Every finding on record at Silver Creek Rehab and Healthcare Center

Based on surveyor observations, clinical record review, and staff interview, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 central (medication) supply closet and 2 of 3 medication carts reviewed. Findings are as follows:Record review of the facility policy titled, Medication Storage states in part, .Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations.Outdated, contaminated, discontinued or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medical disposal. 1. A surveyor observation on [DATE] at approximately 8:55 AM, of the first-floor central supply area in the presence of Licensed Practical Nurse (LPN), Staff H, revealed the following:-One unopened box of Prosource Tube Feeding (TF) Liquid neutral flavor with 100 pieces of 1.5 fluid ounce container labeled with the manufacturer's expiration date of [DATE].-One opened box of Prosource Tube Feeding (TF) Liquid neutral flavor with 100 pieces of 1.5 fluid ounce container labeled with the manufacturer's expiration date of [DATE].-Three bottles of Pink Bismuth 8 fluid ounce with expiration dates of 11/2025.-Two bottles of Gerimox Regular strength 12 ounce, with expiration dates of 6/2025.During a surveyor interview following the observation with Staff H, she acknowledged that the above-mentioned items were expired and should have been discarded.2. During a surveyor observation on [DATE] at 9:30 AM, of the East and South Unit medication carts in the presence of LPN, Staff I, revealed the one bottle of Nitroglycerin (a medication prescribed to treat chest pain) 0.4 milligrams tablets prescribed for Resident ID #100, with an expiration date of [DATE].During a surveyor interview immediately following the above observation with Staff I, she acknowledged the medication should be discarded.3. During a surveyor observation on [DATE] at 9:55 AM, in the presence of Certified Medication Technician (CMT), Staff J, of the lower-level medication cart, revealed one bottle of Gerilanta 12 fluid ounces with an expiration date of 11/2025.During a surveyor interview on [DATE] at 1:21 PM with the Director of Nursing Services, she revealed it would be her expectation that the above-mentioned items would have been removed from central supply and medication carts upon expiration.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that services provided meet professional standards of quality relative to following physician's orders for 1 of 1 resident who has an order for simvastatin (a medication prescribed to treat high cholesterol), Resident ID #45, for 1 of 2 residents recently admitted that were reviewed for weekly weights, Resident ID #14, and for 1 of 3 residents observed receiving a skin treatment, Resident ID #27.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.1. Record review revealed Resident ID #45 was re-admitted to the facility in August of 2025 with a diagnosis including, but not limited to, hyperlipidemia (a condition characterized by an abnormally high level of fats, such as cholesterol and triglycerides, in the blood).Record review revealed a physician's order dated 8/11/2025 for simvastatin, 10 milligrams every night at bedtime, for cholesterol control. Further record review revealed that the simvastatin was discontinued on 9/24/2025.Record review failed to reveal evidence of a provider order or a rational for discontinuing the simvastatin.Record review of the September 2025 Medication Administration Record (MAR) revealed that the simvastatin order was signed off as administered daily, until 9/23/2025. Further review of the October, November, December 2025 and January 2026 MARs, failed to reveal evidence of an order for simvastatin. During a surveyor interview on 1/23/2026 at 11:29 AM and at 12:28 PM with Registered Nurse, Staff C, she was unable to provide evidence why the resident's simvastatin was discontinued, she was also unable to provide evidence that a lipid panel (a laboratory test that measures the levels of cholesterol in the blood) was obtained. Additionally, after Staff C was informed by the surveyor that the resident's simvastatin was discontinued in September, she revealed that she notified the resident's physician and he ordered a lipid panel to be obtained.During a surveyor interview on 1/23/2026 at 1:25 PM with the Director of Nursing Services (DNS), she revealed that the simvastatin had been discontinued in error, and that the resident's physician has now ordered a lipid panel to be obtained to test the resident's cholesterol level.2. Record review revealed Resident ID #14 was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, abnormalities of gait and mobility.Record review revealed a nursing progress note dated 1/6/2026 indicating that the resident had experienced an unfavorable weight gain of 10 pounds (lbs.) in one month. After reporting the weight gain to the provider, the provider ordered the resident's weight to be obtained weekly, for 4 weeks.Record review revealed a physician's order dated 1/5/2026, incorrectly transcribed for Weekly weights every 4 weeks [monthly] on Monday for 4 weeks, and to notify the physician if there is a weight loss/gain of 3 lbs. in one day or 5 lbs. in 1 week.Record review of the weight documentation failed to reveal evidence that the resident's weights were obtained weekly, as ordered.During a surveyor interview on 1/22/2026 at 3:38 PM with the DNS, she acknowledged that weekly weights were not obtained, and she would have expected that the resident would be weighed weekly, as ordered. 3. Record review revealed Resident ID #27 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, erythema intertrigo (an inflammatory skin condition characterized by red, inflamed skin to the skin folds. It is caused by friction, moisture, and heat, creating an environment conducive to bacterial and fungal growth).Record review revealed a physician's order dated 1/9/2026 to cleanse the right and left buttocks with normal saline (a mixture of a water and salt solution), followed by triple antibiotic ointment (a topical ointment containing three antibiotics), and a dry sterile dressing.During a surveyor observation on 1/23/2026 at approximately 10:45 AM with Registered Nurse, Staff A, revealed that Staff A applied Triad cream (a topical cream prescribed to treat various skin conditions) to the resident's buttocks rash instead of the ordered triple antibiotic ointment.During a surveyor interview on 1/23/2026 at 12:28 PM with Staff A, she acknowledged that she had applied the Triad cream to the resident's buttocks, instead of the ordered triple antibiotic ointment. During a surveyor interview on 1/23/2026 at 12:59 PM with the DNS, she acknowledged that the resident did not have a treatment order for Triad cream, and she would have expected that the resident receive the triple antibiotic ointment, as ordered.

Based on record review and staff interview, the facility failed to obtain written authorization of residents who choose to deposit personal funds with the facility relative to 4 of 7 residents reviewed, Resident ID #s 2, 6, 77, and 111.Findings are as follows: 1. Record review revealed Resident ID #2 was admitted to the facility in April of 2022. Further review revealed his/her personal funds are held by the facility with a balance of $425.17.Further record review failed to reveal evidence that a written authorization was obtained from the resident or his/her representative to hold his/her funds. 2. Record review revealed Resident ID #6 was admitted to the facility in December of 2022. Further review revealed his/her personal funds are held by the facility with a balance of $603.75.Further record review failed to reveal evidence of a completed authorization form including the date, resident's name, Medicaid number, and a witness signature. 3. Record review revealed Resident ID #77 was admitted to the facility in April of 2023. Further review revealed his/her personal funds were held by the facility with a balance of $2265.68.Further record review failed to reveal evidence that a written authorization was obtained from the resident or his/her representative to hold his/her funds. 4. Record review revealed Resident ID #111 was admitted to the facility in April of 2017. Further review revealed his/her personal funds were held by the facility with a balance of $2607.32.Further record review failed to reveal evidence that a written authorization was obtained from the resident or his/her representative to hold his/her funds.During a surveyor interview on 1/22/2026 at 10:45 AM with the Business Office Manager, he was unable to provide evidence that written authorization forms were completed in their entirety for the above-mentioned residents whose personal funds are held by the facility.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive laboratory services relative to diagnostic testing, for 1 of 1 resident reviewed with a physician's order for clozapine (an antipsychotic medication) level (a laboratory test that measures the amount of medication in the blood to ensure that the medication is at a therapeutic range), Resident ID #27.Findings are as follows:Record review revealed Resident ID #27 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, schizophrenia (a serious mental health condition that affects how people think, feel and behave).Record review revealed the following physician's orders:-4/30/2025 for clozapine 75 milligrams (mg) daily.-12/12/2025 obtain a clozapine level.Record review of the December 2025 Treatment Administration Record revealed that the clozapine level was signed of as completed 12/12/2025.Record review of a lab slip dated 12/12/2025 indicates additional testing: clozapine level.Record review of a Lab Results Report dated 12/12/2025, revealed that a clonazepam blood level (a medication prescribed to treat anxiety) was obtained for the patient instead of a clozapine level, as ordered.During a surveyor interview on 1/21/2026 at 2:47 PM and 1/22/2026 at approximately 8:30 AM, with the Director of Nursing Services, she acknowledged that the laboratory completed a clonazepam level and not a clozapine level as ordered.During a surveyor interview on 1/23/2026 at 9:37 AM with the Nurse Practitioner, Staff K, she indicated it would be her expectation for the clozapine level to have been obtained as ordered on 12/12/2025.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that a resident with limited range of motion receives the appropriate treatment to prevent further decrease in range of motion for 1 of 2 residents reviewed who utilizes a hand roll (an assistive device that helps maintain or prevent decline in mobility), Resident ID #54.Findings are as follows:Record review revealed the resident was admitted to the facility in October of 2020 with a diagnosis including, but not limited to, generalized muscle weakness.Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed the resident has an impairment to both upper extremities.Record review revealed a physician's order revised on 10/31/2025 to apply a left-hand roll daily.Surveyor observations failed to reveal evidence that the hand roll was applied, as ordered, on the following dates and times:- 1/20/2026 at 10:21 AM and 12:25 PM- 1/21/2026 at 9:05 AM- 1/22/2026 at 8:55 AM and at approximately 3:00 PMDuring a surveyor interview on 1/22/2026 at 3:16 PM with Registered Nurse, Staff A, who was assigned to the resident, she revealed that she was unaware that the resident has a physician's order for a hand roll to be applied daily. Additionally, she acknowledged that the hand roll order was not transcribed to the Treatment Administration Record (TAR) to be applied to the resident.During a surveyor observation and simultaneous interview on 1/23/2026 at 10:00 AM with Nursing Assistant, Staff D, she applied the resident's hand roll, and the resident demonstrated tolerance and maintained the device in place following the application.During a surveyor interview on 1/23/2026 at 12:33 PM with the Director of Nursing Services, she acknowledged that the hand roll order was not transcribed to the TAR. Additionally, she revealed that she would expect the hand roll order to be transcribed in the TAR for staff to document the application of the hand roll daily, as ordered.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote and maintain skin integrity for 1 of 1 resident reviewed, relative to a fungal rash, Resident ID #27.Findings are as follows:Record review revealed Resident ID #27 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, erythema intertrigo (a common inflammatory skin condition characterized by red, inflamed skin to the skin folds. It is caused by friction, moisture, and heat, creating an environment conducive to bacterial and fungal growth).Record review of the Wound Care Nurse Practitioner's progress note dated 1/15/2026, revealed a recommendation to cleanse the area with wound cleanser followed by nystatin (an antifungal) cream, twice daily to the resident's right buttocks fungal rash.Record review of a progress note dated 1/15/2026 authored by the Registered Nurse, Staff L, revealed the resident was seen during wound rounds with an assessment of a raised, circular diffuse area to the resident's right buttocks consistent with a fungal rash.Record review failed to reveal evidence that the Wound Care Nurse Practitioner's recommendation for nystatin cream was implemented.During a surveyor interview on 1/23/2026 at 11:30 AM with the resident's attending physician, Staff G, he indicated that he would have expected staff to implement the Wound Care Nurse Practitioner's recommendations for the nystatin cream.During a surveyor interview on 1/23/2026 at 12:59 PM with the Director of Nursing Services, she was unable to provide evidence that the nystatin cream recommended by the Wound Care Nurse Practitioner was implemented.

Based on surveyor observation, clinical record review, and resident and staff interview, the facility failed to ensure the assessments accurately reflect the resident's status for 2 of 4 residents reviewed with dental concerns, Resident ID #s 6 and 9, and for 1 of 1 resident reviewed who is prescribed clozapine (an antipsychotic medication), Resident ID #27.Findings are as follows: 1a. Record review revealed Resident ID #6 was readmitted to the facility in January of 2025 with diagnoses including, but not limited to, type 2 diabetes mellitus, dysphagia (difficulty swallowing), and the need for assistance with personal care.During a surveyor interview and simultaneous observation with the resident on 1/21/2026 at 11:26 AM, s/he indicated that s/he has dental concerns and revealed several teeth that are either broken or missing.Record review of a dental consult dated 10/9/2025 indicated the resident has eight missing teeth and three broken teeth.Record review of an annual Minimum Data Set (MDS) assessment dated [DATE], Section L, Oral/Dental Status, revealed that the resident did not have any oral or dental problems, including broken natural teeth.Additional record review failed to reveal evidence that the resident's dental status was accurately reflected in his/her care plan.During a surveyor interview on 1/22/2026 at 12:36 PM with the Regional MDS Coordinator, she acknowledged that the resident's annual MDS dental status was not accurately coded and that she would expect the resident's dental status to be reflected on his/her care plan. 1b. Record review revealed Resident ID #9 was admitted to the facility in March of 2025 with a diagnosis including, but not limited to, muscle weakness.During a surveyor interview and simultaneous observation with the resident on 1/22/2026 at approximately 12:30 PM, s/he indicated that s/he was edentulous (without teeth).Record review of an admission MDS assessment dated [DATE], Section L, Oral/Dental Status, revealed that the resident was Unable to examine and did not indicate that s/he was edentulous.Additional record review revealed an Admission/readmission Evaluation dated 3/7/2025, which indicated that during the physical evaluation, the resident's oral cavity was marked as Unable to examine.Record review failed to reveal evidence that the resident's dental status was accurately reflected in his/her care plan.During a surveyor interview on 1/23/2026 at 11:13 AM with the MDS Coordinator, she was unable to provide evidence that the resident was accurately coded for his/her MDS Assessment.During a surveyor interview on 1/23/2026 at 11:29 AM with the Regional MDS Coordinator, she acknowledged that the resident's dental status was not coded accurately on his/her admission MDS assessment. Furthermore, she indicated she would expect that it would be reflected on the resident's care plan. 2. Record review revealed Resident ID #27 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, schizophrenia and depression.Record review revealed a physician's order dated 4/30/2025 for clozapine (an antipsychotic medication), 75 milligrams every evening.Record review of an annual MDS assessment dated [DATE], Section N, Medications, failed to reveal evidence that the resident was coded as receiving antipsychotic medications.During a surveyor interview on 1/23/2026 at 2:05 PM with the Director of Nursing Services, she acknowledged that Resident ID #27's MDS assessments were coded inaccurately and failed to reflect the resident's status.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents have a right to be treated with respect and dignity, related to providing privacy during a skin treatment for 1 of 3 treatments observed, Resident ID #27. Findings are as follows:Record review revealed the resident was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, erythema intertrigo (an inflammatory skin condition characterized by red, inflamed skin to the skin folds).During a surveyor observation on 1/23/2026 at 11:45 AM of Registered Nurse, Staff A, revealed the resident was lying on his/her back while in bed, with only a towel draped over his/her pelvic region and the rest of his/her body exposed. Staff A walked from the resident's bed to the doorway to access the treatment cart, located in the hallway, leaving the resident's door completely open and the privacy curtain only partially closed, leaving the resident visible to people from the hallway. Staff A returned to the resident to complete the treatment, exited the room leaving the resident wearing only a brief with his/her pants left around his/her ankles, with the door still open, leaving the resident visible from the hallway where staff were observed walking by.During a surveyor interview with Staff A, immediately following the observation, she acknowledged that the resident's privacy curtain was only partially closed and that the door was completely open, leaving the resident visible from the hallway. During a surveyor interview on 1/23/2026 at 12:59 PM with the Director of Nursing Services, she indicated that the privacy curtain should have been drawn completely, providing privacy to the resident.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure each resident's drug regimen is free from unnecessary drugs for 1 of 3 residents reviewed with a topical treatment, Resident ID #6.Findings are as follows:Record review revealed the resident was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, generalized muscle weakness.Record review revealed a physician's order with a start date of 10/16/2025 for Santyl Ointment (a topical medication prescribed to remove dead tissue from chronic dermal ulcers) 250 units/gram, followed by calcium alginate (a treatment dressing), and a bordered gauze dressing to the left medial (the middle) knee every evening shift for a Stage III pressure ulcer (full thickness tissue loss, fat tissues may be visible but bone, tendon or muscle is not exposed. Slough [dead tissue] may be present but does not obscure the depth of tissue loss).Record review of the Wound Care Nurse Practitioner note dated 12/18/2025, revealed that the left medial knee wound was resolved, and she made a recommendation to discontinue the above-mentioned treatment order.During a surveyor observation on 1/22/2026 at 2:45 PM with Registered Nurse, Staff E, the resident was noted to have a dressing to his/her left medial knee. Staff E acknowledged that the wound was closed but the treatment order remained in place. Record review of the December 2025 and January 2026 Treatment Administration Records failed to reveal evidence that the Santyl ointment was discontinued as recommended and the treatment was signed off as being completed for 30 of 34 opportunities.During a surveyor interview on 1/22/2026 at 3:12 PM with the resident's physician, Staff F, he revealed that he would expect the facility staff to follow the Wound Care Nurse Practitioner's recommendations and the Santyl ointment should have been discontinued after the recommendation was made on 12/18/2025.

Based on surveyor observations, clinical record review, and staff interview, the facility failed to ensure a sanitary environment to help prevent the transmission of infections for 2 of 3 residents observed during treatments, Resident ID #s 27 and 122.Findings are as follows:1. Record review revealed Resident ID #27 was admitted to the facility in May of 2023 with a diagnosis that including, but is not limited to, erythema intertrigo (a skin condition that manifests as a red, inflamed rash, often accompanied by a burning or itching sensation).During a surveyor observation on 1/23/2026 at approximately 10:45 AM, Registered Nurse (RN), Staff A, was observed applying Triad cream, a topical treatment for skin conditions, to the resident's left and middle buttocks, groin, and armpit without changing gloves or performing hand hygiene between applications. The nurse proceeded from the dirtiest area to the cleanest area of the resident's body.2. Record review for Resident ID #122 revealed the following physician's orders:-1/16/2026, cleanse right posterior (back) calf wound with normal saline, apply Xeroform (a medicated bandage used to cover, protect, and help heal wounds) and cover with dry dressing every day shift.-1/21/2026, cleanse right forearm skin tear with normal saline or wound wash, apply xeroform followed by bordered gauze every day shift.During a surveyor observation of the above-mentioned treatments on 1/23/2026 11:38 AM, with RN, Staff A, the following was observed:Staff A was observed wearing two pairs of gloves on each hand. She removed the resident's soiled dressing from the right lower leg and cleansed the wound. Staff A then removed only the outer pair of gloves and proceeded to complete the treatment without removing all gloves, performing hand hygiene, or donning (putting on) new clean gloves prior to applying the clean dressing During a surveyor interview immediately following the observation, Staff A acknowledged that she removed only the outer pair of gloves and did not perform hand hygiene until after completing the treatment.During a surveyor interview on 1/23/2026 at 12:59 PM with the Director of Nursing Services (DNS), she revealed that she would expect Staff A to change gloves and perform hand hygiene when applying the ordered cream to different sites. Additionally, she revealed that she would expect staff to remove their gloves and perform hand hygiene prior to applying the new treatment.

Based on surveyor observation and staff interview, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent surveys conducted of the facility.Findings are as follows:During a surveyor observation of the facility on 1/20/2026 at approximately 9:00 AM, the results of the most recent surveys conducted in the facility were not available to be reviewed without asking for staff assistance.During a surveyor interview on 1/22/2026 at 11:33 AM with the front desk attendant, Staff B, she revealed that the survey results binder is in the rack located inside the front desk office.During a surveyor interview on 1/23/2026 at 12:48 PM with the Administrator, he revealed that he was unaware that the survey results were supposed to be available without asking for staff assistance.

46241 Based on surveyor observation, record review, and resident and staff interview it has been determined that the facility failed to ensure that the residents' environment remains as free from accident hazards as possible, as the facility experienced a fire incident. Findings are as follows: Review of a facility reported incident form submitted to the Rhode Island Department of Health on 1/24/2025 revealed that at approximately 7:25 AM on 1/24/2025, a Nursing Assistant was completing rounds and found a piece of paper on fire in a resident's room. A code red was initiated, and the fire was extinguished. The form further revealed that at the time of the fire, the room was unoccupied. Review of a manufacturer's booklet, for the electric baseboard heaters installed in the facility, titled, [NAME] Electric Baseboard Heaters states in part, .WARNING .This heater is hot when in use. To avoid burns, do not let bare skin touch hot surfaces. Keep combustible materials, such as furniture, pillows, bedding, papers, clothes, and curtains away from heater .Furniture: maintain at least 6 inches (152 mm [millimeter]) space between furniture and heater to allow for proper air flow . A. Surveyor observation of photographs submitted to the Rhode Island Department of Health on 1/24/2025 at 10:06 AM by the Office of the State Fire Marshal revealed a reclining chair with areas of charring to the right side of the chair and arm rest. The chair was positioned in close proximity of an electric baseboard heater. Additionally, the area on the wall above the baseboard heater was observed to have notable charring and the damage extended up the wall to the window ledge, with charred matter scattered across the floor. Review of an email submitted to the Rhode Island Department of Health on 1/24/2025 at 11:36 AM received from the Office of the State Fire Marshal states in part, Investigators .responded to .a fire in a nursing home. The fire was confined to a chair and blankets in a patient room. The chair and/or blankets w[ere] in direct contact with an electric baseboard heating unit. The fire is accidental, due to lack of clearance to a heating unit . During a surveyor interview on 1/24/2025 at 11:25 AM with the Administrator, Director of Nursing Services (DNS), and the Regional Infection Preventionist, they revealed that a fire occurred in Resident ID #1 and 2's room around 7:25 AM, while both residents were out of the room. Record review revealed Resident ID #1 was admitted to the facility in January of 2021 with diagnoses including, but not limited to, dementia and the need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating Resident ID #1's cognition was moderately impaired. Further review revealed the resident is dependent upon staff for transfers. Record review revealed Resident ID #2 was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, muscle weakness and the need for assistance with personal care. Review of an MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15, indicating Resident ID #2's cognition was intact. During a surveyor interview on 1/27/2025 at 12:23 PM with Resident ID #2, s/he revealed that s/he recently moved to a new room, due to a fire in his/her previous room. S/he revealed that recently staff moved his/her roommate's (Resident ID #1's) bed away from the wall towards to the center of the room, and placed a recliner against the wall, where the bed was previously located. The resident indicated that it was his/her interpretation that the facility moved the furniture due to the cold weather. B. During a surveyor interview on 1/24/2025 at 1:20 PM with the Administrator, he revealed that the facility was going to ensure that all electric baseboard heaters would have the required 6-inch clearance from all furniture and bedding. He further indicated the facility was going to move all resident's beds away from the electric baseboard heating units and chairs would be placed in the center of the rooms. During the initial tour of the facility on 1/24/2025 from approximately 11:30 AM to 2:30 PM, revealed approximately 46 resident rooms with electric baseboard heaters located along the exterior walls and under the windows. Many rooms were noted to have combustible items, such as beds, chairs, tray tables, trash cans and bedding, directly touching the electric baseboard heaters or closer than the required 6-inch clearance from the electric baseboard heater, per the manufacturer instructions. During a surveyor observation of room [ROOM NUMBER] on 1/24/2025 at approximately 12:20 PM, the electric baseboard heater was in use. Additionally, the heater was too hot to touch. During a surveyor observation and subsequent interview on 1/24/2025 at approximately 2:20 PM with the Administrator, he acknowledged that the facility had failed to move all of the facility's residents' furniture away from the electric baseboard heating units. Additionally, he acknowledged that many resident rooms still had combustible items, such as beds, chairs, tray tables, trash cans and bedding that were closer than 6-inches to the electric baseboard heaters. Of note, this was approximately seven hours after the facility had experienced a fire incident. During a surveyor interview on 1/24/2025 at approximately 3:14 PM with the Administrator, Regional Director of Operations, and Regional Infection Preventionist, they were unable to provide evidence that the facility ensured that the residents' environment remained as free from accident hazards as possible. The facility's failure to ensure that there was a clearance between the resident's chair and the electrical baseboard heating unit resulted in a fire. In addition, after the fire had occurred, the surveyor observed furniture on 1/24/2025 from approximetly 11:30 AM to 2:30 PM that was placed in a manner that if a resident utilized the furniture for lying or sitting it would place him/her at risk for serious harm, serious impairment, serious injury or death.

47279 Based on record review and staff interview, it has been determined that the facility failed to provide care consistent with professional standards of practice for 3 of 3 residents reviewed with an ostomy (colostomy/ileostomy; are surgical procedures that reroute the bowel to an opening in the abdomen, called a stoma. A wafer, which is fitted or cut to the individual size of the stoma, and a pouch are attached externally around the stoma, to collect the stool from the intestines), Resident ID #s 24, 60, and 99. Findings are as follows: Review of a facility policy titled, Colostomy and Ileostomy Care last revised on 6/1/2021, states in part, .Applying or changing the pouch .Empty, remove, and discard the old pouch, if applicable .Wipe the stoma and peristomal skin gently with a washcloth or gauze .Carefully wash the peristomal skin with soap and water and dry by patting gently .Allow the skin to dry thoroughly .Inspect the color and skin integrity of the stoma and peristomal skin .Notify physician .of abnormal findings .Apply skin prep or liquid skin sealant around the peristomal area covering the skin surface which will be in contact with the pouching system .If needed, apply a ring of stoma paste or a molded barrier ring around the opening on the back of the skin barrier .Document .date and time pouching system changed or emptied, noting character of drainage including color, amount, type, and consistency .type and size of appliance used .Appearance of the stoma and peristomal skin .Notification of physician .patients response . 1) Record review revealed that Resident ID #99 was readmitted to the facility in March of 2024 with a diagnosis including, but not limited to, necrotizing fasciitis (a serious bacterial infection that results in the death of the body's soft tissue). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Record review revealed that Resident ID #99 has a colostomy to his/her left lower abdomen. Record review revealed the following progress notes relative to his/her colostomy: - 9/16/2024: Resident ID #99 reported concerns with his/her ostomy site. S/he revealed that s/he is experiencing pain around the edges of the skin/stoma and that both areas are bleeding - 9/17/2024: The stoma site has mild peristomal skin (the skin that the ostomy wafer adheres to) breakdown, largely in part to aperture [stoma appliance and collection device for waste products] cut too large and .irrigation fluids not being drained entirely from [colostomy] bag . - 10/19/2024: The ostomy appliance was changed because it was leaking and the peristomal skin was noted to be irritated - 10/27/2024: The ostomy appliance was changed because it was leaking and the peristomal skin remains irritated Record review failed to reveal evidence that the physician was contacted, and a treatment was implemented for the breakdown of the peristomal skin. Further record review failed to reveal evidence indicating when the ostomy appliances are to be changed or the type and size of appliances that are to be used for the resident. During a surveyor interview on 10/30/2024 at 9:43 AM with Nursing Assistant (NA), Staff B, she revealed that Resident ID #99 has ostomy supplies in his/her room. Staff B revealed that she does not provide ostomy care for the resident although s/he is on her assignment. During a surveyor interview on 10/30/2024 at 12:19 PM with the Director of Nursing Services (DNS), she was unable to explain why a treatment was not in place for Resident ID #99's peristomal skin breakdown and would expect a treatment to be in place. Additionally, she was unable to provide evidence of documentation that would indicate to the facility's staff as to when the ostomy appliances are to be changed or the type and size of appliances that are to be used. She further revealed that she would expect there to be orders to be in place indicating when to change the ostomy appliance, and the type and size of the ostomy appliances to be used. During a surveyor interview on 10/31/2024 at 9:20 AM with the resident, in the presence of the DNS, s/he revealed that the site around his/her stoma is red and sore and indicated that it burns and bleeds at times. Further, the resident revealed that staff only change his/her ostomy when it is leaking stool. At this time, the DNS indicated to Resident ID #99 that a treatment will be put into place moving forward to help with his/her peristomal skin breakdown and burning. 2) Record review revealed that Resident ID #60 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, ileostomy status. Review of a MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15, indicating moderately impaired cognition. Additional record review failed to reveal evidence indicating when the ostomy appliance is to be changed or the type and size of appliance that is to be used for the resident. During a surveyor interview on 10/30/2024 at 11:09 AM with NA, Staff D, she revealed that sometimes she changes Resident ID #60's ostomy appliance and sometimes the nurse will do it. She further revealed that she does not measure the size of the stoma. Further, she picked up Resident ID #60's clean ostomy appliance and indicated she cuts it to 55 millimeters (mm). During a surveyor interview on 10/30/2024 at 12:00 PM with Licensed Practical Nurse, Staff A, she revealed that nurses change the ostomy appliances, and NAs only empty the collection bag. She further revealed there are no specific orders to change the ostomy appliance and she only changes the appliance when it comes loose. Furthermore, she picked up Resident ID #60's clean ostomy appliance and indicated that she cuts it to 32-38 mm. Additionally, she acknowledged that there are no current orders in place indicating when to change the ostomy appliance including the type and size of the appliance to be used. During a surveyor interview on 10/30/2024 at 2:42 PM with Resident ID #60, s/he revealed that s/he is unsure who changes her ostomy appliances or how often staff changes them. 3) Record review revealed that Resident ID #24 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, overactive bladder and the need for assistance with personal care. Record review revealed that Resident ID #24 has a colostomy on his/her left lower abdomen. Additional record review failed to reveal evidence indicating when the ostomy appliance is to be changed or the type and size of appliance that is to be used for the resident. During a surveyor observation and simultaneous interview on 10/30/2024 at 9:45 AM of Resident ID #24's ostomy site with NA, Staff C, Resident ID #24's stoma was noted to be prolapsed. Staff C revealed that Resident ID #24's stoma has been prolapsed. Record review of an order dated 4/17/2024 revealed to apply a small amount of granulated sugar directly to the resident's stoma due to a prolapsed stoma (a complication of ostomy surgery where a piece of the intestine pushes out through the stoma) every 12 hours as needed. Additionally, the order indicated that the sugar should come back out on its own, and to notify the surgeon and in-house physician if it does not. Review of the October 2024 Treatment Administration Record failed reveal evidence that the above-mentioned order was documented as administered. Staff C further revealed on 10/30/2024 at 9:45 AM, that she utilizes the ostomy appliance in Resident ID #24's room for ostomy care and indicated that she cuts the ostomy appliance and applies them to the resident's stoma. Additionally, Staff C was unable to provide specific days or times when Resident ID #24's ostomy appliance should be changed. During a surveyor interview on 10/30/2024 at 12:19 PM with the DNS, she was unable to provide evidence of documentation that would indicate to the facility's staff as to when the ostomy appliances are to be changed or the type and size of appliances that are to be used. Additionally, she revealed that she would expect orders to be in place indicating when to change the ostomy appliance, and the type and size of the ostomy appliances to be used. Furthermore, she revealed that she was unsure of the order to apply granulated sugar to Resident ID #24's prolapsed stoma and would need to reach out to the surgeon. During a surveyor interview on 10/30/2024 at 12:49 PM with the physician, he revealed that he was unaware that the resident had a prolapsed stoma and was unable to explain why sugar should be applied to it. Additionally, he revealed that he was unsure of how much sugar should be applied or how often the sugar should be applied to the prolapsed stoma. A call was placed to Resident ID #24's surgeon by the surveyor on 10/30/2024 at 12:54 PM, a return call has not been received. During a surveyor interview on 10/30/2024 at 1:09 PM with the Regional Clinical Director, she acknowledged that there is not an order in place to change Resident ID #24's ostomy appliances but indicated that staff have been changing the bag. Additionally, she acknowledged that the facility needs to contact the surgeon in order to clarify the granulated sugar. Lastly, she acknowledged that Resident ID #24 does have a prolapsed stoma. During a surveyor interview on 10/31/2024 at 12:33 PM with the DNS, she revealed that after receiving clarification from the surgeon, the sugar is to be applied to the entire stoma if the stoma is greater than 6 centimeters (cm). Review of the revised prolapsed stoma order dated 10/31/2024 states in part, For prolapsed stoma of 6 cm or more: Apply granulated sugar to cover entire area of stoma, allow sugar to sit on stoma, stoma should begin to retract. If stoma is unable to retract to less than 6 cm of prolapse contact general surgeon . Additionally, record review revealed an order dated 10/31/2024 to measure the stoma twice daily, after the concerns were brought to the facility's attention by the surveyor.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to Enhanced Barrier Precautions (EBP; involves using gown and gloves during high-contact resident care activities) for 1 of 1 resident observed for transfers, Resident ID #76, and relative to COVID-19 for 1 of 1 resident reviewed for COVID-19 precautions, Resident ID #78. Findings are as follows: 1) Review of a facility policy titled, Guidelines for Management of MDROs [multi-drug resistant organism] states in part, .Caring for a resident with a MDRO .Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] beyond situations in which exposure to blood and body fluids is anticipated and refers to gown and glove use during high-contact resident care activities for residents with infection or colonization with a targeted MDRO .High risk resident care activities provide opportunities for the transfer of MDROs to staff hands and clothing. Examples of resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing .Transferring .Providing hygiene . Record review revealed Resident ID #76 was readmitted to the facility in March of 2024 with a diagnosis including, but not limited to, assistance with personal care. Review of a document titled, Lab Results Report dated 9/26/2024 revealed Resident ID #76 was positive for Extended Spectrum Beta Lactamase (ESBL; an MDRO). Record review revealed a physician's order dated 10/25/2024 to maintain EBP as appropriate. During a surveyor observation on 10/28/2024 at 12:16 PM, Nursing Assistant (NA), Staff F, was observed providing morning care to Resident ID #76 in his/her room, without wearing a gown. Further observation revealed signage posted at the resident's door which indicated to wear a gown and gloves during high contact care activities. Additional observation on 10/28/2024 at 12:22 PM, NA, Staff G, was observed transferring Resident ID #76 with Staff F, without wearing a gown. During a surveyor interview on 10/28/2024 at 12:29 PM, with Staff F and G, they acknowledged the signage posted at Resident ID #76's door and revealed that they were unsure about the use of EBP and were unaware if the resident required EBP during care. During a surveyor observation on 10/29/2024 at 11:12 AM, NA, Staff H, was observed fixing Resident ID #76's clothing by pulling up his/her pants and was preparing to transfer him/her, without wearing a gown. Additional observation on 10/29/2024 at 11:16 AM, revealed NA, Staff I, entered Resident ID #76's room and assisted Staff H with transferring the resident, without wearing a gown. During a surveyor interview on 10/29/2024 at 11:23 AM, with Staff H and I, they acknowledged the signage posted at Resident ID #76's door and revealed that they thought the EBP was for the resident's roommate. Further, they acknowledged that they should have been wearing a gown when providing care and transferring him/her. During a surveyor interview on 10/30/2024 at 11:31 AM, with Licensed Practical Nurse (LPN), Staff A, she revealed that she would expect staff to wear both gloves and a gown for any physical contact, including providing personal care and transferring a resident who is on EBP. During a surveyor interview on 10/30/2024 at 12:03 PM, with the Director of Nursing Services (DNS), she revealed that she would expect staff to follow the EBP signage and wear the appropriate PPE, during high contact care activities for residents on EBP. 2) Review of facility signage titled, DROPLET CONTACT PRECAUTIONS EVERYONE MUST for COVID-19, providers and staff must wear a mask at all times, wear gloves, a gown, and a face shield prior to entering a resident's room. Record review revealed Resident ID #78 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, dementia. Record review revealed the resident tested positive for COVID-19 on 10/28/2024 and was placed on droplet contact precautions. During a surveyor observation on 10/30/2024 at 8:08 AM, NA, Staff J, was observed entering Resident ID #78's room without eye protection. During a surveyor interview on 10/30/2024 at 8:20 AM, with Staff J, she acknowledged that she did not wear eye protection, as required, when entering a COVID-19 positive resident room. During a surveyor interview on 10/30/2024 at 8:48 AM, with LPN, Staff K, she revealed that prior to entering a COVID-19 positive room, all staff should be wearing full PPE, which includes a gown, gloves, N95 mask, and eye protection. During a surveyor interview on 10/30/2024 at 12:50 PM, with the DNS, she revealed that she would expect staff to wear full PPE, including a gown, gloves, N95 mask, and eye protection, when entering a COVID-19 positive resident room. 46539

Based on record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 1 resident reviewed with a deep tissue injury (DTI; a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure), Resident ID #76. Findings are as follows: Review of a facility policy titled, Skin Care Protocol states in part, .With each dressing change or at least weekly, the following documentation must be present: location and staging .exudate [drainage] .pain .wound bed .description of wound edges . Record review revealed the resident was readmitted to the facility in March of 2024 with diagnoses including, but not limited to, muscle weakness and obesity. Record review of the care plan revealed the resident is at risk for impaired skin integrity with interventions including, but not limited to, evaluate the wound for size, depth, margins such as, peri-wound skin, undermining, exudate, edema (swelling), granulation (healing tissue), infection, necrosis (dying tissue), eschar (dead tissue often covering a wound bed), gangrene (death of tissue due to lack of blood supply), and document the progress of the wound healing on an ongoing basis. Record review of a skin assessment dated [DATE] revealed the resident has a DTI to his/her right heel measuring 2 centimeters (cm) X (by) 2 cm. Additionally, the skin assessment revealed s/he has a DTI to his/her left heel measuring 4 cm X 2 cm. Record review revealed a physician's order dated 10/3/2024 to apply skin prep to the DTIs on the right and left foot daily. Record review failed to reveal evidence of weekly documentation of the DTIs to the resident's left and right heels that included, measurements, staging, exudate, pain, wound bed, or a description of wound edges on 10/10, 10/17 and 10/24/2024. During a surveyor interview with Licensed Practical Nurse, Staff A, on 10/30/2024 at 9:10 AM she was unable to provide evidence of documentation in the medical record to include measurements, staging, exudate, pain, wound bed, or description of the wound edges for three consecutive weeks. During a surveyor interview on 10/30/2024 at 11:34 AM with the Director of Nursing Services, she was unable to provide evidence of documentation of the resident's wounds on 10/10, 10/17 and 10/24/2024. Additionally, she revealed that it is her expectation that the staff document weekly on wounds including, staging, exudate, pain, wound bed, and wound edges.

Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from physical abuse for 2 of 4 residents reviewed, Resident ID #s 2 and 3. Findings are as follows: Review of a facility policy titled, Abuse Prohibition last revised on 10/31/2022 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, mistreatment, neglect .Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish . Review of a facility reported incident received by the Rhode Island Department of Health on 8/2/2024 states in part, On 8/1/24 at or around 9pm staff were made aware of an incident when they heard screaming .[Resident ID #1] was found on top of [Resident ID #2] with a sheet over [his/her] head . Record review revealed that Resident ID #1 (perpetrator) was admitted to the facility in September of 2023 with diagnoses including, but not limited to, dementia, anxiety and depression. Review of a Minimum Data Set (MDS) Assessment for Resident ID #1 dated 7/5/2024 revealed a Brief Interview for Mental Status (BIMS) Score of 4 out of 15 indicating severe cognitive impairment. Additional review of the MDS revealed s/he transfers and ambulates independently. Record review revealed that Resident ID #2 (victim) was admitted to the facility in September of 2022 with diagnoses including, but not limited to, breast cancer and anxiety. Review of an MDS Assessment for Resident ID #2 dated 7/12/2024 revealed a BIMS score of 0 indicating severe cognitive impairment. Further review of the MDS revealed Resident ID #2 is non-ambulatory and is dependent for all activities of daily living. Additionally, it revealed that s/he is receiving hospice services. During a surveyor interview via telephone on 8/8/2024, at 10:44 AM with Nursing Assistant (NA) Staff B, she revealed that on 8/1/2024 she witnessed Resident ID #1 in Resident ID #2's bed. Resident ID #1 was on top of Resident ID #2 holding a sheet over his/her face, Resident ID #2 was screaming. Review of second facility reported incident received by the Rhode Island Department of Health dated 8/2/2024 states in part, During our initial investigation the facility was made aware of another resident incident. [Resident ID #3] made a supervisor aware [s/he] was afraid of [Resident ID#1] and said something was put over [his/her] head . Record review revealed that Resident ID #3 (victim) was admitted to the facility in June of 2024 with diagnoses including, but not limited to, dementia, anxiety and depression. Review of an MDS Assessment for Resident ID #3 dated 6/11/2024 revealed a BIMS score of 15 out of 15 indicating intact cognition. Additional review of the MDS revealed s/he requires supervision or touching assistance with transfers and ambulation. Review of a facility provided statement authored by Licensed Practical Nurse, Staff A, dated 8/2/2024 revealed that on 7/31/2024 Resident ID #3 reported feeling scared of his/her roommate (Resident ID #1) and felt like s/he was trying to kill him/her and had put a blanket over his/her face. The statement further revealed that the facility moved Resident ID #3 to another room for safety reasons. During a surveyor interview on 8/8/2024 at approximately 10:00 AM with the Assistant Director of Nursing (ADNS) she revealed that she was made aware of the accusations that Resident ID #3 had made against Resident ID #1 on 7/31/2024. Additionally, she revealed that a room change was made for Resident ID #3. The ADNS further revealed that no additional investigation was completed regarding this allegation on 7/31/2024 or 8/1/2024. The ADNS revealed that she was too busy to investigate the allegation any further. During a surveyor interview on 8/8/2024 at 10:22 AM with the Social Worker, Staff C, she revealed that she was made aware of the accusations by Resident ID #3 against Resident ID #1 on 7/31/2024 and that she made a room change for Resident ID #3. Staff C acknowledged moving Resident ID #2 into same room as Resident ID #1, even though there had been an accusation of abuse made against Resident ID #1. Staff C further revealed that she did not interview Resident ID #1 or Resident ID #3 on the day the allegation was made, as she was too busy to investigate the allegation any further. Review of the census report revealed Resident ID #3 and Resident ID #2 switched beds on 7/31/2024. During a surveyor interview on 8/8/2024 at approximately 10:40 AM with the Regional Director of Nursing, she acknowledged that Resident ID #2 was moved into a room with Resident ID #1, even though Resident ID #1 was accused of being abusive on that same day. Additionally, she was unable to provide evidence that Resident ID #2 had been kept free of abuse. Cross reference F610

Based on record review and staff interview it has been determined that the facility failed to provide evidence that an alleged violation of abuse was investigated, relative to an allegation of resident-to-resident abuse between Resident ID #s 1 and 3, which in turn resulted in Resident ID #2 sustaining abuse by the same alleged perpetrator, Resident ID #1. Findings are as follows: Review of a facility policy titled, Abuse Prohibition last revised on 10/31/2022 states in part, .Any instance of actual or suspected abuse, neglect, mistreatment, involuntary confinement, misappropriation of resident property, including injuries of unknown origins including bruises, skin tears, or lacerations must be reported immediately to the DNS [Director of Nursing Services]/designee, i.e., supervisor on duty and an incident report is filled out .immediate response to allegations and/or incidents may include as appropriate but not limited to, examination of the victim for physical injury, trauma assessment for psychosocial injury, increased supervision of the victim and others as needed, room changes as needed, provision of ongoing emotional support during the investigation and ongoing as needed . Review of a facility reported incident received by the Rhode Island Department of Health dated 8/1/2024 states in part, On 8/1/24 at or around 9pm staff were made aware of an incident when they heard screaming .[Resident ID #1] was found on top of [Resident ID #2] with a sheet over [his/her] head . Review of a second facility reported incident received by the Rhode Island Department of Health dated 8/2/2024 states in part, During our initial investigation the facility was made aware of another resident incident. [Resident ID #3] made a supervisor aware [s/he] was afraid of [Resident ID#1] and said something was put over [his/her] head . Record review revealed that Resident ID #3 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, dementia, anxiety, and depression. Review of a Minimum Data Set Assessment for Resident ID #3 dated 6/11/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of a facility provided statement authored by Licensed Practical Nurse, Staff A, dated 8/2/2024 revealed that on 7/31/2024 Resident ID #3 reported feeling scared of his/her roommate (Resident ID #1) and felt like s/he was trying to kill him/her and had put a blanket over his/her face. The statement further revealed that the facility moved Resident ID #3 to another room for safety reasons. During a surveyor interview on 8/8/2024 at approximately 10:00 AM with the Assistant Director of Nursing (ADNS) she revealed that she was made aware of the accusation that Resident ID #3 had made against Resident ID #1 on 7/31/2024. Additionally, she revealed that a room change was made for Resident ID #3. The ADNS further revealed that no additional investigation was completed regarding the allegation Resident ID #3 made on 7/31/2024. During a surveyor interview on 8/8/2024 at 10:22 AM with the Social Worker, Staff C, she revealed that she was made aware of the accusation of abuse made by Resident ID #3 against Resident ID #1 on 7/31/2024 and that she made a room change for Resident ID #3. Staff C further revealed that she did not interview Resident ID #1 or Resident ID #3 on the day the abuse allegation was made. Additionally, she stated that she and did not initiate any type of investigation regarding this allegation of abuse, because she was too busy. Review of the census report revealed Resident ID #3 and Resident ID #2 switched rooms/beds on 7/31/2024. Review of an MDS Assessment for Resident ID #2 dated 7/12/2024 revealed a BIMS score of 0 indicating severe cognitive impairment. Further review of the MDS revealed Resident ID #2 is non ambulatory and is dependent for all activities of daily living (ADL) and is receiving hospice services. During a surveyor interview via telephone on 8/8/2024, at 10:44 AM with Nursing Assistant (NA) Staff B, she revealed that on 8/1/2024 she witnessed Resident ID #1 in Resident ID #2's bed. Resident ID #1 was on top of Resident ID #2 holding a sheet over his/her face, Resident ID #2 was screaming. Additionally, Staff B revealed that she was unaware of the previous abuse allegation that Resident ID #3 had made against Resident ID #1 and was not made aware of it until after she had witnessed Resident ID #1 on top of Resident ID #2 holding a sheet over his/her face. During a surveyor interview on 8/8/2024 at approximately 10:40 AM with the Regional Director of Nursing she acknowledged that there was not an investigation initiated on 7/31/2024 even though Staff A, Staff C and the ADNS were all aware of the abuse allegation reported by Resident #3. The facility's failure to investigate the allegation of abuse made by Resident ID #3 on 7/31/2024, placed Resident ID #2, a vulnerable resident who was cognitively impaired, unable to ambulate, dependent on staff for all of his/her ADLs and receiving hospice services, placed him/her at risk for serious injury, serious harm, impairment or death. Cross reference F600

Based on record review and staff interview it has been determined that the facility failed to ensure that residents who require supervision with meals, received supervision when eating, for 1 of 4 residents reviewed, 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 4:17 PM, the Heimlich maneuver (first aid method used when a person is choking) was initiated followed by Cardiopulmonary Resuscitation (CPR). The facility contacted Emergency Medical Services (EMS) and the resident was transported to the Hospital at 5:00 PM where s/he expired. Record review of the EMS report revealed that they were dispatched to the facility for a resident with airway obstruction, who was unconscious and not breathing. The facility communicated with EMS that the resident was eating pizza for dinner in his/her room when s/he choked causing complete airway obstruction and s/he started turning blue. The resident's roommate called for help and the facility staff found the resident actively choking. The facility staff attempted to perform the Heimlich maneuver without success. At this time the resident became unconscious, and the facility staff assisted Resident ID #1 to the floor and chest compressions were started. Per the EMS report the facility staff attempted to manually remove the foreign body via suctioning without success and then proceeded to call 911. When EMS arrived the resident's airway was completely compromised. High quality CPR was being performed by the facility staff and the automated external defibrillator (a device that can help restart a person's heart during cardiac arrest) was attached to the resident and s/he was being passively ventilated. The suction canister next to the resident had blood and secretions in the tubing after the facility staff attempted removal of the foreign body. EMS took over resuscitation efforts and initiated continuous compressions. EMS removed chucks of melted cheese and bread from his/her airway, and they continued to suction copious (large in quantity) amounts of blood and secretions until the airway was patent (open). The procedure took approximately 10 minutes until the airway was completely clear of the obstruction. EMS was unable to intubate due to the copious amount of blood and secretions. Nine rounds of epinephrine (a medication that is used in an emergency to increase blood circulation and breathing) were administered to the resident with no improvement. Resuscitation continued for 30 minutes at the facility and then the resident was transported to the hospital where s/he was pronounced deceased . Record review revealed that Resident ID #1 was readmitted to the facility in October of 2020 with diagnoses including, but not limited to, Barrett's esophagus (a change in the cellular structure of the esophagus lining in which a patient can develop difficulty swallowing), hemiplegia (paralysis in one side of the body), and hemiparesis (muscle weakness on one side of the body) following a stroke, and dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident is cognitively intact. Additionally, the assessment revealed that the resident required supervision of one staff member when eating. Review of a comprehensive care plan revealed the following: -[DATE] a focus area indicating that the resident receives a therapeutic mechanically altered diet related in part to dysphagia (difficulty swallowing). Interventions include monitoring, reporting signs and symptoms of dysphagia, and documenting; pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and/or appearing concerned during meals. -[DATE] a focus area for dental care related to the resident being edentulous (having no teeth). Interventions are to monitor for discomfort or difficulty chewing. Review of a physician's order dated [DATE] revealed a consistent carbohydrate diet (CCD), minced and moist in texture. In addition, it includes directions for low lactose, small portions, built up utensils, a plate guard with meals and no carrots. Review of the Speech Therapy Discharge Summary dated [DATE] authored by Speech Language Pathologist (SLP), Staff A, revealed that the resident had a skilled intervention to follow safe swallowing strategies. Additionally, the summary indicates recommendations for a minced and moist textured diet to safely swallow solid foods. Record review of a nursing assistant task document titled ADL [Activities of Daily Living]-Eating, Question 2 describes the following, EATING: SELF PERFORMANCE-How resident eats and drinks, regardless of skill . revealed the following: From [DATE] through [DATE] -For 9 out of 62 opportunities the resident was documented total dependence, full staff performance for eating. -For 30 out of 62 opportunities the resident was documented as needing supervision, oversight, encouragement or cueing for eating. Record review of the progress notes revealed the following: -[DATE], a nutritional/dietary note that revealed a quarterly nutritional assessment indicating the resident requires varying levels of assistance from set up to hands on assistance from staff for meals. -[DATE], a nursing note authored by Licensed Practical Nurse, Staff G, states in part, At approximately 1617 [4:17 PM] hours, while passing medications, this writer responded to [Resident ID #1] who called out for water. Upon entering the room, the resident was unable to speak and appeared to be choking. I called for help and immediately initiated the Heimlich maneuver. A code blue was initiated, EMS was called. Nurses throughout the building participated in CPR. EMS arrived at 1627 [4:27 PM] hours and took over resuscitation procedures . During a surveyor interview on [DATE] at 1:20 PM with SLP, Staff A, she revealed that the resident was last seen by speech in June of 2024. She indicated that the resident has no teeth, is impulsive, forgetful, and needed reminders to pace him/herself because s/he tends to eat at a fast rate. Additionally, Staff A revealed that whole pizza slices were not a part of the resident's prescribed diet. She further revealed that the resident required assistance and supervision from staff to remind him/her to swallow their food. During a surveyor interview on [DATE] at 2:40 PM with Nursing Assistant, Staff B, she revealed that the resident required supervision for all meals because s/he has a moist and minced modified diet. In addition, she revealed that when the resident desired to have food that was not minced and moist the resident could be easily redirected to get another snack or meal that was appropriate for his/her prescribed diet. During a surveyor interview on [DATE] at 1:13 PM with the resident's child, s/he revealed that s/he could not understand how another resident was allowed to give his/her parent [Resident ID #1] whole slices of pizza without the staff's knowledge, or why they were not monitoring him/her when s/he was eating the pizza, if they were aware s/he had whole slices of pizza. S/he further indicated that his/her stepchild, who works at a pizzeria, brought in a special made pizza for the resident's birthday approximately a week prior. The pizza was prepared moist and minced, as the family was aware of the resident's modified diet. Furthermore, when the pizza was brought into the facility for the resident on his/her birthday, a nurse approved the pizza prior to the resident's consumption, and the family supervised the resident while s/he ate it in its entirety. During a surveyor interview on [DATE] at 3:04 PM, with Registered Nurse (RN), Staff C, she indicated that on [DATE], while she was receiving a nurse to nurse report and preparing to count medications, she saw a pizza delivery person heading towards Resident ID #2's room. Staff C completed the medication count and proceeded to Resident ID #2's room. She discovered that Resident ID #2 had given 2 slices of whole pizza to Resident ID #1. Staff C found Resident ID #1 in his/her room, with 2 whole pizza slices on a plate. Staff C tried to educate the resident about the potential choking hazards of eating pizza, but the resident reacted defensively. She then left the resident unsupervised and went upstairs to inform RN's, Staff D, and E about the situation. After discussing with them, she went back downstairs and discussed the situation with RN, Staff F. At that time someone suggested getting the speech pathologist. Staff C made her way to the speech pathologist's office, but she was not there. Further interview with RN, Staff C revealed that she then returned to Resident ID #1's room and noticed that the resident had almost finished the pizza, as only the crust remained on the plate. She tried to educate the resident but the resident, stated she had pizza for his/her birthday. Staff C stated that she left the resident with the pizza crust on the plate. Later, while preparing to administer pain medication to another resident, she heard another staff member screaming for help and found 3 other nurses in the resident's room where she observed the resident trying to speak but the words were not clear. The Heimlich maneuver was initiated but was unsuccessful and CPR was started. EMS arrived on site, took over CPR and attempted to intubated and suction the resident. EMS finally transported the resident to the hospital after approximately 43 minutes of resuscitation. Additionally, Staff C acknowledged that she left the resident without supervision in his/her room on [DATE] on two occasions, and that she was aware that the pizza was not approved for his/her modified diet of a minced and moist texture. Record review revealed that Resident ID #2 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease and generalized muscle weakness. Review of an MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident is cognitively intact. During a surveyor interview on [DATE] at 1:40 PM with Resident ID #2, s/he revealed that on [DATE] s/he ordered a pizza. S/he indicated that the delivery person was assisting him/her with the food. Resident ID #1 approached the door and asked for some pizza. Resident ID #2 instructed the delivery person to give 2 slices of pizza to Resident ID #1. Resident ID #1 then took the pizza and returned to his/her room. Resident ID #2 further revealed that s/he informed RN, Staff C, that s/he gave 2 slices of whole pizza to Resident ID #1. Furthermore s/he stated that Staff C told him/her that s/he should not have given the pizza to Resident ID #1. During a surveyor interview on [DATE] at 11:34 AM with the Director of Nursing Services, he acknowledged that the resident expired from choking on slices of whole pizza that the resident consumed. The facility failed to provide Resident ID #1 with adequate supervision while s/he was eating whole pizza slices which is not the resident's ordered diet texture. Staff C was aware that the resident was given whole pizza slices by another resident, and she left the resident unsupervised on two occasions to eat the pizza independently. This failure resulted in Resident ID #1 choking on whole pizza slices, received the Heimlich maneuver and CPR, being suctioned, received 9 rounds of epinephrine and later expired at the hospital.

Based on record review, 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 4 residents reviewed for a modified diet of the minced and moist 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 4:17 PM, the Heimlich maneuver (first aid method use when a person is choking) was initiated followed by Cardiopulmonary Resuscitation (CPR). The facility contacted Emergency Medical Services (EMS) and the resident was transported to the Hospital at 5:00 PM where s/he expired. Record review of the EMS report revealed that they were dispatched to the facility for a resident with airway obstruction, was unconscious and was not breathing. The facility communicated with EMS that the resident was eating pizza for dinner in his/her room when s/he choked causing complete airway obstruction and s/he started turning blue. The resident's roommate called for help and the facility staff found the resident actively choking. The facility staff attempted to perform the Heimlich maneuver without success. At this time the resident became unconscious, and the facility staff assisted Resident ID #1 to the floor and chest compressions were started. Per the EMS report the facility staff attempted to manually remove the foreign body via suctioning without success and then proceeded to call 911. When EMS arrived the resident's airway was completely compromised. High quality CPR was being performed by the facility staff and the automated external defibrillator (a device that can help restart a person's heart during cardiac arrest) was attached to the resident and s/he was being passively ventilated. The suction canister next to the resident had blood and secretions in the tubing after the facility staff attempted removal of the foreign body. EMS took over resuscitation efforts and initiated continuous compressions. EMS removed chucks of melted cheese and bread from his/her airway, and they continued to suction copious (large in quantity) amounts of blood and secretions until the airway was patent. The procedure took approximately 10 minutes until the airway was completely clear of the obstruction. EMS unable to intubate due to the copious amount of blood and secretions. Nine rounds of epinephrine (a medication that is used in an emergency to increase blood circulation and breathing) were administered to the resident with no improvement. Resuscitation continued for 30 minutes at the facility and then the resident was transported to the hospital where s/he was pronounced deceased . Record review revealed that Resident ID #1 was readmitted to the facility in October of 2020 with diagnoses including, but not limited to, Barrett's esophagus (a change in the cellular structure of the esophagus lining in which a patient can develop difficulty swallowing), hemiplegia (paralysis in one side of the body), and hemiparesis (muscle weakness on one side of the body) following a stroke, and dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident is cognitively intact. Additionally, the assessment revealed that the resident required supervision of one staff member when eating. Review of a comprehensive care plan revealed the following: -[DATE] a focus area indicating that the resident receives a therapeutic mechanically altered diet related in part to dysphagia (difficulty swallowing). Interventions include monitoring, reporting signs and symptoms of dysphagia, and documenting; pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and/or appearing concerned during meals. -[DATE] a focus area for dental care related to the resident being edentulous (having no teeth). Interventions are to monitor for discomfort or difficulty chewing. Review of a physician's order dated [DATE] revealed a consistent carbohydrate diet (CCD), minced and moist in texture. In addition, it includes directions for low lactose, small portions, built up utensils, a plate guard with meals and no carrots. Record review of the progress notes revealed an entry dated [DATE], authored by Licensed Practical Nurse, Staff G, that states in part, At approximately 1617 [4:17 PM] hours, while passing medications, this writer responded to [Resident ID #1] who called out for water. Upon entering the room, the resident was unable to speak and appeared to be choking. I called for help and immediately initiated the Heimlich maneuver. A code blue was initiated, EMS was called. Nurses throughout the building participated in CPR. EMS arrived at 1627 [4:27 PM] hours and took over resuscitation procedures . Review of the Speech Therapy Discharge Summary dated [DATE] authored by Speech Language Pathologist (SLP), Staff A, revealed that the resident had skilled interventions to follow safe swallowing strategies. Additionally, the discharge summary recommendations include a minced and moist textured diet to safely swallow solid foods. During a surveyor interview on [DATE] at 1:20 PM with SLP, Staff A, she revealed that the resident was last seen by speech in June of 2024. She indicated that the resident has no teeth, is impulsive, forgetful, and required reminders to pace him/herself because s/he tends to eat at a fast rate. Additionally, Staff A revealed that whole pizza slices were not a part of the resident's prescribed diet. She further revealed that the resident required assistance and supervision from staff to remind him/her to swallow their food. During a surveyor interview on [DATE] at 12:58 PM with the Director of Nursing Services (DNS) he was unable to provide evidence of a policy pertaining to food that is brought in from outside. He indicated that the facility has no such policy. During a surveyor interview on [DATE] at 3:04 PM, with Registered Nurse (RN), Staff C, she indicated that on [DATE], while she was receiving a nurse to nurse report and preparing to count medications, she saw a pizza delivery person heading towards Resident ID #2's room. Staff C completed the medication count and proceeded to Resident ID #2's room. She discovered that Resident ID #2 had given 2 slices of whole pizza to Resident ID #1. Staff C found Resident ID #1 in his/her room, with 2 whole pizza slices on a plate. Staff C tried to educate the resident about the potential choking hazard of eating pizza, but the resident reacted defensively. She then left the resident unsupervised and went upstairs to inform RN's, Staff D, and E about the situation. After discussing with them, she went back downstairs and discussed the situation with RN, Staff F and it was suggested to get the speech pathologist involved. Staff C made her way to the speech pathologist's office, but she was not there. Further interview with RN, Staff C revealed that she then returned to Resident ID #1's room and noticed that the resident had almost finished the pizza, as only the crust remained on the plate. She tried to educate the resident, but the resident stated she had pizza for his/her birthday. Staff C stated that she left the resident with the pizza crust on the plate. Later, while preparing to administer pain medication to another resident, she heard another staff member screaming for help and found 3 other nurses in the resident's room where she observed the resident trying to speak but the words were not clear. The Heimlich maneuver was initiated but was unsuccessful and CPR was started. EMS arrived on site, and they took over CPR, attempted to intubate and suction the resident, finally they transported him/her to the hospital. Additionally, Staff C acknowledged the whole pizza slices were not approved for his/her modified diet of minced and moist texture. Record review revealed that Resident ID #2 was readmitted to the facility in May of 2024. Review of an MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident is cognitively intact. During a surveyor interview on [DATE] at 1:40 PM with Resident ID #2, s/he revealed that on [DATE] s/he ordered pizza. S/he indicated that the delivery person was assisting him/her with the food. Resident ID #1 approached the door and asked for some pizza. Resident ID #2 instructed the delivery person to give 2 slices of pizza to Resident ID #1. Resident ID #1 then took the pizza and returned to his/her room. Resident ID #2 further revealed that s/he informed RN, Staff C, that s/he gave 2 slices of whole pizza to Resident ID #1. Furthermore s/he stated that Staff C told him/her that s/he should not have given the pizza to Resident ID #1. During a surveyor interview on [DATE] at 11:34 AM with the DNS, he revealed that he would have expected someone to have been with the resident while s/he was eating the pizza. He acknowledged that the resident expired from choking on slices of whole pizza that the resident consumed. During a surveyor interview on [DATE] at 1:13 PM with the resident's child, s/he revealed that s/he could not understand how another resident was allowed to give his/her parent [Resident ID #1] whole slices of pizza without the staff's knowledge, or why they were not monitoring him/her when s/he was eating the pizza, if they were aware s/he had whole slices of pizza. S/he further indicated that his/her stepchild, who works at a pizzeria, brought in a special made pizza for the resident's birthday approximately a week prior. The pizza was prepared moist and minced, as the family was aware of the resident's modified diet. Furthermore, when the pizza was brought into the facility for the resident on his/her birthday, a nurse approved the pizza prior to the resident's consumption, and the family supervised the resident while s/he ate it in its entirety. The facility failed to ensure that Resident ID #1 received food in the appropriate form as s/he was observed by Staff C eating whole pizza slices which is not the resident's ordered diet texture. Staff C was aware that the resident was given whole pizza slices by another resident, and she left the resident unsupervised on two occasions to eat the pizza independently. This failure resulted in Resident ID #1 choking on whole pizza slices, received the Heimlich maneuver and CPR, being suctioned, received 9 rounds of epinephrine and later expired at the hospital.

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 4 residents reviewed, Resident ID #4. Findings are as follows: Review of the 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 .Definitions: Abuse: Willful infliction of injury .and includes physical, verbal, sexual, and mental abuse. Examples of abuse include but are not limited to the following .Physical-Hitting, punching, pinching, kicking . Record review of a facility incident report submitted to the Rhode Island Department of Health on 6/24/2024, indicates that Resident ID #s 4 and 5 were participating in a coloring activity in a common area and had a disagreement. The perpetrator, Resident ID #5 grabbed a pen and made contact with the victim, Resident ID #4's, hand causing a skin tear that required medical treatment. Record review revealed that Resident ID #4 was admitted to the facility in January of 2021 with diagnoses including, but not limited to, dementia without behavioral disturbances and anxiety. Review of the Minimum Data Set (MDS) Assessment for Resident ID #4 dated 7/3/2024, revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating that the resident's cognition was moderately impaired. Record review of Resident ID #4 progress notes revealed the following: -4/22/2024 a nursing note that revealed that Resident ID #4 was participating in a group coloring activity when Resident ID #5 got upset and aggressive towards him/her for throwing pencils on the ground. Resident ID #5 had pencils in his/her hand and injured Resident ID #4's left hand resulting in a skin tear requiring treatment. Resident ID #5 was also observed by staff to be kicking Resident ID #4 in the legs. -4/23/2024, revealed a social service note authored by Social Worker, Staff I, that indicates she met with Resident ID #4 after the incident with Resident ID #5 and that Resident ID #4 expressed feeling pain in his/her left hand. Record review of a skin observation tool dated 4/22/2024 revealed that Resident ID #4 had a skin tear to the back of his/her left hand measuring 2.5 centimeters (cm) in length by 2.0 cm in width by 0.1 cm in depth. Review of the physician's orders revealed an order dated 4/24/2024 for a skin tear on the left hand to wash with normal saline followed by Medi honey (gel/ointment use to treat wounds) and a dry sterile dressing to be applied in the evening and to discontinue once resolved. The order had a start date of 4/25/2024 and was discontinued on 5/11/2024. Record review revealed that Resident ID #5, was admitted to the facility in July of 2023 with diagnoses including, but not limited to, dementia and depression. Review of a Quarterly MDS Assessment for Resident ID #5 dated 3/22/2024, revealed a BIMS score of 6 out of 15, indicating severe cognitive impairment. Review of Resident ID #5's care plan dated 4/26/2024 failed to reveal evidence that interventions were put into place relative to the incident of physical aggression towards Resident ID #4 on 4/22/2024. Record review of a progress note dated 4/22/2024 for Resident ID #5, revealed that s/he was observed by staff becoming agitated and aggressive with Resident ID #4. Additionally, the progress note revealed that Resident ID #5 grabbed the pencils and caused a skin tear to Resident ID #4's left hand. It further revealed that Resident ID #5 was observed kicking Resident ID #4. During a surveyor interview on 7/30/2024 at 3:34 PM with the Director of Nursing Services, he acknowledged that Resident ID #4 sustained a skin tear caused by Resident ID #5 and that it is considered physical abuse as described in the facility policy. Additionally, he was unable to provide evidence that the facility kept Resident ID #4 free from physical abuse.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 2 residents reviewed for pressure ulcers (a localized injury to the skin or underlying tissue due to pressure), Resident ID #2. Findings are as follows: Review of the facility policy titled, Skin Care Protocol dated 2/2/2020, states in part, .The facility will follow appropriate standards of care as they relate to residents' skin care; identification of those at risk, appropriate interventions and documentation .Documentation: when a pressure ulcer exists, there must be daily monitoring to maintain awareness of area. Documentation of wound status shall include: an evaluation of the ulcer .the status of the area surrounding the ulcer .The presence of possible complications such as signs of increasing area of the ulceration . Record review revealed Resident ID #2 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, diabetes mellitus (high blood sugar), non-pressure chronic ulcer of the right lower leg and peripheral vascular disease (inadequate circulation of the blood). Record review of the Admission Minimum Data Set (MDS) assessment, dated 11/14/2023, revealed Section M-Skin conditions indicated the resident was admitted without a pressure ulcer/injury. Additionally, the assessment revealed the resident is at risk of developing a pressure ulcer/injury. Record review of a Skin Observation document dated 11/22/2023 and authored by the Wound Nurse, identified a new Stage 3 (full-thickness tissue loss of the skin) pressure ulcer to his/her coccyx (area over the tailbone) measuring 1.5 cm (centimeters) in length x 0.5 cm in width x 0.2 cm in depth. Additional review of the document failed to reveal evidence of a description of the wound bed and surrounding skin as required per the facility's policy. Record review of a Visit Report dated 11/21/2023, authored by the Wound Physician, revealed a new Stage 3 pressure injury to the resident's buttocks with measurements documented as, 1.5 cm in length x 0.5 cm in width x 0.2 cm in depth. Further description of the wound bed tissue revealed 1-25 % granulation (red tissue with cobblestone or bumpy appearance), 1-25% eschar (dead tissue) and 26-50% slough (non-viable yellow, tan, gray, green or brown tissue). Further review of the Visit Report revealed wound recommendations from the Wound Physician for the new Stage 3 pressure injury as follows: -Cleanse buttocks with normal saline or wound cleanser, apply honey alginate (absorbent wound dressing), cover wound with bordered foam (dressing) and change dressing daily. Record review of the physician orders failed to reveal evidence that the recommendations given by the Wound Physician for the Stage 3 pressure injury were not reviewed with the facility's physician or acted upon. Further review of the physician orders failed to reveal evidence that any treatment was being provided for the resident's Stage 3 pressure injury, indicating the pressure injury was untreated for 5 days. Record review of a subsequent Visit Report, dated 11/28/2023, and authored by the Wound Physician revealed the Stage 3 pressure injury measurements were documented as 2.8 cm in length x 0.4 cm in width x 0.2 cm in depth and the wound bed tissue revealed 1-25 % granulation, 1-25% eschar and 26-50% slough. Additionally, the peri wound (around the wound) was documented as irritation. Further review of the wound document indicated, The wound is deteriorating. Indicating the wound increased in size from 1.5 cm in length to 2.8 cm in length while left untreated. During a surveyor interview on 12/28/2023 at approximately 11:50 AM with the facility's Wound Nurse, Registered Nurse, Staff E, she acknowledged that the resident's wound treatment recommendations given by the Wound Physician were not implemented, until 11/27/2023, which was 5 days after the wound was first identified. Additionally, she revealed she reviews the wound doctor's recommendations with the resident's physician and then implements the ordered treatment. Lastly, she was unable to provide evidence that the recommendations were reviewed with the resident's physician, and she was unable to explain why a wound treatment order for the resident's Stage 3 pressure ulcer was not implemented when it was first identified on 11/21/2023. She further acknowledged the Wound Physician had found that the wound had deteriorated on 11/28/2023 after it was left untreated for 5 days. During a surveyor interview on 12/28/2023 at approximately 12:00 PM with the Director of Nursing Services, she indicated that she would expect that, when a wound is identified, the physician is notified of the wound recommendations and that it is acted upon. Additionally, she was unable to provide evidence that Resident ID #1 was provided necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident reviewed with congestive heart failure (CHF), who experienced an acute change in condition which resulted in a hospital admission, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/26/2023 alleges the following, .The resident's daughter stated that during [the resident's] stay [s/he] suffered pneumonia, swelling of extremities, and swelling of [his/her] abdomen . Record review of a facility policy titled, Resident Change in Condition dated 10/17/2023, states in part, .POLICY: The facility will ensure that resident changes in condition are identified timely, reported to the Physician .and documentation in the medical record .1.changes in condition require assessment by the RN [Registered Nurse] and notification to the MD [Medical Doctor] . Record review of a facility policy titled, Weight Loss/Gain Protocol and Heights dated 5/1/2022, states in part, . For purposes of this policy, significant weight discrepancy is defined as .2. A loss/gain of 5% or greater within one month .When a significant weight loss/gain is noted .the following interventions must occur .start weekly weights, if not already on . Record review revealed Resident ID #1 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, hypertension, acute respiratory failure with hypercapnia (an increase of arterial carbon dioxide), pneumonia and congestive heart failure (a condition when your heart can't pump blood adequately and fluids collect in your lungs and legs overtime. Symptoms include but are not limited to shortness of breath, swelling in your ankles and legs). Record review of a Brief Interview for Mental Status assessment dated [DATE] reveals a score of 11 out of 15, indicating moderate impaired cognition. Record review revealed a physician order dated 11/14/2023 for daily weights for three days, then weekly weights for 4 weeks. Record review of the Treatment Administration Record for November and December 2023 revealed the following: 11/14/2023 166.0 pounds (lbs.) 11/16/2023 166.0 lbs. 11/17/2023 168.8 lbs. 11/20/2023 168.2 lbs. 11/27/2023 a weight was not obtained 12/4/2023 173.0 lbs. 12/11/2023 174.8 lbs. 12/15/2023 173.0 lbs. Additional record review revealed the resident had a chest x-ray completed on 11/23/2023 which indicated that s/he was in mild CHF. The physician ordered Lasix 20 mg ( a medication given to help treat fluid retention (edema) and swelling that is caused by CHF), to be administered to the resident once a day on 11/23, 11/24 and 11/25/2023. Further record review failed to reveal evidence that the resident's weight was obtained as ordered on 11/27/2023. Lastly, review of the above-mentioned weights revealed that from 11/14/2023 through 12/15/2023 the resident had a 5.4% weight increase, indicating s/he experienced a significant weight gain. Record review of a progress note dated 12/13/2023, authored by the Registered Dietician (RD), revealed the resident triggered for a significant weight gain in 30 days, which was documented as unfavorable. During a surveyor interview on 12/27/2023 at 1:45 PM with the RD, she revealed she had noticed the resident had increased edema and was aware that the resident had experienced a significant weight gain in 30 days. Additional record review failed to reveal evidence that the the RD implemented any new interventions for the resident even though she noticed the resident had edema and experienced a significant weight gain in 30 days. During a surveyor observation and simultaneous interview with the resident on 12/27/2023 at approximately 9:45 AM revealed the resident was lying in bed with the head of the bed elevated and a grimaced look on his/her face. S/he was breathing heavily and appeared short of breath. When questioned about how s/he was feeling, the resident stated, I just want to die. During a surveyor interview on 12/27/2023 at 9:55 AM, with Registered Nurse, Staff A, she revealed that she had not observed Resident ID #1 yet this shift and was prompted by the surveyor to assess the resident and obtain his/her vital signs. During a surveyor observation of the resident with Staff A, vital signs were obtained which revealed the following: -Blood pressure (BP) 220/84 (normal BP 120/80) -Pulse 80 (normal 60-90) -Respirations 26 (normal range 12-20) -Pulse oximetry (a device that indicates the oxygen level in the blood) in room air 65% (normal range 95-100%) Immediately following the above observation, Staff A asked Staff B if she had given the resident his/her morning medications. Staff B then indicated that she had given the resident his/her morning medications and that [the resident] seemed in distress today. During a surveyor interview on 12/27/2023 at 10:01 AM with Staff B, she revealed that when she observed the resident earlier that morning, his/her face appeared distressed. Staff B further revealed that she had then returned to the resident's room at approximately 8:20 AM to see how the resident responded to the Tylenol that was administered on the previous shift and Staff B stated, I felt when I left [s/he] was in distress and [s/he] wasn't comfortable. Additionally, Staff B revealed that she did not inform the nurse that the resident was uncomfortable and appeared to be in distress. During a surveyor interview on 12/27/2023 at approximately 10:15 AM with Staff A, she indicated that Staff B did not make her aware that the resident was observed to be in distress that morning. During a surveyor interview on 12/27/2023 at approximately 11:55 AM with Nursing Assistant (NA), Staff C, she revealed that she removed the resident's meal tray after breakfast and noticed the resident was not [his/her] usual self. Additionally, Staff C acknowledged that she did not report the resident's change in condition to the nurse. Record review of the NA's task list for the resident reveals a task for monitoring him/her for shortness of breath. Record review of the resident's Activities of Daily Living documentation revealed two questions were asked relative to monitoring for shortness of breath: -Did the resident have shortness of breath or trouble breathing with exertion (e.g., walking, bathing transferring)? -Did the resident have shortness of breath or trouble breathing when lying flat? Record review of the documentation for 12/26/2023 at 2:29 PM revealed both answers were documented as yes by Nursing Assistant, Staff D, who had provided care to the Resident that day. During a surveyor interview on 12/27/2023 at 1:38 PM with Staff D, she acknowledged the above-mentioned documentation. Additionally, she acknowledged that she did not inform the nurse that the resident was short of breath when s/he cared for him/her on 12/26/2023. Record review of a progress note dated 12/27/2023 at 10:38 AM revealed the resident was transferred emergently to the hospital via 911. Record review of the Emergency Department history and physical documentation dated 12/27/2023 at 11:29 AM states in part, Chief Complaint shortness of breath .work up in the emergency room .BNP [level over 100 pg [picogram]/ml[milliliter] level of 550 .chest x-ray .bilateral pleural effusions[an unusual amount of fluid around the lungs ] .pCO2[a measure of carbon dioxide within the blood] of 73 ml [normal range 35 to 45] .patient placed on Bipap [noninvasive ventilation to assist with breathing] .patient is to be admitted with acute hypoxic [low oxygen levels], hypercarbic respiratory failure [a serious condition where the lungs cannot remove enough carbon dioxide from the blood] secondary to diastolic CHF .plan for IV [intravenous] diuretics [medication to reduce fluid build-up] this evening . During a surveyor interview on 12/28/2023 at 11:40 AM with the Director of Nursing Services (DNS), she acknowledged the resident experienced a significant weight gain. Additionally, she was unable to provide evidence that Staff D alerted a nurse on 12/26/2023 when she noted the resident to be short of breath, as documented in the resident's record, or that Staff B and C alerted a nurse when they noted the resident to have a change in condition that required the resident to be transferred emergently to the hospital on 12/27/2023. She further revealed it would be her expectation that staff who identify changes in residents' condition, would report those changes to the nurse so the nurse could further assess the resident, and notify the provider as indicated. Lastly, the DNS was unable to provide evidence that Resident ID #1 received the necessary care and services to maintain his/her highest practicable physical, mental, and psychosocial well-being.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for 1 of 4 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/12/2023 from a hospital social worker alleges in part, .Doctor is concerned about neglect based on patient's medical condition . During a surveyor interview with the complainant on 8/16/2023 at 12:45 PM, she revealed that due to the degree of dehydration the resident was admitted with, the medical team suspected neglect. According to National Library of Medicine, Adult Dehydration, last updated 2022, indicates that dehydration may complicate other medical problems and may cause significant illness. A resident may appear with dark urine or decreased urine output and may be lethargic upon observation in severe cases of dehydration. Failure to treat dehydration in older adults may lead to significant mortality. The Centers for Disease Control and Prevention encourages adults to maintain a fluid intake between 2,000 - 3,000 mL (milliliters) per day. Record review revealed the resident was admitted to the facility in May of 2023 with diagnoses including, but not limited to, acute on chronic diastolic heart failure (blockage affecting the heart which may have developed over time), hypertension (high blood pressure), overactive bladder, and lymphedema (swelling that happens when something affects your lymphatic system). Record review of the resident's care plan dated 5/11/2023 revealed that s/he is at risk for fluid imbalances related to his/her history of congestive heart failure, diuretic (medications that cause increased urination) therapy, and lymphedema. Further review revealed an intervention to obtain and monitor laboratory blood tests as ordered. Record review revealed the following blood test results dated 7/26/2023: - BUN (blood urea nitrogen; is a test measure for kidney function). The normal range of BUN is 8-23 mg/dl (milligrams per deciliter). An elevated BUN is an indicator of dehydration. Resident ID #1 had a BUN level of 28 mg/dL. - Sodium (blood test that measure the sodium in the blood). The normal range of Sodium is 135-146 mEq/L (milliequivalents per liter). An elevated sodium is an indicator of dehydration. Resident ID #1 had a Sodium level of of 150 mEq/L. Record review following the above blood test results revealed a physician's order with a start date of 7/26/2023 at 3:00 PM to PUSH fluids every shift for 5 Days. Further record review failed to specify the amount of fluids necessary to push fluids to the resident that would prevent him/her from experiencing dehydration. During a surveyor interview with the Licensed Practical Nurse, Staff A, on 8/16/2023 at 1:00 PM, she was unable to specify the amount required to push fluids to the resident to prevent dehydration. Record review revealed the following total daily fluid intakes for the resident: -1,080 mL on 7/26/2023 - 720 mL on 7/27/2023 - 840 mL on 7/28/2023 -1,400 mL on 7/29/2023 -1,080 mL on 7/30/2023 Further record review revealed the following: -1,300 mL on 7/31/2023 - 840 mL on 8/1/2023 -1,200 mL on 8/2/2023 - 526 mL on 8/3/2023 - 840 mL on 8/4/2023 Additional record review revealed the resident continued taking two diuretics from 7/26/2023 to 8/3/2023; Bumetanide 2 mg daily, and Spironolactone 12.5 mg daily. Record review of multiple progress notes dated 8/5/2023 revealed the resident was discharged to the hospital at approximately 1:00 PM and was admitted with a diagnosis of hypernatremia (high amount of sodium in the blood). Record review of the hospital's physician assessment note for the resident dated 8/5/2023 states in part, .presents with decreased mental status found to have severe hypernatremia. Unclear what caused decreased PO [by mouth] intake in the first place however [s/he] is on diuretics and with decreased PO, hypernatremia likely in the setting of severe dehydration. Additional review of the hospital records revealed the following critical blood test results dated 8/5/2023: - BUN level of 93 mg/dl - Sodium of 184 mEq/L During a surveyor interview with the Director of Nursing Services on 8/16/2023 at 2:15 PM, she was unable to specify the amount of fluids necessary to push fluids to the resident that would prevent dehydration. Additionally, she was unable to provide evidence that the resident received adequate fluids to maintain health. During a surveyor interview on 8/16/2023 at 2:40 PM with the Physician, who implemented the order to push fluids he indicated that he would expect staff to offer more fluids subjectively. However, he would not indicate how much fluid the staff should have provided Resident ID #1 per his order topush fluids.

Based on record review, surveyor observation, and staff interview it has been determined that the facility failed to implement infection control measures for the prevention of the spread of Coronavirus Disease (COVID-19) relative to Resident ID #1. Findings are as follows: 1. Record review of the facility's policy titled, Facility Daily Operation Resident Related; General Information During COVID-19 Outbreak, last revised on 5/29/2021 states in part, .POLICY: It is the policy of this facility to comply with the CDC [Centers for Disease Control and Prevention], CMS [Centers for Medicaid and Medicare Services], and RI Department of Health (DOH) guidelines regarding awareness and prevention of the spread of Corona Virus (COVID-19) .Residents who are COVID-19 positive must remain in their room or an alternate setting/area with other COVID-19 positive residents .At no time is it allowed to have negative and positive cases in the same area at the same time . Review of the Rhode Island Department of Health document titled, COVID-19 Quarantine and Isolation Guidance by Population, last updated on August 11, 2021 states in part, .Nursing Home and Assisted Living Facility Residents .Isolation Duration -AND- End Isolation Requirements .Symptomatic person .Isolate for at least 10 days .Asymptomatic person, tested positive and does not have symptoms .Isolation may be discontinued when at least 10 days have passed since the date of their first positive diagnostic test . Record review revealed the resident was admitted to the facility in June of 2017. His/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's document titled, Covid testing line list Positive resident revealed the resident tested positive for COVID-19 on 8/23/2021. Review of a care plan last revised on 8/25/2021 states in part, Resident is COVID + [positive] .precautions as per protocol, monitor for increase temp, cough, respiratory distress, chills, body aches . Record review revealed the following progress notes which state in part: - 8/25/2021 9:58 AM, .Dementia with behaviors .COVID positive 08/23/21 . - 8/25/2021 3:24 PM, Resident alert/confused with paranoid/agitated behaviors wandering about the halls in and out of residents rooms . - 8/26/2021 10:14 PM, Resident alert/confused with paranoid/agitated behaviors wandering about the halls in and out of residents rooms .continues to wonder [sic.] halls and in and out patients rooms. - 8/27/2021 9:37 PM, Resident is alert to self and able to make needs known. Resident very hard to redirect and refuses to stay in [his/her] room . - 8/28/2021 2:05 PM, Call placed to doctor .Resident is in and out of patients room, Resident refuses to wear a mas [mask], resident comes in very close contact with other writer and cna [certified nurse assistant] have to come in between resident for social distancing .per MD [Medical Director] resident will need to be sent out if isolation is not possible . - 8/29/2021 11:10 PM, Resident alert/confused at baseline .noted wandering in the hallway .staff also able to have [him/her] rest in the lobby .[Resident] with a noted non-productive cough . - 8/30/2021 9:54 PM, .continue to be on precaution for positive covid .[s/he] is unable to stay in [his/her] room . - 8/31/2021 5:29 PM, Resident with some behaviors this afternoon during lunch as [s/he] was wandering into other residents rooms, throughout the dining room during meal time and halls .remains Covid (+) at this time on droplet precautions . During a surveyor observation on 9/1/2021 at approximately 1:00 PM of the downstairs unit, the resident was observed in the lobby area sitting at a table in front of the nurses' station, actively eating his/her lunch. At this time, several residents were observed actively eating in the unit's dining room located on the opposite side of the lobby where the resident sat. During a surveyor interview on 9/1/2021 at 1:05 PM with the Director of Nursing Services (DNS) and Staff Nurse A, the DNS acknowledged that the resident had tested positive for COVID-19 and was not isolated to his/her room. She revealed that the resident has dementia, is combative, and at times spits at staff. When asked how long the resident was seated at the table in front of the nurses' station, Staff Nurse A stated, about an hour. During an additional surveyor observation on 9/1/2021 at approximately 1:41 PM of the downstairs unit, the resident was observed again sitting at the same table in the lobby in front of the nurses' station not wearing a mask. During a surveyor observation on 9/1/2021 at approximately 1:50 PM, the resident stood up from his/her seat not wearing a mask and wandered into the therapy wing. The resident was then observed entering the therapy room. At this time, Staff B walked out of the therapy room with the resident and both walked back to the same table in front of the nurses' station. Staff Nurse A then approached the resident and walked with him/her back to his/her room. During a surveyor interview on 9/1/2021 at 1:56 PM with Staff B, she indicated that she was aware the resident had tested positive for COVID-19 and acknowledged that s/he was not isolated to his/her room. 2. During a surveyor observation on 9/1/2021 at approximately 12:45 PM, Staff C removed her gown, gloves, and eye protection prior to exiting a quarantine room. After exiting the quarantine room, she did not perform hand hygiene and proceeded to open the door of a meal truck in the hall. She then removed a meal tray from the truck and delivered it to a different room. During a surveyor interview on 9/1/2021 at 12:53 PM with Staff C, she acknowledged that she did not wash her hands with soap and water or use alcohol-based hand rub (ABHR) after removing her gown, gloves, and eye protection. During a surveyor interview on 9/1/2021 at 1:15 PM with the DNS, she indicated that she expects staff to wash their hands or use ABHR after removing personal protective equipment such as a gown, gloves, and eye protection.