Every finding on record at Royal of Westerly Nursing Center

Based on clinical record review and staff interview, the facility failed to inform the resident or resident's representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering of, and administration of, psychotropic medications (a medication that affects brain activities associated with mental processes and behavior) for 5 of 5 residents reviewed for psychotropic consent, Resident ID #s 3, 9, 26, 46 and 64.Findings are as follows:Review of a facility policy titled, Policy and Procedure for Informed Consent for Psychotropic Medications, states in part, .It is the policy of this facility that informed consent for the administration of psychotropic medications will be obtained prior to the administration of any psychotropic medication.Procedure.Facility staff will utilize the Informed Consent Form for Psychotropic Administration provided from the Department of Public Health. Staff will obtain informed consent for any prescribed medication that is used to treat a psychiatric diagnosis or symptoms prior to the administration of the medication.Documentation will include: Name of resident.Date of the discussion.Facility Representative Name and Title.Medication Proposed/Prescribed.Dosage Range for the medication.Purpose of the medication.Risks of use of the medication; if on antipsychotics, the black box warning is reviewed for the use of antipsychotics in dementia-related psychosis.Benefits of use of the medication.Check to consent or refuse the medication.Signature of the resident or representative with date of signature.The side effects need to be written on the sheet or med pass stickers can be used.The completed form will be placed in the medical record.A new consent form will be generated and the above process will be re-addressed in the following circumstances.Each time a renewed prescription of the psychotropic medication falls outside of the dosage range that the resident or representative previously consented to.On an annual bases and with a significant change of status.A) Record review revealed Resident ID #3 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, Alzheimer's disease and anxiety disorder.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment.Review of a care plan focus area dated 9/2/2025 revealed the resident is prescribed psychotropic medications related to dementia and behavior management.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-Lorazepam 0.25 milliliters (ml) every 4 hours, as needed-Mirtazapine 15 milligrams (mg) once daily at bedtime-Trazodone 50 mg, twice daily-Haloperidol lactate oral concentrate, 0.5 mg every 8 hours-ABH gel (lorazepam 2mg/ml, diphenhydramine 25 mg/ml, haloperidol 2 mg/ml, gel 2 ml) with instructions to apply topically, twice dailyRecord review failed to reveal evidence that the resident's representative was informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident representative was informed of the risks and benefits, side effects, and/or treatment alternatives.Additional record review failed to reveal evidence of a signed psychotropic medication consent form, per facility policy.B) Record review revealed Resident ID #9 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, Alzheimer's disease and major depressive disorder, severe with psychotic features.Review of an MDS assessment dated [DATE] revealed a BIMS score of 6 out of 15, indicating severe cognitive impairment.Review of a care plan focus area dated 12/15/2025 revealed the resident is prescribed psychotropic medication related to his/her diagnosis of dementia with psychotic features.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-Trazodone 50 mg, once daily, as needed-Quetiapine fumarate, 12.5 mg once daily-Quetiapine fumarate, 25 mg, once daily in the eveningRecord review failed to reveal evidence that the resident's representative was informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident representative was informed of the risks and benefits, side effects, and/or treatment alternatives.Additional record review failed to reveal evidence of a signed psychotropic medication consent form, per facility policy.During a surveyor interview on 2/18/2026 at 8:45 AM, with the resident's representative, s/he revealed that s/he has never been asked to provide consent for Resident ID #9's psychotropic medication use, stating that s/he usually finds out after the fact. S/he further revealed that s/he has never signed a psychotropic medication consent form and never had a conversation with facility staff about the side effects, risks and benefits of the medication or alternative treatment methods. Additionally, s/he revealed that s/he was unaware Resident ID #9 was receiving Trazodone.C) Record review revealed Resident ID #26 was admitted to the facility in September of 2025 with diagnoses including, but not limited to, dementia and depression.Review of an MDS assessment dated [DATE] revealed a BIMS Assessment was unable to be completed, due to the resident being rarely/never understood, indicating severe cognitive impairment.Review of a care plan focus area initiated on 9/8/2025 revealed the resident is prescribed an antidepressant medication due to his/her diagnosis of depression.Record review revealed the resident was prescribed and subsequently administered Effexor XR (a psychotropic medication), 75 mg, with instructions to administer three capsules once daily.Record review revealed the resident was prescribed lorazepam intensol oral concentrate (a psychotropic medication) 2 mg/ml, with instructions to administer 0.5 mg every 6 hours, as needed.Record review failed to reveal evidence that the resident's representative was informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident representative was informed of the risks and benefits, side effects, and/or treatment alternatives.Additional record review failed to reveal evidence of a signed psychotropic medication consent form, per facility policy.D) Record review revealed Resident ID #46 was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, depression and anxiety disorder.Review of an MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15, indicating intact cognition.Review of a care plan focus area initiated on 12/5/2023 revealed the resident is prescribed anti-anxiety medication related to his/her diagnosis of anxiety disorder.Review of a care plan focus area initiated on 12/5/2023 revealed the resident is prescribed antidepressant medication related to his/her diagnosis of depression.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-Alprazolam, 0.125 mg, once daily-Buspirone, 10 mg, twice daily-Sertraline, 200 mg, once dailyRecord review failed to reveal evidence that the resident or his/her representative was informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident or representative was informed of the risks and benefits, side effects, and/or treatment alternatives.Additional record review failed to reveal evidence of a signed psychotropic medication consent form, per facility policy.During a surveyor interview on 2/18/2026 at 9:59 AM, with Resident ID #46, s/he revealed the facility did not discuss alternative treatments, side effects, nor risk/benefits prior to initiating new psychotropic medications. E) Record review revealed Resident ID #64 was admitted to the facility in June of 2021 with diagnoses including, but not limited to, intellectual disabilities and major depressive disorder.Review of an MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15, indicating moderately impaired cognition.Review of a care plan focus area dated 6/24/2021 revealed the resident is prescribed antidepressant medications related to his/her diagnosis of depression.Review of a care plan focus area dated 11/13/2025 revealed the resident is prescribed anti-anxiety medications related to his/her diagnosis of anxiety disorder.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-Buspirone HCI, 5 mg, three times daily-Duloxetine HCI oral capsule delayed release sprinkle, 60 mg, with instructions to administer 2 capsules, once daily-Trazodone, 25 mg, twice daily, as needed-Trazodone, 50 mg, once daily at bedtime-Trazodone, 75 mg, twice daily-Seroquel 12.5 mg, once daily-Seroquel 12.5 mg, three times a day-Seroquel 25 mg, twice daily-Divalproex sodium, 500 mg, twice dailyAdditional record review revealed the resident was prescribed trazodone 25 mg, every 12 hours as needed.Record review failed to reveal evidence that the resident's representative was informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident representative was informed of the risks and benefits, side effects, and/or treatment alternatives.Additional record review failed to reveal evidence of a signed psychotropic medication consent form, per facility policy.During a surveyor interview on 2/19/2026 at 9:44 AM, with Resident ID # 64's resident representative, s/he revealed that s/he has never been asked to provide consent for Resident ID #64's psychotropic medication use, indicating that staff only make him/her aware of the implementation of new psychotropic medications. S/he further revealed that staff has not discussed any side effects, risks or benefits, or any alternative treatment methods prior to initiating psychotropic medication.During a surveyor interview on 2/18/2026 at 8:57 AM, with Licensed Practical Nurse (LPN), Staff A, she revealed that staff speak with resident representatives when a new psychotropic medication is initiated and discuss the reason for the increase and any side effects or potential interactions the medication could have. She revealed that this conversation, including what was discussed, should be documented in a progress note. She further revealed that resident representatives do not sign a consent form for psychotropic medications, stating, it is not our policy.During surveyor interviews on 2/18/2026 at 9:44 AM and at 11:04 AM with Unit Manager, Registered Nurse, Staff B, she revealed that she obtains verbal consent from residents and or representatives and discusses side effects as well as risk/benefits of the medication. She revealed that the discussion should be documented in a progress note and indicated that she keeps the documentation simple, writing that the representative or resident agrees. During a surveyor interview on 2/18/2026 at approximately 10:05 AM, with Nurse Practitioner, Staff C, she revealed that she would expect consent to be obtained from the resident, representative, or family, when initiating a new psychotropic medication. She further revealed that she would expect staff to discuss the side effects and risks/benefits prior to initiating therapy.During a surveyor interview on 2/18/2026 at 1:33 PM, with the Director of Nursing Services, she was unable to provide evidence that Resident ID #s 3, 9, 26, 46, 64 and/or their representatives were informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications, prior to initiating therapy. Additionally, she was unable to provide evidence that the resident/representative was informed of the risks and benefits, side effects, and/or treatment alternatives. Furthermore, she was unable to provide evidence of signed consents for psychotropic medications for Resident ID #s 3, 9, 26, 46 and 64, per facility policy.

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 3 of 3 residents reviewed for Hospice services, Resident ID #s 3, 5, and 48 and and for 1 of 1 resident reviewed for a medication with administration parameters, Resident ID #67.Findings are as follows:1. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.a. Record review revealed Resident ID #3 was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, Alzheimer's disease. Further record review revealed the resident was admitted to hospice services in January of 2026.Record review revealed Resident ID #3 was seen by a hospice nurse on 2/16/2026 and the following recommendations were made:-Amoxicillin Clavulanate 875-125 milligrams (mg), by mouth, twice daily, for five days-Miralax 17 grams mixed in 6-8 ounces of fluids, by mouth, once dailyRecord review revealed a physician's order dated 2/16/2026 at 9:52 PM for Amoxicillin-Pot Clavulanate Oral Tablet 875-125 mg, with instructions to administer 1 tablet by mouth two times a day for respiratory symptoms for 5 Days, was entered into the resident's record by Licensed Practical Nurse (LPN), Staff F. Further review of the physician's order revealed the Amoxicillin-Pot Clavulanate was documented as being ordered by the Medical Director and was obtained over the phone.Record review revealed a physician's order dated 2/16/2026 at 10:00 PM for MiraLAX Oral Powder 17 GM/SCOOP, with instructions to administer 2 scoops by mouth one time a day for constipation, was entered into the resident's record by Staff F. Further review of the physician's order revealed the MiraLAX was documented as being received via a telephone order from the Medical Director.Record review failed to reveal evidence that the provider was notified of the 2/16/2026 hospice recommendations for Resident ID #3, prior to the medications being initiated.Surveyor interviews were attempted with Staff F on 2/19/2026 at 8:52 AM and 10:03 AM. Voice messages were left; however, a return call was not received by the surveyor.During a surveyor interview on 2/19/2026 at 8:56 AM, with Nurse Practitioner (NP), Staff C, she revealed that any medication recommendations received after 6:00 PM, would be addressed with the on-call providers, which should be documented in a progress note. Lastly, she revealed that she did not personally approve the hospice recommendations from 2/16/2026, indicating she was not aware Resident ID #3 was receiving an antibiotic.During a surveyor interview on 2/19/2026 at 9:56 AM, with the Medical Director, he revealed that he did not recall approving Resident ID #3's antibiotic recommendation from hospice on 2/16/2026, indicating it may have been approved by another provider.During a surveyor interview on 2/19/2026 at 10:23 AM, with Unit Manager, Registered Nurse, Staff B, she revealed that on Tuesdays and Fridays, the Medical Director is the covering provider and on Mondays, Wednesdays, Thursdays, Staff C is the covering provider. She revealed the facility has a communication book that is utilized by the providers; however, she revealed that the Medical Director does not always review the communication binder, indicating that staff have to track him down.b. Record review revealed Resident ID #5 was admitted to the facility in June of 2021 with a diagnosis including, but not limited to, chronic pain. Further record review revealed the resident was admitted to hospice services in January of 2026.Record review revealed Resident ID #5 was seen by a hospice nurse on 2/6/2026 and the following recommendations were made:-Oxycodone (pain medication) 5 mg give one tab every six hours scheduled-Oxycodone 5 mg give one tab every six hours as needed for painRecord review revealed a physician's order dated 2/7/2026 at 7:29 AM was entered into the resident's record by LPN, Staff G, for oxycodone 5 mg, with instructions to administer one tablet by mouth every six hours for pain. Further review of the physician's order revealed the oxycodone was documented as being received via a telephone order from the Medical Director.Record review revealed a physician's order dated 2/6/2026 at 8:36 PM was entered into the resident's record by LPN, Staff H, for oxycodone 5 mg, with instructions to administer one tablet by mouth every six hours as needed for pain. Further review of the physician's order for the oxycodone was documented as being received via a telephone order from the Medical Director. Record review failed to reveal evidence that the provider approved or was notified of the 2/6/2026 hospice recommendations for Resident ID #5, prior to the medications being initiated.c. Record review revealed Resident ID #48 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, dementia. Further review revealed the resident was receiving hospice services.Record review revealed Resident ID #48 was seen by a hospice nurse on 2/13/2026 and the following recommendations were made:-Discontinue the following medications: mirtazapine, aspirin, Vitamin D, Vitamin B, multivitamin, rosuvastatin, and the house nutritional supplement.-Schedule lorazepam 2 mg/milliliter (ml), with instructions to administer 0.5mg/0.25ml, every 6 hours, around the clock.-Add 2-4 liters of oxygen, as needed, for comfort and shortness of breath-Add Bactrim (an antibiotic medication), 200 mg - 40 mg/5ml, with instructions to give 20 ml, twice daily for 7 days.Record review revealed on 2/13/2026, LPN, Staff I, discontinued the following medications:-Mirtazapine 2.5 mg, once daily-Aspirin 81 oral tablet, once daily-Cholecalciferol (Vitamin D) 25 micrograms, once daily-Multivitamin, once daily-Rosuvastatin Calcium 40 mg, once daily-House frozen supplement, 4 ounces, twice dailyRecord review revealed a physician's order initiated on 2/13/2026 at 3:35 PM, for lorazepam 2 mg/ml, with instructions to administer 0.25 ml by mouth every 6 hours, was entered into the resident's record by Staff I. Further review of the physician's order revealed the lorazepam was documented as being received via a verbal order from the Medical Director.Record review revealed a physician's order initiated on 2/13/2026 at 3:37 PM, for Bactrim 200 mg-40 mg/5 ml, with instructions to administer 20 ml by mouth every 12 hours, for 7 Days, was entered into the resident's record by Staff I. Further review of the physician's order revealed the lorazepam was documented as being received via a verbal order from the Medical Director.Record review revealed a progress note dated 2/13/2026 at 3:39 PM, authored by Staff I, which states, .Hospice in to see resident, new [recommendation] [discontinue] mirtazapine, supplements, aspirin, vitamin D, multivitamin, rosuvastatin. Schedule lorazepam 2mg/ml, give 0.5 mg/0.25ml [every 6 hours] around the clock. Add Bactrim 200mg-40ml/5ml, give 20ml [twice daily for] 7 days. APRN [Advanced Practice Registered Nurse] notified and family.During a surveyor interview on 2/19/2026 at 8:56 AM, with NP, Staff C, she revealed that on 2/13/2026, the covering provider was the Medical Director, indicating he would have been the provider to address Resident ID # 48's hospice recommendations.During a surveyor interview on 2/19/2026 at 9:11 AM, with the Medical Director, he revealed that he did not recall approving Resident ID #48's hospice recommendations, indicating they might have been approved by another provider.During surveyor interviews on 2/19/2026 at 10:13 AM and 11:01 AM, with Staff I, she initially stated that she spoke with Staff C to approve Resident ID #48's hospice recommendations. However, when the surveyor revealed that she had already spoke to Staff C who had stated that she was not the provider who was on call for the approval for the resident's new hospice recommendations, Staff I revealed that she had not spoken to any provider prior to implementing the hospice recommendations for Resident ID #48. She further revealed that the process for any hospice recommendations is that hospice will give the facility nurses their recommendations, facility nurses will implement the recommendations, sign the paper copy provided from the hospice nurse, and place the paper into a communication binder for a provider to review when they come into the facility.During a surveyor interview on 2/19/2026 at 11:06 AM, with Staff C, she revealed that she would expect nursing to reach out to the providers and discuss any hospice recommendations prior to initiating or discontinuing orders.During a surveyor interview on 2/19/2026 at 11:36 AM, with the Medical Director, he revealed that he has not spoken to any staff regarding the hospice recommendations for Resident ID #s 3, 5, and 48. He revealed that nurses do not always call the providers for approval of hospice recommendations, indicating he did not expect them too. However, he revealed that he would expect nursing to speak with him regarding the initiation of an antibiotic medication for a hospice resident.During a surveyor interview on 2/19/2026 at 12:14 PM, with the Director of Nursing Services, she was unable to provide evidence that the above Hospice recommendations for Resident ID #s 3, 5, and 48 were approved by a provider, prior to initiating or discontinuing medications.2. Record review revealed Resident ID #67 was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, essential hypertension (high blood pressure).Review of a physician's order dated 11/21/2025 revealed to administer metoprolol succinate (a medication prescribed to lower blood pressure) extended release administer 12.5 milligrams once daily at 8:00 AM. Additionally, the medication was to be held if the resident's systolic blood pressure (the top number in a reading, measuring the maximum pressure in your arteries when the heart contracts and pumps blood) was below 110.Further review of the above order failed to have an associated task to ensure a blood pressure reading is obtained prior to administering the medication.Record review revealed the resident's blood pressure on the following dates and times:-11/22/2025: 93/60 at 1:47 PM-11/23/2025: 98/56 at 2:08 PMRecord review failed to reveal evidence that the resident's blood pressure was obtained prior to administering the resident his/her medication.Review of the November 2025 Medication Administration Record revealed the resident was administered his/her metoprolol succinate for 2 of 2 opportunities when the medication should have been held, as ordered.During a surveyor interview on 2/17/2026 at approximately 10:15 AM with Unit Manager, RN, Staff B, she acknowledged the resident's blood pressures on the above-mentioned dates and revealed that the medication should have been held, as ordered.During a surveyor interview on 2/17/2026 at approximately 12:50 PM with the DNS, she was unable to provide evidence that the physician's order for metoprolol was held per the parameter that was ordered by the provider.Cross reference F 710

Based on clinical record review and staff interview, the facility failed to provide appropriate treatment and services for 1 of 3 residents reviewed with a foley catheter (a flexible plastic tube inserted into your bladder to drain urine), Resident ID #70, and for 1 of 1 resident reviewed with a suprapubic catheter (SP tube, a flexible plastic tube inserted into your bladder to drain urine through an opening in the abdomen), Resident ID #5.Findings are as follows:1. Record review revealed that Resident ID #5 was admitted to the facility in June of 2021 with a diagnosis including, but not limited to, obstructive and reflux uropathy (a condition when urine flow is blocked or flows backward into the kidneys).Record review revealed that the resident has an SP tube.Review of a urology continuity of care form document dated 11/6/2024 revealed that the facility requested to complete catheter exchanges in the facility and decrease the frequency of catheter exchanges which were being completed monthly at the urology appointments. Additionally, it indicated that the urologist provided approval for the catheter exchanges to be completed at five-week intervals in the facility.Record review failed to reveal an order was in place for routine catheter exchanges at five-week intervals as approved by the resident's urologist.During a surveyor interview on 2/18/2026 at 9:37 AM with Unit Manager, Registered Nurse, Staff B, she revealed that the resident is no longer followed by the urologist, due to the resident frequently cancelling his/her appointments and the only reason she was going was to have his/her SP tube exchanged. Staff B further revealed that the resident's SP tube should be exchanged approximately every four weeks. Additionally, she acknowledged that there was no order in place to exchange the SP tube and was unsure of the last time it was exchanged.During a surveyor interview on 2/18/2026 at 10:05 AM with the Nurse Practitioner, Staff C, she revealed that she would expect exchanges to be completed at least every 28 days and an order to be in place for Resident ID #5's SP tube.2. Record review revealed that Resident ID #70 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, retention of urine.Record review revealed Resident ID #70 has an indwelling foley catheter in place.Record review failed to reveal evidence of a physician's order for the foley catheter to include: an appropriate diagnosis for the indication for catheter use, the catheter type and size, and the catheter's balloon size (an inflatable portion of the catheter near the catheter's tip that is inflated to secure the catheter's placement).During a surveyor interview on 2/17/2026 at 11:19 AM with Licensed Practical Nurse, Staff I, she acknowledged that the resident has an indwelling foley catheter and should have orders in place.During a surveyor interview on 2/18/2026 at 1:24 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the facility provided appropriate treatment and services relative to Resident ID #s 5's SP tube and Resident ID #70s indwelling catheter.Additional, record review revealed a provider's order dated 2/17/2026 for Resident ID #70's foley catheter that included the catheter and balloon size was entered into his/her medical record after it was brought to the facility's attention by the surveyor.

Based on clinical record review and staff interview, the facility failed to ensure the medical care of each resident is supervised by a physician for 3 of 3 resident's reviewed who receive Hospice services, Resident ID #s 3, 9 and 48.Findings are as follows:1. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.a. Record review revealed Resident ID #3 was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, Alzheimer's disease. Further record review revealed the resident was admitted to hospice services in January of 2026.Record review revealed Resident ID #3 was seen by a hospice nurse on 2/16/2026 and the following recommendations were made:-Start Amoxicillin Clavulanate 875-125 milligrams (mg), by mouth, twice daily, for five days-Start Miralax 17 grams mixed in 6-8 ounces of fluids, by mouth, once dailyRecord review revealed a physician's order dated 2/16/2026 at 9:52 PM for Amoxicillin-Pot Clavulanate Oral Tablet 875-125 mg, with instructions to administer 1 tablet by mouth two times a day for respiratory symptoms for 5 Days, was entered into the resident's record by Licensed Practical Nurse (LPN), Staff F. Further review of the physician's order revealed the Amoxicillin-Pot Clavulanate was documented as being ordered by the Medical Director and was obtained over the phone.Record review revealed a physician's order dated 2/16/2026 at 10:00 PM for MiraLAX Oral Powder 17 GM/SCOOP, with instructions to administer 2 scoops by mouth one time a day for constipation, was entered into the resident's record by Staff F. Further review of the physician's order revealed the MiraLAX was documented as being received via a telephone order from the Medical Director.Record review failed to reveal evidence that the provider was notified of the 2/16/2026 of the hospice recommendations for Resident ID #3, prior to the medications being initiated by Staff F. Additional record review revealed that, as of 2/19/2026, Resident ID #3's physician's orders for MiraLAX and Amoxicillin-Pot Clavulanate were not signed by a provider.During a surveyor interview on 2/19/2026 at 8:56 AM, with Nurse Practitioner, Staff C, she revealed that any medication recommendations received after 6:00 PM, would be addressed with the on-call providers, which should be documented in a progress note. She revealed that she did not personally approve the hospice recommendations from 2/16/2026, indicating she was not aware Resident ID #3 was receiving an antibiotic.During a surveyor interview on 2/19/2026 at 9:56 AM, with the Medical Director, he revealed that he did not recall approving Resident ID #3's antibiotic recommendation from hospice on 2/16/2026, indicating it may have been approved by another provider.b. Record review revealed Resident ID #5 was admitted to the facility in June of 2021 with a diagnosis including, but not limited to, chronic pain. Further record review revealed the resident was admitted to hospice services in January of 2026.Record review revealed Resident ID #5 was seen by a hospice nurse on 2/6/2026 and the following recommendations were made:-Oxycodone (pain medication) 5 mg give one tab every six hours scheduled-Oxycodone 5 mg give one tab every six hours as needed for painRecord review revealed a physician's order dated 2/7/2026 at 7:29 AM for oxycodone 5 mg, with instructions to administer one tablet by mouth every six hours for pain, was entered into the resident's record by LPN, Staff G. Further review of the physician's order revealed the oxycodone was documented as being ordered by the Medical Director and was obtained over the phone.Record review revealed a physician's order dated 2/6/2026 at 8:36 PM for oxycodone 5 mg, with instructions to administer one tablet by mouth every six hours as needed for pain, was entered into the resident's record by LPN, Staff H. Further review of the physician's order revealed the oxycodone was documented as being received via a telephone order from the Medical Director.Record review failed to reveal evidence that a provider was notified of the 2/6/2026 hospice recommendations for Resident ID #5, prior to the medications being initiated by Staff G and H. c. Record review revealed Resident ID #48 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, dementia. Further review revealed the resident is receiving Hospice services. Record review revealed Resident ID #48 was seen by a hospice nurse on 2/13/2026 and the following recommendations were made:-Discontinue the following medications: mirtazapine, aspirin, Vitamin D, Vitamin B, multivitamin, rosuvastatin, and the house nutritional supplement.-Schedule lorazepam 2 mg/milliliter (ml), with instructions to administer 0.5mg/0.25ml, every 6 hours, around the clock.-Add 2-4 liters of oxygen, as needed, for comfort and shortness of breath-Add Bactrim (an antibiotic medication), 200 mg - 40 mg/5ml, with instructions to give 20 ml, twice daily for 7 days.Record review revealed on 2/13/2026, Staff I, discontinued the following medications:-Mirtazapine 2.5 mg, once daily-Aspirin 81 oral tablet, once daily-Cholecalciferol (Vitamin D) 25 micrograms, once daily-Multivitamin, once daily-Rosuvastatin Calcium 40 mg, once daily-House frozen supplement, 4 ounces, twice dailyRecord review revealed a physician's order initiated on 2/13/2026 at 3:35 PM, for lorazepam 2 mg/ml, with instructions to administer 0.25 ml by mouth every 6 hours, was entered into the resident's record by Staff I. Further review of the physician's order revealed the lorazepam was documented as being ordered by the Medical Director and was obtained verbally. Additionally, this order was signed off by the Medical Director on 2/16/2026.Record review revealed a physician's order initiated on 2/13/2026 at 3:37 PM, for Bactrim 200 mg-40 mg/5 ml, with instructions to administer 20 ml by mouth every 12 hours, for 7 Days, was entered into the resident's record by Staff I. Further review of the physician's order revealed the lorazepam was documented as being ordered by the Medical Director and was obtained verbally. Additionally, this order was signed off by the Medical Director on 2/16/2026.Record review revealed a progress note dated 2/13/2026 at 3:39 PM, which state, .Hospice in to see resident, new [recommendation] [discontinue] mirtazapine, supplements, aspirin, vitamin D, multivitamin, rosuvastatin. Schedule lorazepam 2mg/ml, give 0.5 mg/0.25ml [every 6 hours] around the clock. Add Bactrim 200mg-40ml/5ml, give 20ml [twice daily for] 7 days. APRN [Advanced Practice Registered Nurse] notified and family.During surveyor interviews on 2/19/2026 at 10:13 AM and 11:01 AM, with Staff I, she initially stated that she spoke with Staff C to approve Resident ID #48's hospice recommendations. However, when the surveyor revealed that she had already spoken to Staff C, who had stated that she was not the provider who was on call for the approval for the resident's new hospice recommendations, Staff I revealed that she had not spoken to any provider prior to implementing the hospice recommendations for Resident ID #48. She further revealed that the process for any hospice recommendations is that hospice will give the facility nurses their recommendations, facility nurses will implement the recommendations, sign the paper copy provided from the hospice nurse, and place the paper into a communication binder for a provider to review when they come into the facility.During a surveyor interview on 2/19/2026 at 10:23 AM, with Unit Manager, Registered Nurse, Staff B, she revealed that on Tuesdays and Fridays, the Medical Director is the covering provider and on Mondays, Wednesdays, Thursdays, Staff C is the covering provider. She revealed the facility has a communication book that is utilized by the providers; however, she revealed that the Medical Director does not always review the communication binder, indicating that staff have to track him down.During surveyor interviews on 2/19/2026 at 8:56 AM and 11:06 AM, with Staff C, she revealed that on Friday, 2/13/2026, the covering provider was the Medical Director, indicating he would have been the provider to address Resident ID #48's hospice recommendations. She revealed that when she goes into the electronic medical record to sign physician's orders, she approves orders in a batch, indicating that each order is not individually reviewed by her.During surveyor interviews on 2/19/2026 at 9:11 AM and 11:36 AM, with the Medical Director, he revealed that he did recall approving Resident ID #48's hospice recommendations from 2/13/2026, indicating they might have been approved by another provider, although he signed off the order on 2/16/2026. When asked by the surveyor if he recalls signing Resident ID #48's orders on 2/16/2026, he acknowledged that he signed off the orders, indicating that he did so assuming that another provider had approved them.During a surveyor interview on 2/19/2026 at 12:14 PM, with the Director of Nursing Services, she revealed that the facility has been advised by the Medical Director that he only wants to be aware if there is a change in condition or an emergency situation, indicating they have been told to put the orders directly into the system, if it comes from a specialty provider, such as hospice, without consulting the Medical Director first. Further, she was unable to provide evidence that the medical care of each Hospice resident is supervised by a physician.Cross reference F658

Based on clinical record review and staff interview, the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 2 of 2 residents reviewed for antibiotic use who were receiving hospice services, Resident ID #s 3 and 48. Findings are as follows:Review of a facility policy titled, Antibiotic Stewardship Program Policy dated January 2025 states in part, .The facility uses the CDC's NHSN [Centers for Disease Control and Prevention's National Healthcare Safety Network] Surveillance Definitions, Updated McGeer criteria, Loeb Minimum Criteria or other surveillance tool to define infections.Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness.1. Review of the CDC/NHSN Surveillance Definitions for Specific Types of Infections dated January 2026 states in part, LOWER RESPIRATORY INFECTION, OTHER THAN PNEUMONIA LUNG-Other infection of the lower respiratory tract and pleural cavity .Other infections of the lower respiratory tract must meet at least one of the following criteria:1. Patient has organism(s) seen on Gram stain of lung tissue or pleural fluid or identified from lung tissue or pleural fluid* (when pleural fluid was obtained during thoracentesis or within 24 hours of chest tube placement) by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment, for example, not Active Surveillance Culture/Testing (ASC/AST). 2. Patient has a lung abscess or other evidence of infection (for example, empyema) on gross anatomic or histopathologic exam. 3. Patient has imaging test evidence of abscess or infection (excludes imaging test evidence of pneumonia) which if equivocal is supported by clinical correlation, specifically, physician or physician designee documentation of antimicrobial treatment for lung infection).Record review revealed that Resident ID #3 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, Alzheimer's and dementia.Record review revealed that Resident ID #3 was admitted to hospice services in January of 2026.Record review of a Multi-Discipline Note dated 2/16/2026 states in part, Routine RN [Registered Nurse] visit.Hospice Rec [Recommendation]: Amoxicillin Clavulanate [antibiotic] 875-125 mg [milligram].5 days.Record review revealed a physician's order dated 2/16/2026 for Amoxicillin Clavulanate 875-125 mg, twice daily for 5 days.Record review failed to reveal evidence of signs and symptoms indicating the resident had a respiratory infection per the NHSN surveillance definition.Further record review failed to reveal evidence that the hospice recommendations were reviewed for appropriateness with the provider per the facility policy.During a surveyor interview on 2/19/2026 at 8:56 AM with Nurse Practitioner (NP), Staff C, she revealed that she was unaware of Resident ID #3 being started on an antibiotic.During a surveyor interview on 2/19/2026 at 9:56 AM with the Medical Director, he revealed that he was unaware of Resident ID #3 being started on an antibiotic. Additionally, he was unable to provide evidence that a review of the antibiotic's appropriateness was conducted.2.Review of the CDC/NHSN Surveillance Definitions for Specific Types of Infections dated January 2026 states in part, Urinary system infections must meet at least one of the following criteria: 1. Patient has organism(s) identified from fluid (not urine) or tissue from affected site by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment, for example, not Active Surveillance Culture/Testing (ASC/AST) 2. Patient has an abscess or other evidence of infection on gross anatomical exam, during invasive procedure, or on histopathologic exam. 3. Patient has one of the following signs or symptoms: fever (>38.0 C) localized pain or tenderness* And at least one of the following: a. purulent drainage from affected site b. organism(s) identified from blood by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment, for example, not Active Surveillance Culture/Testing (ASC/AST). AND imaging test evidence definitive for infection, for example, ultrasound, CT scan, magnetic resonance imaging [MRI], or radiolabel scan [gallium, technetium]), which if equivocal is supported by clinical correlation, specifically, physician or physician designee documentation of antimicrobial treatment for urinary system infection.Record review revealed that Resident ID #48 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, stroke.Review of a document titled, Visit Notes-Hospice dated 2/13/2026 revealed that Resident ID #48 presented with increased confusion, unresponsiveness and his/her spouse was questioning a urinary tract infection. Additional review revealed that hospice recommended to start Bactrim (antibiotic) 800 mg twice daily for 7 days.Record review revealed lab results dated 2/11/2026, 2 days prior to the start of the antibiotic, with a white blood cell count (WBC) of 7.3 (regular WBC is 4 -10), which is not indicative of an infection.Record review revealed a physician's order dated 2/13/2026 for Bactrim 800mg every 12 hours for 7 days.Record review failed to reveal evidence of signs and symptoms indicating a urinary tract infection per the NHSN surveillance definition.Further record review failed to reveal evidence that the hospice recommendations were reviewed for appropriateness with the provider per the facility policy.During a surveyor interview on 2/19/2026 at 8:56 AM with Staff C, she revealed that she was unaware of Resident ID #48 was started on an antibiotic.During a surveyor interview on 2/19/2026 at 9:56 AM with the Medical Director, he revealed that he was unaware of Resident ID #48 being started on an antibiotic. Additionally, he was unable to provide evidence that a review of the antibiotic's appropriateness was conducted.During a surveyor interview on 2/19/2026 at 12:14 PM with the Director of Nursing Services she was unable to provide evidence that Resident ID #s 3 and 48 had symptoms of infection. Additionally, she was unable to provide evidence that Resident ID #s 3 and 48 were kept free of unnecessary medications. Cross Reference F710 and F881

Based on clinical record review, surveyor observation, and staff interview, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional standards for 3 of 3 medication carts observed and 1 of 1 medication rooms observed.Findings are as follows:Review of an undated facility policy titled, Storage of Medications states in part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner.1a. During a surveyor observation on 2/16/2026 at 10:01 AM of the Westerly Unit Medication Cart, in the presence of Licensed Practical Nurse (LPN), Staff A, revealed the following:-One bottle of Nutricia UTI-Stat 30 fluid ounces open and undated. Review of the manufacturer's instructions on the bottle states, Discard 3 months after opening.-One bottle of Nutricia Pro-Stat Concentrate liquid protein medical food, open and undated.Review of the manufacturer's instructions on the bottle states, Discard 3 months after opening.-One bottle of Lorazepam Oral Concentrate 2 milligram (mg)/ milliliter (ml) for Resident ID #3, open and undated and inside the medication cart.Review of the manufacturer's instructions on the box revealed to discard 90 days after opening and to keep refrigerated.During a surveyor interview immediately following the above observation with Staff A, she acknowledged that the above noted medications were opened, undated and that the Lorazepam Oral Concentrate should be refrigerated.1b. During a surveyor observation on 2/16/2026 at 10:18 AM of the Watch Hill Unit Medication Cart, in the presence of Registered Nurse (RN), Staff L, revealed the following:-One Trelegy Ellipta inhaler dated 10/31/2025 for Resident ID #5.Review of the manufacturer's instructions on the box indicate to discard 6 weeks after opening.-One bottle of Lorazepam Oral Concentrate 2mg/ml for Resident ID #14 open and stored in the medication cart.Review of the manufacturer's instructions on the box revealed to keep refrigerated.During a surveyor interview directly following the above observation with Staff L she acknowledged that the Trelegy inhaler was expired and the Lorazepam Oral Concentrate was not stored properly in the refrigerator.1c. During a surveyor observation on 2/16/2026 at 10:30 AM of the Mystic Unit Medication Cart in the Presence of RN, Staff K, revealed the following:-One bottle of UTI-Stat urinary tract protection complex 30 fluid ounces, open and not dated.Review of the manufacturer's instructions on the bottle revealed to discard 3 months after opening.-One vial of Humalog 100 units/ml insulin for Resident ID #30 with an open date of 1/15/2026 and expiration date of 2/12/2026.-Two Wixela Inhalers for Resident ID #11, open and undated.Review of the manufacturer's instructions on the box reveal to discard 1 month after opening.-One Trelegy Ellipta for Resident ID #12, open and undated.Review of the manufacturer's instructions on the box reveal to discard 6 weeks after opening.-One Wixela Inhaler for Resident ID #22, open and undated.Review of the manufacturer's instructions on the box revealed to discard 1 month after opening.During a surveyor interview immediately following the above observation with Staff K she acknowledged the insulin is expired and the inhalers were opened and undated.2. During a surveyor observation on 2/16/2026 at 10:25 AM on the Medication Room in the presence of RN, Staff L, revealed 1 vial of tuberculin purified protein derivative solution (PPD solution), opened and undated.Review of the manufacturer's instructions on the box revealed to discard 30 days after opening.During a surveyor interview with Staff L she acknowledged that the PPD solution was open and undated.During a surveyor interview on 2/17/2026 at 10:58 AM with the Director of Nursing Services she revealed that she would expect staff to date medication when it is opened and to be aware of when medications should be discarded.

Based on clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 3 of 3 residents reviewed for antibiotic use, Resident ID #s 1, 3, and 48. Findings are as follows:According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Perform antibiotic 'time outs.' .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions: Does this resident have a bacterial infection that will respond to antibiotics?If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration?Can the spectrum of the antibiotic be narrowed or the duration of therapy shortened (i.e., de-escalation)?Would the resident benefit from additional infectious disease/antibiotic expertise to ensure optimal treatment of the suspected or confirmed infection . A. Record review revealed that Resident ID #1 was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, pneumonia and respiratory failure.Record review revealed a physician's order dated 2/17/2026 for Cefdinir (an antibiotic) oral 300 milligrams (mg) twice a day for 7 days for pneumonia.Record review failed to reveal evidence of an antibiotic review or an antibiotic time out.B. Record review revealed that Resident ID #3 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, Alzheimer's and dementia.Record review revealed a physician's order dated 2/16/2026 for Amoxicillin Clavulanate (an antibiotic) 875-125 mg, twice daily for 5 days.Record review failed to reveal evidence of an antibiotic review or an antibiotic time out.C. Record review revealed that Resident ID #48 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, stroke.Record review revealed a physician's order dated 2/13/2026 for Bactrim (an antibiotic) 800mg every 12 hours for 7 days.Record review failed to reveal evidence of an antibiotic review or an antibiotic time out.During a surveyor interview on 2/18/2026 at 12:10 PM with the Director of Nursing Services she revealed that they do not perform antibiotic time outs or reviews 48-72 hours after initiating an antibiotic, as required by the CDC. Cross Reference F710 and F757

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed who had skin impairments without any treatment orders in place. Additionally, the facility failed to ensure the resident was placed on Enhanced Barrier Precautions (EBP, in addition to standard precautions, EBP includes wearing personal protective equipment (PPE) that includes a gown and gloves when performing high contact care activities) as required relative to his/her wounds, Resident ID #14.Findings are as follows:1. Record review revealed the resident was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, stroke.1a. Review of a policy titled, Wound Treatment Management last revised in January of 2026 states in part, Wound treatments will be provided in accordance with physician orders.In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders.During a surveyor observation in the presence of Hospice Nursing Assistant, Staff J, on 2/16/2026 at 10:08 AM, the resident was observed with the following two wound dressings in place to his/her lower legs:-Left lower leg dressing dated 2/6, indicating it has been in place for 10 days, initialed by Registered Nurse (RN), Staff K, that was noted to be soiled with bloody drainage.-Right lower leg dressing dated 2/13 without any initials to indicate who applied the dressingDuring a surveyor interview immediately following the above observations with Staff J, she acknowledged the above dressings and revealed that she was going to inform the nurse about the left lower leg dressing dated 2/6. Record review failed to reveal evidence of a physician's order for the left lower leg dressing.During a surveyor interview on 2/16/2026 at 10:47 AM with RN, Staff B, she revealed that her roles are the Unit Manager and Wound Nurse. She then revealed that she was unaware that the resident had a wound to his/her left lower leg, until it was brought to the facility's attention by the surveyor.Record review revealed a wound treatment order initiated on 2/16/2026 to cleanse the open area to the left lower leg with normal saline (a wound cleanser) and apply xeroform (a wound treatment) and cover the wound with a foam dressing once daily and as needed, after the wound was brought to the facility's attention by the surveyor.During a surveyor interview on 2/18/2026 at 9:53 AM with RN, Staff K, she revealed that she was the person that identified a skin impairment to the resident's lower leg. She further revealed that she cleansed the area and placed a protective dressing over it and informed Nurse Practitioner (NP), Staff C. Further, she revealed that she did not enter or obtain a wound treatment order.During a surveyor interview on 2/19/2026 at 8:56 AM with Staff C, she revealed that she was unaware that the resident had an opened area to his/her left lower leg and would expect to have been notified when the wound was discovered.1b. During a surveyor observation in the presence of Staff J, on 2/16/2026 at 10:08 AM, the resident was observed with a dressing to his/her right lower leg dated 2/13.During a surveyor observation and simultaneous interview on 2/16/2026 at 10:32 AM with RN, Staff L, she acknowledged the resident's right lower leg dressing dated 2/13.Record review revealed a physician's order dated 2/14/2026 to cleanse his/her right lower leg skin tear with normal saline and apply a bandage every evening.Review of the February 2026 Treatment Administration Record revealed that the above wound treatment order was documented as completed on 2/14 and 2/15 by Licensed Practical Nurse, Staff F. However, the dressing was dated 2/13 indicating wound care was not provided on 2/14 or 2/15.Surveyor telephone interviews were attempted with Staff F on 2/19/2026 at 8:52 AM and 10:03 AM. Voice messages were left; however, a return call was not received.1c. Review of a policy revised December 2024 states in part, Implementation of Enhanced Barrier Precautions.Make gown and gloves available immediately near or outside of the resident's room.PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.Enhanced barrier precautions should be used.until the resolution of the wound.During a surveyor observation in the presence of Staff J on 2/16/2026 at 10:08 AM, the resident was observed with the following two wound dressings in place to his/her lower legs:-Left lower leg dressing dated 2/6 initialed by Staff K-Right lower leg dressing dated 2/13Additional observation failed to reveal gowns and gloves immediately near or outside the resident's room.During a surveyor interview following the above observation with Staff J, she revealed that she had just finished completing the resident's personal care. Additionally, she revealed that she does not utilize a gown when providing personal care for the resident unless it is indicated to do so. Further, she acknowledged that there was no EBP sign or PPE outside of the resident's room.Record review failed to reveal evidence that the resident was on EBP related to his/her leg wounds.During a surveyor interview on 2/16/2026 at 10:47 AM with Staff B, she revealed that the resident is not currently on EBP and should be.During a surveyor observation following the above interview with Staff B, she was observed placing the resident on EBP after it was brought to the facility's attention by the surveyor.During a surveyor interview on 2/18/2026 at 1:16 PM with the Director of Nursing Services, she was unable to provide evidence that the facility provided appropriate treatment and services relative to wound care including initiating timely treatments, initiating appropriate transmission-based precautions, and accurately documenting wound care as being provided.Cross reference F 842

Based on surveyor observation, clinical record review, and staff interview, the facility failed to maintain medical records that are accurately documented, in accordance with professional standards and practices, for 1 of 3 residents reviewed with skin impairments, Resident ID #14.Findings are as follows:Record review revealed the resident was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, stroke.Review of a physician's order dated 2/14/2026 revealed to cleanse the resident's right lower leg skin tear with normal saline and apply a bandage every evening.During a surveyor observation and simultaneous interview on 2/16/2026 at 10:32 AM with Registered Nurse, Staff L, she acknowledged the resident's right lower leg dressing was dated 2/13, indicating it had not been changed on 2/14 or 2/15.Review of the February 2026 Treatment Administration Record revealed that the above wound treatment order was documented as completed on 2/14 and 2/15 by Licensed Practical Nurse, Staff F.Surveyor telephone interviews were attempted with Staff F on 2/19/2026 at 8:52 AM and 10:03 AM. Voice messages were left; however, a return call was not received.During a surveyor interview on 2/18/2026 at 1:16 PM with the Director of Nursing Services, she was unable to provide evidence that medical records are accurately documented and maintained.Cross reference F 684

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed who was transferred to the hospital and found to have an ileus (a temporary lack of movement in the intestines that can lead to pain, nausea, bloating, and other symptoms) and a fecal impaction (when a large, hard mass of stool is stuck in your colon or rectum and you are unable to push it out), Resident ID #1. Findings are as follows: Record review of a community complaint submitted to the Rhode Island Department of Health (RIDOH) on 2/3/2025 alleged in part, that Resident ID #1 was neglected. Review of a facility policy titled, Bowel Protocol last reviewed in September of 2024 states in part, Purpose .1. To promote a standard for bowel care in the prevention of constipation .impaction and diarrhea, if resident's regular bowel regimen has proven ineffective 2. To promote regularity of bowel movements. 3. Requires MD [Medical Doctor] review and approval before initiating. Procedure 1. Residents should be encouraged to consume 1500 ml [milliliters] of fluid daily, unless contraindicated. 2. Accurate observation and documentation of bowel movement on BM [Bowel Movement] Record is to be done by each shift. 3. BM record is to be reviewed daily at the beginning of 3-11 shift [second shift] by 3-11 Charge Nurse. If no BM recorded in the previous six (6) shifts, the following protocol is to be followed: a. 3-11: Administer 30 ML (Milliliters) M.O.M (Milk of Magnesium) after dinner unless contraindicated by specific MD order, resident medical status or by resident preference/refusal. If no results by 5:00 am: b. 11-7 [third shift]: Administer Bisacodyl suppository between 5:00 am and 6:00 am unless contraindicated as noted above. If no results by 8:00 am; c. 7-3 [first shift]: Administer Fleets enema unless contraindicated as noted above. 4. If no BM by 7:00 am the following day, contact MD/NP (Nurse Practitioner) for additional orders . Record review of a facility document titled Laxative List dated 1/17/2025 states in part, .Bowel Protocol to be initiated after a resident has not had a bowel movement for 3 days (9 shifts). Protocol is as follows: 1. 3-11 starts with Miralax (laxative) or MOM. 2. If no result by end of shift, 11-7 is responsible for giving suppositories. 3. If no result by end of shift, 7-3 give a Fleet enema . Record review revealed that Resident ID #1 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, generalized muscle weakness, obstructive and reflux uropathy (urinary tract conditions that can cause urine to back up and damage the kidney), and chronic kidney disease, stage 4 (severe; a significant decline in kidney function). Additional review revealed that the resident is bedbound (someone who is unable to move around safely or comfortably. They may need to help to get to and from the toilet, to sit up in bed or to move from the bed to a chair, and help to change their position in bed). Record review of a progress note dated 1/23/2025 at 12:10 AM states in part, .While doing rounds at start of shift. Resident was observed being unable to wrap [his/her] lips around a straw to take a sip of water. Swabbed resident's mouth, [s/he] unable to speak to this nurse. B/P 80/40 [blood pressure; normal range is 120/80], [temperature] 99.8, 119 [pulse; normal range is 60 to 100 beats per minute], 92% [oxygen saturation; normal level is 95 to 100%] RA [room air] .Sent out by EMS [emergency medical services] @ [at] 12:02am . Record review failed to reveal evidence that the resident had a bowel movement on the following dates and shifts: 1/13/2025, first 7:00 AM to 3:00 PM, second (3:00 PM to 11:00 PM), and third shift (11:00 PM to 7:00 AM) 1/14/2025, first, second, and third shift 1/15/2025, first, second, and third shift 1/16/2025, first, second, and third shift 1/17/2025, first and second shift From 1/13/2025 to 1/17/2025, the resident failed to have a bowel movement for a total of 14 shifts Record review of the resident's January 2025 Medication Administration Record (MAR) failed to reveal evidence that the facility implemented their bowel protocol when the resident did not have a bowel movement for 6 shifts, per the facility policy. Additionally, the MAR failed to reveal evidence that the facility implemented their Laxative List policy when the resident had gone 9 shifts without moving his/her bowels. Further record review failed to reveal evidence that the resident had a bowel movement on the following dates: 1/18/2025, first, second and third shift 1/19/2025, first, second and third shift 1/20/2025, first, second and third shift 1/21/2025, first, second and third shift 1/22/2025, first and second shift From 1/18/2025 to 1/22/2025, the resident failed to have a bowel movement for an additional 14 shifts Additional review of the January 2025 MAR revealed that an order was obtained on 1/19/2025 to administer Miralax to the resident every 24 hours, as needed for constipation. Further review of the MAR revealed that the resident did not receive Miralax until 1/21/2025 at 2:54 PM, two days after the order was obtained, and after 10 shifts passed without the resident having a bowel movement. Further review of the resident's January 2025 MAR failed to reveal evidence that the facility implemented their bowel protocol when the resident did not have a bowel movement for 6 shifts, per the facility policy. Additionally, the MAR failed to reveal evidence that the facility implemented their Laxative List policy when the resident had gone 9 shifts without moving his/her bowels. Record review of a hospital document dated 1/25/2025 revealed that Resident ID #1 was transferred to the hospital on 1/23/2025 due to a decrease in appetite, low blood pressure, and burning in his/her mouth. In addition, the document revealed that the resident was admitted with multiple diagnoses including, fecal impaction and mouth sores. Further review of the hospital document revealed that the resident received a suppository and an enema while in the hospital for treatment. Additionally, it revealed diagnostic X-rays were completed and revealed evidence of an ileus. It further revealed that a bowel regimen was recommended for this resident. During a surveyor interview on 2/4/2025 at approximately 2:30 PM with the Director of Nursing Services, she acknowledged that the bowel protocol was not followed for the resident, as required per the facility policy. Additionally, she acknowledged Resident ID #1 was transferred to the hospital and found to have a fecal impaction on 1/23/2025.

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID # 1. According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage. Record review of a community reported complaint submitted to the RIDOH on 2/3/2025 alleged that Resident ID #1 was hospitalized because s/he was dehydrated and malnourished. Record review of the hospital documents dated 1/25/2025 revealed that the resident was admitted to the hospital on 1/23/2025 with multiple diagnosis including, a urinary tract infection and an acute kidney injury (a condition where the kidneys suddenly lose their ability to function properly, leading to a decrease in urine output and an accumulation of waste products in the blood). It further revealed that Resident ID #1's indwelling catheter was improperly placed and the balloon was blown up into the prostate. Record review of a facility policy titled, Catheter Care, Urinary dated May 2023, states in part, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Changing Catheters .Documentation The following information should be recorded in the resident's medical record .1. The date and time the catheter care was given. 2. The name and title of the individual(s) giving catheter care. 3. All assessment date obtained when giving catheter care .8. The signature and title of the person recording the data .10. Report other information in accordance with facility policy and professional standards of practice . a. Record review revealed a physician's order dated 11/27/2024 for an indwelling catheter size 18 Fr (French size) with a 30 cc (cubic centimeter) balloon and to change as needed based on clinical indications such as an infection, obstruction, or if the closed system is compromised. Record review a progress note dated 1/22/2025 at 2:44 PM, revealed in part, Resident .ill appearing. replaced [indwelling catheter] on previous shift . Record review revealed a progress note dated 1/15/2025 at 7:48 AM, revealed in part, that the resident's indwelling catheter was replaced with a catheter size 16 Fr and a 10 cc balloon, not the ordered catheter size 18 Fr with a 30 cc balloon. Additional record review of a patient report sheet for Resident ID #1 for the evening shift of 1/21/2025 revealed that the resident's indwelling catheter was replaced with a catheter size 16 Fr, not the ordered catheter size 18 Fr with a 30 cc balloon. Further review of the progress notes failed to reveal evidence of a physician's order to replace the resident's indwelling catheter with a 16 Fr 10 cc catheter on 1/15 and 1/21/2025. b. Additional review of the physician's orders revealed an order dated 4/17/2024 to monitor the resident's indwelling catheter output every shift. Review of the January 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident's indwelling catheter output was monitored on every shift, as ordered, on the following dates and shifts: 1/1/2025 - third shift 1/4/2025 - second shift 1/5/2025 - second and third shifts 1/7/2025 - third shift 1/8/2025 - third shift 1/13/2025- second shift 1/15/2025- first shift 1/18/2025- third shift 1/20/2025- first shift 1/27/2025- second shift 1/28/2025-first shift 1/29/2025-first shift 1/30/2025-first shift During a surveyor interview on 2/4/2025 at approximately 2:30 PM with the Director of Nursing Services (DNS), she acknowledged that the physicians' orders for the resident's indwelling catheter were not followed. Furthermore, the DNS was unable to provide evidence that staff had contacted the physician regarding the insertion of the different sized indwelling catheter. Lastly, she acknowledged that there was no output documented for resident's urinary output on the above-mentioned dates and shifts.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with edema (swelling due to excess fluid trapped in the body's tissues), Resident ID #260. Findings are as follows: Review of the policy titled Change in a Resident's Condition or Status dated May 2023 states in part, .Our facility shall promptly notify .his or her Attending Physician .of changes in the resident's medical/mental condition and/or status .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . Record review revealed the resident was admitted to the facility in November of 2024 with diagnoses including, but not limited to, acute kidney failure, cardiac arrhythmias (abnormal heart rhythm), and the presence of a cardiac pacemaker. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact. Further review revealed the resident requires supervision or hands on assistance by staff with transfers and walking. During a surveyor interview with the resident on the initial tour of the facility on 12/1/2024 at 12:33 PM, the resident indicated that s/he hasn't been getting out of bed as much because s/he has pain and swelling to his/her legs. S/he further indicated that the staff have been wrapping his/her legs with an ACE bandage due to the swelling. Review of the Clinical Admission assessment dated [DATE] revealed the resident had No Edema issues with a goal to return home. Further review revealed the resident did not indicate pain and had a steady gait. Review of a skin assessment dated [DATE] revealed edema was not noted at that time. Review of a physician's admission note dated 11/25/2024 revealed the resident had no edema of his/her extremities at that time. Review of a skin assessment dated [DATE] revealed the resident was noted to have swollen ankles. Record review revealed the following progress notes: -11/28/2024, .[complaint of] pain to both feet [related to] edema . -11/29/2024, Resident will be discharged to home as of 12/4/24 . -11/29/2024, .BLE [bilateral lower extremities] elevated and wrapped [with] ace bandages for non-pitting edema [the accumulation of excess fluid in soft tissues which is usually localized to certain body parts] . -12/3/2024, Resident will not be discharged on [DATE] due to [his/her] medical condition . During a surveyor interview on 12/4/2025 at 11:57 AM with Registered Nurse, Staff A, the surveyor questioned the resident's edema and she indicated that she would make the physician aware. Further review of the resident's record failed to reveal evidence that the physician was notified of the resident's lower extremity edema until 12/4/2024, after it was brought to the facility's attention by the surveyor, and 7 days after it was initially assessed by a nurse at the facility. Additional review of the progress notes revealed a note dated 12/4/2024, which revealed the resident's physician was notified of his/her BLE edema on his/her feet/ankles and a new order was obtained to resume hydrochlorothiazide (a medication prescribed to treat edema). Record review revealed a physician's order dated 11/23/2024 for acetaminophen (Tylenol) 325 milligram by mouth every 4 hours as needed for pain. Record review of the November and December 2024 Medication Administration Records (MARs) revealed the resident received acetaminophen for pain with the associated pain levels on the following dates: -11/26, pain level of 8 -11/27, pain level of 6 -11/28, pain level of 8 -11/29, pain level of 2 -12/2, pain level of 2 -12/4, pain level of 5 -12/5, pain level of 8 Further review of the November and December 2024 MARs failed to reveal evidence that the resident's pain was addressed with acetaminophen on the following dates: -11/30/2024, pain level of 4 -12/1/2024, pain level of 3 During surveyor observations and interviews with the resident on the following dates and times, his/her BLE were edematous: -12/1/2024 at 12:09 PM -12/2/2024 at 9:44 AM and 2:00 PM -12/3/2024 at 11:13 PM -12/4/2024 at 10:50 AM -12/5/2024 at 11:59 AM Review of a physician's note dated 12/5/2024 revealed the resident was noted to have .+1 [pitting] edema [a condition where the skin remains indented after being pressed and is graded on a scale of +1 to +4 based on the depth of the depression and how quickly it rebounds] in lower leg [and] ankles . During a surveyor interview on 12/4/2024 at 10:50 AM with the resident, s/he indicated that his/her feet had started swelling a few days after s/he was admitted to the facility. The resident further revealed that s/he was experiencing a pain level of 8 out of 10 in his/her feet. Additionally, the resident indicated that the pain was preventing him/her from walking as much, so s/he could not be discharged home that day as planned. During surveyor interviews on 12/4/2024 at 11:07 AM and on 12/5/2024 at 10:47 AM with Registered Nurse, Staff A, she indicated that she was aware of the edema to the resident's feet and legs; however, she was unaware if the physician had been notified. She further indicated that the resident appeared weaker since admission related to generalized pain and pain to his/her feet. Additionally, she indicated that the resident was not safe to be discharged home at that time. During a surveyor interview on 12/4/2024 at 11:47 AM with the resident's physician, he revealed that he had not been made aware of the resident's edema by the facility. He further indicated that he would have expected to be notified if there was a change in the resident's condition. During a surveyor interview on 12/4/2024 at 12:09 PM with Licensed Practical Nurse, Staff B, she indicated that she initially observed edema to the resident's feet and legs on 11/29/2024 during his/her shower. Additionally, she could not provide evidence that the physician was made aware of the new onset of edema. During a surveyor interview on 12/5/2024 at 10:30 AM with Occupational Therapist (OT), Staff C, she indicated that the resident was having increased difficulty with standing and transferring since the initial OT assessment due to pain, therefore s/he could not be safely discharged home on 12/4/2024, as planned. During a surveyor interview on 12/5/2024 at 11:09 AM with Physical Therapist, Staff D, she indicated that the resident had complained of pain to his/her feet and refused to walk with the therapist. During a surveyor observation and interview on 12/5/2024 at approximately 12:00 PM, in the presence of the Director of Nursing Services (DNS) and the Assistant Director of Nursing Services, Staff E, the resident was observed to have 2 + pitting edema to his/her feet. Additionally, the resident complained of pain to his/her feet and indicated that s/he could not stand due to the pain. During a surveyor interview with the DNS immediately following the above observation, she acknowledged that the resident presented with 2 + pitting edema to both of his/her feet. Additionally, she could not provide evidence that the physician had been notified of the edema to the resident's bilateral lower extremities prior to it being brought to the attention of the facility by the surveyor.

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 5 residents reviewed for medication administration, Resident ID #1. Findings are as follows: Record review revealed Resident ID #1 was initially admitted to the facility in June of 2021 and readmitted to the facility in October of 2024 with diagnoses including, but not limited to, hypercholesterolemia (high cholesterol) and hypertension (high blood pressure). Record review of a document titled, Consultant Pharmacist Recommendation to Prescriber, dated 6/27/2024 revealed the resident is currently receiving Lipitor (a medication prescribed to treat high cholesterol) 20 (mg) milligrams daily. Further review of the document revealed a recommendation to decrease his/her Lipitor to 10 mg daily, which was approved by the provider. Record review revealed that the physician approved the recommendation to decrease the Lipitor to 10 mg daily with a start date of 7/9/2024. Record review of the July 2024 Medication Administration Record (MAR) revealed that both the Lipitor 20 mg daily and the Lipitor 10 mg daily were signed off as administered on 7/9, 7/10, 7/12 and 7/13/2024, indicating that the resident received a total daily dose of Lipitor 30 mg, instead of the ordered 10 mg. During a surveyor interview on 12/5/2024 at approximately 12:30 PM with Licensed Practical Nurse (LPN), Staff E, she was unable to provide evidence the Lipitor 20 mg dose was discontinued, as ordered, when starting the Lipitor 10 mg dose daily. During a surveyor interview on 12/3/2024 at 3:42 PM with the Director of Nursing Services (DNS), after bringing the medication error to the DNS's attention, she acknowledged that the resident received Lipitor 30 mg daily in error on 7/9, 7/10, 7/12 and 7/13/2024. Additionally, she could not provide evidence the order for Lipitor 20 mg daily was not discontinued, when the new order for Lipitor 10 mg daily was implemented.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, for 2 of 4 residents reviewed relative to the use of transmission-based precautions, Resident ID #s 13 and 260. Findings are as follows: Review of a facility policy titled, Isolation-Categories of Transmission-Based Precautions states in part, .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .Infections requiring Contact Precautions include but are not limited to .infections with multi-drug resistant organisms .wear gloves (clean not sterile) when entering the room .wear a disposable gown upon entering the Contact Precautions room .If use of common items is unavoidable, then adequately clean and disinfect them .Signs- The facility will implement a system to alert staff to the type of precaution resident requires . 1) Record review revealed Resident ID #13 was readmitted to the facility in October of 2023 with a diagnoses including, but not limited to, type 2 diabetes mellitus and absence of left leg above the knee. Record review revealed an order dated 11/15/2024 to clean the right heel ulcer with normal saline followed by Medihoney (a wound gel with antibacterial properties) to the wound followed by calcium alginate (a highly absorbent wound dressing) then cover with an abdominal pad (a thick dressing used to help manage wound drainage) and a gauze wrap. Record review of a wound culture of the heel, reported on 11/24/2024, revealed that the wound was positive for Methicillin Resistant Staphylococci aureus (MRSA- a bacteria that is resistant to certain antibiotics). Record review of the November and December 2024 Medication Administration records revealed an order dated 11/27/2024 for Levaquin (an antibiotic) 750 milligrams (mg) daily for 10 days. The last scheduled dose of the antibiotic was due to be administered on 12/6/2024. During a surveyor observation of the wound treatment to the right heel on 12/5/2024 at 9:39 AM with Registered Nurse (RN), Staff A, the Contact Precautions sign was no longer on the resident's door, only a sign for Enhanced Barrier Precautions. Staff A entered the resident's room in a gown and gloves pushing a small black table that contained the supplies for the wound dressing change. During the dressing change Staff A placed the normal saline spray bottle, and the tube of Medihoney on the resident's bed near his/her foot, which is being treated for a MRSA infection. After the dressing was completed Staff A placed the normal saline spray bottle and the Medi honey tube back on the black table and without sanitizing, pushed the table out into the hallway outside the resident's room. She then closed the door and wearing the same gloves she had worn to put the resident's shoe on, Staff A assisted Nursing Assistant (NA), Staff F to bring the resident to the bathroom using a sit to stand mechanical lift. They then placed the mechanical sit to stand lift out into the hallway without sanitizing it. During a surveyor interview on 12/5/2024 at 10:15 AM with NA, Staff F, she acknowledged that they failed to clean the sit to stand lift after using the device to transfer the resident to the bathroom. During a surveyor interview on 12/5/2024 at 10:18 AM with RN, Staff A, she acknowledged that after she put the tube of Medihoney, which was a house stock medication (not specifically prescribed for one patient), on the resident's bed, she had returned it to the table and without sanitizing it, she pushed the table out of the room and into the hallway. Additionally, she acknowledged that after she used the sit to stand lift with the resident, she moved the lift into the hallway without sanitizing it. During a surveyor interview on 12/5/2024 at 11:47 AM with the Director of Nursing Services (DNS), she acknowledged that the resident should still be on contact precautions because s/he had not completed the antibiotics for his/her MRSA infection. Additionally, she acknowledged that the Medihoney should not have been placed on the resident's bed near his/her foot, and that the table and the lift should have been cleaned before placing them in the hallway. 2) Review of an undated facility policy titled, Enhanced Barrier Precautions [EBP] states in part, .Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition .As part of Standard Precautions, which apply to the care of all residents, the use of PPE [personal protective equipment] is based on the anticipated exposure to blood, body fluids, secretions, or excretions. Enhanced Barrier Precautions are recommended for residents .Known to be colonized or infected with a MDRO .Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care activities . Record review revealed Resident ID #260 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, urinary tract infection (UTI) and overactive bladder. Review of a hospital Continuity of Care form dated 11/23/2024, revealed the resident was on contact precautions in the hospital, due to a diagnosis of extended-spectrum beta-lactamase (ESBL; an MDRO). Further review revealed the resident completed his/her antibiotic treatment in the hospital. Record review revealed a care plan dated 12/4/2024, which revealed the resident is incontinent of bladder. Record review failed to reveal evidence that the resident was on EBP for his/her diagnosis of ESBL. During multiple surveyor observations throughout the survey from 12/1 through 12/4/2024, failed to reveal evidence that the resident was placed on EBP for his/her diagnosis of ESBL. During a surveyor interview on 12/4/2024 at 11:16 AM with Nursing Assistant, Staff F, she revealed that the resident can be incontinent of urine and requires staff assistance for all activities of daily living (ADL). She further revealed that the resident has not been on any type of precautions since his/her admission to the facility. During a surveyor interview on 12/4/2024 at 11:29 AM with Registered Nurse, Staff As she revealed that the resident requires staff assistance with ADL care and acknowledged that the resident was not on precautions. During a surveyor interview on 12/4/2024 at 11:54 AM, with the DNS and the Infection Preventionist, Staff E, they revealed that the facility does not place residents with a history of ESBL on EBP, although the facility policy indicates EBP is required for residents who are known to be infected or colonized with an MDRO. During a surveyor observation on 12/5/2024 at 11:59 AM, revealed the resident had been placed on EBP after it was brought to the facility's attention by the surveyor. 46241

Based on record review, staff, and resident interview, it has been determined that the facility failed to provide routine medications to its residents for 5 of 15 residents reviewed, Resident ID #s 165, 1, 57, 21, and 46. Findings are as follows: Review of a facility policy titled UNAVAILABLE MEDICATIONS dated May 2023 states in part .The facility must make every effort to ensure that medication are available to meet the needs of each resident .Nursing staff shall: 1. Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available . 1. Record review revealed that Resident ID #165 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to diabetes. Record review of an admission Minimum Data Set (MDS) Assessment revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating the resident is cognitively intact. Record review revealed that Resident ID #165 has the following physician's orders: - Zolpidem Tartrate Oral Tablet 5 MG (milligram, hypnotic medication, Ambien) Give 1 tablet by mouth one time a day for insomnia (difficulty sleeping) with a start date of 1/06/2024 - SITagliptin-metFORMIN HCl (hydrochloride) Oral Tablet Extended Release 24 Hour 50-1000 MG (medication to lower blood sugar) Give 1 tablet by mouth one time a day related to diabetes with a start date of 1/07/2024 Record review of the January 2024 Medication Administration Record (MAR) revealed the resident did not receive the following medications due to the medications being unavailable on the following dates and times: - 1/8/2024 and 1/9/2024: Zolpidem Tartratre oral tablet 5MG bedtime doses. - 1/7/2024 and 1/8/2024: SITagliptin-metFORMIN HCl ER oral extended release 24 hour 50-1000 MG. Review of an admission note dated 1/8/2024 authored by Nurse Practitioner (NP), Staff A, states in part, . [resident] has not slept in 2 days since [his/her] Ambien had not arrived from the pharmacy . During a surveyor interview with Resident ID #165 on 1/9/2024 at 10:06 AM, s/he revealed that s/he did not receive the above medications for 2 days. Additionally, Resident ID #165 revealed that the facility did not have the medications for 2 days until his/her family brought them from home. 2. Record review revealed that Resident ID #1 was admitted to the facility in September of 2022 with a diagnosis including but not limited to atrial fibrillation (abnormal heart rate). Record review revealed that Resident ID #1 has a physician's order dated 1/22/2022 for Xarelto tablet (blood thinner) 20 MG by mouth in the evening related to atrial fibrillation. Record review of the MAR for January 2024 revealed Xarelto was not administered on, 1/7/2024 and 1/9/2024 due to the medication being unavailable. During a surveyor interview with the DNS on 1/12/2024 at 9:02 AM she acknowledged that the above medication was not administered on 1/7/2024 and 1/9/2024 due to the medication being unavailable. 3. Record review revealed Resident ID #57 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, dementia with anxiety and agitation. Record review revealed the following physician orders: -Rexulti (antipsychotic) 1 (MG), one time a day, with a start date of 12/23/2023 and an end date of 1/2/2024. -Rexulti 2 MG, one time a day, with a start date of 1/3/2024. Review of the January 2024 MAR revealed the above orders were documented with a 9 which indicates Other / See Nurses Notes on 1/1/2024, 1/6/2024, and 1/7/2024. Review of the progress notes revealed the following medication administration notes relative to Rexulti: -1/1/2024 states, not available -1/6/2024 states, med on back order -1/7/2024 states, med back ordered During a surveyor interview on 1/11/2024 at 12:22 PM with the DNS and the Assistant Director of Nursing Services (ADNS), they revealed the Rexulti was on back order during the above dates and was unable to provide evidence that the facility provided pharmaceutical services, including acquiring medication, to meet the needs of each resident. 4. Record review revealed Resident ID #21 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, Alzheimer's disease and low back pain. Record review revealed a physician's order dated 11/2/2023 for Salonpas (pain relieving patch), with instructions to apply to lower back, two times a day for pain. Review of the January 2024 MAR revealed the above order was documented with a 9 which indicates Other / See Nurses Notes on 1/9/2024, 1/10/2024, and 1/11/2024. Review of the progress notes revealed the following medication administration notes relative to Salonpas: -1/9/2024 states, not available -1/10/2024 states, not available -1/11/2024 states, on order 5. Record review revealed Resident ID #46 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of fats in the artery wall) and muscle weakness. Record review revealed a physician's order dated 11/2/2023 for Salonpas with instructions to apply to right hip one time a day for pain. Review of the January 2024 MAR revealed the above order was documented with a 9 which indicates Other/See Nurses Notes on 1/9/2024, 1/10/2024, and 1/11/2024. Review of the progress notes revealed the following medication administration notes relative to Salonpas: -1/9/2024 states, not available -1/10/2024 states, no patches -1/11/2024 states, on order During a surveyor interview on 1/11/2024 at 12:07 PM with Registered Nurse, Staff B, she revealed there were no Salonpas patches available at the facility and indicated they were on backorder. During a surveyor interview on 1/11/2024 at 12:22 PM with the DNS and the ADNS, they were unable to provide evidence that the facility provided pharmaceutical services, including acquiring medication, to meet the needs of the above mentioned residents. 43987 46241 47939 49923

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 medication storage rooms and 2 of 3 medication carts observed. Findings are as follows: Review of the facility policy titled, Storage of Medications, dated [DATE], states in part, .discontinued, outdated .drugs or biological's are returned to the dispensing pharmacy or destroyed. 1. During a surveyor observation of the Watch Hill Unit medication room on [DATE] at 11:43 AM, in the presence of Registered Nurse (RN), Staff D, the following was revealed: -One multidose vial of purified protein derivative (PPD, a skin test reagent used for the diagnosis of tuberculosis), approximately half full, opened and not dated. The manufacturer's instructions indicate to discard the opened product after 30 days. -One bottle Rhopressa Solution 0.02% (a medication used to treat high pressure in the eye), approximately half full, with an expiration date of [DATE] -One Combivent Respimat inhaler 20 mcg (microgram)/100 mcg, (used to control symptoms caused by asthma and lung disease), with an expiration date of [DATE] -One Combivent Respimat inhaler 20 mcg/100 mcg, expiration [DATE] During a surveyor interview immediately following the above-mentioned observations, Staff D, acknowledged that the Combivent and Rhopressa medications were expired and should be destroyed. Additionally, she acknowledged that the PPD solution was not dated when the vial was originally opened. 2. During a surveyor observation of the Watch Hill Unit medication cart on [DATE] at 12:23 PM, in the presence of Staff D, the following was revealed: -One bottle Olopatadine 0.1% (used for treatment of allergies), approximately half full, with an expiration date of [DATE] -One bottle Travatan 0.004% (used to lower the pressure in the eye) approximately half full, with an expiration date of [DATE] -One Trelegy ellipta inhaler (used to control symptoms caused by asthma and lung disease), with an expiration date of [DATE] During a surveyor interview immediately following the above-mentioned observations, Staff D, acknowledged that the above-mentioned medications were expired and should have been removed from the medication cart. 3. During a surveyor observation of the Mystic Unit medication cart on [DATE] at 1:49 PM, in the presence of Licensed Practical Nurse, Staff E, the following was revealed: -1 multidose vial of purified protein derivative (PPD, a skin test reagent used for the diagnosis of tuberculosis), approximately half full, opened, not dated, and stored at room temperature. The manufacturer's instructions indicate to discard the opened product after 30 days and store at 35 to 48 degrees Fahrenheit (refrigerate). -One Insulin lispro injectable pen 100 units per Mililiter (a medication used for high blood sugar) expired [DATE] During a surveyor interview immediately following the above-mentioned observations, Staff E, acknowledged that the Lispro medication was expired and should have been removed from the medication cart. Additionally, she indicated that the PPD solution should be dated when opened and refrigerated. During a surveyor interview on [DATE] at approximately 3:30 PM with the Director of Nursing Services (DNS), she indicated that her expectation is that medication vials should be dated when opened and medications are discarded when they are expired.

43987 Based on record review, staff, and resident interviews, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 3 of 15 sample residents reviewed, Resident ID #s 165, 1, and 57. Findings areas follows: Review of a facility policy titled, Administering Medications states in part, .3) Medications must be administered in accordance with the order as prescribed by the physician, nurse practitioner, or physician assistant. 4) Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified . 1. Record review revealed that Resident ID #165 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, diabetes. Record review revealed a physician's order dated 1/7/2024 for SITagliptin-metformin HCl Oral Tablet Extended Release 24 Hour 50-1000 milligram (mg) (medication used to treat high blood sugar), administer one time daily in the morning at 8:00 AM. Review of the January 2024 Medication Administration Record (MAR) revealed that Resident ID #165 did not receive the above mentioned medication on 1/7/2024 and 1/8/2024. Record review revealed that on 1/8/2024 at 3:09 PM, Resident ID #165 had an elevated blood sugar of 548 milligrams per deciliter (mg/dL normal range is 80-130 mg/dL). Additionally, record review revealed Resident ID #165 has a physician's order dated 1/6/2024 for Zolpidem Tartrate Oral Tablet 5 mg (used to treat insomnia) to administer at bedtime at 8:00 PM. Review of the January 2024 Medication Administration Record (MAR) revealed the resident did not receive the Zolpidem Tartrate 5mg on 1/6/2024 and 1/7/2024. During a surveyor interview on 1/10/2024 at 1:03 PM with Registered Nurse, Staff C, she revealed that Resident ID #165's blood sugar increased to 548 mg/dL and that she received a new order to administer 18 units of Lispro insulin. During a surveyor interview with the Director of Nursing Services (DNS) on 1/11/2024 at 12:00 PM, she revealed that she was unaware that Resident ID #165 did not receive Sitagliptin-metformin HCL ER ,d+[DATE] mg and Zolpidem tartrate 5 mg for 2 consecutive days. Additionally, she revealed that she was unaware that Resident ID #165's blood sugar was 548 mg/dL until it was brought to her attention by the surveyor. 2. Record review revealed that Resident ID #1 was admitted to the facility in September of 2022 with a diagnosis of, but not limited to, atrial fibrillation (abnormal heart rate). Record review revealed a physician's order dated 1/22/2022 for Xarelto 20 mg (blood thinner) administer in the evening related to atrial fibrillation. Review of the January 2024 MAR revealed that Resident ID #1 did not receive Xarelto on 1/7/2024 and 1/9/2024. Additionally, record review revealed Resident ID #1 has a physician's order dated 2/6/2023 for Zyprexa 5 mg (antipsychotic medication) at bedtime for bipolar disorder. Review of the January 2024 MAR revealed that the resident did not receive Zyprexa 5 mg on 1/3, 1/5, 1/6, 1/7 and 1/9/2024, as ordered. During a surveyor interview with the DNS on 1/12/2024 at 9:02 AM, she was unable to provide evidence that the resident received the above medications as ordered. The DNS further revealed that the physician was not made aware of the missed Xarelto and Zyprexa until it was brought to her attention by the surveyor. 3. Record review revealed that Resident ID #57 was admitted to the facility in December of 2023 with diagnoses of, but not limited to, dementia with anxiety, restlessness and agitation. Record review revealed the following physician orders: -Rexulti (antipsychotic) 1 (MG), one time a day, with a start date of 12/23/2023 and an end date of 1/2/2024. -Rexulti 2 MG, one time a day, with a start date of 1/3/2024. Review of the January MAR revealed that Resident ID #57 did not receive his/her Rexulti on 1/1/2024, 1/6/2024 and 1/7/2024. During a surveyor interview with the DNS on 1/11/2023 at 12:22 PM, she was unable to provide evidence that the resident received the above mentioned medication as ordered. 47939 49923

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances at least quarterly for 5 of 5 residents reviewed, Resident ID #s 6, 9, 28, 35, and 363. Findings are as follows: 1. Record review revealed that Resident ID #6 was readmitted to the facility in November of 2023. Review of a facility provided document titled, Trial Balance revealed that Resident ID #6 has funds being held by the facility. Record review failed to reveal evidence of a quarterly statement for Resident ID #6. 2. Record review revealed that Resident ID #9 was admitted to the facility in June of 2021. Review of a facility provided document titled, Trial Balance revealed that Resident ID #9 has funds being held by the facility. Record review failed to reveal evidence of a quarterly statement for Resident ID #9. 3. Record review revealed that Resident ID #28 was readmitted to the facility in January of 2023. Review of a facility provided document titled, Trial Balance revealed that Resident ID #28 has funds being held by the facility. Record review failed to reveal evidence of a quarterly statement for Resident ID #28. 4. Record review revealed that Resident ID #35 was readmitted to the facility in July of 2023. Review of a facility provided document titled, Trial Balance revealed that Resident ID #35 has funds being held by the facility. Record review failed to reveal evidence of a quarterly statement for Resident ID #35. 5. Record review revealed that Resident ID #363 was admitted to the facility in June of 2021. Review of a facility provided document titled, Trial Balance revealed that Resident ID #363 has funds being held by the facility. Record review failed to reveal evidence of a quarterly statement for Resident ID #363. During a surveyor interview on 1/12/2024 at approximately 11:15 AM with the Business Office Manager, she was unable to provide evidence that the facility provided quarterly statements for the above mentioned residents for 2023. During a surveyor interview on 1/12/2024 at approximately 12:30 PM with the Administrator, she acknowledged that the above residents had not been provided a written accounting of his/her deposits, withdrawals, and balances at least quarterly per the regulation.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to 1 of 1 resident reviewed for urinary tract infections (UTIs), Resident ID #3. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 7/26/2023 alleges in part that on 7/17/2023 the complainant requested a urinalysis secondary to Resident ID #3's history of urinary tract infections with sepsis. The urinalysis was not obtained until 7/23/2023 and then a treatment was not implemented until 7/26/2023, after the complainant inquired what antibiotic was ordered to treat the UTI. Review of the resident's record revealed s/he was admitted to the facility in June of 2021 with diagnoses including, but not limited to, traumatic brain injury, quadriplegia, cognitive communication deficit (mute), and cystitis. Record review of a Minimum Data Set assessment dated [DATE] revealed the resident is incontinent of bladder and bowel and is totally dependent on staff and requires assistance with personal hygiene and toilet use. Review of the resident's care plan dated 7/6/2021, and revised on 9/23/2022, revealed the resident has bowel and bladder incontinence and may get UTI's. Interventions include, but are not limited to: clean peri-area with each incontinence episode, monitor/document for signs and/or symptoms UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns . Further record review revealed a physician order dated 12/22/2022 to conduct urinalysis and culture and sensitivity testing (UA/C&S) via straight catheter as needed for suspected UTIs. Record review revealed the resident has had six UTIs from 2/5/2023 to 7/22/2023. During a surveyor interview on 7/27/2023 at 1:10 PM with the resident's family member, she revealed that the resident has a history of UTIs. She further revealed that on 7/17/2023 while out of the facility with the resident, she noted the resident had foul smelling and cloudy urine. She indicated that this is typically the first sign when the resident has a UTI. Additionally, she indicated that upon return to the facility with the resident, she informed Licensed Practical Nurse, Staff A, that the resident's urine was cloudy and foul smelling and needed to be tested for a suspected UTI. The family member further revealed that when she asked about the results of the urinalysis on 7/26/2023, she was informed that the urine sample had not been collected until 7/23/2023, 6 days after she brought her concern to the facility's attention. Additionally, she revealed that when she asked which antibiotic the resident was receiving to treat his/her UTI, the staff informed her that the resident had not been started on an antibiotic to treat his/her UTI. Review of the results from the UA/C&S obtained on 7/23/2023 revealed a positive test result. Additional review of physician orders revealed an order dated 7/26/2023 for Keflex (antibiotic used to treat symptoms of a UTI) 500 milligrams four times a day for 7 days. During a surveyor interview on 7/27/2023 at approximately 2:15 PM with Staff A, she acknowledged that she had a conversation with the resident's family member on 7/17/2023 during the 3-11 shift and was made aware the resident had symptoms of a UTI . In addition, Staff A acknowledged that the family member requested a urine sample to be obtained to determine if the resident had a UTI. Staff A further revealed that she did not notify the physician or nurse practitioner of the above nor did she obtain a urinalysis as per the standing physician order dated 12/22/2022. During a surveyor interview on 7/27/2023 at 2:10 PM with Nurse Practitioner, Staff C, she revealed that the resident has a history of UTI's. In addition, Staff C revealed that she first learned of the positive test result on 7/26/2023 while at the facility. Staff C indicated that the nurse had informed her that the resident's family member was asking about the test results and together, she and the nurse looked up the results. She further revealed that this is when she initiated the order for Keflex to treat the resident's UTI. During a surveyor interview on 7/27/2023 at 2:40 PM with the Director of Nursing Services, Assistant Director of Nursing Services and the Administrator, they were unable to provide evidence as to why the facility did not follow the standing physician order dated 12/22/2022 to obtain a urinalysis via straight cath as needed, why staff waited six days before obtaining a urinalysis on 7/23/2023 when it was reported to the nurse that the resident was symptomatic on 7/17/2023. Based on the above investigative findings, deficient practice was identified on the part of the facility as evidenced by the facility's failure to conduct testing in a timely manner for a resident who was symptomatic of a UTI and has a history of recurring UTI's.

Based on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Department of Health), in accordance with State law for 1 of 1 residents reviewed for abuse and injury of unknown origin, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/30/2023 alleges in part, .This patient was .seen for a left femur [bone of the upper leg or thigh] fracture on 5/22/2023 .family reported facility was being rough when getting [resident] into the shower . Record review of the facility policy titled, ABUSE POLICY revised on 2/15/2017, states in part, .all alleged violations of Federal or State laws which involve .abuse, injuries of unknown source .will also be reported to State agencies in accordance with existing State law. The facility will investigate each alleged violation thoroughly and report the results of all investigations to the Executive Director or his or her designee, as well as to State agencies as required by State and Federal Law .The results of all investigations must be reported .as required by State law with initial report in 2 hours and follow up within five (5) working days of the violation .Definitions .ABUSE: Unjustified physical contact, intentional or careless, which is likely to result in physical or psychological harm . Record review revealed that the resident was admitted to the facility in September of 2021 with diagnoses including, but not limited to, failure to thrive, history of falling, and knee pain. Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed that the resident was not ambulatory and required the assistance of two staff members for transferring. Further record review revealed a document titled, Psychological Services Supportive Care PROGRESS NOTE dated 5/18/2023 states in part, .writer met with patient for follow-up visit .Patient presented with a depressed and agitated mood .Unfortunately, [s/he] reported that [s/he] had 'not slept well in 3 days' and attributed [his/her] lack of sleep to [his/her] poor mood and quality of care [s/he] says was provided to [him/her] .The patient stated that all of [his/her] issues with [his/her] sleep and [his/her] mood stemmed from [his/her] complaints about [his/her] care, which were due to 'the person who cared for me early this week,'[S/he] stated that .[s/he] was not changed or cleaned up until nearly 3 PM and then on another day [s/he] had a shower and wasn't washed 'properly' .writer asked patient if [s/he] had utilized [his/her]communication .skills to advocate for [his/her] self-care. The patient said that [s/he] did not bother because 'it never makes any difference what I say' .The patient shared that because [s/he] didn't get proper care, [s/he] had a lot of anxiety and that led to [his/her] bouts of sleeplessness . Record review revealed a care plan dated 6/22/2022 which indicates that the resident prefers to stay in bed and is only up for showers. Record review revealed a physician's order with a start date of 4/24/2023 which indicated that the resident's showers were scheduled every Monday on the 7:00 AM - 3:00 PM shift. Record review of a Nursing Assistant skin monitoring and shower document revealed that the resident received a shower on 5/15/2023. Additional record review revealed the following progress notes which state in part: - 5/21/2023 at 2:35 PM, .Resident c/o [complained of] pain to left knee which appears to have increased edema and size greatly increased. Resident denies trauma or knowledge of incident. Call placed to Dr. [Doctor] . - 5/21/2023 at 2:36 PM, .New orders received for x-ray to the left knee . - 5/22/2023 at 6:01 AM, .Received X-ray results .Patient has a distal femoral fracture in the left knee .[s/he] is to be sent to [hospital name redacted] . Record review of the Emergency Department provider note under Medical Decision Making, states in part, .[S/he] is experiencing pain in [his/her] left femur .X-ray pelvis and femur were ordered. Pelvis x-ray was negative for any acute fractures, femur x-ray did reveal a distal femur fracture .Clinical impressions as of 5/22/2023 at 7:13 AM .fracture of left femur . During a surveyor interview with the resident's family member on 5/31/2023 at 10:44 AM, she revealed that the resident told his/her family member that a staff member was rough when s/he was being moved during his/her last shower prior to 5/22/2023. During a subsequent surveyor interview with the resident's family member on 6/2/2023 at 9:07 AM, she indicated that the resident told her that Staff A moved him/her a little too rough while in the Hoyer lift and stated resident said, he was showing off how strong he was. The resident's family member further indicated that she informed the Director of Nursing Services (DNS) of the allegations. During a surveyor interview with the DNS on 6/2/2023 at approximately 10:00 AM, she indicated that she did not report the allegation of rough care or injury of unknown origin on 5/21/2023 as required by law and indicated in the facility policy. Additionally, she indicated that she was not aware of the resident's complaint of rough care in the shower until the week of 5/30/2023. Furthermore, she indicated that she was unaware of the psych providers progress note which indicated that the resident had complaints regarding the care that s/he had received in the days prior to the psych note dated 5/18/2023. The DNS further indicated that she was unaware of this information until it was brought to her attention by the surveyor. She also indicated that the psych provider usually updates her after seeing residents. Additionally, she was unable to provide evidence that the resident's injury from 5/21/2023 and the allegations of rough care were reported or investigated.

Based on surveyor observation, interview and record review, the facility failed to identify hazards and risks to ensure an environment that is free from accident hazards, and provides supervision to each resident to prevent avoidable accidents for 1 of 20 residents who reside on the secured Westerly Unit relative to supervision and exit door alarms. Findings are as follows: On 2/6/2018 resident ID# 1 exited the glass exit door to an outdoor patio which is adjacent to the common area of the secured Westerly Unit. The resident was noted to fall outside of the door onto the ground which went un-noticed by staff. Resident ID# 1 was on the ground outdoors for an unknown period which resulted in a hospital admission for hypothermia and a laceration above her eye. During surveyor observation of the secured Westerly Unit on 2/8/18 at approximately 9:20 AM, it was identified that there were two exit doors which open to the outside. Both doors have an alarm located adjacent to the top of door which when in the on position will sound an alarm if the door is open. This alerts staff that someone has opened the door. The alarms can be shut off to each exit door by manually pressing the on and off switch. The common room exit door has a glass front full view and a push bar which easily opened with very little resistance and was noted to close itself upon exit. During an interview with the Director of Nursing on 2/8/2018 at approximately 9:40 AM she stated elopement assessments are not the practice of Royal Healthcare and therefore one was never completed for resident ID# 1. Additionally, she stated this resident had no elopement history and has never attempted to leave the facility. She states the door alarms should be on always and could not explain why the alarm had been shut off or who may have shut the alarm off. She states, according to nursing staff it appeared the resident may have stood up from her chair, ambulated to door, pushed on the door handle and fell out the door. It appears the door closed behind her with the resident on the ground outside of the building, and out of view of the glass door. During an interview on 2/8/18 at approximately 10:00 AM, with the activity staff member for the secure unit she states she works full time on this unit. She states she started activity approximately 10:10 AM and identified that resident ID# 1 was not there and thought she may be with the hairdresser or in her room. The activity staff states several minutes later she went to the patient's room to check on her and she was not there. She states, I then asked the nurse on the unit where the resident was. The nurse called the hairdresser and physical therapy to see if the resident was in either place. She states when it was found the resident was not with anyone else they began an immediate search and found the resident on the ground outside. During an interview with the unit nurse on 2/8/18 at approximately 10:10 AM, she stated that although she was not the nurse on 2/6/18 the unit was fully staffed with one nurse, three nursing assistants and one activity staff. During an interview on 2/8/18 at approximately 11:00 AM, with two full-time Westerly Unit nursing assistant, staff A and B, revealed that resident ID# 1 was left unattended in the common room on the Westerly Unit, which is described as a secure unit. The resident was last seen by staff at approximately 9:30 AM, and then found outside on the concrete patio which is adjacent in the common room. Per the incident report the resident was found outside at 10:45 AM. S/he had fallen outside to the side of the glass door. Staff A and B told the surveyor that the resident was not visible from the inside of the facility. Additionally, both stated the door alarm did not sound and was noticed to be off when the resident was found. Review of the resident record for resident ID# 1 revealed s/he was admitted on [DATE] to the secured unit with a [DIAGNOSES REDACTED]. S/he was unable to complete a brief mental status test due to severe cognitive impairment. Review of the quarterly comprehensive assessment completed 1/2018 revealed the resident was a total assistance with all aspects of care and required the assistance of 1-2 staff to transfer and ambulate, however per the plan of care the resident sometimes forgets her limitations and gets up without assistance and is at risk for falls. Interventions/Approaches to this problem include: observe frequently and encourage activity in a supervised area when out of bed. Staff to stay with me when I am not in a common area because I am impulsive. Review of the incident report and progress notes for 2/6/2018 reveals that at approximately 10:45 AM resident ID# 1 was found outside of the common room exit door on the ground. Her temperature was noted to be between 81 and 82 degrees when she was found. She had a laceration above her eye. The resident was verbally responsive and cold to touch. Nursing staff wrapped the resident in blankets and 911 was called. Staff noted the door alarm was in the off position and did not sound to alert staff that the door had been opened. During an interview with the Director of Nursing on 2/8/2017 at approximately 1:10 PM, she was unable to provide a policy for maintenance or monitoring of the alarms on this secure unit, but did provide a hand-written log for the past 3 weeks of weekly alarm testing by maintenance which had just been implemented 3 weeks ago. Additionally, she stated that prior to this incident there was no one responsible to make sure the alarms are on and functioning daily and was unable to provide evidence of staff education regarding the alarm system prior to this incident. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with the applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities, they are deficiencies under State regulations and grounds for licensure sanctions.