Every finding on record at Saint Elizabeth Home East Greenwich

Based on record review and staff interview, the facility failed to complete an annual performance review for every nurse aide (NA), at least once every 12 months, for 3 of 3 NA personnel records reviewed, Staff B, C, and D.Findings are as follows:Record review of the personnel file for Staff B revealed she was hired in January of 2000. Further review revealed her last annual performance review was completed on 4/8/2024.Record review of the personnel file for Staff C revealed she was hired in January of 2008. Further review revealed her last annual performance review was completed on 2/13/2024.Record review of the personnel file for Staff D revealed she was hired in February of 2023. Further review revealed her last annual performance review was completed on 3/11/2024.During a surveyor interview on 4/22/206 at 10:22 AM with the Director of Nursing Services, she acknowledged that the above-mentioned NA's have not had a yearly performance review since 2024.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 1 resident reviewed with a wanderguard (a wearable tag, often in a bracelet or anklet form, used to prevent individuals with cognitive impairments from eloping or wandering from a secured area), Resident ID #113. Findings are as follows:Review of a facility policy titled, Wanderguard System and Assessments; Checks, last revised 4/2/2026, states in part, .The bracelet will be checked each shift to assure placement; the nurse will sign this as checked in the treatment record. The functionality of the bracelet is also to be tested routinely (weekly) and documented in the medical record.Wanderguard bracelets do expire and must be checked and replaced accordingly.Record review revealed the resident was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, dementia.During surveyor observations on the following dates and times, the resident was noted to have a wanderguard on his/her walker:-4/20/2026 at 9:35 AM-4/21/2026 at 11:38 AM -4/22/2026 at 1:25 PMReview of an Elopement assessment dated [DATE] revealed a score of 3, indicating the resident is at risk for elopement.Review of a care plan focus area initiated on 11/17/2025 revealed the resident is at risk for elopement, related to recent wandering and verbalizing wanting to go home. Interventions include, but are not limited to, wanderguard in place and staff to check placement and functionality per physician's order.Record review failed to reveal evidence of a physician's order for the wanderguard device, an order to check for placement each shift, or an order to check for functionality weekly. Additional record review failed to reveal documentation that the resident's wanderguard was being monitored for placement and functionality, per the facility policy.During a surveyor interview on 4/22/2026 at 1:25 PM, with Registered Nurse, Unit Manager, Staff A, she acknowledged that there were no active physician's orders for the resident's wanderguard to include the checking for placement and functionality of the device and indicated that there should be.During a surveyor interview on 4/22/2026 at 1:33 PM, with the Director of Nursing Services, she revealed that there should be physician's orders in place for the wanderguard to include checking for placement and functionality of the device.

Based on record review and staff interview, it has been determined that the facility failed to keep residents free from abuse for 1 of 3 residents reviewed relative to a resident-to-resident incident, Resident ID #1.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 10/19/2025 revealed in part, Upon entering room [ROOM NUMBER]A at 7a, [Nursing Assistant (NA), Staff A] observed [Resident ID #2] on top of [Resident ID #1]. [Resident ID #2] was disrobed on [his/her] bottom half. [Resident ID #1] was fully clothed with brief intact and fastened.Record review revealed Resident ID #1 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, Alzheimer's disease with late onset, unspecified psychosis, dementia with behavioral disturbances, and primary insomnia.Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed, the resident has a Brief Interview for Mental Status (BIMS) score of 99, indicating s/he could not complete the assessment due to severe cognitive impairment. Additionally, the MDS revealed s/he exhibited wandering behaviors in the lookback period.Record review of Resident ID #1's care plan revealed a focus area initiated on 7/31/2025 and revised on 10/21/2025 indicating that Resident ID #1 has a tendency to wander throughout the neighborhood and into other's rooms. The resident was found in another resident's room with his/her hands in their groin area. The resident also has a tendency to wander into Resident ID #2's room. Interventions include, but are not limited to, monitoring his/her whereabouts as s/he tends to lay on other residents' beds, monitoring his/her wandering on the unit, directing him/her away, and a stop sign has been placed across Resident ID #2's door to deter him/her away.Record review revealed Resident ID #2 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, dementia, unspecified hearing loss, and cognitive communication deficit.Review of a Quarterly MDS assessment dated [DATE] revealed the resident has a BIMS score of 15 out of 15, indicating s/he is cognitively intact.Record review of a care plan last revised on 10/20/2025 revealed a focus area which indicates the resident dislikes when other elders enter his/her room. An intervention includes placing a motion sensor at his/her door to alert staff that someone has entered the room.Record review revealed the following nursing progress notes: - 8/7/2025 at 3:41 PM, another resident was found in Resident ID #2's room touching him/her in the groin area. The other resident was redirected out of the room. - 8/8/2025 at 2:34 PM, the facility spoke to Resident ID #2's family member and was agreeable to putting a motion sensor on his/her door to alert staff that someone has gone into his/her room. - 8/21/2025 at 5:43 AM, the resident is currently resting comfortably in bed, the motion sensor is plugged in as ordered. - 8/26/2025 at 2:12 PM, a stop sign was placed in the doorway to deter elders from entering Resident ID #2's room. - 10/19/2025 at 7:26 AM, Resident ID #2 was observed in bed with a resident of the opposite sex, Resident ID #1. Resident ID #2 was not wearing any pants or brief. Resident ID #1 was fully clothed. The residents were separated, and a full assessment was completed with no new findings. - 10/20/2025 at 4:26 PM, the Social Worker was aware that Resident ID #2 was involved in a resident-to-resident incident on 10/19. Resident ID #2 was pleasant and smiling with no concerns relative to the incident. A stop sign and doorbell were in place in efforts to alert staff when other elders are entering his/her private room.Additional record review revealed physician's orders to plug in the motion sensor alarm at 6:00 AM and to unplug the motion sensor alarm at 10:00 PM.Record review of the October 2025 Treatment Administration Record (TAR) failed to reveal evidence that the order to plug in the motion sensor at 6 AM was signed off as completed on 10/19/2025.During a surveyor interview with Nursing Assistant, Staff A, on 10/21/2025 at 11:39 AM, she revealed that on 10/19/2025, she started her shift at 7:00 AM and started to do rounds at approximately 7:15 AM when she noticed Resident ID #1 was not in his/her bed. She indicated that s/he frequently wanders up and down the hallway, so she began checking other residents' rooms. She revealed she found Resident ID #1 in Resident ID #2's bed, with Resident ID #2 making thrusting motions above Resident ID #1. Additionally, she indicated that Resident ID #2 was undressed below the waist while Resident ID #1 had his/her pants on and brief intact. Further, she indicated that Resident ID #2 has a motion alarm in his/her doorway that typically makes a sound when someone enters his/her room. However, she indicated that it did not sound when she entered the room to separate the two residents.During a surveyor interview with Registered Nurse (RN), Staff B, on 10/21/2025 at 3:01 PM, she indicated that on 10/19/2025 at approximately 7:00 AM when she came in for her shift, she observed Resident ID #1 sitting in the small common area at the end of the hallway. While she was receiving report from the third shift nurse, RN, Staff C, at the nurses' station, Staff A came and requested help in Resident ID #2's room. She revealed that when they entered the room, Resident ID #2 was bare bottomed with no pants or brief on with Resident ID #1 beneath him/her fully clothed. Additionally, she revealed that when they were walking in/out of the room, the sensor alarm on the door was not chiming. She indicated the alarm can typically be heard a pretty good distance while in the hallway and in the common area. Further, she indicated that the third shift nurse is responsible for plugging in the motion sensor and documenting it in the TAR.The surveyor attempted to contact RN, Staff C via phone on 10/21/2025 at 3:00 PM, 3:15 PM, and at 3:48 PM but was unsuccessful.During a surveyor interview with the Director of Nursing Services on 10/21/2025 at approximately 3:50 PM, she revealed that when Staff B and C went into Resident ID #2's room to address the incident, they did not observe the motion sensor on the door to be plugged in. She indicated that she would expect the motion sensor on the door to be plugged in at 6:00 AM and documented in the TAR. Additionally, she indicated that if the motion sensor was missing, broken, or not plugged in that it would be documented in the resident's record. Further, she was unable to provide evidence that Resident ID #1 was kept free from abuse.

Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/13/2025, revealed in part, that Resident ID #s 1 and 2 were sitting in the dining room, at opposite ends of a table, when Resident ID #2 walked over to Resident ID #1 and struck him/her in the face multiple times. Further review revealed both residents were immediately separated, Resident ID #1 was assessed for injury, with no injury noted, and Resident ID #2 was sent to the hospital for a geriatric psychiatric evaluation. Review of a policy titled, Abuse Prohibition last revised 1/17/2023 states in part, .It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse .DEFINITIONS .Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish and includes physical .Examples of abuse include but are not limited to .Physical-Hitting, punching . Record review revealed that Resident ID #1, the victim, was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, dementia. Review of Resident ID #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating the resident has severely impaired cognition. Record review revealed that Resident ID #2, the perpetrator, was admitted to the facility in August of 2023 with a diagnosis including, but not limited to, dementia. Review of Resident ID #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 out of 15, indicating the resident has severely impaired cognition. Review of Resident ID #2's care plan revealed a focus area, last revised on 7/26/2024, which indicated the resident has a history of physical aggression related to his/her diagnosis of dementia and poor impulse control. An intervention includes, but is not limited to, I appear to be triggered by increased stimulation from my peers and become agitated, staff will encourage me to go to a quieter area. Record review for Resident ID #2 revealed a progress note dated 5/13/2025 at 5:11 PM, which states in part, Elder was sitting in the dining room with [his/her] peers, elder had no [signs or symptoms] of agitation or aggression when this writer saw elder approximately 5 [minutes] prior to incident. Staff report that [Resident ID #2] got up from [his/her] chair and walked over to another elder and struck other elder in the face multiple times causing other elder's glasses to fall off. Incident appeared to be unprovoked by other elder. At the time of the incident there was increased stimulation in the dining room and activity room and other elder was repeating phrases to [him/herself] which is normal .NP [Nurse Practitioner] aware of incident and elder to be sent out to geri-psych . Record review for Resident ID #1 revealed a progress note dated 5/13/2025 at 5:00 PM, which states in part, Elder was involved in an altercation with another elder this evening. [Resident ID #1] was sitting in a chair in the dining room across from other elder, [s/he] was calm but repeating mamma what do I do? Mamma where do I go. [His/her] repetition of phrases is per usual for elder, [s/he] was calm and the volume of [his/her] talking .was low. Other elder got out of [his/her] chair and walked over to [Resident ID #1], [s/he] struck [him/her] multiple times in the face and [Resident ID #1's] glasses fell off. Staff immediately intervened and elder's were separated. [Resident ID #1] was assessed for injury with no redness, bruising or swelling noted. Elder denies pain and has no non-verbal [signs or symptoms] of pain. [Resident ID #1] was assisted out of the dining room and into the activity room. [Resident ID #1] was in a pleasant mood once [s/he] arrived to the activity room and had no recollection of the incident when talking to this writer . Review of an assessment titled Skin Incident Report, for Resident ID #1, dated 5/14/2025, revealed the resident had a change in skin integrity due to the incident with Resident ID #2 on 5/13/2025. Further review revealed the following skin impairments: - right dorsal (the top) hand bruise measuring 0.3 centimeters (cm) X 0.3 cm - 2 bruises to his/her left forearm measuring 0.4 cm X 0.2 cm and 0.3 cm X 0.3 cm - 2 linear scratches to his/her right lower forearm measuring 1.5 cm X less than (<) 0.1 cm and 1.3 cm X < 0.1 cm Review of a witness statement, authored by Hospice Registered Nurse, Staff A, dated 5/13/2025, states in part, In the late afternoon of 5/13/25 I was taking a patient back into the dinning room. Upon my approach I heard two residents arguing and yelling loudly. When I entered the dinning room I saw [Resident ID #1] on a chair at one end of the table, [s/he] was facing me and turned slightly into the table. [Resident ID #2] was positioned at [Resident ID #1's] left back and side, [Resident ID #2] had one arm positioned down from [Resident ID #1's] shoulder and chest and with [his/her] other hand [s/he] was punching [Resident ID #1]. [Resident ID #2] knocked [Resident ID #1's] glasses askew. I said loudly 'no, no, no' and walked toward the scuffle. [Resident ID #2] stopped hitting [Resident ID #1] and went back to where [s/he] was sitting at the other end of the table. [Resident ID #1] continued to yell at [Resident ID #2] about [him/her] shutting up .Staff then came and removed [Resident ID #2] from the table. During a surveyor interview on 6/4/2025 at 2:43 PM, with Unit Manager, Staff B, she revealed that initially, no staff were present in the dining room when the incident occurred, as one had just left to assist with care. She revealed that Staff A entered the dining room and saw Resident ID #2 hitting Resident ID #1 in the face. She further revealed that the following day, a full skin assessment was completed on Resident ID #1, due to this incident, and the resident was noted to have bruises and scratches on his/her arms, indicating they were consistent with defensive marks. Further, she revealed that Resident ID #2 has been involved in previous resident to resident incidents and was being followed by psychiatric services. During a surveyor observation on 6/4/2025 at 3:10 PM, Resident ID #1 was observed sitting outside with his/her peers. When approached by the surveyor and Staff B, s/he appeared pleasantly confused and in good spirits. Additionally, s/he was unable to be interviewed due to his/her cognitive impairment. During a surveyor interview on 6/4/2025 at 3:23 PM, with the Director of Nursing Services, she revealed that Resident ID #2 has been involved in previous resident to resident incidents, with the last one occurring in August of 2024. She further revealed that Resident ID #2 has a history of behaviors and indicated that s/he was completely unprovoked during the resident-to-resident incidents. She further revealed that Resident ID #2 was admitted to the hospital for a geriatric psychiatric evaluation, following this incident, and the decision was made to not accept him/her back to the facility due to safety concerns. Additionally, she was unable to provide evidence that Resident ID #1 was kept free from abuse.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food service safety relative to the main kitchen, 3 of 3 kitchenettes and 4 of 4 [NAME] House kitchens observed. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 edition, Section 3-602.11 Food Labels states, .Label information shall include: (1) The common name of the food . Review of the facility's policy, food brought to residents from the outside, states in part, .the food must be clearly labeled with the resident's name and room number, the date the food was brought to the resident, and also the use by date .Resident and family should be informed that if the food is not consumed within 72 hours, it will be discarded for food safety concern . Additionally the policy reveals that if the food is not eaten within 72 hours the resident or family will be notified and the foods will be discarded by the nursing staff. During the initial tour of the main kitchen, 3 of 3 kitchenettes, and 4 of 4 [NAME] House kitchens on 2/17/2025 at 8:20 AM, in the presence of the Director of Dining Services, the following was revealed: - Walk in refrigerator in the main kitchen: 2 one-gallon zip lock style bags approximately half full, containing sliced lemon wedges with a discard date of 2/16/2025. - Walk in freezer in the main kitchen: 3 packages of 12 frozen waffles, 2 packages of 6 frozen bagels, 1 bag of frozen fish sticks not labeled or dated. - Hill Unit kitchenette: Resident food consisting of a paper plate in a zip lock style bag containing 3 cooked chicken legs, one small to-go style container containing cooked pasta in a red sauce, and a large to-go style container containing eggplant parmesan that did not indicate a discard or arrival date. - Cove Unit kitchenette: one gallon zip lock style bag, approximately half full containing cut lemon wedges, without a label or a discard date. - [NAME] House #19 kitchen: a Rubbermaid style container, approximately 1/2 quart in size containing diced tomatoes, two packages of 12 frozen waffles, a half-gallon container of ice cream 3/4 full with a substantial amount of freezer burn, without a label or a discard date. One unopened package of 12 english muffins with a sell by date of January 29th. - [NAME] House #21 kitchen: one opened package of 4 frozen chicken patties, without a label or a discard date. During a surveyor interview following the above observations with the Director of Dining Services, he acknowledged the above-mentioned findings. He further indicated that the above-mentioned items should have been labeled, dated, and discarded, as indicated in the facility food service policy and per the regulations. 2. Review of The Rhode Island Food Code 2018 Edition 4.601.11 reads in part, .equipment food contact surfaces .shall be clean to sight . During the initial tour of the main kitchen, 3 of 3 kitchenettes, and 4 of 4 [NAME] House kitchens on 2/17/2025 at 9:54 AM, in the presence of the Director of Dining Services, the following was revealed: - Bay Unit kitchenette: the microwave that is used for residents was observed with an accumulation of a dried light brown matter splattered on the inside of the glass door, along the inside wall, and on the glass turn plate. - [NAME] House #15: the freezer drawer below the refrigerator in the pantry, revealed an accumulation of food particles and debris including tortellini pasta on the bottom. - [NAME] House #17: the microwave that is used for the residents revealed an accumulation of brown matter, scattered on the inside of the glass door and on the ceiling. - [NAME] House #21: the microwave that is used for the residents revealed an accumulation of a greasy residue scattered on the inside of the glass door, on the ceiling, and on the glass turn plate. During a surveyor on interview on 2/17/2025 at approximately 9:35 AM with the Director of Dining Services, he acknowledged the above-mentioned observations. He indicated that the Shahbaz staff (nursing assistants who work in the [NAME] Houses that provide comprehensive direct care to those residents) for each [NAME] House are responsible for cleaning the microwaves, and that there is a weekly cleaning schedule in place with a designated day of Tuesday. Additionally, he indicated it would be his expectation that the microwaves be cleaned according to the weekly cleaning schedule, and as needed.

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, relative to following a physician's order for nutritional supplements, for 2 of 2 residents reviewed, Resident ID #s 6 and 54, and for 1 of 1 resident reviewed for blood pressure monitoring who is prescribed furosemide, (a medication used to reduce fluid), Resident ID #54. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. 1a. Record review revealed Resident ID #6 was admitted to the facility with diagnoses including, but not limited to, dementia and diabetes. Record review revealed the following physician's orders: -7/6/2024 house supplement 4 ounces (oz.), three times per day for weight loss -7/26/2024 Pro-Stat AWC, (a concentrated liquid protein) 30 milliliters (ML), one time per day for wound care During a surveyor observation of the medication administration task on 2/19/2025 at approximately 9:20 AM with Registured Nurse (RN) Staff A, she was observed administering Resident ID #6 his/her morning medications. Additionally, Staff A was not observed to administer his/her supplements at the time of the observation. Record review of the February 2025 Medication Administration Record (MAR) revealed the above-mentioned supplements were documented as being administered on 2/19/2025 by RN, Staff A. 1b. Record review revealed Resident ID #54 was admitted to the facility with diagnoses including, but not limited to, dementia, and hypertensive heart disease (a heart condition that is caused by high blood pressure) with heart failure. Record review revealed the following physician's orders: -1/31/2024 furosemide, 20 milligrams (MG), give three tablets (60 mg) one time per day and monitor the resident's blood pressure. -5/7/2024 Pro-Stat AWC, 30 ML's one time per day. During a surveyor observation of the medication administration task on 2/19/2025 at approximately 9:30 AM with RN, Staff A, she was observed administering the resident's furosemide. Additionally, Staff A, was not observed to administer the supplement nor obtain the resident blood pressure when administering his/her furosemide at the time of the observation. Additionally, record review of the MAR revealed the furosemide was documented as administered with a blood pressure reading for the scheduled 10:00 AM dose. Record review of the February 2025 MAR revealed that the Pro Stat was documented as being administered on 2/19/2025 by RN, Staff A. During a surveyor interview on 2/19/2025 at 10:56 AM with Staff A, she acknowledged that she did not administer the supplements as ordered to Resident ID #s 6 and 54. Additionally, she revealed that she did not obtain Resident ID #54's blood pressure when she administered his/her furosemide. Further, she acknowledged that she documented that the supplements were given, and the blood pressure was obtained. During a surveyor interview on 2/19/2025 at 11:44 AM with the Director of Nursing Services, she revealed it would be her expectation that the nurse would follow the physician's orders.

Based on record review, staff and resident interview it has been determined that the facility failed to ensure that a newly admitted resident received adequate supervision to prevent an elopement for 1 of 1 resident reviewed who successfully eloped from the facility, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 1/2/2025 states in part, Patient left facility without alerting staff. Patient was unable to re-enter the building and decided to walk. [NAME] by called 911 and patient was sent to ER [emergency room ] for evaluation. Review of a community reported complaint submitted to the RIDOH on 1/2/2025 alleges that Resident ID #1 eloped from the facility and was found sitting on a main road and taken to the hospital at approximately 3:00 AM. It further revealed that the resident's family member was not notified by the facility that the resident was unable to be located during rounds until 7:14 AM. This was approximately 3 hours after the resident was found sitting in the road. Record review of a facility policy titled Missing Resident Policy states in part, Purpose: To provide direction to staff when a resident is determined to be missing or has eloped. Notify the Person in charge and/or charge nurse. Determine the time that the resident was discovered missing and when and where he/she was last seen .Check with other staff. Contact family to ask them if the resident is with them. If unable to determine where the resident is, notify other staff in the building and promptly search the facility and premises .If missing resident is not found following and expedite search (approximately 30 minutes), call 9-1-1 and provide Name of the resident, Date/time and location resident was last seen . Record review revealed that Resident ID #1 was admitted to the facility on [DATE] at approximately 2:00 PM, after a hospital stay. S/he was discharged after a fall with a head strike and a left basal ganglia intraparenchymal hemorrhage (a hemorrhage inside the brain that is primarily caused by uncontrolled hypertension.) While in the hospital the resident was alert and oriented times two and experienced periods of forgetfulness. Record review of a progress note dated 1/1/2025 at 4:58 PM by Registered Nurse (RN), Staff A, revealed that the resident was observed with intermittent confusion and forgetfulness. Record review of the January 2025 Medication Administration Record revealed that the resident received his/her evening medications at 8:08 PM on 1/1/2025. Further record review failed to reveal evidence of the resident's whereabouts from approximately 8:00 PM on 1/1/2025 until approximately 7:15 AM on 1/2/2025 when they were made aware by the resident's family member that s/he was at the hospital. Record review of a Police Department Call Log dated 1/2/2025 states in part, ELDERLY [person] IN THE LOBBY VERY CONFUSED AND COLD . Additionally it states that the resident did not know where s/he lived and was transferred from the police station by Rhode Island Emergency Medical Services (EMS) to an acute care hospital for an evaluation. Record review of an EMS Report dated 1/2/2025 revealed in part, .Hypothermic [significant and potentially dangerous drop in body temperature mostly caused by prolonged exposure to the cold] Primary Symptom: Altered mental status .pt [Resident ID #1] sitting in lobby of police station wrapped in a mylar blanket [an emergency blanket used to keep a person warm], shivering, in pajamas with cold wet socks on, no shoes .Pd [police department] stated that pt [Resident ID #1] was dropped off from a newspaper delivery person who found the pt [Resident ID #1] walking in Post Road . Pt is cold .has decrease mental state .obviously confused and not answering all questions appropriately . Pt states that [s/he]went out when it was light out to bring flowers to President Cartes [sic] Memeorial [sic] but got locked out and could not get back inside. Pt was unable to tell EMS if [s/he] was home or from a nursing facility .Removed cold wet socks, placed .in heated ambulance .and transfer to [hospital name redacted] . Review of an emergency room note dated 1/2/2025 revealed in part, .presented for evaluation of being found wandering around the road .for altered mental status. Patient was hypertensive [high blood pressure] to a systolic blood pressure greater than 180 on arrival [normal systolic blood pressure range is considered to be less than 120] .Contacted [family member] over the phone who was not aware the patient was in the Emergency Department . Record review revealed the resident returned from the hospital to the facility during the evening shift (3:00 PM through 11:00 PM) of 1/2/2025. During a surveyor interview on 1/3/2025 at approximately 12:00 PM, with the Administrator she acknowledged that the resident eloped from the facility unsupervised. She further revealed that both the 1st and 2nd floor doors had alarms that would have been activated when s/he left the facility. Additionally, she revealed that staff had not responded to any alarms on the night shift of 1/1-1/2/2025. During a subsequent interview with the Administrator on 1/6/2025 at 9:14 AM, she revealed that the alarms on the doors had been turned off by staff members. Additionally, she revealed that the facility would be placing additional alarms on the doors that will require a key for deactivation. Furthermore, she indicated that the keys for these alarms will remain with the nurse on the unit. During a surveyor interview with the resident on 1/3/2025 at approximately 1:00 PM s/he revealed that s/he remembers walking out of the building but could not recall the time of day. Additionally, the resident stated in part, there was no one there it was quiet, and I just walked out. Furthermore, s/he revealed that once s/he was outside s/he was cold because s/he did not have a coat or shoes on. Lastly, s/he revealed that s/he was waving his/her arms and a person helped him/her by taking him/her to the police station, where they gave him/her a blanket and transferred him/her to the hospital. Record review of a written statement dated 1/2/2025, by Licensed Practical Nurse (LPN), Staff C, the charge nurse on the resident's unit on 1/1/2025 from 3:00 PM to 11:00 PM, revealed that she had last observed the resident sometime between 8:00 PM and 9:00 PM on 1/1/2025. During a surveyor interview with Staff C on 1/13/2025 at 2:51 PM, she revealed that she did not administer medications to the resident on the evening of 1/1/2025. She revealed that a medication technician had administered the resident's medication. She further revealed that she did not see the resident after 9:00 PM, noting that the last time she observed the resident on the unit was sometime between 8:00 and 9:00 PM. Record review of a written statement by LPN, Staff B, the charge nurse on the resident's unit from 11:00 PM on 1/1/2025 to 7:00 AM on 1/2/2025 revealed that during his shift he did not see or interact with Resident ID #1. During a surveyor interview on 1/14/2025 at 8:13 AM with Staff B, he revealed that he never conducted rounds of the unit on the third shift of 1/1 into 1/2/2025. He stated that he only responded to calls for the residents that needed medication. He acknowledged that he did not assess the newly admitted resident who had recently experienced a brain bleed. He stated that he was notified that Resident ID #1 was missing at approximately 6:00 AM on 1/2/2025. Additionally, he revealed that he looked for the resident for about 10 to 15 minutes, during which time he did not remember anyone assisting him. Staff B, then contacted the on call Manager, Registered Nurse (RN), Staff F at approximately 6:20 AM, who instructed him to read an education book and to follow the appropriate steps of the missing resident policy. Staff B was unable to find the book, so Staff F proceeded to read him the steps over the telephone. Staff B informed the unit's staff that the resident was missing, and a search was initiated. Staff B further revealed that the resident had not been seen by any of the facility's staff since approximately 8:00 PM on 1/1/2025 and that staff members were unsure if the resident went missing on the second or third shift. Lastly, Staff B revealed that before 7:00 AM, a different Nurse Manager, Staff E arrived at the facility and took over the investigation. During a surveyor interview on 1/6/2025 at 10:46 AM with the Nurse Manager, Staff E, she revealed that she arrived to work on 1/2/2025 at approximately 6:50 AM and was made aware that all staff were looking for the resident. Additionally, she indicated that she contacted the resident's family member at approximately 7:15 AM to inform them that the resident was missing. At that time the family member informed her that s/he had already been contacted by the EMS and the police. Staff E acknowledged that the facility did not follow the missing resident policy protocol which includes to notify the family and to notify the police within 30 minutes. During a surveyor interview on 1/3/2025 at approximately 2:00 PM with Nursing Assistant (NA), Staff D, he revealed that when he presented to work on 1/1/2025 for the 11:00 PM to 7:00 AM shift he did not receive report from the prior shift because it was hectic. Additionally, he stated that when he went to check on the resident's room, at approximately 11:30 PM, Resident ID #1 was not there. He further revealed that the resident's bed had no linens on it, so he assumed that s/he had been sent out to the hospital. Further, he revealed that at approximately 5:00 AM the nurse requested that the resident's vital signs be obtained and he notified the nurse that Resident ID #1 was not in his/her room. During a surveyor interview on 1/3/2025 at approximately 2:30 PM with the Director of Nursing Services (DNS) she acknowledged that Resident ID #1 was unaccounted for by staff since approximately 8:00 PM on 1/1/2025. She acknowledged that Staff E was notified by the family member that Resident ID #1 was in the hospital. The DNS further acknowledged staff did not properly follow the missing resident policy. Additionally, she could not provide evidence that the facility ensured the resident received adequate supervision to prevent the elopement. The facility failed to ensure the resident environment remains as free of accident hazards as is possible for all residents that are deemed as elopement risks as the facility staff turned off the door alarms. Additionally, after the IJ had been identified the facility did not complete their original immediate plan in its entirety by installing additional alarms. These failures placed all residents deemed as an elopement risk at continued risk from 1/1/2025 through 1/8/2025. Resident ID #1 was last seen at approximately 8:00 PM on 1/1/2024. The weather was approximately 37 degrees Fahrenheit with interment snow showers. The resident was not wearing a coat or shoes, s/he only had slipper socks on. Staff B, the charge nurse on the 11:00 PM to 7:00 AM shift acknowledged that he failed to conduct rounds and failed to observe the resident. At approximately 5:30 AM on 1/2/2025 almost 9 hours after the Resident was last seen, Staff B was notified that the resident was missing, and he started to look for him/her. The on call nurse was contacted at approximately 6:20 AM, and she instructed him on the appropriate steps of the missing resident policy. Staff E arrived at the facility at 6:50 AM on 1/2/2025 and was made aware the resident was missing and at approximately 7:15 AM s/he contacted the resident's family. Staff E contacted Resident's ID #1's family at approximately 7:15 AM who informed her that the resident was in the hospital. The facility's failure to supervise a confused resident resulted in the resident's elopement from the facility. This placed the resident at risk for more than minimal harm, impairment, or death, as they failed to implement appropriate interventions to keep him/her safe.

Based on record review and staff interview, it has been determined that the facility was not being administered in a manner that enabled it to utilize resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident related the elopement of Resident ID #1. This failure resulted in an Immediate Jeopardy for F 689. Findings are as follows: Record review of a facility policy titled Missing Resident Policy states in part, Purpose: To provide direction to staff when a resident is determined to be missing or has eloped. Notify the Person in charge and/or charge nurse. Determine the time that the resident was discovered missing and when and where he/she was last seen .Check with other staff. Contact family to ask them if the resident is with them. If unable to determine where the resident is, notify other staff in the building and promptly search the facility and premises .If missing resident is not found following and expedite search (approximately 30 minutes), call 9-1-1 and provide Name of the resident, Date/time and location resident was last seen . Record review revealed that on 1/2/2025 at approximately 4:00 AM, Resident ID #1 was observed by a passerby sitting down in a busy main roadway, unsupervised by staff. The resident was taken to the police station where emergency medical services were called to transport the resident to the hospital. Additionally, the temperature at the time was approximately 37 degrees Fahrenheit with intermittent snow showers. Review of video footage dated 1/2/2025 at 2:31 AM revealed Resident ID #1 was wandering around the main entrance of an Assisted Living Residence located 0.2 miles from the facility, without a coat or shoes on. During a surveyor interview on 1/14/2025 at 8:13 AM with Staff B, he stated that he was notified that Resident ID #1 was noted to be missing at approximately 6:00 AM on 1/2/2025. Additionally, he revealed that he looked for the resident for 10 to 15 minutes. He does not remember anyone assisting him in his search for the missing resident. At this time Staff B contacted the on call Manager, Registered Nurse (RN), Staff F at approximately 6:20 AM, who instructed him to read an education book in order to follow the appropriate steps for the missing resident policy, which was located in an office. Staff B revealed he was unable to locate the book, so Staff F proceeded to read him the steps on what to do over the telephone. During surveyor interviews on 1/13/2025 at 1:15 PM and 1:42 PM with the Director of Nursing Services (DNS), she revealed that Resident ID #1 was last seen at approximately 8:00 PM on 1/1/2024. Additionally, she revealed that on call manager, Staff F was notified at 6:20 AM on 1/2/2025 that the resident was missing and that she was notified approximately two minutes later. Additionally, she revealed that she arrived at the facility was at approximately 7:25 AM. Furthermore, she revealed that Staff E contacted Resident's ID #1's family at approximately 7:15 AM who informed her that the resident was in the hospital. She furthermore acknowledged that the resident was unaccounted for by the facility for an extended period of time, approximately 10 hours after she was last seen by the second shift staff. Lastly she acknowledged that the staff did not properly follow the elopement policy and failed to notified family and the police timely. During a surveyor interview on 1/3/2025 at approximately 12:00 PM, with the Administrator she acknowledged that the resident eloped from the facility unsupervised even though there were two alarmed doors located on the 1st and 2nd floors that s/he would have to have activated when s/he left the facility. Additionally, she revealed that staff had not responded to any alarms on the night shift of 1/1-1/2/2025. During a subsequent interview with the Administrator on 1/6/2025 at 9:14 AM, she revealed that the alarms on the doors had been turned off by staff. Furthermore, she revealed that facility would be placing additional alarms on the doors and the keys to deactivate them will remain with the nurses on the unit, so that staff will unable to turn them off. During an additional surveyor interview on 1/13/2025 at 4:56 PM with the Administrator, she acknowledged that Resident ID #1 was unaccounted for an extended period and left the facility unsupervised and was seen on another facilities video footage at 2:31 AM. In addition, she acknowledges that facility staff did not follow the facility's policy for a missing resident. She furthermore stated that during this incident, everything that could go wrong, went wrong. Cross reference F689

Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that residents receive and consume food in the appropriate form for 1 of 3 residents reviewed for a modified diet of pureed texture, Resident ID #1. Findings are as follows: Review of a facility reported incident received by the Rhode Island Department of Health on [DATE] revealed that Resident ID #1 experienced a choking incident at 6:00 PM, the Heimlich maneuver (first aid method use when a person is choking) was initiated and the Emergency Medical Services (EMS) was promptly contacted. Upon the arrival of the EMS team the resident was noted to be without a pulse or respirations (number of breaths per minute). The resident expired at 6:24 PM. Record review revealed that Resident ID #1 was admitted to the facility in October of 2019 with diagnoses including, but not limited to, dementia and aphasia (language disorder making speaking and the ability to be understood difficult) following a stroke. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating that the resident has severe cognitive impairment. Additionally, the assessment revealed that the resident required a mechanically altered diet, which includes pureed texture. Record review of a physician's order dated [DATE] revealed a regular diet with a pureed texture. Review of a comprehensive care plan dated [DATE] revealed a focus area for dysphagia with increased difficulty swallowing. Interventions are to provide the diet as ordered which is puree. In addition, staff are to provide assistance at meals and between meals, if needed. Record review of the facility's diet manual titled, Indiana Diet Manual,10th Edition, states in part, .Pureed, foods are totally pureed .desserts should be smooth, like custard or yogurt. No coarse or textured desserts . Record review of the dinner meal for [DATE] for puree textured diets revealed the following: -Puree Manhattan Clam Chowder -Puree Chicken Salad Sandwich -Puree Seasoned [NAME] Beans -Puree Sugar Cookie Record review of the progress notes revealed an entry dated [DATE] at 8:00 PM, authored by Registered Nurse, Staff A, that states in part, .While eating staff noted the resident did not appear right. I promptly went to assist and noted that [s/he] was choking. [His/her] face was red and [s/he] appeared to be choking. I initiated the Heimlich and 911 was called immediately. Unable to attempt to finger sweep [his/her] mouth due to the resident clenching [his/her] jaw. The Heimlich was continued until the EMS arrived. Multiple staff from other units came to assist the resident. Upon EMS's arrival, the resident was absent of all vitals or cardiac rhythm . An additional progress noted dated [DATE] at 11:00 PM authored by Licensed Practical Nurse, Staff B, stated in part, .writer alerted to assist with code blue. When writer entered the Heimlich was being performed by Staff A. The patient was blue in the face and was absent of respirations and pulse for greater than one minute. Approximate time of death was 6:24 PM and that the EMS notified the East [NAME] police department . During a surveyor interview on [DATE] at 11:50 AM with Nursing Assistant, Staff C, she revealed that the incident happened so fast. She further revealed she was assisting another resident in the dining room with the dinner meal when Resident ID #1 grabbed a visitor's arm in the dining room and the visitor called for [Staff A] because the resident was choking. Additionally, she revealed that the resident had an oatmeal chocolate chip cookie in his/her hand. She further revealed the cookie in the resident's hand was a regular textured cookie, it was not pureed. During a surveyor interview on [DATE] at approximately 12:00 PM with the Director of Culinary Services, he revealed that the 2:00 PM snack cart had oatmeal chocolate chip cookies on it. During a surveyor observation in the presence of the Director of Culinary Services, on [DATE] at 12:00 PM of the lunch meal in the memory care dining room, a binder was observed with a document titled, Diet Type Report. The document had a date of [DATE] with each resident's name, diet type, allergies, adaptive equipment and any other pertinent dining considerations. An additional Diet Type Report was reviewed with a date of [DATE]. Immediately following the observation, the Director of Culinary Services revealed the document is printed daily and placed in the binder. During a surveyor interview on [DATE] at approximately 12:45 PM with Staff A, she revealed the resident was in the dining room and she placed four oatmeal chocolate chip cookies on a plate and the resident ate three without any problems. She handed him/her the fourth cookie and went to assist another resident. Upon further interview with Staff A, the surveyor asked what the resident's diet was and she stated puree. The surveyor then asked if regular texture cookies were allowed on a puree diet and she stated, they are not allowed, it was an accident. Upon further interview, Staff A revealed she was aware of the binder with all the residents diets and other dining considerations. During a surveyor interview on [DATE] at 11:30 AM with the Director of Nursing Services, she acknowledged that the resident expired while eating a cookie that was not in pureed form. The facility failed to ensure that Resident ID #1 received food in the appropriate form as s/he was given a cookie by Staff A that was not his/her ordered diet texture. This failure resulted in the resident choking on the cookie and expiring.

Based on record review, and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and #2, resulting in a skin tear for Resident ID #2. Findings are as follows: Review of a facility policy titled, Abuse prohibition states in part, .It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse .Abuse: Willful infliction of injury .resulting in physical harm .Examples of abuse include but are not limited to the following: Physical - Hitting, punching, pinching, kicking . Record review of a facility reported incident of resident-to-resident abuse was submitted to the Rhode Island Department of Health on 9/17/2024. The report indicates that Resident ID #2 was being assisted out of the chair to be moved when Resident ID #1 bent over and pinched Resident ID #2 on the leg causing a skin tear. Record review revealed Resident ID #2, (the victim), was readmitted to the facility in June of 2021 with diagnoses including, but not limited to, Alzheimer's disease and type II diabetes. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. Review of a progress note dated 9/11/2024 at 4:09 PM revealed, Resident ID #1 told Resident ID #2 not to touch his/her food. Additionally, it revealed that Resident ID #2 was being removed from the table when Resident ID #1 reached under the table and pinched Resident ID #2 in the leg, causing a skin tear. Review of a physician's order dated 9/13/2024 revealed, clean Resident ID #2's shin skin tear with normal saline, pat dry, and apply xeroform (wound treatment) to wound bed and cover with a foam dressing, every 3 days. Review of the September 2024 Treatment Administration Record revealed, Resident ID #2's wound was treated from 9/13/2024 through 9/28/2024, a duration of 22 days. Record review revealed Resident ID #1, (the perpetrator) was admitted to the facility in August of 2022 with a diagnosis including, but not limited to, dementia. Review of a quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 out of 15, indicating severely impaired cognition. Review of a progress note dated 9/11/2024 at 4:09 PM revealed, Resident ID #1 told Resident ID #2 not to touch his/her food. Additionally, it revealed that Resident ID #2 was being removed from the table when Resident ID #1 reached under the table and pinched Resident ID #2 in the leg, causing a skin tear. During a surveyor interview on 10/3/2024 at 8:24 AM with Nursing Assistant, Staff A, she revealed Resident ID #1 told Resident ID #2 not to touch his/her food. She further revealed that when staff intervened with the family to separate Resident ID #2 from Resident ID #1, Resident ID #1 reached under the table and pinched Resident ID #2. During a surveyor interview on 10/3/2024 at 9:54 AM with the Unit Manager, she revealed Resident ID #2 attempted to touch Resident ID #1's food and that the residents were being separated. She revealed that during staff and family intervening to separate the resident's, Resident ID #1 reached under the table and pinched Resident ID #2, which resulted in a skin tear on his/her leg that required a treatment. A surveyor interview was attempted on 10/3/2024 at 11:13 AM with Resident ID #2 but the resident was unable to recall the above-mentioned incident due to impaired cognition. A surveyor interview was attempted on 10/3/2024 at 11:50 AM with Resident ID #1 but the resident was unable to recall the above-mentioned incident due to impaired cognition. During surveyor interviews on 10/3/2024 at 9:31 AM and approximately 1:30 PM with the Director of Nursing Services, she acknowledged that Resident ID #1 pinched Resident ID #2's leg resulting in a skin tear. Additionally, she was unable to provide evidence that Resident ID #2 was kept free from physical abuse.

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 and the comprehensive care plan relative to 1 of 1 resident reviewed with a skin tear, Resident ID #2. Findings are as follows: Record review revealed Resident ID #2 was readmitted to the facility in June of 2021 with diagnoses including, but not limited to, Alzheimer's disease and type II diabetes. Review of a progress note dated 9/11/2024 revealed, a resident reached under a table and pinched Resident ID #2 in the leg, resulting in a skin tear. Review of a physician's order dated 9/13/2024 revealed, clean Resident ID #2's shin skin tear with normal saline, pat dry, and apply xeroform (wound treatment) to wound bed and cover with a foam dressing, every 3 days. Review of the September 2024 Treatment Administration Record revealed, Resident ID #2's wound was treated from 9/13/2024 through 9/28/2024, a duration of 22 days. Review of a skin assessment dated [DATE] revealed, the resident had a skin tear with the following instructions related to documentation which should include, the type of wound (abrasion, pressure, skin tear, etc.), measurements of wound length by width by depth, odor, edema, edges, type of tissue in the wound bed, evidence of infection, pain, drainage type and amount, and surrounding skin. Record review failed to reveal evidence at the time of the skin tear or during the following skin assessment on 9/16/2024 that the wound documentation in the medical record included the size of the wound, wound edges, and the wound bed, shape, and the condition of surrounding tissue, per the regulation. During a surveyor interview on 10/3/2024 at 12:40 PM with the Unit Manager, she revealed that the wound was a flap of skin that was pinched and that the wound did bleed at the time of the initial injury. Furthermore, she acknowledged that the residents wound was not measured and there was no identifying characteristics of the wound documented. A surveyor interview was attempted on 10/3/2024 at 11:13 AM with Resident ID #2 but the resident was unable to recall the the above-mentioned incident related to impaired cognition. During surveyor interviews on 10/3/2024 at 9:31 AM and approximately 1:30 PM with the Director of Nursing Services, she acknowledged that there was no documentation regarding Resident ID #2's skin tear on 9/11/2024 or 9/16/2024.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 3 of 3 kitchenettes, and 4 of 4 Green House kitchens. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 edition, Section 3-602.11 Food Labels states, .(B) Label information shall include: (1) The common name of the food . Review of the facility's policy, food brought to residents from the outside, states in part, .the food must be clearly labeled with the resident's name and room number, the date the food was brought to the resident, and also the use by date .Resident and family should be informed that if the food is not consumed within 72 hours, it will be discarded for food safety concern . Additionally the policy reveals that if the food is not eaten within 72 hours, refrigerated or at room temperature, resident or family will be notified and the foods will be discarded by nursing staff. A. During the initial tour of the main kitchen on 3/4/2024 at 9:31 AM, in the presence of the Cook, Staff I, and the Culinary Director, the following was revealed: 1. Walk in refrigerator: a plastic bag of string beans, not labeled or dated and 1 container of strawberries that were noted to have a fuzzy covering. 2. Walk in freezer: an opened plastic bag of uncooked chicken, not labeled or dated. During a surveyor interview with the Staff I, following the above observations, she revealed the above items should be labeled and dated. B. A surveyor observation on 3/4/2024 at 1:10 PM of the Hill Unit kitchenette revealed a refrigerator containing 4 chocolate mighty shakes. The instructions on the carton states, store frozen thaw at or below 40 F [Fahrenheit] use thawed products within 14 days keep refrigerated. The above-mentioned shakes did not indicate a date when thawed, nor a discard date. During a surveyor interview with Certified Medication Technician, Staff F, on 3/4/2024 at 1:03 PM, she revealed that was unaware that the shakes needed to be dated when thawed. C. A surveyor observation on 3/4/2024 at 1:19 PM of the Bay kitchenette revealed the refrigerator contained 1 chocolate mighty shake and 12 vanilla mighty shakes without discard dates or dates when thawed. During a surveyor interview with Culinary Aide, Staff G, following the above observation she acknowledged the thawed mighty shakes did not have a discard date. D. A surveyor observation on 3/4/2024 at 1:21 PM of the Cove Unit Kitchenette revealed the freezer contained a box of cheese and pepperoni bagel bites which were not label or dated. During a surveyor interview following the above observation with Culinary Aide, Staff H, she revealed if there is no label on the food item it should be discarded. During a surveyor interview on 3/4/2024 at 2:27 PM with Staff I, she indicated the food and drinks in the kitchenettes need to be labeled and dated correctly, and if not, they need to be discarded. Additionally, she indicated the Mighty shakes should have been dated when brought to the unit and that the shakes would be good for 5 days. 2. Review of The Rhode Island Food Code 2018 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight . During the initial tour of the Green House kitchenettes revealed the following findings: 1. Green House #15 During a surveyor observation on 3/4/2024 at 10:46 AM, the ice machine an accumulation of a dark grey matter was noted along and on the sides of the condensation panel. During a surveyor interview following the above observation with Certified Nursing Assistant (CNA), Staff O, she acknowledged the above observations. Additionally, she revealed that an outside company last serviced to the ice machine on 12/4/2023. 2. Green House #17 During a surveyor observation on 3/4/2024 at 9:07 AM, the ice machine the interior was noted to have black matter scattered on the inside of the door and on the top area. During a surveyor interview following the above observation with CNA, Staff P, she acknowledged the black matter inside the ice machine and could not provide evidence that it was kept clean. During a surveyor interview on 3/4/2024 at approximately 9:20 AM with Nurse Unit Manager, Staff N, she acknowledged the black matter and indicated that it should not be inside the ice machine; she stated it looked like mold. 3. Green House #19 During a surveyor observation on 3/4/2024 at 11:25 AM, the ice machine was noted to have an accumulation of dark grey matter around the condensation panel. During a surveyor interview, immediately following the above observation with CNA, Staff Q, she acknowledged the dark grey matter accumulated around the condensation panel. 4. Green House #21 During a surveyor observation on 3/4/2024 at approximately 12:00 PM, the ice machine had an accumulation of black matter that was scattered inside the door and on the upper area. During a surveyor interview following the above observation with Dietitian, Staff R, she acknowledged the ice machine was not clean and that the black matter appeared to be mildew. 43987 47808

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident receives incontinence care per the resident's plan of care for 1 of 3 residents reviewed for incontinence care, Resident ID #196. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2024 with a diagnosis including, but not limited to, dementia. Record review of an Admission Minimum Data Set Assessment revealed the resident's Brief Interview for Mental Status score was 3 of 15, indicating severe cognitive impairment. Record review of the resident's current care plan dated 2/29/2024 revealed .a decline in ADLS [Activities of Daily Living] and mobility . with interventions including, but not limited to; .I need assist with toileting . Further review of the care plan revealed, .incontinent of bladder and need assistance with toileting . with interventions including, but not limited to, .Offer toileting routinely on rounds .Provide routine incontinent care on rounds . During a surveyor observation of the resident on 3/5/2024 from 9:35 AM through 2:20 PM (approximately 5 hours) revealed the resident sitting in his/her wheelchair either in the dining room or in the activity room. During this observation period, toileting or incontinence care was not provided to the resident. An additional observation of the resident on 3/6/2024 from 11:01 AM through 2:45 PM (approximately 3 and 1/2 hours) revealed the resident sitting in his/her wheelchair either in the dining room, hallway or activity room. During this observation period, toileting or incontinence care was not provided to the resident. During a surveyor interview with the Unit Manager, Registered Nurse, Staff A, on 3/6/2024 at 2:20 PM, she revealed that the facility does not have a policy or procedure relative to toileting or providing incontinence care. Staff A further revealed that staff are expected to toilet the residents frequently, at least twice per shift, before lunch and after lunch. During a surveyor interview with the Director of Nursing Services on 3/6/2024 at 3:02 PM, she revealed that the facility does not have a policy or procedure relative to toileting or providing incontinence care. Additionally, she indicated that staff should provide incontinence care to residents at least every 2 hours.

Based on record review and staff interview, it has been determined that the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of the clinical reference ranges in a timely manner for 1 of 2 residents reviewed relative to labratory services, Resident ID #89. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2019 with a diagnosis including, but not limited to, Alzheimer's disease. Record review of a progress note dated 2/28/2024 revealed the resident was noted to have an increased body temperature of 99.8 degrees Fahrenheit (a potential symptom of an infection). Record review revealed a urine sample was obtained for a culture and sensitivity test on 2/29/2024. Review of the Lab Results Report dated 3/2/2024 revealed the results of the urine culture and sensitivity indicated that the resident was positive for a urinary tract infection (UTI) and was Reported to the facility on [DATE] at 12:17 PM. Record review revealed the results of the urine culture and sensitivity were not reviewed by staff until 3/3/2024 at 11:17 PM, approximately 35 hours after the results were Reported to the facility. Additional record review revealed a physician was notified of the above results and a new order was obtained on 3/4/2024 at 12:17 AM for Levofloxacin (antibiotic) oral tablet 250 milligrams, administer once a day for 3 days. During a surveyor interview with a Certified Medication Technician, Staff B, on 3/4/2024 at 2:27 PM, she revealed that she administered the first dose of the above mentioned medication to the resident that morning at 10:20 AM (almost 2 days after the results of the urine culture and sensitivity were Reported). During a surveyor interview via telephone with the Lab Client Services Supervisor, on 3/6/2024 at 1:49 PM, she revealed the results of the urine culture and sensitivity were finalized on 3/2/2024 and the results were reported via electronic medical record to the facility on [DATE] at 12:17 PM. During a surveyor interview with the Unit Manager, Registered Nurse, Staff A, on 3/6/2024 at 2:18 PM, she revealed that staff are expected to review the lab results at least every shift and report the results to the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist in a timely manner. During a surveyor interview with the Director of Nursing Services on 3/6/2024 at 3:01 PM, she revealed that the facility does not have a policy for reporting lab results to the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist. She further revealed she would expect that staff review resident's lab results at least every shift and report the results to the ordering physician within 2 hours.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive and consume fluids in the appropriate form for 1 of 1 resident observed with a dietary order for nectar thickened fluids, Resident ID #67. Findings are as follows: Review of a document titled, Thickening Liquids Information Sheet, revealed in part, .Nectar-thick but pourable like syrup, consistency of a milk shake, or V-8 juice .Mixing Starch-based Thickeners .Thick & Easy .1. Determine the number of ounces of the liquid that needs thickening and how much thickener you need to add, which is located on the can .Some liquids might need a little bit more or less of thickener to reach the desired consistency so check it before drinking or serving . Review of the resident's record revealed s/he was admitted to the facility in April of 2023 with diagnoses including but not limited to, dementia and dysphagia (difficulty swallowing). Review of a physician's order dated 2/22/2024 revealed s/he is to be provided with nectar thick consistency fluids and no straws as s/he is on aspiration precautions (practices to prevent food or fluids from getting into the airway). Review of the care plan, revised on 2/22/2024, revealed that s/he is to be provided with nectar thick fluids as ordered, is on aspiration precautions, and was treated for pneumonia on 2/15/2024. During a surveyor observation of the resident in his/her room on 3/4/2024 at 2:06 PM, revealed that s/he was sitting in the bedside chair wearing a nasal cannula (a device used to deliver supplemental oxygen), with his/her mouth open and breathing rapidly. S/he indicated to this surveyor that s/he just returned from the dining room and was tired. This surveyor instructed him/her to press the call light and Nursing Assistant, (NA), Staff C, entered the room. As this surveyor was interviewing NA Staff C, NA, Staff D, entered the room and handed Staff C a clear plastic cup with a lid and a straw that contained fluid. Staff C then handed this cup to the resident to drink. Licensed Practical Nurse (LPN), Staff E, then entered the room and when asked by the surveyor about the fluids the resident was drinking in the cup she indicated that the resident cannot have straws and that the fluid in the cup was not thickened to the appropriate nectar thick consistency. Additionally, she indicated that her expectation would be that the resident's dietary order would be followed. During a surveyor interview on 3/4/2024 at 2:20 PM with Staff D, it was indicated that she used Thick & Easy thickener to prepare the drink for the resident. Additionally, she acknowledged that she did not add the appropriate amount of thickener for nectar thick consistency as ordered. Additionally, she acknowledged a straw was provided with the drink. During a surveyor interview on 3/6/2024 at 3:25 PM with the Director of Nursing Services, she was unable to provide evidence that the physician's order was followed regarding nectar thick fluids and no straws.

Based on record review and staff interview, it has been determined that the facility failed to provide required in-service training, including dementia management training for 4 of 7 staff members reviewed, Staff D, J, K, and L. Findings are as follows: Review of the employees' annual in-service education on 3/6/2024 at approximately 10:00 AM with the Director of Nursing Services (DNS) and the Education and Employee Health, Registered Nurse, failed to reveal evidence that Staff D, J, K, and L, had annual required dementia management training. During an interview with the DNS immediately following the above review, she indicated that she would expect the required dementia management in-service training to have been completed annually.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order specific to as needed (PRN) medication for agitation for 1 of 6 residents reviewed, Resident ID #1. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #1 was admitted to the facility in November of 2023, with diagnoses including, but not limited to, neurocognitive disorder with behaviors (behavioral and psychosocial symptoms of dementia that can include aggressive behavior), psychotic disturbance (mental disorder characterized by a disconnection from reality), and anxiety. Review of a care plan dated 12/8/2023, states in part, .resident has the potential to be physically aggressive towards elders. Interventions include, but are not limited to, administer medications as ordered . monitor/document for side effects and effectiveness .report PRN any signs or symptoms of resident posing danger to self and others. Review of physician orders dated 11/20/2023 and 12/13/2023 revealed Trazodone 50 mg [milligrams] to be administered PRN for agitation for 14 days. Record review of a progress note dated 12/7/2023 at 2:15 PM, states in part, .resident was walking into activity room when a fell ow peer walked pass and resident struck fell ow peer in the left shoulder and grabbed onto fell ow peer's sweater. Additional review of a progress note written on the same date at 4:04 PM states in part, .resident exhibited increased agitation/anxiety this afternoon .resident observed pacing in dining room and hallway .expressing him/herself in an aggressive way and shaking hands with agitation . Review of a progress note at 11:15 PM on this date states in part, .resident combative with evening care hitting CNA. Additional review of progress notes revealed the following: -12/13/2023 at 11:48 AM, .resident combative with care .writer attempted to redirect with no effect and increased agitation noted with redirection .care ongoing, will continue to monitor. -12/13/2023 at 3:12 PM, .staff report resident was combative with care .increased agitation noted when staff encouraged resident to utilize walker .redirection and comfort provided with no effect. -12/13/2023 at 5:52 PM, .NP [Nurse Practioner] gave order to extent [SIC] PRN Trazodone once daily for agitation with additional 14 days. -12/18/2023 at 5:25 PM, authored by MD (Medical Doctor) which states in part, .neurocognitive disorder with behavioral disturbances .continue Trazodone 25 mg as needed. -12/26/2023 at 2:10 PM, .resident observed with increased agitation .verbal redirection provided with fair effect. -1/5/2024 at 2:46 PM, .elder was sitting in chair in the activity room with another elder sitting in front of [him/her] .no precipitating factors were noted prior to [name redacted] striking other elder .presents with increased agitation at this time. Record review failed to reveal evidence that the PRN Trazodone was administered to the resident for agitation as ordered following attempts at redirection with no effect. Additional record review revealed Resident ID #1 was involved in 2 separate resident-to-resident abuse incidents on 12/7/2023 and on 1/5/2024, both of which were unprovoked and involved him/her exhibiting physical aggression towards other residents. Review of the following incidents reported to the Rhode Island Department of Health by the facility states as follows: -12/7/2023, states in part, .as the elders passed each other in the hallway [name redacted] reached out and hit [name redacted] in the back/shoulder area and grabbed elder's sweater. Review of the facility's 5-Day Investigation report specific to facility system changes made to decrease the risk of similar incidents from occurring states in part, .[name redacted] resident seen by psych and med changes were made .will continue to be followed by psych. -1/5/2024, states in part, .[name redacted] resident was sitting in the activity room and [name redacted] resident was sitting in front of [him/her] .resident struck other resident in the back multiple times in an aggressive manner .incident appeared unprovoked. Review of the facility's 5-Day Investigation report specific to facility system changes made to decrease the risk of similar incidents from occurring states in part, .both elders suffer from dementia and are followed by psych services. During a surveyor interview on 1/22/2024 at approximately 2:27 PM with the Director of Nursing Services (DNS), she acknowledged that the resident exhibits agitation and anxiety and is followed by psych services. The DNS also acknowledged that the PRN order for Trazodone was not administered as indicated in the order for agitation. Additionally, the DNS revealed that she instructs staff to first try with redirection during a resident's bout of agitation, restlessness, and/or anxiety, however, when unsuccessful she indicated that her expectation is that staff would administer the PRN medication and document the effects.

Based on record review and staff interview, it has been determined that the facility failed to ensure a physician reviewed the resident's total program of care, including medications and treatments, at each visit, for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, kidney failure, insomnia, depressive disorder and anxiety. Record review revealed s/he was admitted to the facility with impaired skin to his/her buttocks and a scab to the left heel. Record review revealed the following physician's orders with a start date 8/25/2023: - Apply skin prep and off-load heels in bed. Every shift for Blanchable redness to the left heel (boggy) - Clean with normal saline and apply Triad to buttocks every day and evening shift for excoriated area until resolved. Further record review revealed a progress note dated 9/29/2023 at 11:24 PM, indicating the assigned Nursing Assistant (NA) found an odorous rash to the resident's left abdomen skin fold. The note states in part, .noted wide range of skin rash to the area .received order for Nystatin [prescription antifungal medication] powder bid [twice a day] for 14 days by on call [physician-name redacted] . Record review revealed the following physician's orders were in place without a stop date: - 8/24/2023, Trazodone 50 milligrams (MG) tablet, give one tablet by mouth as needed for insomnia at bedtime. - 9/27/2023, Trazodone 25 MG by mouth as needed for anxiety, give prior to therapy. Further record review of the physician's progress notes for Resident ID #1 failed to reveal evidence of a review of the resident's total program of care at the time of the required visits which included Trazodone PRN ordered without a stop date (Refer to F758) or treatments relative to his/her skin condition (Refer to F684). During a surveyor telephone interview on 12/4/2023 at 4:20 PM, with the resident's physician she indicated that she was not aware of the resident's skin condition and indicated she would have expected staff to make her aware. Additionally, she acknowledged she did not document a review of the resident's total program of care at the required visits.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 1 resident reviewed with an order for psychotropic medication ordered as needed (PRN) without a stop date, Resident ID #1. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .PRN orders for psychotropic drugs are limited to 14 days. Except .if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order . Record review revealed Resident ID #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, kidney failure and insomnia. Record review revealed an unsigned pharmacy recommendation document dated 9/20/2023 which states in part, .REPEATED RECOMMENDATION from 8/25/2023 .[Resident ID #1] has a PRN order for a sedative/hypnotic, without a stop date: Trazodone for insomnia .This order has been in place for more than 14 days which exceeds the maximum allowed per federal regulations . Record review revealed the following physician's orders without a stop date: - 8/24/2023, Trazodone 50 milligrams (MG) tablet, give one tablet by mouth as needed for insomnia at bedtime. - 9/27/2023, Trazodone 25 MG by mouth as needed for anxiety, give prior to therapy. Record review of the September and October 2023 Medication Administration Records (MAR) revealed the Trazadone was administered on the following dates, which was 19 doses after the medication was in place for greater than 14 days: - 9/8, 9/9, 9/10, 9/11, 9/12, 9/13, 9/14, 9/15, 9/16, 9/17, 9/19, 9/20, 9/22, 9/23, 9/28, 9/27, 9/28, 9/29 - 10/1 Further record review failed to reveal evidence of documentation from the physician indicating that the PRN Trazodone order should be extended beyond 14 days, or a rationale indicating the duration. During a surveyor interview on 12/4/2023 at 11:47 AM, with the Director of Nursing Services, she acknowledged the Trazodone PRN order was in place for Resident ID #1 since admission, without a stop date and indicated it should have had a stop date. Additionally, she was unable to provide evidence of documentation from the physician indicating the order should be extended or a rationale indicating the duration. During a surveyor interview on 12/4/2023 at 4:20 PM, with the physician, she indicated that she reviews PRN psychotropic medications on the 14-day mark with the nurse and extends the order if the resident needs it. Additionally, she indicated that she would give an order to extend the medication for another 14 days and then review and document in the resident's record. Furthermore, she acknowledged that Resident ID #1's record lacked documentation from her indicating that the medication should be extended beyond 14 days or a rationale indicating the duration.

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 2 of 2 residents reviewed for skin conditions, Resident ID #'s 1 and 3. Additionally, for 1 of 1 residents reviewed with orders for a consultation with an outside specialist relative to the diagnosis of kidney failure, Resident ID #1. Findings are as follows: A. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/30/2023 alleges Resident ID #1, was transferred from the nursing facility to an acute care hospital on 10/2/2023. Upon admission to the hospital, s/he was noted with a significant skin infection to his/her abdominal skin, groin, and a pressure ulcer to his/her buttocks. Additionally, the report states in part, .The [resident's family member] revealed that during the hospital admission, staff was assessing the rash and [the resident] stated that [s/he] felt as [s/he] has been 'shot down there.' . During a surveyor interview with the resident's family member on 12/1/2023 at 10:07 AM, revealed the following. The family member was informed by a hospital nurse that their loved one was, destroyed in the area of his/her chest, abdomen, groin, inner thighs, and sexual organ. The family member indicated the facility informed him/her of a quarter size fungal rash to [his/her] abdomen and that is all. [His/her sexual organ] looked like purple hamburger meat. The family member further indicated that a hospital physician told him/her that the resident was complaining of discomfort in the areas of his/her skin conditions and indicated that resident said s/he had been shot at the nursing home. Record review of a hospital document dated 10/3/2023 at 12:54 PM, titled, Admission note, revealed the following in part, .Skin thin and fragile. Bottom with stage 1 [ a pressure ulcer characterized by non-blanchable redness] on L [left] buttock. Very excoriated [abraded skin damage] and reddened coccyx [tailbone], blanchable. Surrounding coccyx tissue purple, looks like old healing wound .patient noted to have significant excoriation to abdominal pannus [excess lower belly skin], as well as inner thighs and [sexual organ]. L inner thigh with significant fungal looking rash. [sexual organ] with excoriation and bleeding, patient very tearful upon cleaning . Record review of a facility policy titled, Pressure Injury, Wound and Skin Care Protocols, revised January 2019, revealed in part, .Provide a systemic approach and monitoring process for skin integrity and chronic wound care .To promote healing of chronic wounds in a .timely manner .On-going documentation by nurses in the medical record to describe the effectiveness of interventions and resident's response to therapy .The facility will address the resident's concerns and offer relevant alternatives, if the resident has refused specific treatments . Record review revealed Resident ID #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, obesity, diabetes, kidney failure, and congestive heart failure. Record review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Additionally, s/he required the physical assistance of one staff member for transferring, moving side to side while in bed, personal hygiene, and toilet use. Furthermore, s/he was documented as being incontinent of bowel and bladder and at risk for pressure ulcers or injuries. Record review of a care plan initiated on 8/31/2023 revealed a focus area indicating the potential or actual impaired skin integrity of the buttocks. Interventions included, but are not limited to, .follow facility protocols for treatment or injury .Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate [drainage] and any other notable changes or observations . Record review of the facility admission skin integrity document completed 8/24/2023, revealed the following in part, .Wide range of excoriation to the bilateral buttocks .Scab on left heel; boggy-blanchable [abnormal texture of skin characterized by sponginess; red when it blanches, turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed] . Additional record review revealed of a progress note dated 8/24/2023 at 10:58 PM, which states in part, .excoriated lesion on peri anal area . Record review revealed the following physician's orders: - 8/25/2023, Clean with normal saline and apply Triad [protective cream used for open wounds] to buttocks every day and evening shift for excoriated area until resolved - 8/25/2023, Apply skin prep & off-loaded heels in bed. every shift for Blanchable redness to the left heel (boggy) . - 9/11/2023, Weekly skin evaluation by nurse. PLEASE DOCUMENT IN PROGRESS NOTES UNDER 'SKIN EVALUATION .' every day shift every Mon [Monday] for Weekly Skin Check . Record review failed to reveal an order for the excoriated areas to his/her peri area. Further record review revealed the following entries for the weekly skin evaluations: - 8/28/2023 12:09 AM, .Known excoriated area to buttocks .Discomfort to buttocks improving according to resident . This skin evaluation failed to reveal evidence of an assessment of his/her left heel or the excoriated peri/anal region. - 9/3/2023 4:48 PM, .Known redness to sacral coccygeal [lower spine] area. small scabbed area to left heel . This evaluation failed to reveal evidence of an assessment of the peri/anal region. - 9/11/2023 11:26 AM, .Weekly skin check, PT [patient] continues with redness to buttocks . This skin evaluation failed to reveal evidence of an assessment of his/her left heel or the excoriated peri/anal region. - 9/18/2023 11:42 AM, .No new skin issues noted . This skin evaluation fails to reveal evidence of an assessment of his/her left heel or the excoriated peri/anal region. - 9/25/2023 10:19 AM, .weekly skin check, PT [patient] continues with red bottom . skin evaluation fails to reveal evidence of an assessment of his/her left heel or the excoriated peri/anal region. Additional record review revealed the 10/2/2023 skin evaluation was documented as not administered and indicated to see the nurses progress note. Furthermore, the skin evaluation note dated 10/2/2023 at 3:48 PM, failed to reveal evidence of documentation of the weekly skin evaluation per the order. Record review failed to reveal evidence of measurements of the left heel scab after 8/24/2023 or evidence that this wound was healed. Additionally, the record failed to reveal evidence that the resident's left heel scab was assessed weekly or evidence of the effectiveness of the interventions and the resident's response to the treatment per the facility policy. Record review revealed a progress note dated 9/29/2023 at 11:24 PM, indicating the assigned Nursing Assistant (NA) found an odorous rash to the resident's left abdomen skin fold. The note states in part, .noted wide range of skin rash to the area .received order for Nystatin [prescription antifungal medication] powder bid [twice a day] for 14 days by on call [physician-name redacted] . Further record review revealed the resident was transferred to an acute care hospital on the evening of 10/2/2023. Additionally, the facility transfer form that was sent to the hospital with the resident, dated 10/2/2023 at 6:38 PM under SECTION D. 2. Skin/Wound Care, failed to reveal evidence of documentation relative to the resident's skin conditions or treatments. A surveyor telephone interview with the Registered Nurse, Staff A, who authored the admission skin integrity document, and progress notes dated 8/24 and 9/29/2023, was attempted and unsuccessful on 12/1/2023 at 3:11 PM and 12/4/2023 at 9:04 AM. During a surveyor interview on 12/1/2023 at 3:22 PM, with Registered Nurse, Staff B, she acknowledged that she was the resident's assigned nurse on 10/2/2023 during the 7:00 AM - 3:00 PM shift and revealed that the resident was not transferred to the hospital on her shift but at some time during the 3:00 PM - 11:00 PM shift. Additionally, she was unable to provide evidence that she completed the resident's weekly skin evaluation on 10/2/2023 and indicated she could not recall the condition of the resident's skin. B. Record review of a nursing progress note dated 9/20/2023 at 3:54 PM, revealed that the physician gave orders for the resident to have a consultation with his/her nephrologist [physician who specializes in conditions of the kidneys]. Further record review failed to reveal evidence that an appointment was scheduled. During a surveyor observation and interview on 12/4/2023 at 8:52 AM, with the scheduler, Staff C, she revealed that she schedules medical appointments for the residents. She was unable to provide evidence that a nephrology appointment was scheduled or attempted to be scheduled for Resident ID #1. During a surveyor interview on 12/4/2023 at 11:20 AM, with the Director of Nursing Services (DNS), she was unable to provide evidence that that an appointment was scheduled or attempted to be scheduled with the nephrologist per the physician's order on 9/20/2023. During a surveyor interview on 12/5/2023 at 10:09 AM, with the resident's physician, she acknowledged that she gave an order on 9/20/2023 for the resident to be seen by his/her nephrologist and cardiologist. Additionally, she indicated that despite it being difficult to schedule outside appointments for nursing home residents, she would expect there to be evidence in the resident's medical record that an attempt was made to schedule an appointment with the nephrologist per the physician's order. C. Record review revealed Resident ID #3 was admitted to the facility October 2019, with diagnoses including, but not limited to, Alzheimer's disease and stroke. Record review of a MDS assessment dated [DATE] revealed s/he has one unhealed stage 2 pressure ulcer (a wound caused by pressure that may appear like a cut or blister). Record review revealed the following physician's orders: - 10/26/2023, Cleanse L [left] heel with NS [normal saline], apply medi-honey [medical honey, a gel used to treat wounds] f/b [followed by] allevyn [dressing] every other day until strongly healed .for wound care . Record review of the documents titled, SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY, revealed the following entries: - 11/16/2023, The document revealed the resident was seen for an assessment of his/her left heel stage 2 wound. The note states in part, .FOLLOW-UP Evaluation by wound care specialist within 7 Day (s) with further intervention as indicated . - 11/22/2023, .The patient's visit has been rescheduled . - 11/30/2023, .The patient's visit has been rescheduled . Record review of a nursing progress note dated 11/22/2023 at 10:58 AM, revealed the resident's left heel wound was assessed. The note indicates the wound measurements were documented and that the wound specialist will follow him/her every other week. Additional record review failed to reveal evidence that wound measurements were documented after 11/22/2023 or evidence of documentation of the left heel wound which would include a description of the wound bed, any drainage, and measurements after 11/22/2023. Further record review of a skin evaluation progress note dated 11/30/2023 at 9:54 PM, failed to reveal evidence of documentation of the left heel stage 2 pressure ulcer. During a surveyor interview on 12/4/2023 at 11:13 AM, with Licensed Practical Nurse, Staff D, she revealed that Resident ID #3 had a wound to his/her left heel with an active treatment order in place. During a surveyor interview on 12/4/2023 at 1:22 PM with the DNS and the Administrator, they were unable to provide evidence that Resident ID #'s 1 and 3 received treatment and care in accordance with professional standards of practice.

Based on record review, staff and resident representative interview, it has been determined that the facility has failed to ensure that residents are free of significant medication errors for 1 of 7 resident's reviewed, Resident ID #1. Findings are as follows: Review of the 2021 policy, titled, Omnicare Guidance for Using Insulin Products, states in part, .Administration Techniques .Before each injection, the resident's name, medication order .should be verified to avoid injecting the wrong type or amount of insulin . Review of a 2/25/2022 document titled, Department of Health, Center for Health Facilities Regulations Nursing Facility Required Reporting, states in part, .Date of incident: 2/24/22 .Medication error by [Staff Nurse A] administering the wrong dose of insulin to patient . Review of the record for this resident revealed that s/he was admitted to the facility in February of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review a February 2022 document titled, Order Recap Report, revealed in part the following 2/23/2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] & Regular [short-acting and starts to work within 30 minutes after injection, peaks in 2 to 3 hours, and keeps working for up to 8 hours] Inject 8 unit subcutaneously [applied under the skin] one time a day . Review of the February 2022 notes revealed the following: - 2/24/2022 at 6:36 PM, .Resident received 100 units of insulin .Sent via rescue to [Hospital] per family request. - 2/24/2022 at 11:21 PM, .Family in attendance at time of incident . During an interview with the resident's daughter on 2/28/2022 at approximately 12:00 PM, she stated while she and the resident's granddaughter were visiting with the resident Staff Nurse A was observed administering the insulin. When questioned by the family as to the amount of insulin administered the nurse replied 100 units were given. During an interview with Staff A on 2/28/2022 at 10:54 AM, she acknowledged administering 100 units of insulin to the resident in error. Review of the 2/25/2022 Continuity of Care hospital documentation revealed in part, .Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Accidental medication error .According to nursing home records, this evening at 5:45 PM, [s/he] was given 100u of NPH 70/30 instead of [his/her] usual 8u .has a BG [blood glucose] monitor .Orders: Dextrose 10% in Water [IV (administered into a vein) solution used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Director of Nursing on 2/28/2022 at approximately 12:00 PM, it was indicated her expectation is that the nurse would implement the 5 rights of medication administration [the right patient, the right drug, the right time, the right dose, and the right route] and verify the amount of insulin ordered prior to administering the medication.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition for 1 of 2 sample residents with significant weight loss (ID #135). Findings are as follows: The facility's policy titled Recording Dietary Intake states in part dietary intake will be recorded and monitored under the following circumstances for a two week period: loss of three lbs. (pounds) if weight is under 100 lbs. or five lbs. if weight is over 100 lbs. and weight loss was not intended Keep a clip board in the Dining Room with sheets to record intake percentage during this time. All interventions put on Care Plan. Record review revealed resident ID #135 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's record revealed a weight of 106.4 lbs. (pounds) on 6/5/2018, a weight of 98.6 lbs. on 7/26/2018. This indicates a 7.33% significant weight loss in 52 days. On 8/8/2018 an additional weight was recorded as 94.0 lbs. Record review revealed a significant change Minimum Data Set ((MDS) dated [DATE] that indicates that the resident had a weight loss of 5% or greater in the last month or 10% or greater in the last 6 months. Further record review revealed a care plan stating, Monitor intake and record. Record review revealed no evidence that the resident's intake was monitored and recorded per the care plan or facility policy. Review of the dietary progress notes on 7/16/2018 states Offer alternatives and shakes as needed for increased intake. Further record review failed to reveal evidence that shakes were ever ordered per the dietitian's recommendation. Record review revealed an additional dietary note on 7/26/2018 indicating that a weight was obtained on 7/25 and dietitian will continue to follow. There was no evidence of any interventions put into place on 7/26/2018, after significant weight loss was determined. During a surveyor interview with Staff Nurse K on 8/9/2018 at 2:30 PM, she could not provide evidence that any interventions were put into place for the weight loss, including shakes per the dietitian's recommendations. During a surveyor phone interview with the Registered Dietitian on 08/10/2018 at 11:00 AM, she acknowledged the resident had weight loss, but she could not provide evidence that any interventions were put into place for the weight loss. She also acknowledged that the facility's policy was not followed regarding recording dietary intake.