Every finding on record at Royal Middletown Nursing Center

Based on record review and staff interview, the facility failed to ensure that prospective employees were screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, as evidenced by 1 of 1 personnel record reviewed for abuse Nursing Assistant (NA), Staff A. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/17/2026 revealed that a staff member reported to the facility that she witnessed a NA grab Resident ID #11's face and kiss him/her on the lips.Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 4/22/2026 alleged inappropriate interactions between a nursing assistant and Resident ID #11. The report included a local police department incident report dated 4/18/2026, indicating that the family of Resident ID #11 intended to pursue charges related to the incident that occurred on 4/17/2026.Review of a policy titled, Abuse, Neglect and Exploitation Policy last revised in March of 2026 states in part, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .sexual abuse is non-consensual sexual act of any type with a resident.Screening.Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.background, reference, and credentials' checks shall be conducted by the facility itself, third party agency or academic institution.The facility will maintain documentation of proof that the screening occurred.Record review revealed Staff A, was hired on 11/18/2025 as a Nursing Assistant.Review of a Bureau of Criminal Identification (BCI) dated 11/6/2025 states in part, As mandated by both federal and state law, the fingerprints of [Staff A] .were processed to determine if they have a criminal record containing disqualifying information. The results of their fingerprint based Comprehensive Criminal Background check shows that they HAVE DISQUALIFYING INFORMATION as delineated under federal and state law .Surveyor record review following the discovery of the positive BCI revealed that Staff A had an extensive criminal history.During a surveyor interview on 4/28/2026 at 11:46 AM, the Human Resource Director stated that Staff A was hired in November 2025, completed orientation, and is currently working independently as a nursing assistant. She further reported that Staff A disclosed disqualifying information from her BCI, indicating a prior drug-related charge from approximately ten years ago. However, the Human Resource Director stated she did not have any documentation specifying the nature of the disqualifying information and that the information was obtained only through word of mouth.During a surveyor interview on 4/28/2026 at 1:58 PM, the Administrator stated she was aware that Staff A's BCI contained disqualifying information and indicated she exercised her own judgment in proceeding with the hire. She acknowledged that she did not receive documentation detailing the nature of the disqualifying information until it was brought to her attention by the surveyor. She further stated that she had not been at the facility since the allegation of abuse was reported on 4/17/2026 and that a determination regarding Staff A's employment would be made upon completion of the investigation. Cross reference F 600

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure residents are treated with respect and dignity relative to 1 of 1 resident observed who was unable to attend meals and activities with his/her fellow peers due to lack of appropriate clothing, Resident ID #3. Findings are as follows:Record review revealed the resident was admitted to the facility in May of 2025 with diagnoses including, but not limited to, anxiety disorder and post-traumatic stress disorder.Record review of a care plan revised on 8/25/2025 indicated that the resident is highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During a surveyor observation on 4/29/2026 at 11:44 AM, the resident was observed in his/her room wearing a hospital gown and seated upright on the bed while other residents were in the dining room for lunch. A subsequent observation of the resident's room revealed only one pair of pants and two T-shirts in the drawer.During a surveyor interview following the above observation, the resident reported that s/he does not attend meals in the dining room due to insufficient clothing appropriate for leaving the room. The resident stated that the facility lost all of his/her clothing, including but not limited to shirts, pants, shorts, and socks, which had been sent to laundry services several months prior and were never returned. The resident further indicated that the Administrator was informed of the issue and stated she would contact the laundry company; however, no follow-up communication occurred, and the missing clothing was neither located nor replaced. Record review failed to reveal evidence of the resident's admission inventory list of his/her belongings during his/her admission in May of 2025.During a surveyor interview on 4/29/2026 at 11:57 AM, the Administrator stated that residents' laundry is handled by an outsourced company and acknowledged that she has contacted the vendor multiple times in the past regarding missing clothing for other residents. She further reported that clothing is sent out without a tracking system or documentation identifying which items belong to which resident. The Administrator also indicated that Resident ID #3 had limited clothing upon admission; however, she was unable to provide documentation of an admission inventory of the resident's belongings. She was unable to provide evidence that the resident was treated with respect and dignity relative to finding appropriate clothing to attend meals and activities in the facility.

Based on clinical record review, surveyor observation, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections relative to a clean dressing change for 1 of 2 residents observed for wound care, Resident ID #40. Findings are as follows:Review of a facility policy titled, Wound Treatment Management last revised January 2025 states in part, To promote wound healing of various types of wounds, it is policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Record review revealed that Resident ID #40 was readmitted to the facility in February of 2026 with diagnoses including, but not limited to, peripheral vascular disease and cellulitis of lower limb.Record review revealed a physician's order to cleanse open areas to the left lower leg with vashe wound wash (an antimicrobial wound cleanser) and apply xeroform (wound dressing) to wound bed and wrap with kling.During a surveyor observation on 4/27/2026 at 11:51 AM of Registered Nurse, Staff E performing wound care, she failed to establish a clean field. Staff E placed all of her supplies directly on the resident's bed next to his/her left leg where the wound was. Additionally, she removed the dirty dressing from the wound, took off the glove on her left hand and it landed on the wound supplies. Staff E failed to cleanse her hands between removing a dirty glove and applying a clean glove.During a surveyor interview with Staff E directly following the above observations she acknowledged not setting up a clean field and putting the wound supplies on the resident's bed. Per Staff E, she did not want to mess up the resident's bedside table. Additionally, she was unable to explain why she put a dirty glove on top of clean wound supplies and also did not cleanse her hands between taking off dirty gloves and applying clean gloves.During a surveyor interview on 4/27/2026 at 12:33 PM with the Director of Nursing Services (DNS) she revealed she would expect the nurse to set up a clean field for her supplies. Additionally, she revealed that the nurse should have thrown her dirty glove into the trash and cleansed her hands between glove changes.

Based on clinical record review and staff interview, the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 1 of 2 residents reviewed who are receiving hospice services, Resident ID #11. Findings are as follows:Record review revealed that Resident ID #11 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, dementia.Record review revealed the resident started with hospice services in March of 2026.Review of the electronic and paper medical records failed to reveal evidence of the following hospice information, per regulation: - The most recent hospice plan of care- Hospice election form- Physician certification and recertification of the terminal illness- Names and contact information for hospice personnel involved in hospice care- Hospice medication information- Hospice physician and attending physician ordersDuring a surveyor interview on 4/28/2026 at 8:55 AM with Registered Nurse Staff E, she acknowledged that the hospice binder was incomplete. She further stated that she was unsure of the frequency of hospice visits for the resident and did not know the personnel involved in the care of Resident ID #11.During a surveyor interview on 4/28/2026 at 10:44 AM with the Director of Nursing Services, she was unable to provide evidence that the facility had the required hospice information per the regulation.

Based on clinical record review, resident and staff interview, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice for 1 of 2 residents reviewed for pain, Resident ID #17. Findings are as follows:Review of an undated facility policy titled Administering Medications states in part, Medication administration times are determined by resident need and benefit, not staff convenience.Record review revealed that Resident ID #17 was admitted to the facility in April of 2026 with diagnoses including, but not limited to, migraines and chronic pain.Review of a care plan dated 4/20/2026 revealed a goal for the resident to verbalize adequate pain relief with an intervention including, but not limited to, respond immediately to any complaint of pain.Record review revealed a physician's order for Butalbital-APAP-Caffeine Oral Capsule 50-300-40 milligrams (Butalbital-Acetaminophen-Caffeine, Fioricet, a medication used to treat migraines) Administer 1 capsule every 12 hours as needed for migraine pain.During a surveyor observation on 4/29/2026 at 10:30 AM Resident ID #17 was in the hallway complaining of a migraine. The resident was noted to be moaning in pain and holding his/her head.During surveyor observations on 4/29/2026 revealed the following:-10:34 AM Nursing Assistant (NA) Staff F, reported to Licensed Practical Nurse (LPN), Staff G that Resident ID #17 wanted pain medication for a headache.-10:35 AM LPN, Staff G, left the unit.-10:37 AM Resident ID #17 continued to complain of migraine pain. Additionally, s/he reported to RN, Staff H, his/her pain. Staff H told Resident ID #17 that she did not have keys to the medication cart and could not get him/her any pain medication.-10:40 AM Resident ID #17 reported that his/her head hurt bad and s/he wheeled back to his/her room to lay down. Additionally, LPN, Staff G was still off the unit.-10:42 AM Staff G, is back on the unit and did not assess Resident ID #17.-10:55 AM Certified Medication Technician, Staff B reported to LPN Staff G, that Resident ID #17 had a headache and was waiting for pain medication.During a surveyor interview on 4/29/2026 at 11:00 AM with Resident ID #17 s/he revealed that s/he has not been medicated for his/her migraine and reported the pain to be 7 out of 10.During a surveyor interview on 4/29/2026 at 11:07 AM with LPN, Staff G, he revealed that he had not medicated Resident ID #17 for his/her migraine.Record review of the April 2026 Medication Administration Record revealed that Resident ID #17 was medicated with Butalbital-APAP-Caffeine Oral Capsule 50-300-40 MG at 11:10 AM on 4/29/2026 for pain 8 out of 10. The medication was administered 40 minutes after the resident initially complained of pain.During a surveyor interview on 4/29/2026 at 11:13 AM with Staff G he revealed that he was downstairs getting soap at 10:35 AM.During a surveyor interview on 4/29/2026 at 11:41 AM with the Director of Nursing Services she acknowledged that a resident should not wait 40 minutes for pain medication. Additionally, she was unable to provide evidence that the facility provided pain management consistent with professional standards.

Based on clinical record review, surveyor observations, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 resident reviewed for following physician orders, Resident ID #32, for 1 of 2 residents reviewed for abuse, Resident ID #11 and for 1 of 2 residents reviewed for wound observations, Resident ID #40. Findings are as follows:1. Record review of an undated policy titled Administering Medications states in part, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by the resident need and benefit .Record review revealed that Resident ID #32 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, dementia and anxiety disorder.Record review of the care plan revised on 4/2/2026 revealed the resident has a communication problem related to a hearing deficit.Record review of a nursing progress note dated 4/22/2026 authored by the Director of Nursing Services (DNS) revealed that the resident complained of difficulty hearing related to the wax build-up in his/her right ear. Record review of a progress note dated 4/22/2026 authored by the Medical Director revealed that the resident was complaining of right ear blockage with wax and ordered Debrox ear drop solution.Review of a physician order dated 4/24/2026 revealed to flush the right ear with warm water two times a day following Debrox usage for 5 days. However, the record did not include a physician's order for the Debrox ear drop solution.Review of the April 2026 Medication Administration Record revealed that the resident's right ear was flushed with warm water on the following dates and times:-4/25 at 8:00 AM and 5:00 PM-4/26 at 8:00 AM and 5:00 PM-4/27 at 8:00 AM and 5:00 PMRecord review revealed that the resident's ears were flushed a total of 6 times.During a surveyor interview on 4/28/2026 at 9:20 AM with the resident, s/he revealed that s/he feels like his/her right ear is still blocked although it had been flushed.During a surveyor interview on 4/28/2026 at 9:42 AM with Registered Nurse (RN), Staff E, she acknowledged that she flushed the resident's right ear with warm water the previous day per the order. Additionally, Staff E, revealed that she was unaware if the resident received the Debrox solution to his/her right ear.During a surveyor interview on 4/28/2026 at 11:12 AM with the DNS she revealed that she received the order for the Debrox ear solution from the Nurse Practitioner due to the resident complaining of ear wax build-up. Additionally, the DNS indicated that the Debrox was ordered to be given twice a day for 5 days and then to flush the right ear. The DNS further acknowledged that she entered the order incorrectly and that the right ear should not be flushed before the debrox solution administration.During a surveyor interview on 4/28/2026 at approximately 2:00 PM with the Nurse Practitioner (NP), she stated that the intended order was for Debrox solution to be administered twice daily for five days prior to ear irrigation, with flushing to be performed one to two times depending on the level of wax buildup. The NP further indicated that she would not have ordered daily ear flushing for a resident. 2. Record review revealed Resident ID #11, was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, dementia.Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/22/2026 alleges that there were inappropriate interactions between a Nursing Assistant (NA) and Resident ID #11 at the facility. The report included an incident report from the local police department dated 4/18/2026 that indicates that the family for Resident ID #11 wanted to press charges.During a surveyor interview on 4/28/2025 at 1:58 PM with the Administrator and the DNS, they confirmed the staff reported that they had witnessed NA, Staff A, kiss Resident ID #11 on 4/15 and 4/17/2026. Record review failed to reveal evidence that the above noted allegation of abuse was reported to the provider.Review of the comprehensive care plan failed to reveal evidence that it was updated following the allegation of abuse, including the implementation of any interventions to prevent further abuse or address behaviors related to the incident During a surveyor interview on 4/28/2026 at 1:41 PM with the Nurse Practitioner she was unaware of the incident and would have expected to be notified.During a surveyor interview on 4/28/2026 at 1:51 PM with the Assistant Director of Nursing Services she acknowledged that the provider had not been notified of the allegation of abuse and that the care plan had not been updated.3. Record review revealed that Resident ID #40 was readmitted to the facility in February of 2026 with diagnoses including, but not limited to, peripheral vascular disease and cellulitis of the lower limb.Record review revealed a physician's order to cleanse open areas to the left lower leg with Vashe wound wash (an antimicrobial wound cleanser) and apply xeroform (wound treatment) to wound bed and wrap with kling.During a surveyor observation on 4/27/2026 at 11:51 AM of Registered Nurse, Staff E, performing wound care, she failed to utilize the Vashe wash as ordered to cleanse the wound and instead used normal saline.During a surveyor interview directly following the above observation with Staff E, she acknowledged using normal saline to cleanse the wound and not the vashe wash as ordered.During a surveyor interview on 4/27/2026 at 12:33 PM with the Director of Nursing Services (DNS) she revealed that she would expect the nurse to follow the wound orders as written. Additionally, she was unable to provide evidence that the facility provided care in accordance with professional standards of practice for the above noted residents.

Based on clinical record review and staff interview the facility failed to ensure that residents are free of any significant medication errors for 1 of 2 residents reviewed for antibiotic use, Resident ID #17. Findings are as follows:Review of a facility policy titled, Notification of Changes Policy last revised May 2025 states in part, .The facility must inform the.resident's physician.when there is a change requiring such notification.Record review revealed that Resident ID #17 was admitted to the facility in April of 2026 with diagnoses including, but not limited to, surgical aftercare and complication of surgical and medical care.Record review revealed a physician's order dated 4/3/2026 for Cefadroxil Oral Capsule (antibiotic) 500 milligrams, administer 1 capsule by mouth two times a day for 14 days.Review of the April 2026 Medication Administration Record revealed that the resident did not receive the antibiotic on following dates:-4/3 at 8:00 PM-4/6 at 8:00 PM-4/11 at 8:00 PM-4/12 at 8:00 AM-4/14 at 8:00 PM-4/17 at 8:00 AMRecord review revealed the resident missed a total of 6 doses of his/her antibiotic.Record review failed to reveal evidence that the provider had been made aware of the missed doses of antibiotics.During a surveyor interview on 4/29/2026 at 10:21 AM with Registered Nurse, Staff H, she acknowledged the 6 missed doses of antibiotics for Resident ID #17. Additionally, she revealed that the missed doses should have been reported to the provider. During a surveyor interview on 4/29/2026 at 11:04 AM with the Medical Director, she revealed that she was unaware of the missed 6 doses of antibiotics. Additionally, she revealed that she would have extended the dose of antibiotics so the resident could complete the course if she had known.During a surveyor interview on 4/29/2026 at 11:37 AM with the Director of Nursing Services (DNS) she acknowledged that the resident did not receive 6 doses of his/her antibiotic. The DNS revealed that she would expect the provider to be made aware if a resident misses any dose of an antibiotic. Additionally, she was unable to provide evidence that the resident was kept free from significant medication errors.

Based on clinical record review and staff interview, the facility failed to ensure that allegations made by residents are recognized as possible abuse by staff and that all allegations are investigated, for 1 of 2 resident's reviewed for abuse, Resident ID #41. Findings are as follows:Review of a facility policy titled, Abuse, Neglect and Exploitation last revised March of 2026 states in part, .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.Record review revealed that the resident was admitted to the facility in October of 2025 with diagnoses including, but not limited to, dementia and traumatic brain injury.Review of a progress note dated 3/5/2026 authored by Registered Nurse, Staff D, revealed that a resident reported to her that Resident ID #41 was being inappropriate with another resident.Review of a Psychiatric Evaluation and Consultation dated 3/6/2026 states in part, .Patient is being seen per facility request due to increased sexually inappropriate behaviors towards other residents.Review of a Psychiatric Evaluation and Consultation dated 3/13/2026 states in part, .Sexual impulses may present an unsafe environment for other patients in facility.During a surveyor interview on 4/27/2026 at 9:39 AM with RN, Staff E, she revealed that Resident ID #41 has been observed touching other resident's shoulders and hands. Per Staff E, Resident ID #41 must be redirected often.During a surveyor interview on 4/27/2026 at 9:58 AM, the Director of Nursing Services (DNS) stated that she was unsure what the documentation regarding Resident ID #41 and the subsequent psychiatric notes referencing sexually inappropriate behavior were referring to.During a surveyor interview on 4/27/2026 at 10:14 AM with RN, Staff D, via the telephone she acknowledged writing a progress note about Resident ID #41 being inappropriate with another resident. Per Staff D, the inappropriate behavior was Resident ID #41 attempting to hug another resident, but s/he did not make contact with the other resident. Additionally, she revealed that she separated both residents and assessed both residents without any concerns identified.During a surveyor interview on 4/27/2026 at 10:30 AM with the Assistant Director of Nursing, she revealed that she was unaware of Resident ID #41 being inappropriate with other residents. Additionally, she acknowledged that the facility did not investigate any allegations regarding Resident ID #41 being sexually inappropriate with other residents.During a surveyor interview on 4/27/2026 at 10:36 AM with the Administrator she acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred with Resident ID #41. Additionally, she was unable to provide evidence that the staff identified allegations made by residents as possible abuse or that all allegations are investigated immediately.

Based on record review and staff interview, the facility failed to keep a resident free from sexual abuse for 1 of 2 residents reviewed, Resident ID #11.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/17/2026 revealed that a staff member reported to the facility that she witnessed a Nursing Assistant (NA) grab Resident ID #11's face and kiss him/her on the lips.Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 4/22/2026 alleged inappropriate interactions between a NA and Resident ID #11. The report included a local police department incident report dated 4/18/2026, indicating that the family of Resident ID #11 intended to pursue charges related to the incident that occurred on 4/17/2026. Review of a policy titled, Abuse, Neglect and Exploitation Policy last revised in March of 2026 states in part, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .sexual abuse is non-consensual sexual act of any type with a resident.Screening.Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.background, reference, and credentials' checks shall be conducted by the facility itself, third party agency or academic institution.The facility will maintain documentation of proof that the screening occurred.Record review revealed Resident ID #11, the victim, was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, dementia.Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating the resident has severely impaired cognition.Record review of the facility's investigation revealed that on 4/17/2026 at approximately 12:00 PM, Certified Medication Technician (CMT) Staff B reported to the Assistant Director of Nursing Services (ADNS) that she observed NA Staff A kiss Resident ID #11 on the lips. The investigation further identified that NA Staff C reported a separate incident in which Staff A was observed kissing Resident ID #11 on the lips on 4/15/2026.During a surveyor interview 4/28/2026 at 8:46 AM with CMT, Staff B, she revealed that on 4/17/2026 she was assisting Resident ID #11 with breakfast. At approximately 9:30 AM, NA Staff A, came into the room and said, I love this [Resident ID #11]. NA Staff A, then made a kissing noise, leaned forward towards the resident and kissed him/her on the lips. She further revealed after the above observation she felt very uncomfortable and discussed the incident with NA, Staff C who reported a similar incident occurred on 4/15/2026.During a surveyor interview on 4/28/2026 at 10:14 AM with Staff C, she revealed that on 4/15/2026 at approximately 10:00 AM she was providing morning care for Resident ID #11. Staff A entered the room and asked Residet ID #11 if s/he remembered her. She then told the resident that she loved him/her and leaned toward the resident making a kissing sound and kissed the resident on the mouth, making full lip to lip contact. When asked whether she reported the incident at the time, Staff C stated that she was fearful of Staff A and only came forward after learning that a similar incident had occurred in the presence of another staff member. During a surveyor interview 4/28/2026 at 11:21 AM with the ADNS she revealed that after the incident was reported the facility started its investigation and suspended Staff A.During a surveyor interview on 4/28/2026 at 1:58 PM with the Administrator and the Director of Nursing Services, they confirmed the above staff reported that they had witnessed Staff A, kiss Resident ID #11 on 4/15 and 4/17/2026. Additionally, she revealed that the staff member was immediately suspended pending the completion of the investigation and that the staff received additional abuse training. The Administrator was unable to provide evidence that all residents were kept free from abuse.Cross reference F606

Based on clinical record review and staff interview, 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 3 residents reviewed who is receiving hospice care, Resident ID #1.Findings are as follows:Record review of a facility policy titled, Coordination of Hospice Services Policy revealed in part, .The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility.The facility will monitor for medications and medical supplies to ensure they are provided by hospice as indicated in the plan of care for palliation and management of the terminal illness.all residents receiving hospice will continue to receive the same facility services as residents who have not elected hospice.medication administration.and ongoing monitoring of resident conditions.Record review revealed the resident was admitted to the facility in January of 2026 with diagnoses including, but not limited to, Alzheimer's disease, hypertension, and atherosclerotic heart disease of the native coronary artery (a buildup of plaque in the coronary arteries that cause narrowing, affecting blood flow).Record review revealed that the resident was receiving hospice services during his/her time at the facility.Record review of a Hospice Recommendation form dated 1/30/2026 revealed the patient was seen for an end-of-life visit. The resident was experiencing periods of apnea (a condition where breathing temporarily stops during sleep) along with a racing pulse and increasing pain. Recommendations were made during the visit which included the following:-To schedule Morphine concentrate (a medication prescribed to relieve severe pain, often prescribed for comfort during end of life) 5 milligrams (mg), every 2 hours-To schedule Ativan concentrate (Lorazepam Intensol- a medication prescribed to relieve anxiety, often prescribed for end-of-life agitation) 0.5mg, every 2 hours-To change as needed Morphine concentrate to 5 mg every hour as needed-To change as needed Ativan concentrate to 0.5 mg every hour as neededDuring a surveyor interview on 2/19/2026 at 1:14 PM with the Hospice Registered Nurse (RN), she revealed that she was called in for an end-of-life visit for the resident who was declining on 1/30/2026 at 4:00 PM- 5:00 PM. She made the above recommendations during this visit. She revealed that the resident was having increased pain and agitation, so she recommended to increase the frequency of Morphine and Ativan to every 2 hours routinely with as needed orders for breakthrough pain or agitation every hour. She stated when she did her assessment of the resident any movement caused him/her to groan and grimace. She further indicated that when asked by the family how long the resident had left to live, she didn't feel it would be long.Record review of the resident's progress notes revealed the following:-On 1/30/2026 at 11:55 AM- Spoke with hospice about resident's [respiratory rate] 30 [Normal respiratory rate is between 12- 20 breaths per minute] and restlessness and received recommendation to increase frequency from Q4hr [every 4 hours] prn [as needed] to Q2 hours prn. [Physician name] informed and approved.-On 1/31/2026 at 6:36 AM- Resident passed away at 0617. [Hospice name] called.Further review of the progress notes failed to reveal any nurses' notes assessing the resident's condition between 1/30/2026 at 11:55 AM and 1/31/2026 at 6:17 AM when it was noted that the resident had passed away, per the facility policy.Record review of the resident's clinical record including the progress notes, physician's orders, and Medication Administration Record (MAR) for January 2026, failed to reveal evidence that the hospice recommendations that were made during the end-of-life visit at 4:00 PM- 5:00 PM on 1/30/2026 were communicated to the resident's physician or implemented for end-of-life comfort.Review of the MAR for January 2026 revealed the last documented dose of the Ativan administered was at 10:00 PM on 1/30/2026, approximately 8 hours prior to the resident's death.Further review of the MAR for January 2026 revealed the last documented dose of the Morphine administered was at 2:13 PM on 1/30/2026, approximately 16 hours prior to the resident's death.During a surveyor interview on 2/19/2026 at approximately 1:00 PM with the Director of Nursing Services, she acknowledged that the resident did not receive his/her Ativan and Morphine per the Hospice recommendations. Additionally, she could not provide evidence the facility nurses provided ongoing monitoring of the resident's condition at end-of-life.Cross reference F 760

Based on clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed for end-of-life comfort medications, Resident ID #1. Findings are as follows:Review of community reported complaint submitted to the Rhode Island Department of Health on [DATE] alleges in part, on [DATE] the facility had multiple problems with the nurse who was working the 11:00 PM to 7:00 AM shift. It revealed that during the shift there was a resident actively passing away and the nurse did not give him/her any comfort medications.Record review revealed the resident was admitted to the facility in January of 2026 with diagnoses including, but not limited to, Alzheimer's disease, hypertension, and atherosclerotic heart disease of the native coronary artery (a buildup of plaque in the coronary arteries that cause narrowing, affecting blood flow).Record review of a Hospice Recommendation form dated [DATE] revealed recommendations to include:-To schedule Morphine concentrate (a medication prescribed to relieve severe pain, often prescribed for comfort during end of life) 5 milligrams (mg), every 2 hours-To schedule Ativan concentrate (Lorazepam Intensol- a medication prescribed to relieve anxiety, often prescribed for end-of-life agitation) 0.5 mg, every 2 hours-To change as needed Morphine concentrate to 5 mg every hour as needed-To change as needed Ativan concentrate to 0.5 mg every hour as neededDuring a surveyor interview on [DATE] at 1:14 PM with the Hospice Registered Nurse (RN), she revealed that she was called in for an end-of-life visit for the resident who was declining on [DATE] at 4:00 PM- 5:00 PM. She made the above recommendations during this visit. She revealed that the resident was having increased pain and agitation, so she recommended to increase the frequency of Morphine and Ativan to every 2 hours routinely with as needed orders for breakthrough pain or agitation every hour. She stated when she conducted her assessment of the resident any movement caused him/her to groan and grimace. She further indicated that when asked by the family how long the resident had left to live, she didn't feel it would be long.Record review of the resident's Medication Administration Record (MAR) for January of 2026 revealed the following active orders at the time of the resident's death on [DATE] at 6:17 AM:-Lorazepam intensol 2 mg/milliliter (ml) give 0.25 ml three times daily- Lorazepam intensol 2 mg/ml give 0.25 ml every 2 hours as need for restlessness- Morphine sulfate 20 mg/ml give 0.25 ml every 2 hours as needed for pain greater than 4Further review of the [DATE] MAR failed to reveal evidence that the hospice recommendations to change the resident's end-of-life comfort medications were implemented.During a surveyor interview on [DATE] at 12:30 PM with Registered Nurse, Staff A, she revealed that the resident was having increased pain and agitation, so hospice was called, and a nurse was sent on the evening of [DATE]. She further indicated that she had texted the new hospice recommendations to the resident's physician.Surveyor observation of the text message dated [DATE] at 5:00 PM revealed, Resident ID #1 had new hospice recommendations for scheduled and as needed every 1-hour Ativan and Morphine. It further stated [s/he] is dying. The physician's text message in response revealed ok.During a subsequent interview on [DATE] at 12:45 PM with Staff A, she failed to provide evidence that the orders for Morphine and Ativan to be administered every two hours routinely were implemented for the resident. Additionally, she failed to provide evidence the as needed orders for Morphine and Ativan were ever changed to reflect that they could be administered every hour.During a surveyor interview on [DATE] at 1:27 PM with the resident's physician, she indicated that the nurse should have implemented the hospice recommendations to increase the frequency for the resident's end-of-life medications after she approved them.Review of the MAR for [DATE] revealed the last administered dose of the Ativan was at 10:00 PM on [DATE], approximately 8 hours prior to the resident's death.Further review of the MAR for [DATE] revealed the last administered dose of the Morphine was at 2:13 PM on [DATE], approximately 16 hours prior to the resident's death.During a surveyor interview on [DATE] at approximately 1:00 PM with the Director of Nursing Services, she acknowledged that the resident did not receive his/her Ativan and Morphine, as ordered, for end-of-life comfort.Cross reference F 849

Based on clinical record review, surveyor observation, and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to not following transmission-based precautions for 1 of 2 residents reviewed, Resident ID #4.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 1/5/2026 alleged that the facility had residents with norovirus (a highly contagious virus that causes gastroenteritis, leading to symptoms like vomiting, diarrhea, and stomach cramps) since last week.Review of an untitled and undated facility policy, states in part, .Transmission based precautions are the second tier of basic infection control and are used in addition to Standard-based precautions for patient who may be infected or colonized with certain infectious agents for which additional precautions are needed.Wear PPE [personal protective equipment] appropriate to the transmission mode or the organism.Types of Transmission Based Precautions: Contact transmission is infection spread through direct contact with an infectious person (e.g., touching during a handshake) or with an article or surface that has become contaminated.Infection Control Measures for Contact Precautions include.Standard precautions infection control measures.PPE, including gloves and gown for all interactions that may involve contact with resident or resident's environment.Review of a facility policy titled, Norovirus Prevention and Control dated December 2023, states in part, .Avoid exposure to vomitus or diarrhea. Place residents on Contact Precautions in a single occupancy room, if possible, when symptoms are consistent with norovirus gastroenteritis .When residents with norovirus gastroenteritis cannot be accommodated in a single occupancy rooms, efforts will be made to separate them from asymptomatic residents.During outbreaks, residents with norovirus gastroenteritis will be placed on Contact Precautions for a minimum of 48 hours after the resolution of symptoms.Longer periods of isolation or cohorting for medically complex residents may be considered based on clinical judgement.Record review revealed Resident ID #4 was readmitted to the facility in November of 2025 with a diagnosis including, but not limited to, dementia.During a surveyor interview on 1/7/2026 at 8:51 AM, with the Administrator, she revealed that the facility was currently experiencing a norovirus outbreak and revealed that those residents experiencing symptoms were placed on contact precautions.During a surveyor interview on 1/7/2026 at 9:03 AM, with the Infection Preventionist, she revealed that the facility admitted a resident on 12/31/2025, who was positive for norovirus, and revealed that by the 3:00 PM to 11:00 PM shift on 1/1/2026, a few residents were experiencing gastrointestinal (GI) symptoms, consistent with norovirus, including vomiting and loose stools (diarrhea). She revealed that all residents who were experiencing GI symptoms were placed on contact precautions, as directed by the RIDOH and the Medical Director. Further, she revealed she had created a line list of residents affected.Review of the facility provided line list revealed that as of 1/6/2026, 21 residents have been identified as experiencing GI symptoms, such as nausea, vomiting, and diarrhea.During a facility tour on 1/7/2026 at 11:43 AM, 10 resident rooms were noted to be on contact precautions, and 2 resident rooms were noted to be on contact/droplet precautions (requires the use of gown, gloves, a face shield, and a mask upon room entry). During a surveyor observation on 1/7/2026 at 11:44 AM, of Resident ID #4's room, revealed signage posted outside the door to utilize contact precautions when entering the resident's room, which includes performing hand hygiene before entering and when exiting the room and wearing a gown and gloves before room entry.Record review revealed a physician's order dated 1/3/2026 for contact precautions relative to GI symptoms.During a surveyor observation on 1/7/2026 at 11:45 AM, revealed Nursing Assistant, Staff C, enter the resident's room without wearing a gown or gloves. Staff C, then exited the resident's room, failed to perform hand hygiene, walked down the hallway and entered a clean linen storage room. Staff C then exited the clean linen storage room with clean linens in her hand, walked back to the resident's room, and re-entered without wearing a gown or gloves. During a surveyor interview on 1/7/2026 at 11:47 AM, following the above observation, with Staff C, she revealed that the resident was on contact precautions due to the norovirus. She acknowledged the contact precautions signage posted outside the resident's room, acknowledged that she did not wear the appropriate PPE, and did not perform hand hygiene after exiting the resident's room. Further, she acknowledged that she should have been wearing the appropriate PPE and performed hand hygiene, when entering and exiting the resident's room, per the signage posted outside of the room.During a surveyor interview on 1/7/2026 at 11:53 AM, with the Infection Preventionist, she revealed that she would expect staff to follow the signage posted outside the resident's room and would expect staff to wear the appropriate PPE, including a gown and gloves when entering the resident's room.During a surveyor interview on 1/7/2026 at 11:58 AM, with the Administrator, she revealed that she would expect staff to follow the contact precaution signage posted outside of the resident's room.

Based on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for blood pressure medications with parameters, Resident ID #3.Findings are as follows:Review of a facility policy titled, Medication Administration Policy, last revised February of 2025, states in part, .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.Record review revealed the resident was admitted to the facility in November of 2025 with diagnoses including, but not limited to, hypertension (high blood pressure) and atrial fibrillation (irregular heartbeat).Review of a care plan focus area initiated on 11/25/2025 revealed, the resident has hypertension. Interventions include, administer hypertension medication, as ordered; obtain vital signs as ordered, and monitor/document/report any signs or symptoms of hypertension.Record review revealed a physician's order dated 12/7/2025 for metoprolol tartrate oral tablet (a blood pressure medication), 100 milligrams (mg) twice daily for hypertension, with instructions to hold for a systolic blood pressure (SBP, the top number in a blood pressure reading, which indicates the pressure in your arteries when your heart beats) less than 110 or a heart rate (HR) less than 60.Record review revealed a physician's order dated 12/7/2025 for amiodarone HCI oral tablet (an antiarrhythmic medication), 200 mg once daily, related to atrial fibrillation and hypertension, with instructions to hold for a HR less than 60.Review of the December 2025 and January 2026 Medication Administration Records (MARs) revealed the resident's metoprolol was documented as being administered, when his/her heart rate was below the indicated parameter, on the following dates and times:-12/10/2025 at 5:00 PM, with a HR of 52-12/12/2025 at 8:00 AM, with a HR of 58-12/12/2025 at 5:00 PM, with a HR of 49-12/16/2025 at 5:00 PM, with a HR of 48-12/17/2025 at 5:00 PM, with a HR of 51-1/2/2026 at 5:00 PM, with a HR of 54-1/6/2026 at 5:00 PM, with a HR of 57Review of the December 2025 MAR revealed that on 12/12/2025, the amiodarone was documented as being administered when the resident's heart rate was 58, which is below the indicated parameter.During a surveyor interview on 1/7/2026 at 12:48 PM, with Certified Medication Technician (CMT), Staff A, he revealed that vital signs are obtained prior to administering the resident's metoprolol or amiodarone, to ensure the resident's vital signs are within the indicated parameters. He acknowledged that the documentation in the MAR indicated the medication was administered on the above-mentioned dates and revealed that he would not have administered the resident his/her metoprolol or amiodarone, as the resident's HR was below the indicated parameter. Further, he revealed that if the medications are held due to the residents' vital signs, the CMT should notify the nurse. Review of the December 2025 MAR revealed the resident's metoprolol was held 13 out of 28 opportunities due to his/her HR being below the indicated parameter. Additional review revealed 5 opportunities, listed above, where the resident's metoprolol was documented as being administered outside of the parameters and should have been held, indicating a total of 18 out of 28 opportunities where the resident's HR was below the parameters.Review of the January 2026 MAR revealed 2 out of 13 opportunities, the resident's metoprolol was held due to his/her HR being below the indicated parameter. Additional record review revealed 2 opportunities, listed above, where the resident's metoprolol was documented as being administered outside of the parameters and should have been held, indicating a total of 4 out of 13 opportunities where the resident's HR was below the parameter.Record review failed to reveal evidence that the resident's provider was notified of the multiple held doses of metoprolol, due to the resident's low HR.During a surveyor interview on 1/7/2026 at 12:54 PM, with Registered Nurse, Staff B, she revealed that if the resident's metoprolol or amiodarone was held due to his/her vital signs, the CMT would inform the nurse. She acknowledged that the resident's metoprolol and amiodarone were documented as being administered, on the above-mentioned dates, and indicated that it should not have been administered, due to his/her HR being below the indicated parameters. She further revealed that if the medications were held multiple times, the nurse should notify the resident's provider and document the notification in a progress note. Additionally, she was unable to provide evidence that the resident's provider was notified of the total opportunities where his/her metoprolol was held due to his/her low HR in December of 2025 and January of 2026.During a surveyor interview on 1/7/2026 at 12:59 PM, with the Director of Nursing Services and the Infection Preventionist, they revealed that CMTs should be obtaining vital signs prior to administering the resident his/her metoprolol or amiodarone and if the medication is held, they should inform the nurse. They acknowledged that the resident's metoprolol and amiodarone were documented as being administered on the above-mentioned dates, and indicated that they should not have been administered, as his/her HR was below the indicated parameters. During a surveyor interview on 1/7/2026 at 1:12 PM, with the resident's provider, she revealed that she would expect nursing staff to follow the parameters associated with the resident's metoprolol and amiodarone orders and would expect the medication to be held if his/her vital signs are below the indicated parameters. She further revealed that she would expect nursing to notify her if the resident's metoprolol or amiodarone were held. Additionally, she revealed that she was unaware the resident's metoprolol was being held often due to his/her low HR and would expect to be notified, indicating that if she had been made aware, she would have considered a medication adjustment.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with wounds receives necessary treatment and services, consistent with professional standards of practice, to promote healing for 2 of 2 residents reviewed for wounds, Resident ID #s 1 and 2.Findings are as follows:Review of a facility policy titled, Wound Treatment Management, revised January 2025, states in part, .Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.1. Review of a community reported complaint submitted to the Rhode Island Department of Health on 10/28/2025, alleged in part that Resident ID #1 has wounds that are worsening but is often told by staff that they are improving.Record review revealed Resident ID #1 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, peripheral vascular disease and disruption or dehiscence (a reopening of a wound) of the abdominal wall surgical wound.Review of several care plan focus areas dated 10/16/2025 revealed, the resident has multiple wounds to his/her right lateral ankle, coccyx (tailbone), abdomen, and thigh. Additionally, s/he is to follow up with the wound physician and treatments are to be administered, as ordered.Record review of a facility provided document Initial Wound Evaluation and Management Summary, dated 10/17/2025, revealed the following wounds and treatment orders:- Wound #1: Right ankle - Apply skin prep (skin protectant) once daily and as needed.- Wound #2: Right buttock - Apply Santyl (wound treatment) and cover with gauze island bordered dressing once daily and as needed.- Wound #3: Right thigh - Apply zinc ointment (wound treatment) once daily and as needed.- Wound #4: Abdomen - Apply Vashe (wound cleanser) moistened alginate with silver (wound treatment) to the wound bed and cover with a gauze island bordered dressing once daily and as needed.1a. Record review revealed the resident's wounds were initially evaluated by the wound physician on 10/17/2025. Review of the October 2025 Treatment Administration Record (TAR) failed to reveal evidence that Wound #2's wound treatment was completed as ordered on 10/18/2025.Additionally, record review revealed the resident's wounds were re-evaluated by the wound physician on 10/20/2025, with orders to change the treatment to apply silver sulfadiazine and cover with a gauze island bordered dressing twice daily (day and evening) and as needed.Review of the October 2025 TAR revealed the facility did not transcribe the wound physician's new order for silver sulfadiazine twice daily for Wound #2 until 10/25/2025, indicating that the resident received the incorrect treatment of Santyl once daily on 10/21, 10/22, 10/23, and 10/24/2025.Additional review of the October 2025 TAR failed to reveal evidence that resident's coccyx wound treatment was completed in the evening on 10/25/2025, as ordered.1b. Record review revealed the wound physician assessed Wound #3 on 10/17/2025 and ordered to apply zinc once daily.Record review failed to reveal evidence that the zinc for Wound #3 was transcribed.Additionally, record review revealed the wound physician reassessed Wound #3 on 10/20, and again on 10/27/2025, with orders to continue with zinc to the wound.Record review failed to reveal evidence that the wound physician's treatment order for Wound #3 was transcribed when it was initially ordered on 10/17/2025, or after Wound #3 was reassessed on 10/20 and 10/27/2025.Review of the October 2025 TAR failed to reveal evidence that Wound #3's wound treatment of zinc once daily was completed from 10/18 through 10/30, indicating 13 days that the wound treatment was not completed.1c. Record review revealed the wound physician assessed Wound #4 on 10/17/2025 and ordered to apply Vashe moistened alginate with silver to the wound bed and cover with a gauze island bordered dressing once daily and as needed.Review of the October 2025 TAR failed to reveal evidence that Wound #4's wound treatment was completed as ordered on 10/18/2025.Additionally, record review revealed the resident's wounds were reevaluated by the wound physician on 10/20/2025. Further review revealed that Wound #4's treatment was changed to cleanse with Anasept (a wound cleanser), apply calcium alginate with silver and a collagen sheet (a wound treatment), and to cover with a gauze island bordered dressing once daily and as needed.Further review of the October 2025 TAR revealed the facility did not transcribe the wound physician's new order of Anasept and the collagen sheet, once daily, for Wound #4 until 10/25/2025, indicating that the resident received the incorrect treatment on 10/21, 10/22, 10/23, and 10/24/2025.During a surveyor interview on 10/30/2025 at 2:40 PM with the Wound Physician, she revealed that she would expect staff to transcribe all wound orders, update wound orders when a treatment changes, and to complete treatments, as ordered.2. Record review revealed Resident ID #2 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, reduced mobility and muscle weakness.Review of a care plan focus area dated 8/7/2025 revealed that s/he has a wound to his/her coccyx. Additionally, s/he is to follow up with the wound physician and treatments are to be administered, as ordered.Review of a physician's order dated 9/11/2025 revealed to cleanse the coccyx wound with normal saline (a wound cleanser), apply skin prep to the peri wound, apply collagen powder (a wound treatment) to the wound bed, and to cover with a dry dressing once daily.Review of the October 2025 TAR failed to reveal evidence that the resident's wound treatment was completed as ordered on 10/6 and 10/24/2025.Record review revealed the resident's coccyx wound was re-evaluated by the wound physician on 10/27/2025. Further review revealed that the resident's coccyx wound treatment was changed to calcium alginate with silver and to cover with a gauze island bordered dressing twice daily (morning and evening) and as needed.Review of the October 2025 TAR revealed the facility did not transcribe the wound physician's new order for calcium alginate with silver twice daily for the resident's coccyx wound until 10/29/2025, indicating that the resident received the incorrect treatment on 10/28/2025.Further review of the October 2025 TAR failed to reveal evidence that resident's coccyx wound treatment was completed in the morning on 10/29/2025, as ordered.During a surveyor interview on 10/30/2025 at 3:30 PM with the Administrator, she was unable to provide evidence that the facility ensured that residents with wounds receive necessary treatment and services, consistent with professional standards of practice, to promote healing.

Based on surveyor observation, record review, and staff interview, the facility failed to; obtain, review, and report laboratory tests, as ordered, and complete ordered COVID-19 testing upon admission and on subsequent days for 2 of 3 newly admitted residents reviewed, Resident ID #s 1 and 2. The facility's failure involved urinary tract infection (UTI) related laboratory testing and follow-up, and the failure to obtain Covid-19 testing, as ordered, resulted in a delay of care, including the hospitalization of Resident ID #1 with diagnoses including Covid-19 and a UTI. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/18/2025 alleged in part that the facility had a Covid-19 outbreak, and that Resident ID #1 was now positive for Covid-19. The complaint further alleged that the resident had blood in his/her urine and was not receiving care that s/he should.1. Record review revealed Resident ID #1 was admitted to the facility in November of 2025 with diagnoses including, but not limited to, UTI and neuromuscular dysfunction of the bladder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed, the resident had a urostomy (a surgical opening in the abdomen to allow urine to exit the body). Further review revealed the resident required moderate assistance with activities of daily living. Record review of a care plan dated 11/13/2025 revealed, Resident ID #1 is at risk for infection related to a left Percutaneous Nephrostomy Tube (PCN, a tube that is surgically placed into the kidney to allow urine to drain out of the body) and right urostomy with interventions including, but not limited to; monitor, document, and report abnormal lab values, as ordered.1a. Record review of the physician's order revealed the following:- 11/12/2025 to obtain a urinalysis, culture and sensitivity (UA C&S- urine tests prescribed to detect UTIs and guide appropriate treatment).Record review of the laboratory results revealed the UA was obtained on 11/12/2025 and resulted on 11/14/2025. Further review revealed Resident ID #1 was positive for a UTI. Record review of the progress notes failed to reveal evidence that the UA C&S results were reported to a provider, or that an intervention was put into place. Further review revealed the resident was transferred to the hospital on [DATE] for an evaluation of shortness of breath, cough, and blood in his/her urostomy and PCN tube.1b. Review of the COVID-19 Testing Informed Consent Form states in part, I understand I will be tested upon admission. revealed Resident ID #1 signed the consent form on 11/6/2025. Record review revealed a physician's order dated 11/8/2025 stating, [Covid-19] Test new admissions or residents who have left the facility for more than 24 hours, regardless of vaccination status, on admission, day 2 and day 4.Record review failed to reveal evidence that Resident ID #1 was tested for Covid on admission, on day two, or on day four, as ordered.Record review of the hospital documentation dated 11/17/2025 revealed, the resident was admitted to the hospital with diagnoses including, but not limited to, a UTI and Covid. Further review of hospital documentation revealed that as of 11/24/2025, Resident ID #1 remained in the hospital.During a surveyor interview on 11/24/2025 at approximately 11:00 AM with Registered Nurse (RN), Staff A, she indicated that the facility currently has a Covid-19 outbreak, which began on 11/17/2025. She further indicated that every resident should be tested for Covid on admission, on day two, and on day four. Additionally, she acknowledged that Resident ID #1 had not been tested for Covid-19 at all while admitted to the facility. Furthermore, she acknowledged that the positive UA C&S results on 11/14/2025 were not reported to a provider and the resident had not been treated at the facility prior to his/her hospitalization.During a surveyor interview on 11/24/2025 at approximately 1:45 PM, with the Infection Preventionist, she acknowledged that Resident ID #1 was not tested for Covid on admission, on day two, or on day four, and that the facility currently has a Covid-19 outbreak. Additionally, she indicated that the UA C&S results, dated 11/14/2025, were not viewed by any facility staff until 11/17/2025, the day the resident was sent to the hospital for shortness of breath, blood in his/her urostomy, and PCN tube. Furthermore, she acknowledged that a provider was not notified of the results and that interventions were not put into place. 2. Record review revealed Resident #2 was admitted in November 2025 with diagnoses including a history of UTIs and muscle weakness. Review of a care plan dated 11/19/2025 revealed, the resident had a UTI with interventions including, but not limited to, to obtain and monitor lab results, as ordered.2a. Record review of the physician's order revealed the following:- 11/19/2025 to obtain a UA C&SRecord review failed to reveal evidence that the UA C&S was completed as ordered. 2b. Record review revealed a physician's order dated 11/13/2025 to [Covid-19] Test new admissions or residents who have left the facility for more than 24 hours, regardless of vaccination status, on admission, day 2 and day 4.Record review failed to reveal evidence that Resident ID #2 was tested for Covid-19 on admission or on day two, as ordered.Record review revealed the resident tested positive for Covid on 11/21/2025.During a surveyor interview on 11/25/2025 at approximately 11:00 AM with RN, Staff B, she indicated that all new admissions are tested for Covid-19 on admission, day two, and day four, and acknowledged that Resident ID #2 had not been tested on admission or on day two, as ordered. Additionally, she acknowledged that the UA C&S still had not been obtained, as ordered, and could not provide evidence that the provider had been notified. During a surveyor interview on 11/25/2025 at 11:21 AM with the Director of Nursing Services, she indicated that she would expect physician's orders to be followed, and that labs would be completed and reported to a provider. She further indicated that the Covid-19 outbreak began on 11/17/2025 and that 19 of 43 residents had tested positive as of 11/24/2025. During a surveyor interview on 11/25/2025 at approximately 11:45 AM with the Medical Director, she indicated that she would expect to be notified of lab results because she does not review results unless the facility notifies her. Additionally, she indicated that she would expect physician's orders to be completed and that nurses document when providers are notified. The facility's failure involved UTI-related laboratory testing and follow-up, and failure to obtain Covid-19 testing as ordered, which resulted in a delay of care, including the hospitalization of Resident ID #1 with diagnoses including a UTI and Covid-19.

Based on surveyor observation, record review, and staff interview, the facility failed to; obtain, review, and report laboratory tests, as ordered; notify a provider of abnormal or missing test results; and complete ordered COVID-19 testing upon admission and subsequent days for 2 of 3 newly admitted residents reviewed, Resident ID #s 1 and 2. The facility's failure involved UTI-related laboratory testing and follow-up, that resulted in a delay of care, including the hospitalization of Resident ID #1.Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/18/2025 alleged in part that the facility had a Covid-19 outbreak, and that Resident ID #1 was now positive for Covid-19. The complaint further alleged that the resident had blood in his/her urine and was not receiving care that s/he should.1. Record review revealed Resident ID #1 was admitted to the facility in November of 2025 with diagnoses including, but not limited to, urinary tract infection (UTI) and neuromuscular dysfunction of the bladder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed, the resident had a urostomy (a surgical opening in the abdomen to allow urine to exit the body). Further review revealed the resident required moderate assistance with activities of daily living. Record review of a care plan dated 11/13/2025 revealed, Resident ID #1 is at risk for infection related to a left Percutaneous Nephrostomy Tube (PCN, a tube that is surgically placed into the kidney to allow urine to drain out of the body) and right urostomy with interventions including, but not limited to; monitor, document, and report abnormal lab values, as ordered.1a. Record review of the physician's order revealed the following:- 11/6/2025, to obtain labs including a complete blood count, (CBC) and complete metabolic panel (CMP) on 11/10/2025.- 11/12/2025 to obtain a urinalysis, culture and sensitivity (UA C&S- urine tests prescribed to detect UTIs and guide appropriate treatment).Record review failed to reveal evidence that the physician's order for a CBC was transcribed to be completed. Additionally, further review failed to reveal evidence that the labs were obtained on 11/10/2025, as ordered.Record review of the laboratory results revealed the UA was obtained on 11/12/2025 and resulted on 11/14/2025. Further review revealed Resident ID #1 was positive for a UTI. Record review of the progress notes failed to reveal evidence that the UA C&S results were reported to a provider, or that an intervention was put into place. Further review revealed the resident was transferred to the hospital on [DATE] for an evaluation of shortness of breath, cough, and blood in his/her urostomy and PCN tube.1b. Review of the COVID-19 Testing Informed Consent Form which states in part, I understand I will be tested upon admission. revealed Resident ID #1 signed the consent form on 11/6/2025. Record review revealed a physician's order dated 11/8/2025 stating, [Covid-19] Test new admissions or residents who have left the facility for more than 24 hours, regardless of vaccination status, on admission, day 2 and day 4.Record review failed to reveal evidence that Resident ID #1 was tested for Covid on admission, on day two, or on day four, as ordered.Record review of the hospital documentation dated 11/17/2025 revealed, the resident was admitted to the hospital with diagnoses including, but not limited to, a UTI and Covid. Further review of hospital documentation revealed that as of 11/24/2025, Resident ID #1 remained in the hospital.During a surveyor interview on 11/24/2025 at approximately 11:00 AM with Registered Nurse (RN), Staff A, she indicated that the facility currently has a Covid-19 outbreak, which began on 11/17/2025. She further indicated that every resident should be tested for Covid on admission, on day two, and on day four. Additionally, she acknowledged that Resident ID #1 had not been tested for Covid-19 at all while admitted to the facility. Furthermore, she acknowledged that the labs were not completed on 11/10/2025, as ordered, and that the positive UA C&S results on 11/14/2025 were not reported to a provider.During a surveyor interview on 11/24/2025 at approximately 1:45 PM, with the Infection Preventionist, she acknowledged that the labs were not completed on 11/10/2025, as ordered. She further acknowledged that Resident ID #1 was not tested for Covid on admission, on day two, or on day four, and that the facility currently has a Covid-19 outbreak. Additionally, she indicated that the UA C&S results, dated 11/14/2025, were not viewed by any facility staff until 11/17/2025, the day the resident was sent to the hospital for shortness of breath, blood in his/her urostomy, and PCN tube. Furthermore, she acknowledged that a provider was not notified of the results and that interventions were not put into place. 2. Record review showed Resident #2 was admitted in November 2025 with diagnoses including a history of UTIs and muscle weakness. Review of a care plan dated 11/19/2025 revealed, the resident had a UTI with interventions including, but not limited to, to obtain and monitor lab results, as ordered.2a. Record review of the physician's order revealed the following:- 11/19/2025 to obtain a UA C&SRecord review failed to reveal evidence that the UA C&S was completed. Additional record review revealed laboratory tests that included a CBC were obtained on 11/14/2025 and resulted the same day; however, the record failed to provide evidence of a physician's order. Furthermore, the record failed to provide evidence that the abnormal results were reported to a provider, or that the UA C&S was obtained as ordered.2b. Record review revealed a physician's order dated 11/13/2025 to [Covid-19] Test new admissions or residents who have left the facility for more than 24 hours, regardless of vaccination status, on admission, day 2 and day 4.Record review failed to reveal evidence that Resident ID #2 was tested for Covid-19 on admission or on day two, as ordered.Record review revealed the resident tested positive for Covid on 11/21/2025.During a surveyor interview on 11/25/2025 at approximately 11:00 AM with RN, Staff B, she indicated that all new admissions are tested for Covid-19 on admission, day two, and day four, and acknowledged that Resident ID #2 had not been tested on admission or on day two, as ordered. She could not provide evidence of a physician's order for the labs obtained on 11/14/2025 or that a provider had been notified of the abnormal results. Additionally, she acknowledged that the UA C&S still had not been obtained, as ordered, and could not provide evidence that the provider had been notified. During a surveyor interview on 11/25/2025 at 11:21 AM with the Director of Nursing Services, she indicated that she would expect physician's orders to be followed, as ordered, and that labs would be completed and reported to a provider. She further indicated that the Covid-19 outbreak began on 11/17/2025 and that 19 of 43 residents had tested positive as of 11/24/2025. During a surveyor interview on 11/25/2025 at approximately 11:45 AM with the Medical Director, she indicated that she would expect to be notified of lab results because she does not review results unless the facility notifies her. Additionally, she indicated that she would expect physician's orders to be completed, as ordered, and that nurses document when providers are notified. The facility's failure involved UTI-related laboratory testing and follow-up, that resulted in a delay of care, including the hospitalization of Resident ID #1.

Based on record review and staff interview, it has been determined that the facility failed to ensure that medical records for each resident are accurately documented for 2 of 2 residents reviewed relative to a fluid restriction, Resident ID #'s 18 and 25, for 1 of 3 residents reviewed relative to insulin administration, Resident ID #2, and for 1 of 1 resident reviewed relative to pressure relieving devices, Resident ID #14. Findings are as follows: 1a. Record review revealed Resident ID #18 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, end stage renal disease (a condition when the kidneys lose their ability to function properly), and dependence on renal dialysis (a treatment that removes excess fluid and waste products from the blood when the kidneys are unable to do so). Record review revealed the following physician's orders related to fluid intake and monitoring: - 11 PM to 7 AM nurse to total the amount of fluid for the past 24 hours every night shift with a start date of 2/26/2025 - Notify the Medical Doctor (MD) if intake exceeds fluid restriction ordered with a start date of 2/26/2025 with a listing of intake for each shift: 7 AM - 3 PM shift, Dietary 400 milliliter (mL), Nursing 120 mL for a total of 520 mL; 3PM - 11PM shift, Dietary 240 mL, Nursing 120 mL for a total of 360 mL; and 11PM - 7 AM shift, nursing 120 mL. - Fluid intake monitoring every shift with a start date of 2/26/2025 Record review of the March 2025 Medication Administration Record (MAR) revealed that the resident's daily fluid total intake failed to be added together and documented accurately for 30 of 31 opportunities. During a surveyor interview on 4/2/2025 at 11:36 AM with the Director of Nursing Services (DNS), in the presence of the Assistant DNS and the Regional DNS, she stated that she would expect staff to add the fluid intake for each shift daily and document them accurately in the MAR, as ordered. 1b. Record review revealed Resident ID #25 was admitted to the facility in February of 2025 with a diagnosis including, but not limited to, acute diastolic congestive heart failure (a condition where the heart muscle pumps inadequately). Record review revealed the following physician's orders related to fluid intake and monitoring: - 1500 ml fluid restriction, 2/10/2025 - 11 PM to 7 AM nurse to total the amount of fluid for the past 24 hours every night shift with a start date of 2/25/2025. - Notify the Medical Doctor (MD) if intake exceeds fluid restriction ordered with a start date of 2/26/2025 with a listing of intake for each shift: 7 AM - 3 PM shift, Dietary 500 mL (milliliter), Nursing 120 mL for a total of 520 mL; 3PM - 11PM shift, Dietary 240 mL, Nursing 120 mL for a total of 360 mL; and 11 PM - 7AM shift, nursing 120 mL. Record review of the March 2025 MAR revealed that the resident's daily fluid total intake failed to be added together and documented accurately for 26 of 31 opportunities. During a surveyor interview on 4/2/2025 at 5:02 PM with the DNS, she acknowledged that Residents ID #25's daily fluid intake for fluid restrictions was inaccurately documented. 2. Record review revealed Resident ID #2 was readmitted to the facility in January of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review of the Quarterly Minimum Data Set assessment dated [DATE] revealed s/he has a Brief Interview for Mental Status score of 15 of 15, indicating intact cognition. Record review revealed a physician's order to administer Humalog injection solution 100 unit/milliliter (fast acting insulin that lowers blood sugar) per sliding scale (administration of insulin based on the resident's blood sugar level). During a surveyor interview on 4/1/2025 at 11:55 AM with Resident ID #2, s/he revealed that s/he has not received his/her insulin yet. Record review of Resident ID #2's April 2025 MAR on 4/1/2025 at 11:58 AM revealed that his/her insulin was signed off as administered on 4/1/2025 at 11:52 AM, indicating 6 units was administered with a site location of his/her abdomen. During a surveyor interview on 4/1/2025 at 12:04 PM with Registered Nurse, Staff E, she revealed that she has not administered Resident ID #2's 11:00 AM Humalog insulin. Staff E acknowledged that she signed off that she administered the insulin but failed to administer the dose, as ordered. During a surveyor interview on 4/1/2025 at 2:31 PM with the Assistant Director of Nursing Services, she acknowledged that Staff E inaccurately documented that she administered the insulin when she had not. 3. Record review of Resident ID #14's Minimum Data Set assessment dated [DATE] revealed that s/he is at risk of developing pressure ulcers/injuries. Record review revealed a physician order with a start date of 9/13/2024, to apply bilateral foam boots to both feet at all times. Record review of the March and April 2025 Treatment Administration Records revealed that the above order was signed off as completed on 3/31/2025 and 4/1/2025 for the 7:00 AM - 3:00 PM shift. Surveyor observations during the following dates and times revealed the resident did not have his/her foam boots on to his/her bilateral feet: - 3/31/2025 at 9:56 AM, 12:20 PM, 12:37 PM, 1:40 PM, 2:11 PM, and 3:33 PM - 4/1/2025 at 9:17 AM, 11:25 AM, 11:47 AM, 11:55 AM, 12:56 PM, and 1:09 PM During a surveyor interview on 4/1/2025 at 2:42 PM with the Director of Nursing Services, she acknowledged that the order was signed off as completed but was unable to provide evidence that the boots were on at all times for the above-mentioned dates and times. 45855

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, relative to a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications) for 1 of 1 resident reviewed with a PICC line, Resident ID #34. Findings are as follows: A. According to the facility's pharmacy document, dated 7/2020, titled .Infusion Intravenous (IV) Access Line Maintenance Protocol (Appendix B) specifies the flushes that are indicated for a valved or non-valved PICC line. The protocol for an intermittent non-valved PICC line indicates a 10 milliliters (mL) IV flush with a normal saline solution (a sterile fluid containing salt and water) is required before the antibiotic is administered and after the medication is administered, followed by an additional 5 mL flush of Heparin (a flush used for an IV catheter to help prevent blockage in the tube after receiving an IV infusion). Further review of the protocol revealed for an intermittent valved catheter a 10 mL normal saline flush is indicated before and after the medication, but it does not indicate a Heparin flush is needed for a valved PICC line. Record review revealed the resident was readmitted to the facility on [DATE] and again on 3/19/2025 with a diagnosis including, but not limited to, osteomyelitis (an infection of the bone tissue) of the vertebra (series of small bones that form the spine), sacral (bony structure that is located at the base of the vertebrae) and sacrococcygeal (the area where the sacrum and coccyx [bottom portion of the spine below the sacrum] meet) region. Record review of the hospital paperwork revealed the resident had a PICC line placed on 2/19/2025. Further review of the document failed to indicate whether the PICC line was valved or non-valved (to determine the appropriate flushes to administer, you must know if the PICC line is valved or non-valved). Record review revealed the following physician's orders: 3/15/2025, PICC: Flush Catheter lumen and change caps pre and post medication administration (See appendix B) 3/26/2025 Vancomycin (an antibiotic prescribed to treat infections) 1500 milligrams (mg) intravenously twice daily. During a surveyor observation of the medication pass and simultaneous interview on 4/2/2025 at 9:29 AM with Licensed Practical Nurse (LPN), Staff D, she reviewed the resident's flush order for his/her PICC line prior to administering the Vancomycin infusion and revealed to the surveyor that the order failed to indicate the appropriate flushes for the PICC line. When asked by the surveyor what type of PICC line (valved or non-valved) did the resident have, Staff D was unable to determine what type of PICC line the resident has and that she needed to review more of the record. After reviewing the record, Staff D was still unable to obtain the PICC line information, she then asked the Director of Nursing Services (DNS) for assistance. During a surveyor interview with the DNS on 4/2/2025 at 9:18 AM, she was unable to state what type, valved or non-valved, of PICC line the resident has. Additionally, she was unable to provide evidence relative to the type of PICC line the resident had. When further asked what flushes were indicated for the PICC line, she was unable to determine as she did not know the type of PICC line it was and acknowledged that the order did not specify the flushes to administer. During a surveyor interview on 4/4/2025 at 9:40 AM with the Assistant Director of Nursing Services (ADNS), she was unable to indicate if the PICC line was valved or non-valved, and acknowledged that the current flush order says to flush pre and post medication and that the order did not indicate what to flush the PICC line with. During a subsequent surveyor interview on 4/2/2025 at 10:18 AM with the DNS, she revealed that after calling the hospital, she was informed that the PICC line was a non-valved catheter. Additionally, she further revealed that the flush order indicates to refer to Appendix B and that the protocol for a non-valved PICC line is to flush the catheter with normal saline before and after administering medication and then to flush the line with Heparin. B. According to the Lippincott Nursing Procedures Ninth Edition (2023), states in part, .Peripherally Inserted Central Catheter Use .Use a sterile measuring tape or the incremental markings on the catheter to measure the external length [the length of the visible portion of the PICC line outside the body] of the catheter from hub [the connector port on the outside of the catheter where medications or fluids are accessed] to skin entry to make sure that the catheter hasn't migrated .Troubleshooting a PICC .if external PICC migration [unintended movement from its intended position] is greater than 3/4 inches (2 [centimeter] cm), notify the practitioner . Record review of the hospital paperwork revealed the resident had a PICC line placed on 2/19/2025 to his/her right arm and the length of the entire catheter line is 44 cm. Additional review of the document failed to reveal evidence of the external catheter length measurement. Record review revealed a physician's order dated 3/15/2025 which indicates the following: -PICC device type is valved -Total catheter length is 44 cm -External catheter length- (nothing indicated) Further review revealed a physician's order dated 3/15/2025 for the PICC line admission assessment dressing change, measure the external catheter length one time upon admission. Record review of the March 2025 Treatment Administration Record (TAR) revealed that on 3/15/2025 the nurse signed off that the order was completed, but she failed to document any measurements for the external catheter length of the PICC line. Further review revealed a physician's order dated 3/21/2025 for a PICC Assessment dressing change, measure the external catheter length every 7 days with the dressing change. Record review of the March 2025 TAR revealed that on 3/21/2025 the nurse signed off that the order was completed and documented that the external catheter length was 44 cm in length, indicating the entire length of the catheter was visible. During a surveyor interview on 4/2/2025 at 12:51 PM and 1:11 PM with Registered Nurse (RN) Staff C, she revealed that on 3/21/2025 she documented the entire length of the catheter and failed to document the external length portion. Additionally, she was unable to explain why she documented the measurement of the entire catheter length instead of the external catheter length. Staff C revealed that she flushed the PICC line according to the order. Further, she revealed that she has not received any formal training relative to caring for a PICC line. During a surveyor interview on 4/2/2025 at 3:33 PM with LPN Staff D, she revealed that she did not have formal training relative to caring for a PICC line. Staff D revealed she was unfamiliar with Appendix B and would have needed to ask for assistance in locating it. During a surveyor interview on 4/2/2025 at 5:10 PM with RN Staff E, she acknowledged that on 3/31/2025 she administered Resident ID #34's Vancomycin antibiotic via the PICC line. Additionally, she revealed that she only flushed the PICC line with a normal saline flush before and after the Vancomycin infusion. Lastly, she revealed that she has never received any formal training relative to caring for a PICC line. During a surveyor interview on 4/2/2025 at approximately 3:00 PM with the Regional Clinical Nurse in the presence of the DNS and the ADNS, she revealed that she would expect all nurses to be IV Certified. Additionally, they were unable to provide evidence that the above-mentioned nurses were competent in providing PICC line care.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 1 resident with an order for foam boots (cushioned boots use to reduce the risk of developing a pressure ulcer [a wound that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period]), Resident ID #14. Findings are as follows: Record review of Resident ID #14's Minimum Data Set assessment dated [DATE] revealed that s/he is at risk of developing pressure ulcers/injuries. Record review revealed s/he has contractures (a condition of shortening or hardening of muscles, tendons or other tissues often leading to deformity and rigidity of joints) to his/her bilateral legs with a care plan intervention to apply pressure relieving foam boots as ordered. Record review revealed a physician's order dated 9/13/2024 to apply bilateral foam boots to both feet at all times. Surveyor observations during the following dates and times revealed the resident did not have his/her foam boots on to his/her bilateral feet: - 3/31/2025 at 9:56 AM, 12:20 PM, 12:37 PM, 1:40 PM, 2:11 PM, and 3:33 PM - 4/1/2025 at 9:17 AM, 11:25 AM, 11:42 AM, 12:56 PM and 1:09 PM During a surveyor interview on 4/1/2025 at 1:26 PM with Nursing Assistant, Staff I, she acknowledged that the resident did not have his/her boots in place. During a surveyor interview on 4/1/2025 at 2:42 PM with the Director of Nursing Services, she was unable to explain why the foam boots were not applied to the resident's bilateral feet on the above dates and times, as ordered.

Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving physical abuse are thoroughly investigated for 1 of 1 resident reviewed, Resident ID #31. Findings are as follows: Review of a facility policy titled, .Abuse Policy states in part, .It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse .and ensure that all alleged violations of Federal and State laws .are reported immediately to the Executive Director of the facility .The facility will investigate each alleged violation thoroughly and report the results of the investigations to the Executive Director .Policy and procedure .The supervisor is to initiate the following steps: a. Immediate investigation into the alleged incident. b. Interview staff member implicated. Get a written statement. c. Interview other staff members. Employee should document incident in a written narrative. d. Interview with resident or resident witness. Supervisor to document incident in a written statement from resident (s) . i. Notify the Social Worker who will interview the resident . Definitions .Abuse: Unjustified physical contact, intentional and careless, which is likely to result in physical or psychological harm .The law is: Each resident has the right to be free from abuse .Residents must not be abused by anyone, including staff .Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . Review of a facility reported incident sent to the Rhode Island Department of Health on 3/24/2025 alleges that the resident reported that a Nursing Assistant (NA) grabbed his/her right forearm tightly and told him/her that s/he needs to get washed up whether s/he likes it or not. Record review revealed the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, dementia, anxiety and depression. Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 9 out of 15, indicating moderate cognitive impairment. Additional review of the assessment revealed that s/he self-propels with a wheelchair and requires moderate assistance for activities of daily living. Record review of a progress note dated 3/24/2025, authored by Registered Nurse, Staff B, indicates the resident reported that s/he was sitting in his/her wheelchair when NA, Staff A, grabbed [his/her] right forearm tightly and told him/her that s/he needs to get washed up whether [s/he] wants to or not. Staff A then attempted to pull the resident out of the wheelchair. The resident appeared frightened and reported right arm discomfort. Further record review failed to reveal evidence that Staff A was interviewed by the facility after the incident, until it was brought to the facility's attention by the surveyor. Additionally, the record failed to reveal evidence that any interviews were conducted by the facility as part of the investigation, including, but not limited interviewing Staff B. During surveyor interviews on 4/1/2025 at 1:10 PM and approximately 3:00 PM with the Director of Nursing Services (DNS), she revealed that on 3/24/2025 she was made aware that Staff A was behaving strange and appeared impaired, sitting on the floor and not responding to call lights. Additionally, the DNS revealed that she did not conduct an interview with Staff A or any other staff member to investigate the alleged incident. Additionally, the DNS provided the surveyor Staff A's written statement regarding the incident that she had just obtained when the surveyor was present in the building and questioning the incident. Staff A's statement indicated that on the night of the incident, Staff A had grabbed the resident's hand to attempt to provide care, the resident refused care and Staff A never returned to the resident's room. Further the DNS was unable to provide any further documentation relative to the investigation. An attempt was made by the surveyor, to interview Staff A on 4/2/2025, but the surveyor did not receive a return call. 45855 \