulder blade. The resident was observed to be grimacing in pain when being repositioned by staff. During a surveyor interview on 1/3/2023 with the Director of Nursing Services and the Administrator at approximately 3:00 PM, they were unable to provide evidence of a completed post fall assessment including musculoskeletal function, observing for change in range of motion and neurological status as indicated by the facility policy. Additionally, they were unable to provide evidence of any documentation of the bruise in the resident medical record. During a surveyor interview with the DON on 12/30/2022 at approximately 9:00 AM she revealed that the resident was diagnosed with a fractured clavicle, and she indicated that the resident's family opted to place him/her on hospice services, as s/he was not a surgical candidate. Further record review revealed the resident was admitted to hospice services on 1/1/2023 and passed away on 1/2/2023.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 6 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility policy titled Administering Medications revised in April of 2019 states in part, .9. The individual administering medications verifies the resident's identity before giving the resident his/her medications .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Record review of a facility-reported incident submitted to the Rhode Island Department of Health on 10/14/2022, alleges in part, .Medication Technician was administering AM [morning] medications she accidentally gave this resident another resident's medications . Record review revealed the resident was admitted to the facility in February of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note dated 10/14/2022 at 12:21 PM states in part, Around 11:30 AM, this nurse was called by a CNA [Certified Nursing Assistant] to patient room because [s/he] was complaining about not feeling well. [S/he] complained of nausea blurred vision and seem a lot more anxious .BP [blood pressure] .slightly low at 96/48 .Patient had received the wrong medications from the medtech [medication technician] which included [MEDICATION(S)] [medication used to relax muscles] 20mg [milligrams], [MEDICATION(S)] [antidepressant medication] 90 mg, [MEDICATION(S)] [medication used to treat seizures and nerve pain] 800mg, [MEDICATION(S)] [medication used to treat seizures] 750mg, [MEDICATION(S)] [medication used to treat high blood pressure] 20mg, vit [vitamin] D 2000 units .Patient was sent to ER [emergency room ] . Record review of a document titled RI EMS [Rhode Island Emergency Medical Services] Patient Care Report dated 10/14/2022, states in part, .patient .reportedly given the wrong medication by staff .Patient states [s/he] does not feel well, is sick to [his/her] stomach and very dizzy .patient also reports hallucinations and seeing 'monsters' . Review of the hospital paperwork reveals an emergency department provider note dated 10/14/2022 at 6:30 PM which states in part, .Patient was admitted to intermediate level of care. However, while awaiting a bed, patient became more lethargic and sedated. Sats [oxygen saturation] dropped to high 60's. Patient was intubated for airway protection . The resident was then transferred to a medical intensive care unit. During a surveyor interview on 10/20/2022 at 10:46 AM with Certified Medication Technician (CMT), Staff A, in the presence of the acting Director of Nursing Services, she revealed she was distracted and administered the wrong morning medications to the resident on 10/14/2022. During an interview with the Administrator and acting Director of Nursing Services on 10/19/2022 at 2:00 PM, they revealed the CMT administered the wrong medications to the resident. They further revealed, the CMT failed to verify the right medications and the right resident.

Based on record review, resident and staff interview, it has been determined that the facility failed to provide adequate supervision and assistance devices to prevent an accident for 1 of 5 sample residents reviewed for elopement, Resident ID #1. Findings are as follows: Review of the facility policy titled, Resident Elopement Policy states in part, .Procedure: Residents that may be at a higher risk for elopement include but are not limited to confused, resistive .if a resident is found to be at risk for wandering, a wander guard bracelet will be placed on resident .staff interventions to prevent an elopement should include but may not be limited to: staff to respond immediately, as indicated .assess surrounding for any sign of resident elopement .Notify Charge Nurse .Charge Nurse to notify MD [medical doctor] and/or family .if resident does exit the building, staff person to stay with resident to maintain safety .In an event of actual elopement .notify the MD, Director of Nursing and the family .Once the resident has been located and returned to the facility: Perform a complete assessment and document .complete an Incident Report . Record review of a community reported complaint submitted to the Rhode Island Department of Health, dated 3/22/2022 revealed this resident eloped from the facility and was found at a coffee shop on 3/20/2022 and the facility was unaware that s/he was missing. Record review revealed the resident was admitted to the facility in October of 2021 with diagnoses which include but are not limited to dementia in other diseases classified elsewhere with behavioral disturbance, other symptoms and signs involving cognitive functions and awareness, muscle weakness, anxiety, and abnormality of gait and mobility. Record review of the resident's admission Minimum Data Set (MDS; an assessment that provides a multidimensional view of the patient's functional capacities and needs), dated 10/12/2021 revealed s/he had a brief interview for mental status (BIMS) score of 6 out of 15, indicating s/he had a severe cognitive impairment. Record review revealed the resident's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15, indicating s/he had severe cognitive impairment. Additional review of both the admission and quarterly MDS indicated the resident requires supervision with locomotion off the unit. Record review of the resident's care plan dated 10/7/2021 which was last revised on 10/16/2021, revealed the resident is at increased risk for falls related to gait and balance problems, poor communication, and comprehension and unaware of safety needs. Record review of an active physician's order dated 10/12/2021 states in part, Please place wander guard - elopement risk, Status: Active, Revision Date: 10/12/2021. Record review revealed this resident left the faciity on [DATE]. The exact time could not be established by the facility. The resident was seen by Certified Nursing Assistant, Staff C, in the parking lot of a coffee shop that is located on a highly traveled main road. Staff C proceeded to the facility and reported this to the receptionist, Staff A. Staff A then reported this information to the Licensed Practical Nurse, Staff B, who proceeded to bring the resident back to the facility. Additionally, this resident had an order for a wander guard which was never initiated until s/he had successfully eloped. Further record review of the resident's progress notes revealed the following: - On 3/20/2022 at 3:36 PM .On the above day this writer confirms [resident] left the building, and [s/he] walked all the way to [coffee shop], CNA [Certified Nursing Assistant] called me on the front phone and informed me that [resident] was in [coffee shop] .I saw [resident] walk out the front door, but [s/he] was sitting on the bench and I let [him/her] be, but I got up to use the ladies' room and I did not see [him/her] out there, I thought [s/he] got cold and [s/he] went back to [his/her] room . - On 3/20/2022 at 3:40 PM It was reported that [resident] was seen at [coffee shop] by second shift staff member .This writer spoke to [resident] to inform [him/her] that it is not safe for [him/her] to leave the building alone .[S/he] was reminded that [s/he] needs to inform staff if [s/he] wants to sit outside because it is not safe for [him/her] to be alone. Nursing staff made aware that [resident] needs a wander guard . Further record review failed to reveal evidence that the wander guard was in place as ordered on 10/12/2021. Additionally, the wander guard was placed on the resident after s/he eloped which was 159 days after it was ordered. Further record review failed to reveal evidence that an assessment of the resident was completed upon his/her return to the facility following the elopement. Additionally, the record failed to reveal evidence that the resident's physician was notified of his/her elopement as indicated in the facility's policy. During a surveyor interview with the resident on 3/23/2022 at 11:50 AM, s/he stated, I just walked out. S/he indicated that s/he was not aware that s/he could not leave the facility unattended and refused to answer any further questions. During a surveyor interview on 3/23/2022 at 1:05 PM with Staff A, she revealed that on 3/20/2022 between the hours of 2:00 PM to 3:35 PM she indicated that she observed the resident walking out of the building and sat on a bench. She indicated that she was unaware that the resident required supervision while outside. She revealed that she left the reception area twice, and upon her return the resident was not observed where she last saw him/her. She acknowledged that she did not locate the resident and did not notify the nurse when the resident was not where she had last seen him/her. During a surveyor interview on 3/25/2022 at 8:40 AM with Staff B, he indicated that on 3/20/2022 at approximately between 3:30 PM-3:45 PM he was notified by Staff A that the resident had eloped. He acknowledged that the resident was observed in the parking lot of a coffee shop located on a busy avenue. Additionally, he indicated that the resident was confused and upset when s/he was found at that location. He also revealed that the staff on the resident's unit were not aware s/he was not on the unit or how long s/he was gone, until they were notified that s/he was found at the coffee shop. He further acknowledged that he did not notify the physician, family, and did not do an incident report as indicated in the facility's policy. During a surveyor interview with the Director of Nursing Services on 3/23/2022 at 1:23 PM and at 1:44 PM, she indicated that she was not aware of the resident's order for the wander guard until it was brought to her attention by the surveyor. She acknowledged that the resident did not have a wander guard on at the time of his/her elopement. She further indicated that she would have expected the resident to be supervised and within sight of the staff while off the unit.

Based on record review and staff interviews, it has been determined that the facility has failed to ensure that residents are free of any significant medication errors for 1 of 6 sample residents (ID #1) relative to insulin administration. Findings are as follows: Review of the facilities admitting physician's orders [REDACTED]. Further review of the record revealed a clarification order written 12/30/2016, for the U-500 insulin to inject 0.06 ml (30 units) everyday with dinner this corrected order was faxed to Omnicare pharmacy by nurse (B). During a phone interview with nurse (B) on 6/27/2017, she indicated she spoke with the pharmacist who called the unit and informed her the 0.6 ml dosage was excessive, a new order was obtained specifying the 0.06 ml dose. The resident received the insulin injection but nurse (B) could not recall what time and there was no medication administration sheet available in the residents file for review. Nurse (B) stated nurse(C) proceeded to draw up the insulin and nurse (A) did the second safety check per facility protocol prior to the administration. Nurse(A)and (C) were not available for interview. During an interview on 6/26/2017 with the Director of Nursing (DNS) she reported that on 12/31/2016, Nurse (C) proceeded to draw up the incorrect dosage of U-500 insulin dose as 0.6 ml. A second nurse, nurse(A) checked the amount in the syringe and agreed it was the correct dosage. Thus, nurse(C) administered the incorrect dosage of 0.6 ml of insulin instead of the prescribed 0.06 ml dosage. Review of resident ID# 1's record revealed on the evening of 12/31/2016 the resident began to exhibit low blood sugar and respiratory distress. Review of nursing notes for 12/31/2016 documented that at 7:03 PM resident ID# 1 had a blood sugar of 53 which indicated the resident was hypoglycemic. The morning of 1/1/2017 he/she steadily declined resulting in rescue being called to transport to the hospital. Further review of the record revealed there was no Medication Administration Record [REDACTED]. On 6/26/2017 a request was made to the DNS to locate the MAR indicated [REDACTED]. On 1/1/2017 a change in condition note was entered into the resident's record. This note indicated at 6:30 AM the resident was lethargic and skin was diaphoretic, pale and cool to touch. A blood sugar was done and indicated the resident was hypoglycemic with a reading of 42. At 11:40 AM the physician was notified and ordered the resident be transferred to the hospital for an evaluation. The resident was administered 2 mg of [MEDICATION NAME] and 15 mg of oral glucose at the nursing facility before the rescue arrived. He/she arrived at the Hospital at 1:08 PM. Review of the emergency room records for ID# 1 reveal a [DIAGNOSES REDACTED]. During an interview with the resident by hospital staff while at the emergency room he/she informed hospital staff he/she was given an excessive dose of U-500 insulin. The course of treatment note for this date indicated that per nursing home staff the patient received a higher dose of insulin than prescribed and his/her blood glucose level had dropped to 23. The patient was treated for [REDACTED]. The medication error was discovered on 1/1/2017. The facility provided education to nursing staff that transcribe and administer medications. This education included new admission orders [REDACTED]. During surveyor interview on 6/26/2017 with the Director of Nursing Services and the Assistant-Administrator on 6/27/2017 they were unable to provide evidence that the medications were administered per physician order [REDACTED]. 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.