Every finding on record at Riverview Healthcare Community

Based on clinical record review and resident and staff interviews, the facility failed to ensure residents were free from significant medication errors for 1 of 1 resident reviewed. The facility failed to ensure Resident ID #1's identity was verified prior to medication administration, resulting in Resident ID #1 allegedly receiving insulin prescribed for Resident ID #3. The facility's failure to follow medication administration practices, including verifying the resident's identity prior to medication administration, placed Resident ID #1 at risk for serious injury, serious impairment, serious harm or death. Findings are as follows:Record review of a community reported complaint received by the Rhode Island Department of Health on 6/11/2026 alleges that Resident ID #1 was administered 10 units of insulin by the nurse and that the nurse also attempted to administer two other medications not prescribed to him/her, and she did not verify his/her name prior to administering the insulin injection. Furthermore, the complaint indicates that Resident ID #1 is not prescribed insulin. According to the facility policy titled Administering Medications, states in part, Medications are administered in a safe and timely manner, and as prescribed .9. The individual administering medications verifies the resident's identity before giving the resident his/her medication. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verify resident identification with other facility personnel. 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 . According to the manufacturer's instructions for Insulin Lispro, states in part, Lispro is a rapid acting human insulin analog indicated to improve glycemic control in adult and pediatric patients with diabetes mellitus. This insulin has a rapid onset of glucose-lowering activity as well as a shorter duration of action. When used as mealtime insulin, the dose of insulin should be given within 15 minutes before or immediately after a meal. Peak serum levels (the highest concentration of the insulin in your blood) for Lispro insulin are seen 30 to 90 minutes after dosing. Hypoglycemia (low blood sugar) is one of the most frequent adverse events experienced by insulin users, which can be brought about by missing or delaying meals, taking too much insulin, an infection or illness. Symptoms of mild to moderate hypoglycemia may occur suddenly and include, but are not limited to dizziness, lightheadedness, restlessness and anxiety. Record review revealed Resident ID #1 was admitted to the facility in June of 2026 with a diagnosis including, but not limited to, type 2 diabetes mellitus with hyperglycemia (a metabolic condition when the body can't use insulin correctly and sugar builds up in the blood).Record review of Resident ID #1's admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating s/he is cognitively intact.Record review failed to reveal evidence that Resident ID #1 had an order for insulin.Record review revealed Resident ID #3 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, type 1 diabetes mellitus (an autoimmune disease where the body's immune system attacks and destroys the insulin-producing cells in the pancreas).Record review revealed the following physician's orders for Resident ID #3:-4/23/2026, check FSBG levels before each meal and at bedtime every day.-4/26/2026, Insulin Lispro Pen-injector 100 unit/milliliter, inject 10 units subcutaneously before meals.During a surveyor interview on 6/12/2026 at 10:38 AM with Resident ID #1, s/he revealed that on the evening of 6/10/2026 at approximately 5:00 PM, Registered Nurse (RN), Staff A, entered his/her room during the dinner meal and approached him/her with insulin and a medication cup containing 2 pills. Staff A obtained the resident's FSBG reading, which was 192 and then asked him/her where s/he would like the insulin injected. The resident informed Staff A that s/he does not take insulin, and Staff A responded that his/her doctor ordered him/her the insulin. The resident replied that s/he would try taking the insulin administration in his/her thigh. When Staff A presented him/her with the medication cup, s/he asked what the pills were for, to which Staff A explained that one pill was for seizures and the other was a sodium pill. The resident told Staff A that s/he does not have seizures and is prescribed a low sodium diet. Staff A then asked the resident if his/her name was that of another resident who resides in the room across the hall from him/her, Resident ID #3. The resident revealed that when she told Staff A that that was not his/her name, Staff A left the room; the resident then put his/her call light on to inform staff of what had transpired with Staff A and that s/he had been administered insulin in error. The resident stated that after s/he received the insulin s/he ate the dinner meal and had candy. Record review of Resident ID #1's blood glucose levels revealed the following:-5:00 PM = 192-6:10 PM = 185-6:30 PM = 148-7:00 PM = 172-7:42 PM = 152-8:05 PM = 112-8:30 PM = 112-8:51 PM = 114-9:05 PM = 114-9:35 PM = 114During a surveyor interview on 6/12/2026 at 12:32 PM with Registered Nurse, Staff A, she revealed that she entered Resident ID #1's room to administer medications to the roommate. While in the room, Resident ID #1 attempted to speak with her, and Staff A believed s/he stated a first name matching that of Resident ID #3, who resided across the hall. Staff A stated that she left the room and searched the electronic medical record (EMR) using the name she believed she heard, identifying Resident ID #3. She revealed that Resident ID #3 was prescribed multiple medications, including Insulin Lispro, Keppra (a medication used to treat seizures), and a sodium tablet (a medication used to treat low sodium levels). Staff A stated that she removed these medications from the medication cart, returned to Resident ID #1's room, and explained the medications she intended to administer. According to Staff A, Resident ID #1 questioned why s/he was receiving Keppra and sodium tablets, stating that s/he did not take those medications. Staff A stated that, at that point, she stepped back and asked Resident ID #1 to identify himself/herself because she believed she may have the wrong resident.Staff A acknowledged that she failed to verify Resident ID #1's identity using any of the resident identifiers required by facility policy prior to accessing the EMR or preparing medications. Instead, she relied solely on the first name she believed she heard Resident ID #1 state, which led her to access Resident ID #3's medical record and prepare Resident ID #3's prescribed medications. Staff A acknowledged that the medications she prepared, including Insulin Lispro, Keppra, and a sodium tablet, were prescribed for Resident ID #3. Staff A denied administering the insulin injection or any of the prepared oral medications to Resident ID #1. During a surveyor interview on 6/12/2026 at 1:47 PM with Unit Manager, RN, Staff B, she revealed that on the evening of 6/10/2026 at approximately 6:00 PM she was informed that Staff A administered 10 units of insulin in error to Resident ID #1. Staff B further indicated that Staff A was a new orientee training with another nurse that evening, and that Staff A was administering medications to the residents while her preceptor, Staff C, was admitting a new resident. Staff B further revealed that when she spoke to Staff A regarding the administration of insulin, Staff A revealed that she had entered Resident ID #1's room in error but denied administering Resident ID #1 the insulin. Subsequently, Staff B spoke with Resident ID #1, who revealed to her that Staff A had given him/her insulin in error, and in response Staff B notified the on-call provider of the allegation, and the provider ordered for the resident's blood glucose levels to be monitored. Record review of a nursing progress note, dated 6/10/2026 at 10:14 PM and authored by Staff B, indicated that Resident ID #1 reported receiving 10 units of insulin in his/her left thigh, which s/he does not have an order for and has never taken. Resident ID #1 reported feeling lightheaded and dizzy and the on-call provider was contacted. The provider ordered to monitor the resident's blood glucose levels every 30 minutes for 4 hours, via finger stick. Additionally, the note indicated that Staff B had obtained the resident's FSBG at 7:00 PM, which was 172. During a surveyor interview on 6/12/2026 at 1:02 PM with Licensed Practical Nurse, Staff C, she revealed that she was the nurse that was training Staff A on the night on 6/10/2026 and was notified that Resident ID #1 reported receiving insulin in error. When she questioned Staff A about administering insulin to Resident ID #1, she revealed that Staff A indicated that she had asked the resident where to administer the insulin, and the resident suggested his/her thigh. Staff A further stated that she put the insulin pen to the resident's leg and then asked Resident ID #1 what his/her name was, and after the resident stated what his/her name was, she took the insulin pen away and took a step back. Staff A denied administering insulin to Resident ID #1Subsequently, Staff C revealed that she spoke with Resident ID #1 about the insulin administration and the resident revealed that Staff A brought the insulin and a cup with pills to his/her room. She asked him/her where s/he takes the insulin, which the resident responded that s/he does not take insulin, but then offered to have it in his/her thigh. Staff A gave him/her the insulin and then asked him/her what his/her name was, s/he revealed his/her name and Staff A left. Additionally, Staff C revealed the resident kept pointing to his/her left thigh for Staff C to observe the insulin needle mark, but no markings were visible. Staff C further revealed that the on-call provider was notified and ordered for the resident's FSBG to be checked every 30 minutes, which was completed. During a surveyor interview on 6/16/2026 at 3:44 PM with the resident's physician, he revealed that after staff notified him of the insulin administration allegation, he came to the facility to assess the resident and s/he was doing well. The facility's failure to ensure medication administration practices, including verification of the resident's identity prior to medication preparation and administration, resulted in a significant medication error. A reasonable person, after considering the totality of the evidence, would conclude that Resident ID #1 received the 10-unit Insulin Lispro injection intended for Resident ID #3. This conclusion is supported by Resident ID #1's consistent account that Staff A obtained his/her finger-stick blood glucose, asked where s/he preferred the insulin injection, administered the injection into his/her thigh, and then attempted to administer two oral medications prescribed for Resident ID #3 before recognizing the resident identification error. Resident ID #1 immediately reported the event to staff, consistently reported the incident during multiple interviews, and subsequently developed symptoms of dizziness and lightheadedness. Although Staff A denied administering the injection, the totality of the evidence supports that the resident received insulin intended for another resident. The administration of rapid-acting insulin to a resident without a physician's order created an IJ because it caused, or was likely to cause, serious injury, serious harm, impairment, or death due to the risk of severe hypoglycemia, loss of consciousness, coma, or death.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 4 of 5 medication carts and 2 of 3 medication supply rooms observed.Findings are as follows: Record review of the facility policy last revised February 2023, titled, Medication Labeling and Storage states in part, .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .Medications requiring refrigeration are stored in a refrigerator . 1. During a surveyor observation on [DATE] at approximately 8:45 AM of the first floor East Wing, B side medication cart, in the presence of Registered Nurse (RN) Staff J, revealed the following: One Advair Diskus Aerosol Powder inhaler opened, with a dose indicator reading of 53, not labeled with the date when opened. One Advair Diskus Aerosol Powder inhaler opened with a dose indicator reading of 52, not labeled with the date when opened. One Advair Diskus Aerosol Powder inhaler opened, with a dose indicator reading of 35, not labeled with the date when opened. Review of the manufacturer's guidance and pharmacy label indicates to discard 30 days after it is removed from the foil pouch or after the dose indicator reads zero. During a surveyor interview with Staff J immediately following the above-mentioned observations, she acknowledged the inhalers were not labeled with the date when they were opened. 2. During a surveyor observation on [DATE] at approximately 9:00 AM of the first floor A side medication cart in the presence of Licensed Practical Nurse (LPN) Staff K, the following was revealed: One Advair Diskus Aerosol Powder inhaler opened, with a dose indicator reading of 24, not labeled with the date when opened. One bottle of Prevnar 20PF (pre-filled) 0.5mL vaccine labeled refrigerate. One container of a nutritional supplement Med Plus 2.0, review of the product label reads refrigerate after opening and discard after three days. Additional observation failed to reveal that the Med Plus 2.0 was being stored on ice. During a surveyor interview with Staff K following the above observation, she acknowledged the inhaler was open and undated and the bottle of Prevnar should have been refrigerated. Additionally, Staff K at 11:37 AM, she revealed that she opened the nutritional supplement container at 7:00 AM and was unsure if the container should be on ice despite what the manufacturer label reads. 3. During a surveyor observation on [DATE] at 10:52 AM, of the 2 East Med cart in the presence of RN, Staff L, revealed the following: One Advair Diskus Aerosol Powder inhaler with a dose indicator reading of 0-1, opened and not labeled with a date when opened. One Advair Diskus Aerosol Powder inhaler with a dose indicator reading of 42, opened and not labeled with a date when opened. Incruse Ellipta inhaler with a dose indicator reading of 21, opened and not labeled with a date when opened. Review of the manufacturer's guidance and pharmacy label indicates to discard 6 weeks after it is removed from the foil pouch. During a surveyor interview with Staff L at the time of the above-mentioned observations, she acknowledged the inhalers should be dated when opened. 4. During a surveyor observation on [DATE] at 11:02 AM, of the 2nd floor South medication cart in the presence of LPN, Staff M, revealed the following: One Trelegy Ellipta inhaler opened with a dose indicator reading of 21, not labeled with the date when opened. One Trelegy Ellipta inhaler opened with a dose indicator reading of 3, labeled with date opened 1/31 and an expiration date of [DATE]. One Bretzi AeroSphere inhaler opened with a dose indicator reading of 100, not labeled with the date when opened. Review of the manufacturer's guidance and pharmacy label indicates to discard three months after removal from the foil pouch. During a surveyor Interview with Staff M at the time of the observations, she acknowledged the inhalers should be dated when opened and that the expired inhaler should have been discarded. 5. During a surveyor observation of the 1st floor East Unit medication room on [DATE] at approximately 11:30 AM in the presence of Staff J, revealed the following: One bottle of Lorazepam liquid opened and not labeled with a date when opened. Review of the manufacturer's guidance indicates to date when it is opened and discarded 90 days after opening. One bottle of vancomycin labeled discard after [DATE]. During a surveyor interview with Staff J at the time of the above-mentioned observations, she acknowledged the Lorazepam should have been dated when opened and the vancomycin should have been discarded. 6. During a surveyor observation of the 2nd floor medication room on [DATE] at 10:50 AM in the presence of Staff M, revealed the following: One bottle of Lorazepam liquid opened and not labeled with a date when opened. During a surveyor interview with Staff M at the time of the observation, she acknowledged the Lorazepam should have been dated when opened. During a surveyor interview on [DATE] at 2:40 PM with the Director of Nursing Services, in the presence of the Regional Director of Operations, Administrator, and Regional Director of Clinical Services, they were unable to provide evidence that medications were being stored in accordance with accepted professional principles, including but not limited to expiration dates.

Based on clinical record review and staff interview, the facility failed to ensure that residents are free from significant medication errors for 1 of 2 residents reviewed who are receiving dialysis (a life-sustaining medical procedure used to filter waste, toxins, and excess fluids from the blood when the kidneys are no longer functioning), Resident ID #4.Findings are as follows:Record review of a facility policy titled Administering Medications dated April 2019, states in part, .Medications are administered in accordance with prescribed orders, including any required time frame.Record review revealed the resident was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, end stage renal disease (when the kidneys are no longer able to function adequately) and gastritis (inflammation of the stomach lining).Record review revealed a physician's order dated 1/11/2026 reveals the resident is scheduled for outpatient dialysis every Monday, Wednesday, and Friday, with transportation pickup at 5:45 AM.Record review revealed a physician's order dated 11/21/2025 for Auryxia (a medication prescribed to lower the amount of phosphate in the blood for adults with chronic kidney disease who receive dialysis) 1 gram, give 3 tablets by mouth before meals at 8:00 AM, 11:00 AM, and 4:00 PM.Record review of the 2026 Medication Administration Record (MAR) failed to reveal evidence that the resident received his/her 8:00 AM dose of Auryxia on the following dialysis days:-1/13, 1/14, 1/16, 1/19, 1/21, 1/23, 1/28, and 1/30-2/2, 2/6, 2/9, 2/11, 2/13, 2/16, 2/18, and 2/20-3/2, 3/4, 3/11, 3/16, 3/18, 3/20, 3/23, 3/25, 3/27, and 3/30/2026.Record review revealed a physician's order dated 1/11/2026 for Pentasa (a medication prescribed to treat certain bowel diseases) 500 milligrams, give 2 capsules three times a day at 8:00 AM, 12:00 PM, and 4:00 PM.Further record review of the 2026 MAR failed to reveal evidence that the resident received his/her 8:00 AM dose of Pentasa on the following dialysis days:-1/13, 1/16, 1/19, 1/21, 1/23, 1/28, and 1/30-2/2, 2/6, 2/9, 2/13, 2/16, and 2/20-3/4, 3/11, 3/18, 3/20, 3/23, 3/25, 3/27, and 3/30/2026.Record review failed to reveal evidence that the physician was notified when the resident's 8:00 AM doses of Auryxia and Pentasa were missed on the above-mentioned dialysis days.During a surveyor interview on 4/1/2026 at 11:25 AM, the Assistant Director of Nursing Services she acknowledged the 8:00 AM dose of Aurexia was not being administered to the resident at the facility on his/her dialysis days. She revealed that the resident receives his/her 8:00 AM dose of Pentasa at the outpatient dialysis center when s/he receives his/her treatments there. During a surveyor interview on 4/1/2026 at 2:15 PM with the Clinical Manager of the outpatient dialysis center, she stated that the dialysis center does not administer Pentasa to the resident during treatments at the center.During surveyor interviews on 3/31/2026 at 2:31 PM and 4/1/2026 at 2:29 PM with Physician, Staff I, he stated that he was unaware that the facility was not administering the resident's Auryxia and Pentasa as ordered. He further stated that had he been informed, he would have adjusted the administration times.During an interview on 4/1/2026, the Director of Nursing Services was unable to provide evidence that the facility ensured the resident remained free from significant medication errors related to these omissions.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed related to a CPAP machine (Continuous Positive Airway Pressure - a medical device used to treat sleep apnea by delivering a steady, continuous stream of pressurized air through a mask into the airway), Resident ID #6, and for 1 of 1 resident reviewed with a tracheostomy (a surgical procedure that creates a secure, airway through an opening in the neck, directly into the wind pipe), Resident ID #15.Findings are as follows: 1. Record review of a facility policy titled CPAP.Support states in part, .Specific cleaning instructions are obtained from the manufacturer/supplier of the [CPAP] device.Record review of the ResMed Air Sense 10 replacement guidelines revealed: .Mask cushions/pillows: Every month (sensitive to oil buildup).Mask Frame: Every 3 months.Headgear/straps: Every 6 months (or when elasticity is lost).Tubing: Every 3 months .Record review revealed Resident ID #6 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and obstructive sleep apnea.Record review of the March 2026 Treatment Administration Record (TAR) revealed a physician's order with a start date of 10/20/2025 to apply a CPAP at bedtime.Record review failed to reveal evidence that the mask, frame, and tubing, were being replaced per the manufacturer's guidelines.During a surveyor interview on 4/1/2026 at 12:03 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the CPAP was maintained per the manufacturer's guidelines.2. According to Lippincott Nursing Procedure Ninth Edition 2023, page 621, states in part, .Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed .Record review revealed Resident ID #15 was readmitted to the facility in November of 2025 with diagnoses including, but not limited to, acute and chronic respiratory failure and tracheostomy status.Clinical record review failed to reveal evidence of physician's order for the intended oxygen flow rate to be administered via the resident's tracheostomy. During a surveyor observation of the resident on 3/31/2026 at 11:25 AM, in the presence of Licensed Practical Nurses (LPN) Staff F and Staff H, revealed the resident was receiving oxygen 5 liters per minute (LPM) via tracheostomy.During a surveyor interview with Staff F following the above observation, she revealed that she is unsure of what the resident's prescribed oxygen flow rate is.Record review revealed a progress note dated 3/31/2026 at 11:52 AM authored by Staff F, revealed that she notified the provider regarding the physician's order that is missing the prescribed oxygen flow rate. Further review revealed an order was obtained to administer oxygen at a flow rate of 4 LPM via tracheostomy.During a surveyor interview on 3/31/2026 at approximately 2:30 PM with the DNS, she was unable to provide evidence that Resident ID #15 received respiratory care consistent with professional standards of practice related to oxygen administration.

Based on clinical record review and staff interview, the facility failed to ensure the implementation of nutritional interventions to maintain acceptable parameters of nutritional status, including usual body weight, for 1 of 2 residents reviewed, Resident ID #8, who experienced significant weight loss. Findings are as follows:Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, dementia, dysphagia (difficulty swallowing), anxiety and cancer of the right kidney.Record review of the resident weighed 147.0 pounds (lbs.) on 3/1/2026 and 121.8 lbs. on 3/30/2026 which indicates a 12.89% weight loss.Record review of a document titled Continuity of Care Consultation and Referral Form dated 3/10/2026 from an oncology consult revealed a recommendation for a high-protein dietary supplement.Record review of a progress note dated 3/18/2026 authored by Advanced Practice Registered Nurse, Staff G, revealed that she was referring the recommended high-protein dietary supplement to the dietician.Record review failed to reveal evidence that a high-protein supplement had been implemented as recommended by the oncologist.During a surveyor interview on 4/2/2026 at 8:58 AM with the Registered Dietitian, Staff E, she revealed that she was unaware of the oncologist's recommendation for the resident to receive a high-protein supplement.During a surveyor interview on 4/2/2026 at 11:42 AM with the Nurse Practitioner, Staff G, she revealed that she referred the selection of the protein supplement to the dietician, so that they could determine what the best supplement would be for the Resident. Lastly she revealed that she was not aware that the high-protein supplement had not been implemented and indicated that she would have expected it to have been.

Based on clinical record review and staff interview, the facility failed to adhere to professional standards of practice by not following physician's orders for 1 of 3 residents reviewed Resident ID #17, related to medications requiring blood pressure monitoring parameters. 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 clients.Record review revealed that the resident was admitted to the facility in February of 2017 with diagnoses including, but not limited to, hypertensive heart disease, and congestive heart failure.Review of physician's orders revealed the following:Amlodipine 5 milligrams (mg), a medication prescribed to treat hypertension, to be administered in the morning at 6:00 AM, with instructions to monitor blood pressure prior to administration. This order was initiated on 7/16/2025.Spironolactone 25 mg, a potassium-sparing diuretic prescribed to treat heart failure, to be administered as one-half tablet twice daily at 6:00 AM and 6:00 PM. The order included parameters to hold the medication for a systolic blood pressure less than 110 mmHg. This order was initiated on 3/10/2026.Review of the Medication Administration Record (MAR) revealed no documented evidence that blood pressure readings were obtained prior to the administration of Amlodipine for 31 of 31 opportunities between 3/1/2026 and 3/31/2026.Further review of the MAR revealed no documented evidence that blood pressure readings were obtained prior to the administration of Spironolactone for 41 of 42 opportunities between 3/10/2026 and 3/31/2026.Further review of the MAR failed to reveal that blood pressures were obtained, as ordered, prior to the administration of Spironolactone for 41 out of 42 opportunities between 3/10/2026 and 3/31/2026.Additionally, review of the blood pressure summary reports and progress notes failed to reveal evidence that blood pressure monitoring was performed prior to medication administration, as ordered.During a surveyor interview on 3/31/2026 at 2:04 PM with Licensed Practical Nurse, Staff A, she was unable to provide evidence that blood pressures were obtained per the physician's orders prior to administration of the above medications. During a surveyor interview on 3/31/2026 at 2:13 PM with the Director of Nursing Services, she acknowledged that the blood pressures should have been obtained per the physician's order prior to administration of the above medications.

Based on surveyor observations, clinical record review, and staff interviews, the facility failed to ensure that staff provided treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed, Resident ID #141, related to the assessment and monitoring of a blister and edema (swelling in the legs due to fluid buildup ) of the lower extremities. Findings are as follows:Record review revealed the resident was admitted to the facility in December of 2020 with diagnoses including, but not limited to, type 2 diabetes, hypertensive heart, and dementia.Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required total assistance with toileting hygiene, moderate assistance with upper and lower body dressing, and maximal assistance with applying and removing footwear. Record reviews of a care plan initiated on 3/15/2023 revealed a focus area for potential skin breakdown. Additionally, on 6/16/2025 a focus area was initiated to monitor and document edema, and to report abnormal findings to the physician.During a surveyor observation on 3/29/2026 at 9:38 AM the resident was observed with a blister on the right lower shin area surrounded by small black scabs and notable edema in both legs.Additional surveyor observations on 3/30/2026 at 10:00 AM, 12:00 PM, 1:00 PM and 2:40 PM revealed the resident sitting in a wheelchair and independently wheeling across the main lobby and the activity/dining area. The resident was again noted to have edema to bilateral lower extremities and a blister to his/her right shin.Record review failed to reveal evidence that the physician was notified of the blister or the edema. Further, the record lacked evidence that treatments or interventions were in place.During a surveyor observation of the resident, in the presence of License Practical Nurse, Staff B on 3/30/2026 at 2:48 PM she acknowledged the resident had a blister to the right shin bilateral edema. Furthermore she revealed that she was unaware of the blister and edema.During a surveyor interview on 3/30/2026 at 2:55 PM with the Unit Manager, Registered Nurse, Staff C, she acknowledged that she was unaware of the resident's blister to his/her shin and revealed that she would expect the provider to be notified of any change in condition. Record review of the progress note dated 3/31/2026, authored by the Infection Preventionist Nurse, revealed that the resident had an intact blister on his/her right shin. The documentation further noted that the blister measured 3.56 centimeters (cm) in length and 4.21 cm in width. During a surveyor interview on 4/1/2026 at 2:04 PM with the Director of Nursing Services, she was unable to provide evidence that the provider was notified or that the facility was aware of the 3.56 cm x 4.21 cm blister located on the resident's right shin, until it was brought to their attention by the surveyor. On 4/1/2026, the physician provided an order for staff to cleanse the right lower extremity wound with normal saline, apply Xeroform, and cover it with a dressing every evening shift until healed.

Based on surveyor observation, and resident and staff interview, it has been determined that 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, relative to 2 of 2 residents reviewed on the One East Unit, Resident ID #s 4 and 5. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 9/20/2025 alleged that on 9/19/2025 on the 11:00 PM - 7:00 AM shift there was only one Nursing Assistant (NA) and one nurse working on the subacute (short term care) unit with 24 residents. The complaint further alleged that residents on the unit were fall risks, required 15-minute checks, and one to one supervision. Additionally, the complaint alleged that management was aware of the unsafe staffing.Review of the Facility Assessment, last reviewed on 9/19/2025 revealed in part, .Our facility had created a base staffing pattern to ensure a sufficient number of qualified staff to meet the needs of our residents on a consistent basis.During a surveyor interview on 10/2/2025 at 8:45 AM with the Assistant Director of Nursing Services, she indicted that she is currently responsible for scheduling the nursing staff and scheduling is based on the census of the unit. She further indicated that the One East Unit is minimally staffed with one nurse and two NAs on the 11:00 PM - 7:00 AM shift. Additionally, she indicated that staffing a unit with less than two NAs would not be safe especially if residents require a lift for transfers, however the nurse is expected to help the NAs. Furthermore, she indicated the following 11:00 PM - 7:00 AM staffing minimums by unit:-1 East- 1 nurse and 2 NAs-1 North/South- 1 nurse and 2 NAs-2 North/South- 1 nurse and 3 NAs-3 North/South- 1 nurse and 3 NAs-A total of 4 nurses and 10 NAs.Record review of the 9/19/2025 11:00 PM- 7:00 AM schedule revealed only 9 NAs worked in the facility that shift, under the above-mentioned facility's staffing minimum.During a surveyor interviews via telephone on 10/1/2025 at 9:20 AM and on 10/2/2025 at 10:11 AM, with NA, Staff A, s/he indicated that there was the only one NA working on the One East Unit on 9/19/2025 for the 11:00 PM - 7:00 AM shift. S/he further indicated that s/he only had time to complete one round of care for each resident on the unit due to insufficient staffing. The surveyor attempted to interview the nurse who worked the One East Unit on the 9/19/2025 11:00 PM - 7:00 AM shift, however the staff member did not return the surveyor's phone call.1a. Record review revealed Resident ID #4 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, dementia, lack of coordination, and a history of falls. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed, the resident was incontinent of bowel and bladder and required maximum assistance from staff with toileting and hygiene. Review of a care plan dated 8/29/2025 revealed the resident had the potential for skin break down related to incontinence with interventions including, but not limited to, checking the resident approximately every two hours and providing incontinence care as needed. Further review of the care plan revealed the resident had a self-care performance deficit related to dementia with interventions including, but not limited to, requiring a total mechanical lift and the assistance of two staff members for transfers.Record review revealed Resident ID #4 was at risk for falls and had multiple falls during his/her admission to the facility on the following dates: 9/6, 9/14, and 9/20/2025. 1b. Record review revealed Resident ID #5 was admitted to the facility in September of 2025 with diagnoses including, but not limited to, cerebral infarction (stroke) and schizoaffective disorder.Review of a MDS assessment dated [DATE] revealed, the resident was incontinent of bowel and bladder. Further review revealed the resident required maximum assistance with hygiene. Additional review revealed the resident had impaired range of motion on one side of his/her body, affecting his/her upper and lower extremities. Review of a care plan revised 9/18/2025 revealed, the resident had a stage two pressure ulcer (an open wound or blister caused by prolonged pressure to a particular area which requires prompt treatment to prevent further complications) with interventions including, but not limited to, repositioning at least every two hours or more as needed.Record review of the resident's progress notes revealed the resident had multiple falls at the facility on the following dates: 9/6, 9/12, 9/17, 9/30, 10/1/2025.During a surveyor interview on 10/2/2025 with Licensed Practical Nurse, Staff B, she indicated that Resident ID #5 requires 15-minute checks for safety following multiple falls. She further indicated that NAs are expected to complete rounds as soon as they start their shift and then every two hours after. Additionally, she indicated that one NA would not be sufficient to complete the required care on the One East Unit. During a surveyor interview with the Director of Nursing Services, on 10/2/2025, she indicated that she would not expect only one NA to care for 24 residents and would expect NAs scheduled on other units to help provide care. Additionally, she could not provide evidence that the facility ensured that a sufficient number of qualified staff worked on 9/19/2025 on the 11:00 PM - 7:00 AM shift to meet the resident's needs.

Based on record review, resident representative and staff interview, the facility failed to ensure that accurate and appropriate information was communicated to the receiving health care provider during an emergent discharge for Resident ID #1. When Resident ID #1 experienced a change in condition requiring emergency transfer to an acute care facility, Licensed Practical Nurse (LPN), Staff A, incorrectly identified the resident. As a result, Resident ID #1 was transferred with another resident's identifiers and medical record, placing Resident ID #1 at risk for delayed and/or inappropriate treatment.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/24/2025, alleges that Resident ID #1 was sent to the hospital on [DATE] with Resident ID #2's medical record.Record review revealed Resident ID #1 was admitted to the facility in June of 2023, with diagnoses including, but not limited to, chronic obstructive pulmonary disease and congestive heart failure (a chronic condition where the heart can't pump enough blood to meet the body's needs, leading to blood and fluid backing up in the body).Record review revealed Resident ID #2 was admitted to the facility in October of 2024, with diagnoses including, but not limited to, type II diabetes and chronic kidney disease.Review of a RI [Rhode Island] EMS [Emergency Medical Services] Patient Care Report dated 11/23/2025, revealed that they were dispatched to a nursing facility for a patient with an altered mental status. Per the report, when EMS arrived, the resident was short of breath, had sputum coming from his/her nose and mouth, and was unable to follow commands or keep his/her head up. Additionally, the report revealed EMS transferred the resident to the hospital. Further review revealed that approximately 2 hours following the transfer, the hospital alerted them that the nursing facility had given them the incorrect patient identifiers and medical record.Record review of a late entry in Resident ID #1's medical record dated 11/23/2025 at 6:57 PM, revealed that Resident ID #1 was significantly altered from baseline, unable to hold his/her head up, producing excessive sputum, and had cool skin.However, a review of Resident ID #2's medical record revealed a progress note and physician order directing Resident ID #2 to be sent to the hospital due to a change in condition. Although, record review confirmed that Resident ID #1 not Resident ID #2 was the resident experiencing the actual change in condition.Review of a progress note for Resident ID #1 dated 11/23/2025 at 6:58 PM further revealed that the resident was admitted to the hospital's Intensive Care Unit and would require intubation (the insertion of a tube either through the mouth or nose and into the airway, to aid with breathing).During a surveyor interview on 11/25/2025 at 9:43 AM with Resident ID #2's representative, s/he revealed that s/he received a telephone call from the hospital on [DATE]. Per the representative, the hospital revealed that Resident ID #2 was admitted to the hospital and would require life support and intubation. The hospital was requesting consent from the representative for the procedure. S/he revealed that the hospital asked if this was something that Resident ID #2 would want, and she responded no.Review of the emergency room admission documentation revealed that Resident ID #1 arrived at 3:47 PM registered under a different name and date of birth . EMS had been provided the incorrect identifiers by the facility for transport. Because Resident ID #1 was obtunded (decreased consciousness) and in respiratory distress on arrival, s/he was unable to correct the information. Documentation showed that medical care, including testing, was conducted under the wrong identity for approximately two hours.During a surveyor interview on 11/25/2025 at 10:17 AM with the Director of Nursing Services (DNS), she acknowledged that the wrong patient 's medical record was sent with Resident ID #1 to the hospital. Additionally, she revealed that Resident ID #1 has a history of respiratory distress requiring intubation. Furthermore, she indicated, to her knowledge the family of Resident ID #1 would have consented to intubation if they had been contacted.The facility's failure to send accurate medical records and patient identifiers during an emergent transfer placed Resident ID #1 at risk for delayed and/or inappropriate treatment. Given the resident's known history of severe respiratory compromise, this error had the potential to result in serious harm, injury, impairment, or death.Cross-reference F 726

Based on record review and staff interview, the facility failed to ensure that licensed nurses possessed the necessary competencies and skills to meet resident needs. When Resident ID #1 experienced a change in condition requiring emergency transfer to an acute care facility, Licensed Practical Nurse (LPN), Staff A, incorrectly identified the resident. Consequently, Resident ID #1 was transferred with another resident's identifiers and medical record, placing Resident ID #1 at risk for delayed and/or inappropriate treatment.Findings are as follows:Review of a facility policy titled, Acute Condition Changes-Clinical Protocol dated March 2018, states in part, .before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician: for example, the history of present illness and previous or recent test results for comparison. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status.Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/24/2025, alleges that Resident ID #1 was sent to the hospital on [DATE] with Resident ID #2's medical record.Record review revealed Resident ID #1 was admitted to the facility in June of 2023, with diagnoses including, but not limited to, chronic obstructive pulmonary disease and congestive heart failure (a chronic condition where the heart can't pump enough blood to meet the body's needs, leading to blood and fluid backing up in the body).Record review revealed Resident ID #2 was admitted to the facility in October of 2024, with diagnoses including, but not limited to, type II diabetes and chronic kidney disease.Review of a RI [Rhode Island] EMS [Emergency Medical Services] Patient Care Report dated 11/23/2025 revealed that they were dispatched to a nursing facility for a patient with altered mental status. Per the report, when EMS arrived, the resident was short of breath, had sputum coming from his/her nose and mouth and was unable to follow commands or keep his/her head up. Additionally, the report revealed EMS transferred the resident to the hospital. Further review revealed that approximately 2 hours following the transfer, the hospital alerted them that the nursing facility had given them the incorrect patient identifiers and medical record.Record review of a late entry in Resident ID #1's medical record dated 11/23/2025 at 6:57 PM, revealed that Resident ID #1 was significantly altered from baseline, unable to hold his/her head up, producing excessive sputum, and had cool skin.However, a review of Resident ID #2's medical record revealed a progress note and physician order directing Resident ID #2 to be sent to the hospital due to a change in condition. Although, record review confirmed that Resident ID #1 not Resident ID #2 was the resident experiencing the actual change in condition.Review of a progress note for Resident ID #1 dated 11/23/2025 at 6:58 PM further revealed that Resident ID #1 was admitted to the hospital's Intensive Care Unit and would require intubation (the insertion of a tube either through the mouth or nose and into the airway, to aid with breathing).Record review revealed LPN, Staff A, reported to an on-call provider that Resident ID #2 was having a change in condition and not Resident ID #1. Record review failed to reveal evidence that Staff A reported to Resident ID #1's provider that s/he had a change in condition and required emergent transfer to the hospital.During a surveyor interview on 11/25/2025 at 8:56 AM with Staff A, she revealed that she did report to an on-call provider at 2:35 PM that Resident ID #2 was having a change in condition, not Resident ID #1, who was the actual resident who required the notification of change and emergent transfer. Additionally, she revealed that she sent Resident ID #2s medical record at the time of transfer with the EMS to the hospital. Per Staff A, she realized at approximately 5:30 PM, that she sent the wrong medical record with Resident ID #1, indicating that for approximately 2 hours the hospital was treating Resident ID #1 as if s/he was Resident ID #2. Furthermore, Staff A revealed that she did not call the hospital to give a verbal report on the resident she transferred to the hospital at the time of the transfer.During a surveyor interview on 11/25/2025 at 10:17 AM with the Director of Nursing Services, she acknowledged that the wrong resident's medical record was sent with Resident ID #1 to the hospital. Additionally, she was unable to provide evidence that LPN, Staff A was competent with the Acute Condition Changes-Clinical Protocol when she transferred Resident ID #1 to the hospital with the wrong medical record or when reporting a change in condition to the wrong provider about the wrong resident.The facility's failure of Staff A to send accurate medical records and patient identifiers during an emergent transfer placed Resident ID #1 at risk for delayed and/or inappropriate treatment. Given the resident's known history of severe respiratory compromise, this error had the potential to result in serious harm, injury, impairment, or death.Cross reference F 628

Based on record review and staff interview, the facility failed to implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 3 residents reviewed for falls and for transferring and lifting needs, Resident ID #s 2 and 3.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 10/23/2025 alleged that patient safety is at risk and that patients fall frequently at the facility.Review of an undated facility policy titled Safe Patient Handling [SPH] - RI, states in part, In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift patients.Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan.1. Record review revealed Resident ID #2 was admitted to the facility in October of 2024, with diagnoses including, but not limited to, type II diabetes, and chronic kidney disease.Record review revealed a progress note dated 11/12/2025, revealed that Resident ID #2 had a fall at 10:40 AM while a Nursing Assistant (NA) and a student were transferring the resident to his/her chair.Record review of Resident ID #2's care plan revealed an intervention dated 6/8/2023 that the resident utilizes a transfer (gait) belt and two staff members for assistance with transfers. On 11/21/2024 the care plan indicated that Resident ID #2 requires a total mechanical lift, and two staff members for assistance with transfers. These interventions contain conflicting information regarding the resident's transfer needs.Record review of Resident ID #2's Kardex (a tool utilized to communicate the needs of a resident) revealed that the resident utilizes a transfer (gait) belt and two staff members for assistance with transfers using a stand and pivot technique and that Resident ID #2 requires a total mechanical lift, with two staff members for assistance with transfers. These interventions contain conflicting information regarding the resident's transfer needs.Record review of a physician's order dated 11/24/2024, revealed that the resident requires the assist of two staff members using a stand and pivot transfer with a gait belt.Record review of a Safe Patient Handling (SPH) Evaluation dated 8/25/2025 revealed that Resident ID #2 requires one staff member to assist with transfers using a gait belt.Record review of the NA unit assignment for 11/26/2025 revealed, Resident ID #2 is a one staff member assist.During a surveyor interview on 11/26/2025 at 10:04 AM, with Licensed Practical Nurse, Staff B, she revealed that there is a physician's order in each resident's medical record as to how each resident is to transfer. Additionally, she revealed that the NAs have assignments that indicate how the staff is to transfer each resident. Furthermore, she acknowledged that Resident ID #2s physician's order states that the resident requires the assist of staff members with a stand and pivot transfer using a gait belt, while the NA assignment states that Resident ID #2 is a one staff member assist. She was unable to provide evidence the communication ensuring that transfer information is consistently and accurately documented to promote safe resident transfers.During a surveyor interview on 11/26/2025 at 10:19 AM, with NA, Staff C, she revealed that she was assigned to care for Resident ID #2 and when she was helping him/her transfer out of bed to his/her chair today she utilized two staff members. She revealed that the assignments were up to date and that the resident is a two person assist for transfers.2. Record review revealed Resident ID #3 was admitted to the facility in March of 2024, with diagnoses including, but not limited to, type II diabetes and muscle weakness.Record review of a physician's order dated 8/27/2025 revealed, the resident requires the assist of two staff members with a gait belt for transfers.Record review of Resident ID #3's care plan revealed an intervention dated 8/10/2025 that the resident needs supervision for ambulation and uses a walker.Record review of Resident ID #3's Kardex revealed, the resident needs supervision for ambulation and utilizes a walker.Record review of a Safe Patient Handling (SPH) Evaluation dated 11/19/2025 revealed, Resident ID #3 requires a mechanical lift, and two staff members for transfers.Record review of the Nursing Assistants (NA) unit assignment for 11/26/2025 revealed, Resident ID #3 requires the use of two staff members using a gait belt.During surveyor interviews on 11/26/2025 at 11:28 AM and 11:48 AM with the 2nd floor Unit Manager, she revealed that each resident has an assessment that is completed for their SPH, and it is then reflected on the NA's assignments. She revealed that the nurse on the floor or NA who is handing out the assignments should be responsible for updating the SPH on the assignments. Additionally, she acknowledged that Resident ID #3's SPH does not match on all forms of communication mentioned above and that Resident ID# 3's information should all match.During surveyor interviews on 11/26/2025 at 10:40 AM and 11:44 AM with the Director of Nursing Services, she acknowledged that Resident ID #s 2 and 3's SPH status was different in each above-mentioned location throughout the resident's record. Additionally, she revealed that she would expect that each resident's SPH would reflect the resident's current status in their care plan.

Based on record review, resident representative, and staff interviews, it has been determined that the facility failed to immediately consult with the resident's physician and inform the resident's representative when there was a change in condition for 1 of 3 residents reviewed, who was sent to the hospital and required emergency services, Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/24/2025, alleges that Resident ID #1 was sent to the hospital on [DATE] with Resident ID #2's medical record.Record review revealed Resident ID #1 was admitted to the facility in June of 2023, with diagnoses including, but not limited to, chronic obstructive pulmonary disease and congestive heart failure (a chronic condition where the heart can't pump enough blood to meet the body's needs, leading to blood and fluid backing up in the body).Record review revealed Resident ID #2 was admitted to the facility in October of 2024, with diagnoses including, but not limited to, type II diabetes and chronic kidney disease.Review of a RI [Rhode Island] EMS [Emergency Medical Services] Patient Care Report dated 11/23/2025 revealed that they were dispatched to a nursing facility for report of a patient with altered mental status. Per the report when EMS arrived the resident (Resident ID #1) was short of breath, had sputum coming from his/her nose and mouth, and was unable to follow commands or keep his/her head up. Additionally, the report revealed that EMS transferred the resident to the hospital. Further review revealed that approximately 2 hours following the transfer, the hospital alerted them that the nursing facility had given them the incorrect patient identifiers and medical record.Record review of a late entry in Resident ID #1's medical record dated 11/23/2025 at 6:57 PM revealed a progress note that Resident ID #1 was significantly altered from baseline, unable to hold his/her head up, producing excessive sputum, and had cool skin.However, a review of Resident ID #2's medical record revealed a progress note and physician order directing Resident ID #2 to be sent to the hospital due to a change in condition. Although, record review confirmed that Resident ID #1 not Resident ID #2 was the resident experiencing the actual change in condition.Review of a progress note for Resident ID #1 dated 11/23/2025 at 6:58 PM further revealed, the resident was admitted to the hospital's Intensive Care Unit and would require intubation (the insertion of a tube either through the mouth or nose and into the airway to aid with breathing).Record review for Resident ID #1 failed to reveal evidence of a physician's order authorizing a transfer to the hospital. The record also did not indicate that Resident ID #1's provider was notified of the resident's change in condition; instead, the facility contacted the on-call provider for Resident ID #2. Additionally, the record did not indicate that Resident ID #1's representative was informed of the transfer to the hospital.During a surveyor interview on 11/25/2025 at 9:43 AM with Resident ID #2's next of kin, s/he stated that s/he received a phone call from the hospital informing her/him that Resident ID #2 had been admitted . S/he reported that the facility had not notified her/him that her/his relative was being sent to the hospital, prompting her/him to call the facility for clarification. When s/he contacted the facility, s/he was told that her/his relative was fine and eating Chinese food.During a surveyor interview on 11/25/2025 at 8:56 AM with Licensed Practical Nurse, Staff A, she acknowledged that at 2:35 PM she notified Resident ID #2's on-call provider about a change in condition, instead of notifying the provider for Resident ID #1, who was the resident actually experiencing the change. This indicates she contacted the wrong provider for the wrong resident. She further stated that she did not notify Resident ID #1's resident representative that the resident had been sent to the hospital.During surveyor interviews on 11/25/2025 at approximately 1:00 PM and 11/26/2025 at approximately 12:15 PM, with the Director of Nursing Services and the Administrator, they were unable to provide evidence that the facility immediately consulted with the resident's physician and informed the resident's representative when there was a change in condition. The facility notified Resident ID #2's provider and not Resident ID #1's provider of the change in condition and failed to inform the resident's representative for Resident ID #1 of their transfer to the hospital.Cross reference F 628 and F 726

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible, relative to maintaining safe water temperatures for 3 of 3 floors observed. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .Some States have regulations regarding allowable maximum water temperature . According to TITLE 216 - DEPARTMENT OF HEALTH, CHAPTER 40 - PROFESSIONAL LICENSING AND FACILITY REGULATION, SUBCHAPTER 10 - FACILITIES REGULATION, PART 1 - Licensing of Nursing Facilities, .In resident areas, hot water temperatures shall not be less than one-hundred degrees Fahrenheit (100 F) nor exceed one-hundred- and eighteen-degrees Fahrenheit (118 F). Thermometers [accuracy of which can be plus or minus two degrees Fahrenheit (+/-2 F)] shall be provided in each residential area to check water temperature periodically on that unit and at each site where residents are immersed or showered . Record review of a facility document titled, Water Temperatures, Safety of last revised 12/2009, states in part, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents .Water temperature at point of service in the resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 F, or the maximum allowable temperature per state regulation .if at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report finding to the immediate supervisor . Record review of a facility document titled, .Water Temps, dated 1/13/2025 revealed the following temperatures that exceeded 120 F: 1/13/2025: -First Floor- room [ROOM NUMBER] , sink 123.0 F -Third Floor- room [ROOM NUMBER], sink 121.0 F During a surveyor interview and observation on 1/28/2025 at 10:34 AM, with Resident ID #1, s/he revealed that the water gets very hot. S/he stated, put your hands under, they will burn. Further observation by the surveyor revealed the water became very hot to touch, reddening skin and steam was rising from the sink. Following this observation, the water temperature was obtained using a digital thermometer and recorded at a temperature of 125.1 F. Record review of a facility document dated 1/19/2025-1/28/2025 titled, Task: GG - Shower/Bathe Self for Resident ID #1, revealed s/he was documented by staff as independent for bathing and does not require staff assistance for 9 out of 13 opportunities. During a surveyor interview and observation on 1/28/2025 at approximately 11:00 AM, with the Regional Maintenance Director, the following water temperatures were obtained and found to exceed 120 degrees F: -First Floor- room [ROOM NUMBER], sink 120.2 F -Second Floor- room [ROOM NUMBER], sink 121.8 F -Third Floor: - room [ROOM NUMBER], sink 125.7 F - room [ROOM NUMBER], sink 122.6 - room [ROOM NUMBER], sink 121.6 F During a surveyor interview immediately following the above observation with the Regional Maintenance Director, he acknowledged the above temperatures exceeded 120 F and further stated, there must be an issue with the mixing valve, that will need to be corrected immediately. During a surveyor interview on 1/28/2025 at approximately 2:05 PM with the Administrator, she acknowledged the recorded temperatures in the Water Temps log on 1/13/2025 exceeded 120 F and could not provide evidence that this was reported and corrected according to the facility policy. During a surveyor interview on 1/28/2025 at approximately 2:21 PM, with the Administrator in the presence of the Director of Nursing Services, she acknowledged that water temperatures should not exceed 120 F. Additionally, they were unable to provide evidence that the facility ensured the resident environment remained as free of accident hazards as possible.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen and 1 of 2 ice machines observed without an air gap (gap between the water supply inlet and the flood level rim of the plumbing fixture). Findings are as follows: 1. Review of the Rhode Island Food Code 2018 Edition 2-402.11, states in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During a surveyor observation of the main kitchen on 12/30/2024 at approximately 8:25 AM, Dietary Aide, Staff I, and Cook, Staff J, were observed with full facial hair and not wearing a beard restraint while in the main kitchen. Additionally, Staff J was observed plating the breakfast meal for the residents. During a surveyor interview following the above observation on 12/30/2024 with the Food Service Director (FSD), she acknowledged that Staff I and J were not wearing a beard restraint, as required. 2. Review of the Rhode Island Food Code 2018 Edition 5-202.13 states in part, .An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or non FOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25mm [millimeter] (1 inch) . During a surveyor observation of the first-floor kitchenette on 1/2/2025 at 11:08 AM with the Director of Maintenance in the presence of the FSD, revealed an ice machine without an air gap. During a surveyor interview directly following the above observation with the FSD, she acknowledged that the ice machine failed to have an air gap as outlined in the Rhode Island Food Code.

Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 3 of 3 floors observed. Findings are as follows: During the resident council task completed on 12/31/2024 at approximately 1:00 PM multiple residents complained of waiting for long periods of time for their call lights to be answered due to the staff no longer carrying walkie talkies. During surveyor observations of all the units from 12/30/2024 to 1/3/2025, revealed that not all resident rooms' call lights are visible from the nurse's station. During a surveyor observation of the first floor on 1/3/2025 at approximately 10:20 AM, revealed lights above the resident doors signaling a call light had been engaged. Further observation failed to reveal that the call light relayed the call directly to staff members or to a centralized staff work area. During a surveyor interview on 1/3/2025 at 10:29 AM with Licensed Practical Nurse (LPN), Staff K, she revealed that previously the call lights would communicate with walkie talkies carried by the Nursing Assistants (NA) but that they no longer work. Additionally, she acknowledged that the call lights do not call directly to a staff member or to a centralized staff work area. During a surveyor interview on 1/3/2025 at 10:33 AM with Unit Manager, Staff D, she revealed that the NA's carry walkie talkies that the call lights communicate directly with. However, Staff D was unable to locate an NA that was carrying a walkie talkie and was unable to provide a functioning walkie talkie. During a surveyor observation on 1/3/2025 at approximately 10:40 AM of the second floor, revealed a call light above room [ROOM NUMBER] engaged. Further surveyor observation of the unit failed to reveal an NA in the hallway at the time the light was engaged. During a surveyor interview on 1/3/2025 at 10:42 AM with LPN, Staff A, she revealed that the NA's carry walkie talkies to alert them when a call light is engaged. During a follow up interview at approximately 10:50 AM Staff A, acknowledged that the staff no longer carry walkie talkies. During a surveyor interview on 1/3/2025 at 10:45 AM with NA, Staff L, he revealed that he does not carry a walkie talkie and the only way he is aware a call light is engaged is by the light above the door. During a surveyor interview on 1/3/2025 at 10:51 AM with NA, Staff M, she revealed that the staff do not utilize walkie talkies and there is no centralized staff area that the call lights alert to. During a surveyor interview on 1/3/2025 at 11:09 AM with LPN, Staff N, she revealed that the staff on the third floor do not use walkie talkies and the call lights do not alert to a centralized location. During a surveyor interview on 1/3/2025 at 11:10 AM with NA, Staff O, she acknowledged that the only way she is aware a call light is engaged is by the light above the door. During a surveyor interview on 1/3/2025 at 12:33 PM with the Administrator, she acknowledged that the call lights in the facility do not communicate the call directly to a staff member or to a centralized staff work area.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to contact precautions (a type of precaution utilized when a resident is known or suspected to be infected with a Multidrug Resistant Organism, MDRO, that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces in the resident's room) for 4 of 4 residents observed for contact precautions, Resident ID #s 77, 153, 330, and 332. Findings are as follows: Review of a facility policy titled Isolation-Categories of Transmission-Based Precautions revealed in part, Contact precautions .staff and visitors wear gloves (clean, non-sterile) when entering the room .Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potential contaminated surfaces with clothing after gown removed . 1. Record review for Resident ID #77 revealed that s/he was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, Methicillin Resistant Staphylococcus Aureus (MRSA, an MDRO) and type 2 diabetes mellitus. Record review revealed that the resident has wounds to his/her bilateral feet. Record review revealed a physician's order dated 12/12/2024 for contact precautions for MRSA in the wounds. Review of the signage posted outside of the resident's room on 12/30/2024 revealed the resident was on contact precautions and indicated to wear a gown and gloves prior to room entry. During a surveyor observation on 12/30/2024 at 12:04 PM revealed Nursing Assistant, Staff P, enter Resident ID #77's room without wearing a gown and gloves prior to entering the room. During a surveyor interview immediately following the above mentioned observation, Staff P acknowledged the signage outside of Resident ID #77's room and that she failed to wear a gown and gloves prior to entering the room. 2. Record review for Resident ID #153 revealed that s/he was admitted to the facility in June of 2024 with a diagnosis including, but not limited to, MRSA. Record review revealed a physician's order dated 12/5/2024 for contact precautions for MRSA in the resident's urine. Review of signage posted outside of the resident's room on 12/30/2024 revealed the resident was on contact precautions and indicated to wear a gown and gloves prior to entering the room. During a surveyor observation on 12/30/2024 at 10:34 AM revealed Licensed Practical Nurse, Staff C, enter Resident ID #153's room without wearing a gown or gloves prior to entering the room. During a surveyor interview immediately following the above mentioned observation, Staff C, acknowledged the signage posted outside of Resident ID #153's room and that she failed to wear a gown and gloves prior to entering the room. 3. Record review for Resident ID #330 revealed that s/he was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, Extended-spectrum beta-lactamases (ESBL, an MDRO). Record review revealed a physician's order dated 12/30/2024 for contact precautions for ESBL in the resident's urine. Review of the signage posted outside of the resident's room on 12/30/2024 and 12/31/2024 revealed the resident was on contact precautions and indicated to wear a gown and gloves prior to entering the room. During a surveyor observation on 12/30/2024 at 12:06 PM revealed Maintenance Staff, Staff Q, enter Resident ID #330's room without wearing a gown prior to entering the room and removed the resident's mattress from his/her bed. During a surveyor interview immediately following the above mentioned observation, Staff Q acknowledged the signage posted outside of Resident ID #330's room and that he failed to wear a gown prior to entering the room. During a surveyor observation on 12/31/2024 at 10:45 AM revealed an Occupational Therapist, Staff R, enter Resident ID #330's room without wearing gown or gloves prior to entering the room and placed her laptop on the resident's dresser in his/her room. During a surveyor interview immediately following the above mentioned observation, Staff R acknowledged the signage posted outside of Resident ID #330's room but thought that it was only for direct contact and not upon room entry. During a surveyor observation on 12/31/2024 at 11:00 AM revealed Activity Aide, Staff S, enter Resident ID #330's room without wearing a gown or gloves prior to entering the room. During a surveyor interview immediately following the above mentioned observation, Staff S acknowledged the signage posted outside of Resident ID #330's room and that she failed to wear a gown and gloves prior to entering the room. 4. Record review for Resident ID #332 revealed that s/he was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, MRSA. Record review revealed a physician's order dated 12/24/2024 for contact precautions for MRSA in the resident's nares. Review of signage posted outside of the resident's room on 12/30/2024 and 12/31/2024 revealed the resident was on contact precautions and indicated to wear gloves and a gown prior to entering the room. During a surveyor observation on 12/31/2024 at 10:48 AM revealed Certified Occupational Therapy Assistant, Staff T, enter Resident ID #332's room without wearing a gown or gloves prior to entering the room. During a surveyor interview immediately following the above mentioned observation, Staff T acknowledged the signage posted outside of Resident ID #332's room but thought that it was only for direct contact and not upon room entry. During a surveyor interview with the Infection Preventionist on 1/2/2025 at 9:55 AM, she revealed that she would expect staff to put on a gown and gloves prior to entering a resident's room who is on contact precautions. During a surveyor interview on 12/31/2024 at 2:24 PM with the Director of Nursing Services and the Administrator, they revealed they would expect staff to put on a gown and gloves prior to entering a resident's room who is on contact precautions. 47279

46539 47279 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 2 of 2 residents observed for wound care, Resident ID #s 33 and 77, 1 of 2 residents reviewed for the utilization of a Freestyle Libre sensor (a continuous glucose monitoring system that is designed to replace finger sticks and lessen the need for test strips for people with diabetes), Resident ID #20, 1 of 1 resident reviewed for hand splints, Resident ID #33, and 1 of 1 resident reviewed for the use of a hot pack (a pack that delivers heat to relax the muscle), Resident ID #103. Findings are as follows: 1. Record review for Resident ID #77 revealed that s/he was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, Methicillin Resistant Staphylococcus Aureus (MRSA, an antibiotic resistant infection) and type 2 diabetes mellitus. Review of the care plan revealed that the resident has bilateral foot wounds with an intervention to administer treatments, as ordered. Record review revealed that Resident ID #77 had increased drainage to his/her left foot on 12/23/2024 and the physician was contacted. Additionally, an order was obtained to complete the wound dressing to the resident's left foot wounds twice a day. Review of the resident's Minimum Data Set assessment dated [DATE] revealed a Brief Mental Status score of 15 out of 15, indicating intact cognition. Review of the December 2024 Treatment Administration Record (TAR) revealed the wound dressing was not changed twice a day per the physician's order on 12/24/2024, 12/29/2024 and 12/30/2024. During a surveyor observation and interview on 12/31/2024 at approximately 11:00 AM with Licensed Practical Nurse (LPN), Staff C and Unit Manager, Staff D, the left foot dressing was dated 12/30/2024 with the initials of LPN, Staff U. Staff C and D revealed, Staff U worked the first shift on 12/30/2024, indicating that this dressing was not changed on 12/30/2024 on the second shift, as ordered. Additionally, during this observation, the dressing had dried drainage on the outside of the dressing. During a surveyor interview on 12/31/2024 at approximately 11:00 AM during the dressing change with Resident ID #77, the resident revealed to the surveyor that his/her dressing should be changed twice a day and that it has not been. During a surveyor interview on 1/2/2025 at 1:21 PM with Nurse Practitioner, Staff B, she revealed that she would expect the dressing to be changed twice a day, per the physician's order. During a surveyor interview on 1/2/2025 at 1:31 PM with the Director of Nursing Services (DNS), she revealed that she would expect the dressing to have been completed twice a day, per the physician's order. Additionally, she was unable to provide evidence that the physician's order was followed on 12/24/2024, 12/29/2024 and 12/30/2024. 2. Record review revealed Resident ID #33 was admitted to the facility in November of 2012 with a diagnosis including, but not limited to, persistent vegetative state. Review of the care plan revealed that the resident has a stage 4 pressure ulcer (the most severe stage, with full-thickness tissue loss and exposed bone or muscle) to his/her coccyx (tailbone) with an intervention to administer treatments, as ordered. Review of a physician's order dated 12/19/2024 revealed to wash his/her coccyx wound with vashe (wound cleanser) and allow it to soak for 5 minutes, followed by silvagel and calcium alginate with silver (wound treatments) followed by a silicone bordered gauze (wound dressing), twice daily. During a surveyor observation of the resident's wound treatment on 12/31/2024 at 11:38 AM, with LPN, Staff A, she was observed to soak the wound with vashe for approximately 2 minutes, instead of allowing the vashe to soak for 5 minutes, as ordered. During a surveyor interview following the above-observation with Staff A, she would not acknowledge that did she not follow the order. Further record review revealed that the resident is followed by a wound physician for his/her coccyx wound. Additionally, the wound was reevaluated on 1/1/2025 with recommendations to continue with the 5-minute soak of vashe. During a surveyor interview on 1/2/2025 at 1:10 PM with the Nurse Practitioner, Staff B, she indicated that she would expect that staff would follow the physician order and allow the wound to soak with vashe for the full 5 minutes. During a surveyor interview on 1/2/2025 at 1:21 PM with the DNS, she indicated that she would expect the staff to follow the physician's order. 3. Record review revealed Resident ID #20 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, type 2 diabetes, and chronic kidney disease. During a surveyor observation and interview on 1/2/2025 at approximately 12:00 PM, the resident was observed to have a freestyle libre2 system placed on his/her upper posterior (back) left arm. The resident indicated that it is used daily to check his/her blood glucose. Record review of the physician's orders failed to reveal an order for the freestyle libre2, how often to change the device, or to monitor for any complications such as, infection or if the device is not working. Record review of the care plan failed to reveal the use of the freestyle libre2 as the method of glucose (blood sugar) monitoring or any interventions to mitigate risk. During a surveyor interview on 1/2/2025 at approximately 3:00 PM with the Assistant Director of Nursing Services, she acknowledged that the resident was utilizing a freestyle libre2 sensor for glucose monitoring and that there was no physician's order or a care plan in place. 4. Record review revealed Resident ID #33 was admitted to the facility in November of 2012 with a diagnosis including, but not limited to, persistent vegetative state. Review of a physician's order dated 8/14/2024 revealed an order to apply resting hand splints to both hands with morning care and remove them during evening care, daily. Surveyor observations revealed the resident was without either hand splint in place on the following dates and times: -12/30/2024 at 11:10 AM -12/31/2024 at 11:38 AM -1/2/2025 at 9:11 AM and 11:34 AM During a surveyor interview following the above observation on 1/2/2025 at 11:34 AM with Nursing Assistant (NA), Staff F, he acknowledged that the resident was not wearing either hand splint. He revealed that he was the NA assigned to his/her care that morning and revealed that he had already completed his/her morning care. Further, he acknowledged that both hand splints were observed on the nightstand and revealed that he was unsure if the resident utilizes them. During a surveyor interview on 1/2/2025 at 11:37 AM with the LPN, Staff A, she revealed that the resident wears hand splints daily and that they should be on. During a surveyor interview on 1/2/2025 at 1:21 PM with the DNS, she revealed that she would expect the staff to follow the physician's order. 5. Record review revealed Resident ID #103 was admitted to the facility in February of 2021 with diagnoses including, but not limited to, type 2 diabetes and pain. Record review of a physician's order dated 12/10/2024 revealed to apply a hot pack for 15 minutes, as needed every 8 hours, for back pain. During the Medication Administration Task on 1/2/2025 at 10:20 AM with the Certified Medication Technician, Staff G, she was observed applying the hot pack to the resident's back. During further observation on 1/2/2025 at 12:07 PM, Staff G was observed entering the resident's room where she removed the hot pack from the resident's back, which was approximately two hours later. During a surveyor interview with Staff G following the removal of the hot pack, she indicated that she placed the hot pack on the resident's back at 10:20 AM and that she does not know how long the hot pack was supposed to be applied for. During a surveyor interview on 1/3/2025 at approximately 11:00 AM with the Director of Nursing Services, she indicated that she would expect the staff to follow the physician's order.

Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that a resident is provided assistive devices to prevent accidents relative to smoking for 1 of 1 resident reviewed, Resident ID #41. Findings are as follows: Review of a facility policy revealed that a smoking assessment will be completed upon admission, quarterly, and when a resident chooses to change their smoking decision. Additionally, it reveals that the resident must be dressed appropriately per the care plan. Record review revealed that the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, traumatic brain injury, schizoaffective disorder, and epilepsy. Review of a Smoking Evaluation dated 10/15/2024 revealed that the resident utilizes a smoking apron. Review of a care plan dated 10/14/2024 revealed that the resident is a smoker with an intervention including, but not limited to, s/he is able to smoke safely with a smoking apron in place at times. Further review failed to reveal evidence when a smoking apron would need to be applied. During a surveyor observation on 1/2/2025 at 10:38 AM in the presence of Registered Nurse (RN), Staff H, of the resident smoking, s/he was not wearing a smoking apron. During the observation the ashes from the resident's cigarette were observed to be landing on his/her pajama pants. During a surveyor interview immediately following the above observation with Staff H, he acknowledged that the resident was not wearing a smoking apron and that the ashes had been landing on his/her pajama pants. Additionally, Staff H acknowledged that the resident's care plan revealed s/he is able to smoke safely with a smoking apron at times. Staff H, indicated they were not aware of when the resident should wear a smoking apron. During a surveyor interview on 1/2/2025 at 11:06 AM with the Assistant Director of Nursing she acknowledged that the resident's smoking assessment revealed that s/he should be utilizing a smoking apron. Record review revealed an order was put in place on 1/2/2025 to utilize a smoking apron with all smoking breaks after it was brought to the facility's attention by the surveyor. During a surveyor interview on 1/2/2025 at 11:20 AM with the Director of Nursing Services (DNS) she acknowledged that the care plan and the most recent smoking assessment revealed the resident should be utilizing a smoking apron. The DNS further revealed that the resident refuses use of the smoking apron at times but was unable to provide evidence of the refusals.

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 7 of 8 residents reviewed receiving Coumadin (an anticoagulant medication that is used to prevent harmful blood clots from forming or growing larger), Resident ID #s 1, 4, 5, 6, 7, 8 and 9. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, atrial fibrillation (an irregular heartbeat often causing blood to flow inadequately through the heart) and long-term use of anticoagulants. Record review revealed a physician's order dated 3/27/2024 for Coumadin 0.5 mg [milligrams] by mouth at bedtime for treating/preventing blood clots. Give with 1 mg tablet to equal 1.5 mg. Record review of a laboratory report dated 4/8/2024 indicated the resident's INR (international normalized ratio-a blood test that measures how long it takes for your blood to clot and the results are used when dosing Coumadin) was elevated with a result of 4.5 (an INR between 2.0 and 3.0 is the therapeutic range for patients receiving Coumadin therapy. An INR greater than 3.0 poses a higher risk of bleeding). Further review at the bottom of the document revealed a hand-written order signed by the Registered Nurse Practitioner (RNP), Staff D, to Hold Coumadin 4/8 + 4/9 Recheck .INR on 4/10. Record review revealed a nursing progress note dated 4/8/2024 at 2:44 PM which states, HOLD coumadin 4/8 and 4/9 re-check .INR on 4/10. Further review of the record failed to reveal evidence of an order to hold the Coumadin on 4/8/2024 and 4/9/2024. Record review of the April 2024 Medication Administration Record (MAR) revealed the Coumadin 0.5 mg was signed off as administered on 4/8/2024. Additional record review of a nursing progress note dated 4/10/2024 at 2:58 AM, indicated the resident had an unwitnessed fall in his/her bedroom. Additionally, the on-call provider was contacted and ordered the resident to be sent to an acute care hospital for an evaluation due to the fall and that the resident was on Coumadin therapy. Further record review revealed a progress note dated 4/10/2024, authored by RNP, Staff D, which states in part, .Returned from ER [emergency room ] visit, review of discharge instructions .past medical history of a-fib on Coumadin .[resident] was sent to the hospital after an unwitnessed fall .[S/he] had an elevated INR of 10.7 [critically high value, indicating the blood is taking a long time to clot and there is a high risk for bleeding] in ER ,d+[DATE]] and was given Vitamin K [a medication used to assist in normalizing an excessively elevated INR] 2.5mg PO [by mouth]. Instructed to hold Coumadin x 48 hrs [hours] and recheck INR on 4/12 . During a surveyor interview on 4/25/2024 at 11:07 AM with RNP, Staff D, she acknowledged that she ordered to hold the resident's Coumadin on 4/8/2024 and 4/9/2024, and she was unaware that the resident had received Coumadin on 4/8/2024. During a surveyor interview on 4/25/2024 at 11:50 AM with the Director of Nursing Services (DNS), she acknowledged that the order to hold Coumadin was not transcribed and that the medication should have been held on 4/8/2024, as ordered. During a surveyor interview on 5/1/2024 at 12:06 PM with Registered Nurse, Staff G, she acknowledged that she received an order on 4/8/2024 to hold the resident's Coumadin on 4/8/2024 and 4/9/2024. Additionally, she was unable to explain why she did not transcribe to hold the Coumadin 0.5 mg order. 2. Record review revealed Resident ID #4 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, atrial fibrillation and long-term use of anticoagulants. Record review revealed a progress note dated 4/1/2024, authored by RNP, Staff F, states in part, .Assessment and Plan .NEW ORDER increase Coumadin to 4.5 mg NEW ORDER: repeat INR .1 week . Record review revealed a physician's order dated 4/1/2024 for Coumadin 4.5 mg by mouth in the evening for 7 days. Further review of the order revealed the Coumadin start date was entered as 4/1/2024 at 8:00 PM and the Coumadin stop date was entered as 4/8/2024 at 7:59 PM, which was 1 minute prior to the 8:00 PM scheduled administration time on 4/8/2024, indicating a transcription error. Further record review of the April 2024 MAR failed to reveal evidence of the scheduled order for an INR on 4/8/2024. Additional record review failed to reveal evidence that the Coumadin was administered to the resident on 4/8/2024, resulting in a missed dose. Record review revealed an INR was completed on 4/9/2024, resulting in an INR of 2.0. Record review of a provider progress note dated 4/9/2024, states in part, .INR reviewed Assessment and Plan .NEW ORDER Coumadin 5.0 mg po once a day thru end of 4/15 Recheck [INR] on 4/16 . Record review revealed a physician's order dated 4/9/2024 for Coumadin 5 mg by mouth in the evening until 4/15/2024. Further review revealed an INR was completed on 4/16/2024 with an INR result of 2.5. Record review of the laboratory report dated 4/16/2024 revealed a handwritten order at the bottom of the report, signed by RNP, Staff D which reads, Reviewed cont [continue] current dose of coumadin (5 mg po daily) Recheck .INR in 1 week . Record review revealed a physician's order dated 4/16/2024 for Coumadin 5 mg by mouth in the evening .until 4/22/2024. Further review of the order revealed the Coumadin start date was entered as 4/17/2024 at 6:00 PM and not 4/16/2024 and the Coumadin stop date was entered as 4/22/2024 at 10 AM, which was 8 hours prior to the scheduled administration time of 6 PM, indicating a transcription error. Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/16/2024 and 4/22/2024, resulting in 2 missed doses. During a surveyor interview on 5/2/2024 at 1:24 PM with Licensed Practical Nurse (LPN), Staff H, she was unable to explain why the resident was not administered his/her Coumadin on 4/8/2024, suggesting the order may have fallen off of the MAR. Additionally, she could not explain why the INR order was not transcribed on 4/8/2024. 3. Record review revealed Resident ID #5 was admitted to the facility in August of 2022 with diagnoses including, but not limited to, atrial fibrillation and prosthetic heart valve (an artificial valve that is implanted to replace their native heart valve). Record review revealed a physician's order dated 3/27/2024 for Coumadin 5 mg by mouth in the evening for 5 days. Further review of the order revealed the Coumadin start date was entered as 3/27/2024 at 6:00 PM and the Coumadin stop date was entered as 4/1/2024 at 5:59 PM, which was 1 minute prior to the 6:00 PM scheduled administration time, indicating a transcription error. Record review of a progress note dated 4/2/2024 and authored by RNP, Staff F, states in part, .Assessment and Plan .INR -2.0 NEW ORDER: increase coumadin to 5.5 mg once daily x 7 days and repeat .INR .7days . Record review of the physician's orders failed to reveal a Coumadin order for 4/2/2024. Additional record review revealed an order for Coumadin 5 mg by mouth in the evening for 7 days with a start date of 4/3/2024 instead of 4/2/2024 and an incorrect Coumadin dose of 5 mg instead of Coumadin 5.5 mg daily, indicating a transcription error. Record review of a provider progress note dated 4/10/2024 and authored by RNP, Staff F, states in part, .Assessment and Plan .INR -2.1 NEW ORDER: increase coumadin to 5.5 mg once daily x 7 days and repeat .INR .7 days . Record review of a nursing progress note dated 4/10/2024 and authored by LPN, Staff B, states, INR reported, orders obtained to continue with 5 mg po qd [daily], recheck INR 4/17. Record review revealed an order with a start date of 4/10/2024 for Coumadin 5 mg in the evening until 4/16/2024, instead of Coumadin 5.5 mg daily, indicating a transcription error. Record review of the provider progress notes, revealed a note dated 4/24/2024 and authored by RNP, Staff F, states in part, .Assessment and Plan .INR -2.6 NEW ORDER: c/w coumadin 5.5 mg once daily x 7 days and repeat .INR .7 days . Record review revealed two orders for Coumadin with a combined total dose of Coumadin 5.5 mg daily, with a start date of 4/24/2024 and a stop date of 4/29/2024, indicating the order was incorrectly transcribed for 6 days instead of the ordered 7 days. Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/1/2024, 4/2/2024 and 4/30/2024, indicating the resident missed 3 doses. Additional review of the MAR revealed the Coumadin 5 mg was signed off as administered daily, instead of the ordered 5.5 mg dose from 4/3/2024 through 4/16/2024, resulting in the resident receiving the incorrect dose of Coumadin for 14 days. During a surveyor interview on 5/2/2024 at 2:40 PM with RNP, Staff F, after reviewing her written progress notes dated 4/3/2024 and 4/10/2024 and the transcribed orders with her, she revealed the orders were transcribed incorrectly, and she would have expected Resident ID #5 to receive Coumadin 5.5 mg daily as ordered on 4/3/2024 and 4/10/2024. 4. Record review revealed Resident ID #6 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, atrial fibrillation. Record review revealed a physician's order dated 4/27/2024 at 9:24 AM to repeat INR today and hold the Coumadin until INR was rechecked. Record review revealed a physician's order dated 4/27/2024 to obtain an INR. Record review failed to reveal evidence of the INR results on 4/27/2024. Further record review failed to reveal evidence of a physician's order to obtain an INR on 4/28/2024 or INR results for 4/28/2024. Record review failed to reveal a Coumadin order for 4/27/2024 and 4/28/2024. Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/27/2024 and 4/28/2024, resulting in 2 missed doses. During a surveyor interview on 5/2/2024 at 2:36 PM with the DNS, she was unable to provide evidence of the ordered INR results for 4/27/2024. 5. Record review revealed Resident ID #7 was admitted to the facility in June of 2021 with a diagnosis including, but not limited to, atrial fibrillation. Record review revealed a physician's order dated 4/18/2024 at 6:05 PM for Coumadin 4 mg by mouth in the evening until 4/25/2024. Further review of the order revealed the Coumadin start date was entered incorrectly for 4/19/2024, instead of 4/18/2024, indicating a transcription error. Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered to the resident on 4/18/2024, resulting in a missed dose. 6. Record review revealed Resident ID #8 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, acute embolism (a foreign substance that moves in the blood stream until it blocks a vessel) and thrombosis (blood clot). Record review revealed a physician's order dated 4/2/2024 for Coumadin 4 mg by mouth in the evening for 6 days. Further review of the order revealed the Coumadin start date was entered incorrectly for 4/3/2024 at 6:00 PM, instead of 4/2/2024, indicating a transcription error. Further review of the orders revealed an order dated 4/9/2024 for Coumadin 4 mg by mouth in the evening for 6 days. Further review of the order revealed the Coumadin start date was entered as 4/9/2024 at 6:00 PM and the Coumadin stop date was entered as 4/15/2024 at 5:59 PM, which was 1 minute prior to the 6:00 PM scheduled administration time, indicating a transcription error. Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/2/2024 and 4/15/2024, resulting in 2 missed doses. 7. Record review revealed Resident ID #9 was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, atrial fibrillation. Record review revealed a physician's order dated 4/15/2024 to hold Coumadin on 4/15 and 4/16/2024, obtain the INR on 4/17/2024. Record review of the laboratory report dated 4/17/2024 revealed a handwritten order at the bottom of the report, signed by RNP, Staff F, which reads, 1. Hold coumadin today 2. Repeat .INR tomorrow [4/18] . Record review revealed a physician's order dated 4/18/2024 for Coumadin 3 mg by mouth in the evening. Further review of the order revealed the Coumadin start date was entered incorrectly as 4/19/2024 instead of 4/18/2024, indicating a transcription error. Record review of the April 2024 MAR failed to reveal evidence that the Coumadin was administered on 4/18/2024, resulting in a missed dose. During a surveyor interview on 5/2/2024 at 2:36 PM with the Administrator, Director of Nursing Services, Regional Director of Clinical Services and VP of Clinical Services, when the above-mentioned findings were reviewed, they acknowledged that the above-mentioned Coumadin and INR transcription errors resulted in significant medication errors.

Based on record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 2 residents reviewed with pressure ulcers (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #1. Findings are as follows: According to the State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities, revised 2/3/2023 states in part, A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must .Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter .Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors .If a PU/PI is present, provide treatment and services to heal it and to prevent .It is important that each existing PU/PI be identified, whether present on admission or developed after admission .Any new PU/PI suggests a need to reevaluate the adequacy of prevention measures in the resident's care plan. When assessing the PU/PI itself, it is important that documentation addresses: - The type of injury (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of injury; - The PU/PI's stage; - A description of the PU/PI's characteristics; - The progress toward healing and identification of potential complications; - If infection is present; - The presence of pain, what was done to address it, and the effectiveness of the intervention; and - A description of dressings and treatments . Record review revealed the resident was admitted to the facility in March of 2024 with diagnoses including, but not limited to, a Stage 2 pressure injury (shallow open ulcer) to the buttocks, adult failure to thrive and pneumonia. Record review of the nursing progress notes revealed a note dated 4/1/2024, authored by Licensed Practical Nurse, Staff A, which states in part, .Skin/Wound : New changes in Skin Integrity resident has redness, non-blanchable [Stage 1 pressure injury-observable pressure related alteration of intact skin reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device] on right .heel encouraged heel to be elevated . During a surveyor interview on 4/25/2024 at 9:44 AM with Staff A, she acknowledged that the resident had a Stage 1 pressure injury identified by her on 4/1/2024. When asked if she had notified the provider of the pressure injury, she could not say. Additionally, she was unable to explain why a treatment was not implemented for the resident's pressure injury. Record review of the weekly skin checks dated 4/12/2024 and 4/19/2024 indicated the resident had a pressure injury to his/her right heel. Additionally, no further description of the wound was documented. Record review of the physician's orders failed to reveal evidence of a treatment to the resident's Stage 1 pressure injury to his/her right heel. During a surveyor interview on 4/25/2024 at 11:55 AM with the Director of Nursing Services, she revealed that she was unaware of a pressure injury to the resident's right heel. Additionally, she was unable to provide evidence that a treatment was implemented when the pressure injury was first identified.

Based on surveyor observation, record review, staff and representative interview, it has been determined that the facility failed to ensure the residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and were offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 2 of 4 residents reviewed for nutrition, Resident ID's #23 and #136. Findings are as follows: 1. Resident ID #23 was admitted to the facility in April of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent quarterly minimum data set assessment dated [DATE] revealed the resident had a moderate cognitive impairment, required extensive assist of 1 person for bed mobility and transfer and required set up help for eating. Review of an initial nutrition assessment dated [DATE] revealed the resident's ideal body weight was 114.6 pounds (lbs.) and that s/he required a mechanically altered diet. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an occupational therapy discharge summary dated 6/13/2021 revealed recommendations to get the resident out of bed for improved activity tolerance and overall bodily functions including participating in independent activities of daily living to maintain current skills set. Review of the resident's weight record and progress notes revealed the following weights: -4/13/2021-114.6 lbs. -4/14/2021-115.1 lbs. -4/26/2021-103.4 lbs. -4/30/2021-106 lbs. -5/3/2021-105 lbs. -5/10/2021-105.2 lbs. -5/27/2021-103 lbs. -6/14/2021-102.8 lbs. -7/1/2021-97 lbs. -7/4/2021-96.6 lbs. -7/8/2021-97 lbs. -7/12/2021-96 lbs. -8/3/2021-88.8 lbs. -8/4/2021-88.8 lbs. -8/18/2021-84.4 lbs. -8/19/2021-84.2 lbs. -8/27/2021-81.1 lbs. The above weights indicate a severe weight loss of 29.23% in a 4-month period. Review of the resident's meal intake documentation and progress notes revealed variable meal intake and meal refusals. Review of a Registered Dietitian (RD) progress note dated 4/14/2021 revealed supplements were recommended between meals to reinforce diet. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's electronic administration record (EMAR) revealed the resident refused supplements for 9 opportunities in May 2021, 23 opportunities in June of 2021, 32 opportunities in July of 2021 and 24 opportunities in August of 2021. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked evidence that a weekly weight was obtained the week of 4/18/2021. Review of an RD progress note dated 5/20/2021 indicates weekly weight pending. The record lacked evidence of a weight obtained between 5/10-5/27/2021. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EMAR revealed the resident refused to be weighed on 6/21, 6/28, 7/19 and 7/26/2021. The record lacked evidence that the physician or the RD were notified of the refusals. Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EMAR revealed the resident refused to be weighed on 8/2, 8/9, 8/16 and 8/23/2021. The record lacked evidence of a nursing note and that the MD or RD were notified of the refusals. Review of a psychiatric progress note dated 8/3/2021 revealed a recommendation for [MEDICATION(S)] 7.5 milligrams (mg) at bedtime for appetite stimulation and an order was placed to start [MEDICATION(S)] daily at bedtime. Review of a rehab screen initiated on 8/12/2021 and completed on 8/13/2021 requested a speech screen due to poor intake. Review of the speech therapy rehab screen revealed recommendations to continue a puree diet. Review of the care plan dated 4/21/2021 revealed a category of nutritional status that indicated the resident was at increased nutritional risk related to being on a therapeutic, modified texture diet and dysphagia. The goal target date was 7/21/2021 to eat greater than or equal to 75% of meal without unintentional weight changes, weight will be 103 pounds +/- 3 lbs. at next review. The care plan lacked evidence to reflect the resident's severe weight loss. Interventions were dated 4/21/2021, no new interventions were reflected on the care plan. Surveyor observation on 8/23/2021 at 9:05 AM revealed 2 boxes of chocolates and a container of small chocolate cupcakes on the resident's bedside table. The resident was observed with a piece of cupcake on his/her clothing and a container of food on the bedside table that appeared to be chopped. Record review failed to reveal evidence of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Nursing Assistant, Staff E, at the time of the observation, she stated the resident's daughter requested the resident eat food that she brought in from home. Staff E indicated she was aware the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor observation on 8/24/2021 at 1:10 PM revealed the resident had eaten approximately ½ of a pudding and the main dish was untouched. At 1:35 PM staff entered, and no attempt was made to encourage or assist the resident with lunch and the tray was removed. Further observation on 8/25/2021 at 9:32 AM revealed the resident's breakfast was untouched on the bedside table. The resident was asleep and lying at approximately a 30-degree angle. The nurse aid came in and covered the food and no attempt was made to encourage or assist the resident. Observation on 8/26/2021 at 9:18 AM revealed breakfast was on the bedside table and was untouched. A nurse aid came into the room and noticed the resident had an accident, left the room and did not return until 10:35 AM (see F600). The nurse aid provided incontinence care and no attempt was made to offer, encourage, or assist the resident with breakfast. During an interview with the resident's daughter on 8/25/2021 at 12:15 PM she revealed she had concerns about the resident's weight and meal intake. She stated they were giving [him/her] mashed potatoes every meal, [s/he] was sick of it. [S/he] leaves every meal. I spoke with them 2-3 weeks ago about a mechanical soft diet at [his/her] age I want [him/her] to eat what [s/he] likes. They never got back to me. Things don't happen .[s/he] is not headed in a good direction, [s/he] is starving to death. [s/he] needs someone to feed [him/her] . During an interview with Speech Therapist, Staff F, on 8/26/2021 at 1:29 PM, she stated the resident's family spoke to nursing and nursing initiated a rehab screen on 8/12/2021 to assess for a diet upgrade. Review of the speech screen revealed the following: Upon arrival, patient was alert and responsive, yet in a very poor position. [S/he] was assisted with 90-degree elevation for intake and was compliant throughout evaluation. Patient was observed to have candy in [his/her] room that was non-compliant with [his/her] diet recommendations. Staff informed and aware. [S/he] consumed 1 of the two scoops of pureed mashed potatoes without difficulty .Recommendations were provided for the continued intake of a puree diet with thin liquids upon completion of the evaluation. Nursing and CNAs informed of recommendations, as well as to ensure patient is in proper upright position for all intake and to remain in this position following intake as the patient was observed attempting to lower [his/her] HOB [head of bed] immediately following intake. Recommendations also provided for continued intake of preferred foods, including mashed potatoes as well as chocolate supplements which [s/he] appeared to enjoy. During an interview with the RD on 8/26/2021 at 11:34 AM she stated she was aware of the resident's weight loss. She stated she had trialed ensure clear (a nutrition drink), but the resident did not like it. Record review failed to reveal that the resident was offered any other interventions of high calorie food/drink when s/he disliked supplement of ensure clear. She stated she implemented weekly weights and was waiting for a reweigh to reevaluate the effects of the appetite stimulant. She was unaware that a weight had been obtained on 8/19/2021 following her request. Review of a progress note dated 8/19/2021 written by the RD revealed discussed at risk meeting r/t [related to] poor intakes and altered appetite. Recent fall and started on [MEDICATION(S)] 7.5 mg with no positive effect at this time. Requested re wt [weight] for verification of weight loss as indicative of 12.1% x 1 m [month] . She was unable to explain why she had not addressed her concern of the appetite stimulant not being effective. She could not provide evidence of any additional interventions for the resident's severe weight loss. Additionally, she was unaware of the chocolates and cupcakes in the resident's room and stated she had not followed up with the resident's daughter relative to a diet upgrade. During an interview with the resident's physician on 8/27/2021 at 9:48 AM he stated he was aware the resident had lost weight and was on a puree diet. He was alarmed to see how severe the resident's weight loss was and stated he usually reevaluates the effectiveness of an appetite stimulant after 1-2 weeks. He went on to state other interventions could have been put into place such as communal dining with supervision and/or an alternative appetite stimulant. 2. Resident ID #136 was admitted to the facility in July of 2021 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set Assessment (MDS) revealed a Brief Interview of Mental Status score of 99 indicating that the resident was unable to complete the interview. The MDS further revealed that the resident requires extensive assist of 1 person for bed mobility and transfer and requires full assistance with eating. Review of resident's care plan dated 7/30/2021 revealed that the resident is at increased risk for alteration in nutrition and lists a goal that resident will eat greater than or equal to 75% of meal without unintentional weight changes. Review of the initial Nutritional Evaluation Assessment performed by the RD dated 7/30/2021 revealed a significant weight change in the last month, assessment indicated that the resident appeared to be meeting his/her needs regarding documented intakes and supplements, and they will proceed to care plan, and monitor intake and weight trends. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor observations of the resident revealed the following: -8/24/2021 at 9:01 AM- Resident not out of bed, already had breakfast. -8/25/2021 at 8:47 AM- Resident not out of bed, already had breakfast, food debris on johnny. -8/26/2021 at 9:05 AM- Resident not out of bed, already had breakfast. Review of residents' weights since admission revealed the following: -7/20/2021- 169 pounds -7/21/2021- 169.3 pounds -7/22/2021- 166.7 pounds -7/23/2021- 163.8 pounds -7/26/2021- 153.8 pounds -8/02/2021- 156.5 pounds -8/03/2021- 157.5 pounds -8/13/2021- 147.2 pounds -8/16/2021- 153.3 pounds The above weights indicate a 9.29% weight loss from 7/20/2021 to 8/16/2021. Review of resident's documented meal intakes revealed that the resident ate 75-100% of most meals documented but failed to reveal evidence of meal intake for 36 meals from 7/21/2021 to 8/24/2021. During a surveyor interview with the RD on 8/26/2021 at 11:38 AM, she revealed that the facility has risk meetings weekly on Thursday where weight loss is discussed. She further indicated that the resident is eating between 75-100% of his/her meals and taking his/her house supplements. The RD revealed that the resident's family member voiced concerns that she did not want the resident over-fed due to history of regurgitation when eating too much. She further acknowledged that she was unaware of the total amount of weight the resident had lost since admission and further interventions will have to be put in place. During a surveyor interview with the physician on 8/27/2021 at 9:58 AM, he revealed that he was unaware of the significant weight loss since admission and indicated that he will be reviewing the resident's case and be putting interventions into place.

Based on surveyor observation, record review and staff interviews, it was determined the facility has failed to ensure that safety devices (seat alarm) are in place to prevent avoidable accidents for 1 of 2 sample residents (ID # 3) who have impaired safety awareness and when indicated on the plan of care. Findings are as follows: Resident ID# 3 has a facility admission date of [DATE] with primary [DIAGNOSES REDACTED]. Review of Nursing Progress Notes dated 4/18/2015 and 5/12/2015 reveal that the resident has had unobserved falls. Documentation reveals that on 4/18/2015, the resident was attempting to get-up from the chair to transfer to bed without calling for assistance and fell hitting the back of his/her head against the dresser sustaining a scalp laceration requiring staples to close the wound. On 5/12/2015, documentation reveals that the resident was found on the floor after telling staff that s/he slid off the bed. Review of the facility's Fall Scene Investigation Report reveals that on 4/18/2015 at 9:10 PM, the resident was found on the floor in his/her room after attempting to transfer from the chair without calling for assistance. Additional documentation reveals that the resident's alarm was missing and that the bed/chair alarms were not being used at the time of the resident's fall. Review of the resident's plan of care dated 12/23/2014 identifies falls as a problem with an approach dated 2/12/2015 to use a chair alarm. Surveyor observations on 5/21/2015 at 10:00 AM finds the resident sitting in his/her room in a wheelchair and self-propelling with his/her feet. Further observations revealed that there was no chair alarm attached to this wheelchair. During an interview at 11:45 AM with the resident's primary Nursing Assistant (NA) (A), she reports, As soon as the resident activates his/her call light, we go to the room right away because s/he won't wait for us to transfer and has fallen a couple of times. When interviewing the medication aide, immediately following the above interview, she reports that the resident is supposed to have a chair alarm. However, after searching the wheelchair, bedside drawer, and surrounding area, she was unable to locate a chair alarm. When conducting a consecutive interview with the resident's primary NA, she was unable to explain why a chair alarm was not attached to the resident's wheelchair. During an interview at 12:00 PM, with the unit Charge Nurse, she stated, He/she use to have a chair alarm but was unable to explain why it could not be found in the resident's room, stating, We are getting him one right away. At 3:10 PM, when conducting an additional interview with a NA (B), who was assigned to the resident on the previous day, she stated, I have taken care of him/her 5 to 6 times in the last couple of weeks and I knew s/he had a bed alarm but I never saw a chair alarm. Review of the resident's Treatment Administration Record (TAR) reveals that from 5/1/2015 through 5/20/2015 the nursing staff have documented that a chair alarm is being used during all three shifts. When interviewing the Director of Nursing Services at 3:12 PM, she was unable to explain why the resident did not have a chair alarm attached to his/her wheelchair as indicated on the resident's plan of care. 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.