Every finding on record at Roberts Health Centre Inc

Based on clinical record review and staff interview, the facility failed to timely notify the physician/provider of a newly identified pressure ulcer (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence). As a result, the resident did not receive timely assessment, treatment, or implementation of appropriate wound care interventions, for 1 of 1 resident reviewed, Resident ID #20, who had an actual pressure injury, did not receive clinically indicated wound treatment for approximately 21 days. Consequently. the wound was later found to be infected with Methicillin-Resistant Staphylococcus aureus (MRSA- a bacteria that has become resistant to many commonly used antibiotics, including methicillin and other penicillin-related drugs). Findings are as follows:Record review of an undated facility policy titled, Skin Care Protocol states in part, .It is the policy of this facility to follow appropriate standards of care as they relate to residents' skin care; identification of those at risk, weekly skin checks, appropriate interventions and documentation.All residents will have a skin 'check'/assessment done on admission.The nurse will also complete the Braden Scale observation tool [an assessment used to determine a resident's risk for skin breakdown].weekly skin observations will be done for every resident regardless of their risk score.Monitoring: weekly observations will be done and maintained in the residents' medical record and care plans must be kept up to date with the resident's most recent condition and treatment. Documentation: when a pressure ulcer [an area of damaged skin or tissue caused when sustained pressure reduces blood flow to vulnerable areas of the body] exists, there must be daily monitoring. Documentation of the wound status shall include: an evaluation of the ulceran evaluation of the status of the dressing, if it is present (whether it is intact and whether drainage is present, is or is not leaking)the status of the area surrounding the ulcer (that can be observed without removing the dressing)the presence of possible complications such as; signs of increasing area of ulceration or soft tissue infection (for example, increased redness or swelling around the wound or increased drainage from the wound)With each dressing change or at least weekly, the following documentation must be present:Location and stagingSize, depth.exudate, if present; nature and frequencypain, if present; type, color, odor, and approximate amountwound bed color and type of tissue/character including evidence of healing (i.e. granulation), or necrosis (slough/eschar) [dead tissue] and description of wound edges and surrounding tissue (i.e. rolled edges, redness, hardness, maceration) as appropriate.The physician and the resident's representative shall be made aware of any pressure ulcers and significant changes in the resident's condition.Record review revealed Resident ID #20 was admitted to the facility on [DATE] with diagnoses including, but not limited to, thoracic vertebra wedge compression fracture (a small breaks or crack in the vertebrae), rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness), and MRSA. Record review of a physician's order dated 4/3/2026, revealed to complete weekly skin checks and document findings in the weekly observation report. Record review of a Braden scale dated 4/10/2026, revealed that the resident was assessed to be at risk for the development of pressure ulcers.Record review of the weekly skin check dated 4/25/2026, revealed an open area was observed to the resident's right foot second metatarsal (one of five long bones located in the second toe). Record review of the weekly skin check dated 5/2/2026, revealed an open area to the right second toe.Additional review of the 5/2/2026 skin check revealed documentation that a new treatment was added. Record review of the weekly skin check completed 5/9/2026 revealed an open area approximately 0.5 inches to the right foot second metatarsal.Additional record review failed to reveal evidence of the pressure ulcer stage, description, or characteristics were documented, per facility policy.Record review failed to reveal evidence the provider was notified, that a treatment order was obtained, or that a treatment was provided for the pressure ulcer noted on 4/25, 5/2 and 5/9/2026. Record review of the weekly skin check completed 5/16/2026 revealed a pressure ulcer was observed to the right foot, second toe.Additional record review failed to reveal evidence of the pressure ulcer stage, description, or characteristics were documented, per facility policy.Record review revealed a physician's order dated 5/16/2026 to cleanse the right second toe with saline, pat dry and apply medihoney (a topical wound gel), and cover with clean dressing daily.Record review failed to reveal evidence that a treatment order was implemented for the newly identified pressure ulcer to the resident's right foot second toe from 4/25/2026, when it was initially identified until 5/16/2026. This indicates the resident's pressure ulcer went without a treatment for 21 days.Further record review revealed a care plan initiated on 5/16/2026, indicating the resident has an open area to the right foot second toe. Interventions include, but are not limited to, following up with the wound specialist the next visit. During a surveyor interview on 5/20/2026 at 2:49 PM with Licensed Practical Nurse, (LPN), Staff A, she acknowledged that she observed an open area to the resident's right foot second toe on 4/25/2026 and on 5/9/2026 during their weekly skin check and failed to document the pressure ulcer stage, description, or characteristics. Additionally, she acknowledged she failed to notify the provider or obtain a treatment for the pressure area.During surveyor interviews on 5/20/2026 at 3:05 PM and 5/21/2026 at 8:29 AM with LPN, Staff B, he acknowledged that he observed a wound to the resident's right foot second toe on 5/2/2026 during their weekly skin check. Additionally, he acknowledged that although he documented that a new treatment order was obtained, no treatment was in place for the resident's right second toe wound. Further, he acknowledged he failed to document the staging, measurements, description, and characteristics of the wound.Record review of a wound evaluation progress note dated 5/20/2026, authored by the wound care, Nurse Practitioner revealed, that a consultation was requested for evaluation of an open wound on the patient's right foot second toe. On evaluation the right foot second toe is noted with a full thickness (a wound that extends into the deep layers of the skin such into the fatty tissue) open wound, measuring 0.8 centimeters (cm) by 1.2 cm by 0.2 cm, with moderate serosanguinous drainage (a bloody/clear fluid). Additionally, review revealed the presence of redness, swelling, and warmth to the surrounding tissue. The wound bed is a mix of granulation (healing) tissue and slough (dead) tissue, and the resident endorses mild discomfort to the wound bed. The provider ordered a wound culture for potential infection. Furthermore, record review of the progress note revealed plan of care is to cleanse with Vashe (a wound cleanser), apply honey gel and calcium alginate with silver (an absorbent wound dressing) to the wound bed, and cover with bordered gauze daily. Record review revealed a wound culture was obtained of the resident's right foot, second toe on 5/20/2026.During surveyor interviews on 5/20/2026 at 12:19 PM and on 5/21/2026 at 10:04 AM with Resident ID #20, s/he indicated that the ulcer on his/her right foot second toe has been there for a few weeks and only recently staff began putting a bandage on it. Additionally, s/he indicated that s/he experiences pain when pressure is applied to the ulcer. During surveyor interviews on 5/21/2026 at 9:44 AM and 10:32 AM, the Physician's Assistant (PA) stated she was not made aware of the pressure ulcer to the resident's right second toe until sometime within the past week. She further indicated that she did not evaluate the wound until 5/21/2026. The PA also reported that when she assessed the area, she did not remove the dressing; however, a dressing was in place at the time of evaluation. Upon observation, PA noted that drainage was seeping through the dressing and that the toe was red and swollen. During a surveyor interview on 5/21/2026 at 11:46 AM. with the Physician. he revealed that he had not been made aware that the resident had a new pressure ulcer until it was brought to his attention by the surveyor. Additionally, he indicated it would be his expectation for nursing to notify him and/or the PA of a newly identified pressure ulcer to obtain an order and provide a treatment. During a surveyor interview on 5/21/2026 at 12:01 PM, with the Director of Nursing Services, she was unable to provide documentation of the pressure injury stage, description, or characteristics until 5/20/2026. Additionally, she acknowledged that the resident did not have a treatment order for his/her wound that was identified on 4/25/2026 until 5/16/2026, 21 days after it was identified.Review of a wound culture report received by the surveyor via email from the facility on 5/26/2026 revealed that a culture of the resident's second toe was obtained on 5/20/2026. The culture results, received on 5/23/2026, indicated that the resident's ulcer was infected with MRSA. Due to the facility's failure to timely notify the physician/provider of a newly identified pressure ulcer, the resident did not receive timely assessment, treatment, or implementation of appropriate wound care interventions. As a result, the resident went without clinically indicated wound management for approximately 21 days, during which time the wound progressed without appropriate oversight, resulting in the resident experiencing pain, infection, and avoidable clinical decline.

Based on surveyor observations, clinical record review, and staff and resident interviews, the facility failed to accurately assess, monitor, and provide timely treatment for 1 of 1 resident reviewed, Resident ID #45, after the resident reported toe pain and presented with multiple skin impairments. This failure placed the resident at risk for worsening skin breakdown, increased pain, and potential complications.Findings are as follows:Record review revealed Resident ID #45 was admitted to the facility in April of 2022 with a diagnosis including, but not limited to, peripheral neuropathy (nerve damage that can affect the sensation to the limbs).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15, indicating moderately impaired cognition. Further review of the MDS revealed the resident requires moderate assistance with putting on and taking off his/her socks and shoes.Review of the care plan dated 5/11/2022, last reviewed on 5/18/2026, revealed the resident is at risk for alteration in skin integrity related to a history to cellulitis (an infection of the skin) to the second toe of the right foot. Further review revealed interventions including, but not limited to, a foot cradle on the bed, monitoring the resident's skin with daily care, reporting changes and abnormal findings to the nurse and provider, applying skin prep as ordered, and conducting a skin assessment by a licensed nurse.Review of a podiatry evaluation dated 4/3/2026 revealed, a focused physical exam which included documentation that the resident's skin was thin and atrophic (thinning, fragile skin that is more prone to injury and slower to heal) with hammertoe contractures (a progressive bending deformity of the toes). Further review revealed a recommended treatment to offload with a band-aid or lambswool. Record review revealed the following progress notes:- 4/6/2026 - Followed up with podiatrist office in regard to.recommendation to 'keep offloading the toe with lambswool, pads or bandaids.' Message left for [family member].- 4/7/2026 - Follow up due to new shoes brought in by nephew - no redness to toes and [resident] prefers no padding to toe due to having space in toe box.Record review failed to revealed evidence that the provider was notified of the podiatry treatment recommendations on 4/3/2026.Record review revealed the following progress notes:- 4/17/2026 - the resident's right 3rd and 5th toes and the left 2nd toe continue with redness. Further review revealed improvement was noted and skin prep (a medical product with a film-forming agent that acts as a protective barrier) was continued as ordered.- 4/22/2026 - the resident's right 3rd and 5th toes and the left 2nd toe continue with redness, skin prep continued with no complaint of pain or discomfort. - 4/29/2026- the resident's right 3rd and 5th toes and the left 2nd toe continue with redness, skin prep continued with no complaint of pain or discomfort. Record review of a Weekly Skin/Body Assessment dated 5/5/2026 revealed, the resident's skin was intact and his/her knuckles to toes were pink blanchable [and] chronic.During a surveyor observation and interview on 5/18/2026 at 10:49 AM with Resident ID #45, during the initial tour of the facility, s/he revealed that his/her toes were red, painful, and had gotten worse over the last few weeks. The resident further stated that his/her toes were not as red yesterday and that s/he maybe needs something to cushion it. Surveyor observations revealed the resident's 3rd and 5th toes on the right foot and the 2nd toe of the left foot were reddened. The 3rd toe on the right foot was observed to be swollen. During the above interview, the resident initiated his/her call light for assistance as s/he had unintentionally applied foot cleanser to his/her feet and needed assistance. A staff member entered the room at 10:59 AM to assist the resident. The resident indicated to the staff member that his/her toes were painful. The staff member stated to the resident that she would notify the nurse.Record review of a Weekly Skin/Body Assessment dated 5/19/2026, the day after the resident complained of redness and pain to the surveyor and the surveyor observation of the reddened toes, failed to reveal any skin impairments to the resident's feet. Further review revealed this assessment was completed by Registered Nurse (RN), Staff E.During a surveyor interview on 5/21/2026 at 9:30 AM with Resident ID #45, four days after the initial interview and observation, the resident revealed that his/her right foot is still painful and the facility had not done anything for it.During a surveyor interview on 5/21/2026 at 9:32 AM with RN, Staff E, she revealed that she was aware that the resident previously had issues with his/her toes, had been seen by podiatry, his/her family member brought him/her new shoes, and that a treatment was in place to apply skin prep daily. Additionally, she stated that the resident's toes were not red at the time of the skin assessment that she completed on 5/19/2026, in the presence of Nursing Assistant (NA), Staff F.During a surveyor interview on 5/21/2026 at 9:56 AM with NA, Staff F, she revealed that she assisted Resident ID #45 with a shower on 5/19/2026 at which time she observed the resident's toes to be reddened and painful while she was washing his/her feet. Staff F revealed that she informed the nurse and the nurse applied skin prep to the resident's toes following the nurse's skin check. Additionally, she revealed that she provides care for the resident weekly and that his/her toes have been reddened for a while.Record review failed to reveal evidence that the provider was notified of the painful, reddened toes prior to the surveyor bringing the concern to the facility's attention on 5/21/2026.Record review of a progress note dated 5/21/2026 at 10:36 AM revealed the following:- the resident was noted to have redness to his/her right foot in the outer 5th toe area, blanchable redness to the 3rd toe with a pinpoint scabbed area, and a white, dry, irritated area between the 4th and 5th toes.- the top of the resident's left foot 2nd toe was pink and blanchable- Nurse Practitioner (NP), Staff G was notified and gave new orders for a podiatry consult and treatments- orthopedic shoes removed and old shoes with cut out toe area applied- the resident complained of pain to his/her feet at nightRecord review revealed the following new orders were received on 5/21/2026, following the NP notification:- Apply Iodosorb (a wound gel) to the 3rd toe pinpoint area on the right foot and cover with a bandaid daily- Apply 2x2 gauze between the 4th and 5th toes on the right foot daily- Apply shoes with cutout in toes and remove at bedtimeDuring surveyor interviews on 5/21/2026 at 10:00 AM and at 12:28 PM with the Director of Nursing Services (DNS), she revealed that she would not expect a nurse to document redness to a resident's skin if the redness was chronic and to only document if there was a change or if pain was observed. She further revealed that she would expect the provider to be notified if there was a change in the resident's skin or if pain was assessed.Record review of a progress note received by email from the DNS, dated 5/22/2026 and authored by the NP, Staff G, revealed the resident was noted with an open area/pressure wound on his/her right 3rd toe, to continue with the wound dressing as ordered, and to follow up with the inhouse wound specialist. Further review revealed the resident was to avoid any pressure on the right foot and to begin Ultram 25 milligrams (a medication prescribed to treat pain) daily as needed for 14 days for pain management.The surveyor attempted to contact the resident's Nurse Practitioner (NP), Staff G, on 5/21/2026 at 12:18 PM and on 5/22/2026 at 1:34 PM. A message was left; however, no return phone call was received. Due to the facility's failure to accurately assess the resident's skin condition, recognize changes in skin integrity and complaints of pain, and timely notify the provider, the resident did not receive appropriate treatment and interventions in a timely manner, resulting in worsening skin impairment and further deterioration of the toes.

Based on surveyor observation and staff interview, the facility failed to properly store and prepare food in accordance with professional standards for food service safety relative to the main kitchen and 1 of 2-unit ice machines.Findings are as follows:1) Record review of Rhode Island Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .Surveyor observation of the refrigerator during the initial tour of the kitchen on 5/18/2026 at 8:48 AM revealed the following:2 packages of Hormel natural choice roast beef with a use or freeze by date of 4/14/2026During a surveyor interview immediately following the above observations with Cook, Staff C, he acknowledged that the above items were expired and should have been discarded.2) Record review of The Rhode Island Food Code 2022, Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight .During a surveyor observation of the facility ice machine located in the second-floor kitchenette during the initial tour on 5/18/2026 at approximately 9:15 AM, revealed a pink substance located on the white shield on the inside of the machine where the ice is dispensed.During surveyor interviews with the Food Service Director on 5/18/2026 at 9:21 AM and 5/21/2026 at 8:30 AM, he acknowledged the pink substance inside of the ice machine and that it needed to be cleaned. Additionally, he acknowledged that the roast beef was past its expiration date and should have been discarded.

Based on clinical record review and staff interview, the facility failed to conduct a comprehensive, and accurate assessment of each resident's functional capacity, needs, strengths and goals for 1 of 2 resident's reviewed for the timely completion and submission of the admission Minimum Data Set (MDS) assessment, Resident ID #50. Additionally, the MDS assessments failed to reveal coding for 2 of 2 residents who receive continuous oxygen, Resident ID #s 1 and 2, and for 6 of 6 residents who utilize safety alarms, Resident ID #s 7, 13, 30, 36, 37, and 38.Findings are as follows:1. Record review revealed Resident ID #50 was admitted to the facility on [DATE], with a diagnosis including, but not limited to, multiple rib fractures.Record review of an admission MDS assessment dated [DATE] revealed that as of 5/20/2026, the comprehensive assessment was incomplete.2a. Record review revealed Resident ID #1 was admitted to the facility in March of 2026 with diagnoses including but not limited to, chronic obstructive pulmonary disease, and dependence on supplemental oxygen.Record review revealed an order dated 4/1/2026 for continuous oxygen at 3-4 liters via nasal canula every shift.Record review of the April and May Medication Administration Records (MAR) revealed documentation that from 4/1 through 5/20/2026, the resident was administered oxygen continuously.Record review of the resident's admission MDS assessment dated [DATE] failed to reveal evidence that the resident was receiving oxygen therapy.2b. Record review revealed Resident ID #2 was admitted to the facility in December of 2025 with a diagnosis including but not limited to, chronic respiratory failure with hypoxia.Record review revealed an order dated 12/26/2025 to change the oxygen tubing and/or humidifier and label both every week on Thursday.Record review revealed an order dated 4/8/2026 for continuous oxygen at 2-4 liters via nasal canula every shift.Record review of May MAR revealed documentation that from 5/1 through 5/20/2026, the resident was administered oxygen continuously.Record review MDS Assessments dated 1/14/2026 and 3/3/3026 failed to reveal evidence that the resident was receiving oxygen therapy.3a. Record review revealed Resident ID # 7 was admitted to the facility in July of 2022 with diagnoses including, but not limited to, dementia, and abnormalities of gait and mobility.Record review revealed an order dated 11/19/2025 to check that the bed alarm is functioning every shift.Record review of the Significant Change MDS assessment dated [DATE] failed to reveal evidence that alarms were utilized for the resident.3b. Record review revealed Resident ID #13 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, dementia and repeated falls.Record review revealed the following orders:2/5/2025- check that the bed alarm is in place and operational3/12/2025- check that the chair alarm is in place and operationalRecord review of the MDS assessments dated 5/30/2025, 8/22/2025, 11/21/2025 and 2/6/2026 failed to reveal evidence that alarms were utilized for the resident.3c. Record review revealed Resident ID #30 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, dementia and repeated falls.Record review revealed the following orders:2/6/2026- check the placement and function of bathroom door alarm every shift3/4/2026- check the placement and function of floor mat alarms twice every shift3/4/2026- check the placement and function of wheelchair alarm every shiftRecord review of the Quarterly MDS assessment dated [DATE] failed to reveal evidence that alarms were utilized for the resident.3d. Record review revealed Resident ID #36 was admitted to the facility in April of 2026 with diagnoses including, but not limited to, Alzheimer's disease and muscle weakness.Record review revealed the following orders:4/26/2026- check the functioning and the placement of the bed alarm4/20/2026- Chair alarm to recliner. This order was discontinued on 5/1/2026Record review of the admission MDS assessment dated [DATE] failed to accurately document that alarms were utilized for the resident.3e. Record review revealed Resident ID #37 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, Alzheimer's disease and a history of falling.Record review revealed the following orders:4/23/2026- ensure floor alarm is in place and functioning properly.3/4/2025- chair alarm to recliner. This order was discontinued on 5/14/2026.6/16/2024- bed alarm in place and functioning when resident is in bed as tolerated. This order was discontinued on 5/14/2026.Record review of the MDS assessments dated 12/12/2025 and 3/13/2026 failed to reveal evidence that alarms were utilized for the resident.3f. Record review revealed Resident ID #38 was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, dementia.Record review revealed an order dated 11/10/2025 to check that the bed alarm is functioning.Record review of an Annual MDS assessment dated [DATE] failed to reveal evidence that alarms were utilized for the resident.During a surveyor interview on 5/20/2026 at approximately 1:45 PM with MDS Coordinator, Staff D, she was unable to provide evidence that the admission assessment for Resident ID #50 was completed within 14 days, as required. Additionally, she revealed that the MDS Assessments should include oxygen if oxygen was administered to the resident during the lookback period; however, she was unable to provide evidence that oxygen usage was documented on the MDS Assessments for Resident IDs #1 and #2. Lastly, she revealed that the MDS assessments should include alarms that are utilized for the residents during the lookback period, but was unable to provide evidence that the alarm usage was documented on the MDS Assessments for Resident ID #s 7, 13, 30, 36, 37 and 38.

Based on surveyor observation, record review, and staff interview, the facility failed to provide a safe environment relative to smoking, smoking areas, and smoking safety.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 12/19/2025, alleges that smoking has been observed within 15 feet of the nursing facility. There have been observations of cigarette butts that are left on the ground and are often dragged into the facility.Review of a facility policy titled Smoking Policy states in part, .residents that wish to smoke are to do so.in a designated area .smoking may be limited to specific times . During a surveyor observation upon arrival to the facility on 3/5/2026 at approximately 8:05 AM revealed, numerous discarded cigarette butts were littered on the ground along the front perimeter of the building, in the parking lot, and in the mulch.During a surveyor observation on 3/5/2026 at approximately 10:25 AM, in the presence of the Administrator at the rear of the building, the ground was observed to be littered with a large quantity of cigarette butts from the rear entrance door extending out approximately 10 feet. Additionally, a bucket with sand that the facility uses as an ashtray was observed to be overflowing with cigarette butts. During a surveyor interview on 3/5/2026 at 1:17 PM with the Director of Maintenance, he acknowledged that cigarette butts littered the grounds in the front and rear of the building. Additionally, he acknowledged that the smoking bucket should have been emptied to allow proper disposal of cigarettes.During a surveyor interview with the Administrator on 3/5/2026 at 1:35 PM, she acknowledged that the facility had a numerous quantity of cigarette butts littered on the ground at the rear of the building. She indicated that she would expect the staff and/or residents who smoke to follow the facility's policy related to the proper disposal of cigarette butts.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1. The 2022 Food and Drug Administration (FDA) Food Code 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, clean equipment, utensils, linens . Surveyor observations of the dietary staff in the main kitchen and main dining room revealed the following: - 4/28/2025 at approximately 9:10 AM, Dietary Staff, Staff A, was observed wearing a hair net with her bangs fully exposed while working in the main kitchen. - 4/29/2025 at 9:41 AM, Staff A, was observed wearing a hairnet with her bangs fully exposed while working in the main kitchen. - 4/29/2025 at 3:00 PM, Dietary Staff, Staff B, was observed wearing a baseball cap with hair strands not in the cap while setting the dining room tables with silverware and glassware. - 4/30/2025 at 2:30 PM, Staff B, was observed wearing a baseball cap with hair strands not in the cap while setting the dining room tables with glassware and silverware. - 4/30/2025 at 3:15 PM, Dietary Staff, Staff C, was observed not wearing a beard restraint while working in the main kitchen. 2. The FDA Food Code 2022 4-101.11 states in part, .multi-use food contact surfaces shall be finished to have a smooth, easily cleanable surface and resistant to scoring . During a surveyor observation on 4/29/2025 at 3:00 PM of the main kitchen, ten red lip plates were observed with deep scorings on the surface. 3. The FDA Food Code 2022 4-201.11 states in part, .equipment and utensils shall be durable to retain their characteristic qualities . During a surveyor observation on 4/29/2025 at 11:41 AM, twelve burgundy colored beverage cups were observed with tan stains on the cavity of the interior. During a surveyor observation of the main kitchen on 5/1/2025 at 10:24 AM, eight white beverage cups were observed with brown stains on the cavity of the interior. 4. The FDA Food Code 2022 6-305.11 states in part, .lockers or other suitable facilities shall be provided for the storage of employees possessions . During a surveyor observation on 4/28/2025 at 9:15 AM, a cell phone was lying on a worktable in the main kitchen. During an additional surveyor observation of the main kitchen on 5/1/2025 at 12:17 PM, a cell phone was on top of a shelf above the serving line. 5. The FDA Food Code 2022 6-501.11 states in part, .physical facilities shall be cleaned as often as necessary to keep clean . A surveyor observation of the main kitchen on 4/28/2025 at 9:15 AM, revealed the areas behind the steam table and worktables there was dried black matter along the floor and baseboard. Further observation revealed brown spills on the yellow tiles behind the steam table and worktables. During a surveyor observation on 4/28/2025 at 9:30 AM of the dish room, revealed black dried matter behind the dish machine. During a surveyor interview on 5/1/2025 at 11:00 AM, with the Assistant Food Service Director, he acknowledged that hair restraints were not properly worn and that a beard restraint was not worn. Additionally, he acknowledged the scoring of the lip plates, the stained cups, and the black matter and brown spills on the floors and walls behind the worktables, and that the dish machine and steam table needed cleaning. He further acknowledged that the staff's personal possessions should not be stored on surfaces in the main kitchen.

Based on record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards and principles that apply to individuals providing services in the facility for 1 of 4 residents reviewed who is receiving hospice care, Resident ID #23. Findings are as follows: Record review revealed that the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (lung disease that restricts your breathing), interstitial pulmonary disease (scarring to the lung which makes it difficult to get oxygen), and pneumonia. Record review revealed a physician's order dated 4/19/2025 to admit to Hospice. Record review of a form titled, Hospice Care and Treatment Recommendations for Facility dated 4/28/2025, revealed a recommendation to start Atropine 1% drops (a medication prescribed to decrease saliva production), 2 drops every 2 hours as needed for increased secretions. This recommendation was noted by Registered Nurse, Staff D. Record review failed to reveal evidence that the hospice recommendation was communicated to the resident's physician to obtain an order. During a surveyor interview on 5/1/2025 at 11:26 AM with Registered Nurse, Staff E, the surveyor brought to her attention that the Atropine drops were recommended for Resident ID #23 on 4/28/2025 by hospice, but the surveyor was unable to find a physician's order. Staff E was unable to provide evidence that the hospice recommendation was communicated to the resident's physician to obtain an order. During a surveyor interview on 5/1/2025 at 11:57 AM with Registered Nurse, Staff D, he revealed that the resident was having increased secretions, so he had requested the Atropine. He further acknowledged that although he did note the Hospice recommendation, he did not recall communicating with the Physician or Nurse Practitioner to obtain an order. During a surveyor interview on 5/1/2025 at 11:57 AM with the Director of Nursing Services, she was unable to provide evidence that the physician was made aware of the recommendation made by Hospice for the Atropine drops. Record review revealed an order dated 5/1/2025 for Atropine 1% drops, 2 drops every 2 hours as needed for increased secretions, after it was brought to the facility's attention by the surveyor.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare food and drink in a form designed to meet individual needs for 1 of 1 resident observed that had a physician's order for a ground diet, Resident ID #263. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2025 with diagnoses including, but not limited to, dysphagia (difficulty swallowing), and anxiety disorder. Record review of a physician order for April 2025 revealed a diet order for a ground diet. Record review of the facility's diet manual, states in part: .Ground consistency to safely provide adequate nutrition and to facilitate eating for individuals with impaired swallowing or chewing .Menu guidelines to include, but are not limited to, fruits and vegetables that are easy to chew i.e. [example] fork mashable .Food groups of vegetables listed vegetables that are to be soft, cooked-fork mashable and or finely ground raw vegetables or vegetables salads . Record review of the facility menu for 4/30/2025 revealed, residents that are on ground diets were to receive a ground turkey and cheddar sandwich with roasted zucchini. During a surveyor observation on 4/30/2025 at 12:31 PM, the resident was served ground chicken salad with shredded lettuce and two slices of fresh tomato. During a surveyor interview with the resident immediately following the above observation, s/he revealed s/he was unable to swallow the lettuce and tomato. During a surveyor interview on 4/30/2025 at 3:15 PM, with the Assistant Director of Food Service, he acknowledged the resident was not served the menu as written for a ground diet.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives necessary respiratory care and services in accordance with professional standards of practice relative to a continuous positive airway pressure device (CPAP-a type of ventilator that assists with breathing and provides continuous positive airway pressure) for 1 of 1 resident reviewed for respiratory care, Resident ID #23. 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 Resident ID #23 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (COPD- a lung disease that restricts your breathing), acute bronchitis (inflammation of the airways leading to your lungs that causes coughing and mucus), and interstitial pulmonary disease (a lung condition that causes scarring of the lung.) Review of a care plan dated 5/16/2024, revealed that the resident requires supplemental oxygen related to his/her diagnoses of COPD, with an intervention including, but not limited to, CPAP at night with home settings. Record review revealed the following physician's orders with a start date of 10/21/2024: -CPAP attached to continual oxygen at bedtime -Clean CPAP machine and tubing daily Record review of the April of 2025 Medication Administration Record (MAR) revealed the following CPAP documentation: -4/27/2025- administered -4/28/2025- not administered broken Record review revealed a progress note dated 4/27/2025 which states in part, Cpap not working .Resident will use oxygen only tonight . Further record review failed to reveal evidence that the provider was notified that the CPAP machine was not working and was unable to be provided to the resident as ordered, although it was signed off as completed on the MAR for 4/27/2025. During a surveyor interview on 5/1/2025 at 11:57 AM with the Director of Nursing Services, she was unable to provide evidence that the CPAP was administered as ordered on 4/27/2025 and 4/28/2025. Additionally, she was unable to provide evidence that the physician was notified.

Based on surveyor observation, record review, resident, and staff interview it has been determined that the facility failed to protect the resident's right to be free from abuse for 1 of 1 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/7/2022 states in part, Care was being provided to [resident]. [Nursing Assistant (NA) Staff A] witnessed [NA Staff B] say to[resident] 'shut the [F .] up' and 'I hope you [F .] die.' Resident assessed for injury-nothing found . Record review of a facility policy titled Abuse Prohibition, states in part, .It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from .Abuse: Willful infliction of .intimidation, or punishment resulting in .mental anguish and includes physical, verbal .abuse .that frightens or demeans a resident such as .derogatory remarks about the resident .Physical-Hitting . Record review revealed that the resident was admitted to the facility in August of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a significant change Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating s/he has severely impaired cognition. Record review of a care plan dated 8/28/2020 and reviewed/revised on 9/29/2022 revealed s/he requires the use of a Hoyer lift (a mechanical device that helps lift and transfer residents with the use of a sling and the support of two or more staff members) for transfers. Review of the facility's investigation file revealed a written statement authored by Staff A dated 10/6/2022 at 11:38 PM which states in part, .I told [Staff B] .Can you help me Hoyer [resident] .She agreed .[resident] was asleep in [his/her] recliner .I gave [him/her] a few taps on [his/her] stomach .[s/he] woke up yelling .[Staff B] seemed angered from [his/her] sudden outburst and began to messily place the Hoyer straps into place .I stopped [Staff B] from moving [resident] into the air because [s/he] was back asleep .I wanted to .wake [him/her] again to prevent more yelling .[Staff B] then said that she 'didn't care,' 'let [him/her] yell', '[s/he] will wake up when [s/he's] in the air.' .she began to lift [him/her] from the recliner. [resident] was startled and let out a multitude of prolonged shrieks .[Staff B] .began to move the Hoyer machine around forcefully in a rough manner, having [resident] swing in the air .causing [him/her] to yell out long, frantic cries. [Staff B] then gets close to [resident] and gave [him/her] a smack on [his/her] left leg and told [him/her] to 'shut the f*** up.' .[resident] continued to yell and flail [his/her] arms .[Staff B] then took both of [resident's] arms and held them together .[Staff B] then told [him/her] 'I hope you f***ing die' .She then knocked over two .drink cups .and left the room .I then tried to apologize to [resident] .but [s/he] was absolutely terrified .it was about 8:20PM .For the remainder of the night [resident] was noticibly traumatized and cried out continuously. Later on when I had attempted to check up on [him/her] [s/he] was absolutely terrified of me and had thought I was [Staff B]. During a surveyor interview with Staff A, on 10/12/2022 at 11:34 AM she acknowledged the information in her written statement dated 10/6/2022. She stated, At around 8:20 PM I asked [Staff B] to help me transfer [him/her] from the recliner to the bed with the Hoyer. Staff A further indicated that the resident was asleep in his/her recliner and stated, I tapped [him/her] on the belly to wake [him/her] before transferring because [s/he] yells out at times. She further indicated that the resident began to yell so she stopped to wait until s/he calmed down. Staff A stated, [Staff B] was impatient because she worked a double [shift] that day and was leaving early and did not want to wait so she started lifting [him/her] and [s/he] started yelling that's when [Staff B] got close to [him/her] and slapped [him/her] on the left leg with an open hand and told [him/her] to shut the [F .] up. She further indicated that the resident continued to yell once s/he was transferred to bed, and Staff B grabbed his/her arms. She also indicated that as Staff B left the room she threw things around in the room. During a surveyor interview with Staff B on 10/12/2022 at approximately 12:00 PM she indicated that on 10/6/2022 at some time after 8:00 PM she helped Staff A transfer the resident from his/her recliner to the bed with the Hoyer lift. Additionally, she indicated that the resident was swinging around in the Hoyer sling during the transfer and was loud because [s/he] was in pain. Staff B further stated, [S/he] was swinging around in the Hoyer so I swore at [him/her] out of frustration. Staff B was unable to recall the specific words she used but did acknowledge that she used expletive language towards the resident. Additionally, she indicated when she was pulling up the Hoyer pad she pushed [his/her] legs. Staff B further indicated that she left the facility after assisting Staff A and that the Director of Nursing Services called her on 10/12/2022 to inform her that she was terminated. Review of a care plan dated 10/7/2022 states in part, .[resident] experienced a traumatic event on 10/6/2022 . The goal indicates s/he .will not exhibit mood, behavior and/or psychosocial issues related to event . Record review revealed a progress note dated 10/7/2022 at 3:30 AM which states in part, Resident agitated .yelling 'Mum don't hurt me.' Medicated w/ [with] .[MEDICATION(S)] (an antipsychotic medication used to treat certain mental/mood conditions). During a surveyor interview with the resident on 10/12/2022 at 10:50 AM she stated, I did have problems but not now, she walked out, I haven't seen her lately, she scared me. During a surveyor interview with the Director of Nursing Services on 10/12/2022 at approximately 1:00 PM, she was unable to provide evidence that the resident was kept free from abuse. She also acknowledged that Staff B was terminated.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health alleges that on 7/30/2022 Resident ID #1 received in error [MEDICATION(S)] (opioid pain medication use to treat moderate to severe pain) instead of his/her prescribed Tylenol (analgesic use to treat minor pains and aches). Record review of the facility's policy titled Medication Administration General Guidelines, states in part, .Medication Preparation .Prior to administration, review and confirm MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] .Medications are administered in accordance with written orders of the prescriber .Note any allergies or contraindications the resident may have prior to medication administration .Verify medication is correct three (3) times before administering the medication .When pulling medication package from med car .When dose is prepared .Before dose is administered .Residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include .Check photograph attached to medical record .Verify resident identification with other nursing care center personnel .Medications supplied for one resident are never administered to another resident . Record review revealed that the resident was admitted to the facility in July of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review revealed that the resident is allergic to [MEDICATION(S)] (semi-synthetic opioid medication used to treat pain). Record review of the progress note dated 7/30/2022 at 3:03 AM that states in part, .This evening after requesting prn [as needed] Tylenol for shoulder px[pain] the patient was accidentally administered 10 mg[milligrams] [MEDICATION(S)] by orienting nurse. Face sheet designates [MEDICATION(S)] as one of the patient's allergies . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor interview on 9/29/2022 at 1:52 PM with the Director of Nursing Services, she acknowledged that the resident received the wrong medication on 7/30/2022.

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. Findings are as follows: Record review of the facility's policy titled, Dietary Department Infection Control Guidelines states in part, .Food .All items stored in the refrigerator will be covered and labeled with the contents and the date. All stock items will be monitored for expiration dates, and used or discarded as necessary .Handling of all food items during preparation process is to be minimized. This is to be accomplished by using clean kitchen tools or by wearing clean gloves for each task .Equipment: All food preparation equipment, dishes, and utensils are to be maintained in a clean, sanitary, and safe manner . During an initial tour of the main kitchen on [DATE] at approximately 4:30 PM, the following was observed prior to the evening meal service: - The Food Service Director (FSD) took the holding temperature of a pan of mashed potatoes using a thermometer without wearing gloves. His right thumb was observed to go into the food. - The FSD then took the holding temperature of an orange, pureed vegetable without wearing gloves. His right thumb and forefinger were observed to go into the food. He did not wash his hands. - The FSD then took the holding temperature of seafood salad through plastic wrap without wearing gloves. Orange residue from the pureed vegetables was observed on the plastic wrap. During a surveyor interview with the FSD at the time of the above observations, he revealed he would expect staff to wear gloves while preparing and touching ready-to-eat foods. He acknowledged that he should have worn gloves while taking holding temperatures prior to the meal service. During subsequent observations of the main kitchen in the presence of the FSD on [DATE] at 4:45 PM, the following was observed in the walk-in refrigerator: - Six raw eggs in an open, gallon-sized plastic container without a label or date - One 16-ounce (oz) container of ham base, approximately half full, opened and not dated - One 5-pound container of sour cream, approximately ,d+[DATE] full, opened and not dated. The product's expiration date was labeled as [DATE]. At the time of the above observation in the walk-in refrigerator, the FSD took the holding temperature of a pan of macaroni salad without using gloves. Upon exiting the walk-in, he acknowledged that he was not wearing gloves and should be wearing them. Additional surveyor observations revealed a spreading knife inside a wall caddy with dried yellow food matter on the blade. During a surveyor interview with the FSD at 4:55 PM, he revealed that the above items in the refrigerator should have been thrown out if expired and would have expected them to be labeled and dated when opened. Additionally, he acknowledged the knife was dirty and should have been cleaned prior to being placed back inside the wall caddy.

Based on record review, surveyor observation and staff interview, it has been determined that the facility failed to ensure that drugs and biological's used in the facility must be labeled in accordance with currently accepted professional principles, for 2 of 4 medication carts observed. Findings are as follows: Review of the facility policy titled, Storage of Medication, states in part, .Medications and biological's are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .Outdated .medications .are immediately removed from stock . 1. Surveyor observations of the second-floor nurse's cart during the medication storage task on 3/14/2022 at 3:53 PM revealed one bottle of [MEDICATION(S)] 0.4 mg with approximately 20 tablets in the bottle. The manufacturer's expiration date on the bottle was 2/5/2022. During an interview with Staff Nurse A on 3/14/2022 at 4:25 PM, he could not explain why the expired medication was stored in the medication cart. 2. Surveyor observations during a medication pass on the first floor with Staff B, Certified Medication Technician on 3/15/2022 at approximately 4:00 PM, revealed her preparing Pro STAT sugar free liquid protein supplement medication, to be administered to Resident ID #10. The bottle had a manufacturer's expiration date of 1/5/2022. During an interview conducted with Staff B immediately following these observations she acknowledged that the protein supplement she was preparing to administer to the resident was expired. Record review for Resident ID #10 revealed the following current physician order: - 12/28/2021, Prostat sugar free liquid, amount 30 mL (milliliters) once an evening Review of the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Director of Nursing, (DNS), on 3/15/2022 at 2:20 PM, she stated that her expectations are that expired medications are not stored in the medication carts. During an interview with the DNS on 3/16/2022 at 9:30 AM, she was unable to explain why Resident ID #10 was administered expired medication in the months of January, February and March.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that staff utilized, reused or properly disposed of Personal Protective Equipment (PPE) to prevent the transmission of COVID-19 for 4 of 4 sample residents who are on quarantine (Residents ID #'s 25, 199, 203 and 204). Findings are as follows: The Center for Disease Control and Prevention (CDC) guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 12/14/2020, states in part, Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses . The CDC guideline titled, COVID-19 Strategies for Optimizing the supply of Eye Protection, updated 12/22/2020 states in part, Once PPE supplies and availability return to normal, healthcare facilities should promptly resume conventional practices . Purpose: This documentation offers a series of strategies or options to optimize supplies of eye protection in healthcare settings when there is limited supply . Conventional Capacity Strategies . Disposable eye protection should be removed and discarded. Reusable eye protection should be cleaned and disinfected after each patient encounter Shift eye protection supplies from disposable to reusable devise (i.e. reusable face shields or goggles) . Ensure appropriate cleaning and disinfection after use if reusable face shields or goggles are used . The facility's policy and procedures for Optimizing PPE during the COVID-19 Respond dated 4/1/2020, states in part, II. STRATEGIES FOR OPTIMIZING THE SUPPLY OF N95 FACE MASK . N95 may be cleaned in between usage with EPA-registered hospital based disinfectant agents and according to Manufactures guidelines . 1. Record review for Resident ID #25 revealed the resident was admitted to the facility from the hospital on [DATE] and is currently on a 14-day quarantine. Staff were observed not cleaning their N95, and/or face shield/goggles after leaving the resident's room on the followings dates; -1/20/2021 at 8:37 AM, a nursing assistant (Staff F) -1/20/2021 at 8:46 AM, a nursing assistant (Staff E) 2. Record review for Resident ID #199 revealed the resident was admitted to the facility from the hospital on [DATE] and is currently on a 14-day quarantine. Staff were observed not cleaning their N95, and/or face shield or goggles after leaving the resident's room on the followings dates; -1/20/2021 at 8:15 AM, a physical therapy staff (Staff G) -1/20/2021 at 9:18 AM, 10:17 AM and 10:31 AM, a nursing assistant (Staff H) -1/20/2021 at 9:38 AM, a housekeeper (Staff I) During an interview after the observation, Staff H acknowledged she did not clean her N95 or goggles when she left the resident's room. 3. Record review for Resident ID #203 revealed the resident was admitted to the facility on [DATE] from the hospital and is currently on a 14-day quarantine. Staff were observed not cleaning their N95, and/or face shield or goggles after leaving the resident's room on the followings dates; -1/20/2021 at 8:28 AM, a physical therapy staff member (Staff G) -1/21/2021 at 9:20 AM, a physical therapy staff member (Staff J) 4. Record review for Resident ID #204 revealed the resident was admitted to the facility from the hospital on [DATE] and is currently on a 14-day quarantine. Staff were observed not cleaning their N95, and/or face shield or goggles after leaving the resident's room on the followings dates; -1/21/2021 at 9:58 AM, a physical therapy staff member (Staff J) -1/21/2021 at 10:10 AM, a nursing assistant (Staff H) During an interview on 1/21/2021 at 10:06 AM, Staff J stated she was told if she goes from room to room, she does not have to clean the N95 or goggles. Staff J stated They are on quarantine but they do not have COVID anyway. Surveyor observations during the survey between 1/19/2021 thru 1/22/2021 revealed the facility has an adequate supply of PPE During interviews with the unit nurse (Staff K) on 1/22/2021 at 10:32 AM and the nursing assistant (Staff L) on 1/22/2021 at 11:32 AM, they revealed the facility has an adequate supply of PPE. During an interview with the Infection Control Nurse on 1/22/2021 at 9:10 AM, she revealed the facility has an adequate supply of PPE. During an interview with the Director of Nurses and the Infection Control Nurse on 1/22/2021 at approximately 2:00 PM, both acknowledged that staff do not cleaned their N95 or eye protection after leaving the quarantine rooms. They further revealed they follow their own policy and procedures, as well as CDC guidance for infection control measures re: COVID-19.

Based on surveyor observation, record review and staff interviews, it has been determined that the facility failed to ensure a resident with limited range of motion receives appropriate treatment to prevent further decline in range of motion for 1 of 3 sample residents (Resident ID #27). Findings are as follows: Record review revealed that Resident ID #27 was admitted to the facility in January 2020 with [DIAGNOSES REDACTED]. Further record review revealed the following physician's orders [REDACTED]. -1/22/2020 Footboard to wc (wheelchair) -10/1/2020 R (right) palm gauze roll a/o (as ordered), check for placement of rolled gauze to right hand The resident has a care plan for right hand tends to remain closed with interventions dated 1/6/2021, for right palm gauze roll as ordered and check for placement of rolled gauze to right hand. The resident also has a care plan for extensive assistance for his/her Activity of Daily Livings with intervention dated 1/23/2020 for footboard to his/her wheelchair. Surveyor observation on the following dates and times revealed the resident without hand roll and footboard to wheelchair. -1/19/2021 at 12:30 PM and 12:42 PM -1/20/2021 at 8:10 AM, 8:56 AM, 10:31 AM and 12:13 PM -1/21/2021 at 9:01 AM During a surveyor interview on 1/21/2021 at 10:20 AM with the Nursing Assistant (Staff A), she acknowledged that she did not put on the resident hand roll. Additionally, she acknowledged that the footboard was not on the wheelchair. During a surveyor interview on 1/21/2021 at 10:27 AM with the unit nurse (Staff B), she acknowledged that the resident hand roll was not applied and the footboard was not on the wheelchair as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 1 of 5 sample residents reviewed for skin impairment (Resident ID #27). Findings are as follows: Record review revealed that Resident ID #27 was admitted to the facility in January 2020 with [DIAGNOSES REDACTED]. Record review of a care plan initiated on 1/21/2020 for potential for skin breakdown revealed Approach start date: 10/13/2020; bilateral geri sleeve as tolerated, q (every) shift. May remove for care. Surveyor observation on the following dates and times revealed the resident without geri sleeves: -1/19/2021 at 12:30 PM and 12:42 PM -1/20/2021 at 8:10 AM, 8:56 AM, 10:31 AM and 12:13 PM -1/21/2021 at 9:01 AM During a surveyor interview on 1/21/2021 at 10:20 AM with the Nursing Assistant (Staff A), she acknowledged that she did not put on the resident geri sleeves after care and could not provide a reason as to why it was not put on. During a surveyor interview on 1/21/2021 at 10:27 AM with the unit nurse (Staff B), she acknowledged that the resident was not wearing his/her geri sleeves as ordered.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological in accordance with currently accepted professional principles for 1 of 2 medication cabinets (2nd floor) and 1 of 3 medication carts observed (2nd floor). Findings are as follows: Review of the facility policy, dated ,[DATE], titled Storage of Medication states in part .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations .Note the date on the label for insulin vial and pens when first opened . outdated medications are immediately removed from stock . Surveyor observation of the medication cabinet and the medication cart on the 2nd floor, in the presence of Staff Nurse (Staff D), on [DATE] at 2:28 PM and 2:38 PM revealed the following: 1. Two bottles of Aspirin 81 Milligrams (MG) [MEDICATION NAME] coated with a manufacturing expiration date of ,[DATE]. 2. Insulin [MEDICATION NAME] Injection Kwik pen (medication used to control high blood sugar) opened and not dated. 3. One Breo Elipta 200 MG/25 MG inhaler (a medication use to treat lung disease), opened and not dated. Manufacturer instructions states in part .discard date is 6 weeks after you open the tray . During an interview immediately following the surveyor observations with Staff Nurse (Staff D), she acknowledged that the 2 bottles of Aspirin were expired, and the insulin pen and the Breo Elipta were opened and not dated. During an interview on [DATE] at 2:51 PM with the Director of Nurses, she acknowledged that the 2 bottles of ASA were expired and should have been discarded. She further acknowledged that both the insulin pen and the Breo Elipta inhaler were opened and not dated.

Based on record review and staff interview, it has been determined that the facility failed to maintain a clinical record on each resident in accordance with acceptable professional standards and practice that are complete and accurately documented for 1 of 14 sample residents reviewed (Resident ID #27). Findings are as follows: Review of Resident ID #27's clinical record revealed physician's orders [REDACTED]. May remove for care. Review of the Treatment Administration Record revealed the orders were signed off by the two unit nurses (Staff B and Staff C) as completed on 1/19/2021 at 10:38 AM and 1/20/2021 at 10:50 AM. During an interview on 1/21/2021 at 10:27 AM with the unit nurse (Staff B), she acknowledged that she did not apply the hand roll and the footboard, and could not explain why she signed off the orders that had not been completed. During an interview on 1/21/2021 at 10:40 AM with the Director of Nurses, she acknowledged that the orders were signed off as completed by both Staff B and Staff C. She further acknowledged that orders should be signed after completing a task, and if a task was not completed the order should not be signed off as completed.

Based on surveyor observation, staff interview and record review, it has been determined that the facility failed to ensure the implementation of infection control practices and precautions, to prevent the transmission of communicable disease and infection during an identified outbreak of Coronavirus Disease (COVID-19) relating to permitting COVID-19 positive Healthcare Personnel (HCP) to screen other HCP and visitors upon entry to the building. Findings are as follows: Review of a CDC document, updated on 7/17/2020, titled Mitigating Staff Shortages states in part, .If HCP are tested and found to be infected with [DIAGNOSES REDACTED]-CoV-2, they should be excluded from work until they meet all Return to Work Criteria (unless they are allowed to work as described below). If shortages continue despite other mitigation strategies, consider implementing criteria to allow HCP with suspected or confirmed COVID-19 who are well enough and willing to work but have not met all Return to Work Criteria to work. If HCP are allowed to work before meeting all criteria, they should be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) and facilities should consider prioritizing their duties in the following order: 1. If not already done, allow HCP with suspected or confirmed COVID-19 to perform job duties where they do not interact with others (e.g., patients or other HCP), such as in telemedicine services. 2. Allow HCP with confirmed COVID-19 to provide direct care only for patients with confirmed COVID-19, preferably in a cohort setting. 3. Allow HCP with confirmed COVID-19 to provide direct care for patients with suspected COVID-19. 4. As a last resort, allow HCP with confirmed COVID-19 to provide direct care for patients without suspected or confirmed COVID-19 . Review of a Rhode Island Department of Health (RIDOH) document titled, COVID-19 Quarantine and Isolation Guidance by Population, updated October 28, 2020, states in part, .Critical Infrastructure Workers (Staff in healthcare, including nursing home/assisted living staff .Work During Isolation Yes, in limited circumstances (healthcare staff only) and in consultation with RIDOH: .May only care for COVID-positive patients .Must remain in units caring only for COVID-positive patients (other than entering/exiting facility) . Review of the facility's policy titled, COVID-19: Staffing in an Emergency (Crisis) states in part, .In the event that essential personnel are COVID-19 positive and asymptomatic, they may work if they are needed to fill a critical staffing position with restrictions .Must only care for COVID positive residents .Other than to enter or exit the facility, must not be in any area of the facility that is NOT a COVID positive care area . During surveyor entry to the facility on [DATE] at 10:20 AM, Staff A instructed the surveyor to enter the vestibule for COVID-19 screening, which includes questions and monitoring temperature, before entering the nursing care unit on the 1st floor. Staff A was wearing an N95, gown and eye protection. She screened the surveyor in the vestibule and allowed surveyor entry to the nursing care unit on the 1st floor. Review of a line list titled, COVID POSITIVE TEST FOR EMPLOYEES indicated that Staff A was tested on [DATE], the result of this test revealed that Staff A was positive for COVID-19. Review of Employee Rosters (facility entry COVID-19 screening tool used for employees) dated 11/17/2020, 11/19/2020, and 11/20/2020 revealed that Staff A screened 3-4 employees entering the facility on those dates. During surveyor interview with Staff A on 11/20/2020 at 12:15 PM and 1:00 PM, she revealed that she does screen employees and visitors upon entry to the building when needed and that she has not been restricted from doing so since testing positive for COVID-19. During a surveyor interview with the Director of Nursing Services (DNS) and the Infection Preventionist (IP) on 11/20/2020 at approximately 11:35 AM, it was revealed that the facility was given permission for COVID positive, asymptomatic HCP to work to fill a critical staffing need when their facility identified an outbreak after a consultation with the Rhode Island Department of Health. The COVID positive employees were given permission to work on COVID positive units in the facility. The IP revealed that they were not told that COVID positive employees could not screen other employees or visitors.

Based on record review and staff interview, it has been determined that the facility failed to ensure the services provided by the facility meet professional standards of quality relative to following physician's orders [REDACTED].#8. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders [REDACTED]. Record review for Resident ID #8 revealed the following: A 5/6/2018 physician's orders [REDACTED]. If Blood Sugar is less than 60, call MD. If Blood Sugar is 60 to 159, give 0 Units. If Blood Sugar is 160 to 200, give 2 Units. If Blood Sugar is 201 to 240, give 3 Units. If Blood Sugar is 241 to 280, give 4 Units. If Blood Sugar is 281 to 320, give 6 Units. If Blood Sugar is 321 to 360, give 8 Units. If Blood Sugar is greater than 360, give 10 Units. If Blood Sugar is greater than 360, call MD. There lacked evidence that the physician was called on the following opportunities before being discontinued on 6/4/2018: -5/20/2018 (4-5:30 PM) for a blood sugar of 376. -5/23/2018 (4-5:30 PM) for a blood sugar of 365. -6/1/2018 (4-5:30 PM) for a blood sugar of 372. Additionally, the record revealed an active 6/5/2018 physician's orders [REDACTED]. There lacked evidence that the physician was called on the following opportunities: -6/6/2018 (4-5:30 PM) for a blood sugar of 322. -6/8/2018 (4-5:30 PM) for a blood sugar of 303. An interview was conducted with the Director of Nursing Services on 06/11/2018 at 1:05 PM. She was unable to provide evidence that the physician was notified of the elevated blood sugars as ordered. 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.