Every finding on record at South Kingstown Nurs. & Rehab Ctr

Based on surveyor observation, clinical record review, and staff and resident interviews, the facility failed to ensure residents remained free from abuse and neglect for 1 of 1 resident reviewed when staff refused the resident's repeated requests for toileting assistance. Specifically, the facility failed to provide necessary care and services to a continent resident, resulting in the resident being left heavily saturated in urine and forced into an incontinent episode. This failure caused actual harm, including the development of a urinary tract infection (UTI) and psychosocial harm, for Resident ID #124.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/23/2026 revealed that Resident ID #124 alleged that Nursing Assistant (NA), Staff A, refused to assist him/her to the bathroom, instead instructed him/her to void in his/her brief, and did not change him/her when requested, during third shift on 4/22/2026 into 4/23/2026. According to ElderAbuse.org, elder neglect includes, but is not limited to, the failure to provide basic assistance to [an] older person who cannot self-perform daily living tasks like bathing, feeding, dressing, or going to the bathroom. Elder neglect can cause harm such as .Hygiene-Related Health Problems.like urinary tract infections.Record review revealed Resident ID #124 was admitted to the facility on [DATE] with diagnoses including, but not limited to, spinal stenosis (the narrowing of spaces within the spine) and surgical aftercare following surgery. Further review revealed the resident was discharged home on 5/3/2026. Review of the hospital Continuity of Care Form dated 4/22/2026 revealed the following provider discharge instructions following spinal surgery:- .full weight bearing.- .Do not remove your dressing. We will remove it at your 2 week follow up appointment.call the office if the dressing becomes saturated- .You are encouraged to be up and walking.Further review of the hospital documents revealed the resident required contact guard with ambulation with his/her rolling walker and assistance with transfers.Record review of the admission progress note dated 4/23/2026 at 12:52 AM, revealed the resident was admitted to the facility on [DATE] at 4:30 PM via ambulance and was transferred into bed by ambulance staff. Further review revealed the resident is alert and oriented to person, place, and time, had a surgical dressing to his/her lower back that was clean, dry and intact, and was continent of bowel and bladder. Additional review revealed the resident could ambulate with a rolling walker and staff assistance.Record review of a care plan dated 4/22/2026 revealed safe patient handling is one person assist with gait belt and rolling walker.Record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Further review revealed the resident is always continent of urine.Record review revealed the following nursing progress notes:-4/23/2026- the resident was able to make his/her needs known, required assist with activities of daily living (ADLS), and ambulates with assistance and a rolling walker. Further review revealed the resident was administered Valium (a medication prescribed to treat anxiety) twice for complaints of increased anxiety. Additional review revealed the surgical dressing to the resident's lower back was changed due to urine saturation and a message was left for the orthopedic surgeon.-4/24/2026 at 6:35 AM- the resident complained of urinary frequency and burning with urination. -4/24/2026 at 7:44 PM- the resident reports urinary frequency and burning with urination. Symptoms reported to the physician and a new order was given to obtain a urinalysis with a culture and sensitivity (UA C&S- a urine test used to diagnose urinary tract infections).-4/25/2026- the resident complains of urinary frequency and burning with urination, urine sample obtained as ordered and ready for lab pick up.-4/26/2026- the resident complains of urinary frequency and burning with urination. UA results reported to the provider. New order given for Bactrim DS (an antibiotic) twice daily for three days.-4/28/2026 at 12:34 PM - the resident's surgical dressing to his/her back was saturated with serosanguinous drainage (thin pink drainage) this morning. Dressing removed with visible redness and maceration (the softening or breakdown of skin caused by the prolonged exposure to moisture) to the incision and a copious amount of drainage observed.-4/28/2026 at 10:03 PM- call out to the orthopedic surgeon to report the redness to the surgical incision and moderate serosanguineous drainage. An appointment was scheduled for 4/29/2026.-4/29/2026 at 1:41 PM- resident out to orthopedic surgeon this morning for evaluation of surgical incision. A new order was received for a daily dressing change.During surveyor interviews on 5/8/2026 at 12:31 PM and on 5/11/2026 at 9:25 AM with Nurse Manager, Staff B, she indicated that she worked first shift on 4/23/2026 and found the resident anxious and upset that s/he was incontinent of urine on that morning since s/he was continent most of the time. She revealed that the resident reported to her that the Nursing Assistant on third shift refused to assist him/her to the bathroom which resulted in him/her being incontinent of urine. She further revealed that the surgical incision dressing was saturated with urine and required a dressing change which should not have been changed until the scheduled orthopedic follow up appointment in May. Additionally, she revealed that the resident began having urinary symptoms, was found to be positive for a UTI, and was treated with antibiotics soon after the incident. Furthermore, she revealed that nursing should review the hospital paperwork for functional status so they can communicate with the NA's who are providing care to the resident. During a surveyor interview on 5/11/2026 at 9:10 AM with the alleged perpetrator, NA, Staff A, she revealed that during third shift on 4/22/2026 into 4/23/2026 she refused to assist Resident ID #124 to the bathroom and further revealed that resident requested to be assisted into the bathroom multiple times. She indicated that she told the resident that she could not assist him/her to the bathroom because s/he had not been assessed by physical therapy yet. Additionally, she revealed she did not assist the resident with incontinence care prior to leaving the facility. During a surveyor interview on 5/11/2026 at 9:32 AM with the Director of Rehab, she revealed that she would expect nursing staff to review a resident's hospital discharge documents for the resident's transfer and ambulation status and implement those instructions until the facility's therapy staff can evaluate the newly admitted resident. During surveyor interviews on 5/8/2026 at 12:51 PM and on 5/11/2026 at 9:44 AM with the Director of Nursing Services, she revealed that Resident ID #124 was able to transfer and ambulate to the bathroom with assistance on admission. She further revealed that the resident reported that NA, Staff A refused to assist him/her to the bathroom during third shift on 4/22/2026 into 4/23/2026, did not offer him/her a bed pan, and told him/her to urinate in his/her brief. Additionally, she revealed that the resident required a dressing change to the surgical incision as it was found to be saturated in urine and that Staff A was terminated from the facility following the incident. Furthermore, she revealed that she would expect nursing staff to review the resident's hospital paperwork for transfer and ambulation status and that staff would assist the resident as needed.During a surveyor telephone interview on 5/12/2026 at 10:35 AM with Resident ID #124, s/he revealed that s/he requested to be assisted to the bathroom many times on third shift, but the staff refused to assist him/her. The resident revealed that s/he was incontinent of urine and became very upset because the staff refused to assist him/her. S/he further revealed that his/her surgical incision dressing became itchy and saturated with urine following the incontinence episode caused by the staff's refusal to assist him/her to the bathroom. Additionally, Resident ID #124 revealed that s/he was not assisted to the bathroom when necessary multiple times that night and later had to be treated for a UTI.The facility's failure to keep the resident free from neglect resulted in psychosocial and physical harm to the resident as evidenced by the resident's increased anxiety following the incident, experiencing urinary symptoms and being diagnosed with a UTI, and requiring dressing changes and an unscheduled outpatient visit with the orthopedic surgeon to evaluate the status of the resident's surgical incision, 8 days prior to the scheduled follow up visit.

Based on clinical record review, resident and staff interviews, the facility failed to provide reasonable accommodation of resident needs and preferences, for 1 of 1 resident reviewed related to not getting out of bed, Resident ID #72.Findings are as follows:Record review revealed the resident was originally admitted to the facility in February of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (a lung condition that causes long-term breathing problems by limiting airflow), encephalopathy (a generalized dysfunction of the brain), and complications of colostomy (a surgical procedure that creates an opening in the abdominal wall, bringing a portion of the large intestine to the surface to allow stool to exit).Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 13 out of 15, indicating the resident is cognitively intact. Further review revealed that the resident is dependent on two staff members for transfers out of bed.Additional review of the MDS Section F- Preferences for Customary Routine and Activities revealed that it was not important to the resident to participate in group activities, however, it was somewhat important to do his/her favorite activities and very important for him/her to participate in religious services or practices as well as to go outside to get fresh air when the weather is good.Record review of a care plan initiated on 2/6/2026 revealed an intervention to encourage the resident to get out of bed but to respect his/her decision to stay in bed if s/he chooses. It further indicated that the resident declines invites to group activities and to offer 1 to 1 visits by activity staff as needed.Record review of a document titled Occupational Therapy OT Discharge Summary dated 10/22/2025, revealed that the resident was out of bed for greater than 6 hours at a time with the use of a cardiac recliner, gel matrix cushion and a pillow to his/her left side to maintain upright posture.During a surveyor interview on 5/6/2026 at 9:12 AM with the resident, s/he revealed that s/he could not recall the last time s/he was out of bed and indicated that staff does not offer to get him/her out of bed. The resident further revealed that s/he was unaware if s/he had a wheelchair to use, however s/he would like to get out of bed for a change of positioning and to go outside.Record review failed to reveal evidence that the resident refuses to get out of bed. During a surveyor interview on 5/8/2026 at 12:43 PM with Nursing Assistant, Staff C, she revealed that she was unable to recall the last time the resident had been out of bed, and indicated that it had been several weeks, possibly months. During a surveyor interview on 5/8/2026 at 12:48 PM with Licensed Practical Nurse, Staff D, she revealed that she was unable to recall the last time the resident had been out of bed. Additionally, she acknowledged that there was no documentation in the record that the resident refused to get out of bed.During a surveyor interview on 5/8/2026 at 2:23 PM with Occupational Therapy Assistant, Staff E, she revealed that she had treated the resident in October of 2025, at which time s/he was getting out of bed 3 to 4 times a week for 6 or more hours a day, and that the resident had not refused treatments. She further revealed that the therapy department had not been informed of any changes in the resident's condition.During a surveyor interview on 5/8/2026 at 3:09 PM with the Activities Director, he revealed that the resident had last been out of bed to attend a social activity on 12/4/2025.During surveyor interviews with the Director of Nursing Services on 5/8/2026 at 3:02 PM and on 5/11/2026 at 9:03 AM, she revealed that it was her expectation that residents are offered and encouraged to get out of bed daily. Additionally, she revealed that Resident ID #72 frequently refuses to get out of bed, however, she was unable to provide evidence of said refusals.

Based on clinical record review and staff interview, the facility failed to meet professional standards of quality regarding not following physician's orders for 1 of 1 resident reviewed related to medications with heart rate (HR) parameters, Resident ID #38.Findings are as follows:Record review of a facility policy titled, Medication Administration Safety Program revealed in part, .the physician's order must be verified before the medication is given.when medication are held/refused, the MD is to be notified timely.Record review revealed the resident was admitted to the facility in March of 2026 with diagnoses including, but not limited to, cardiomyopathy (a disease effecting the heart muscle which causes the heart to have a harder time pumping blood), and atrial fibrillation (an irregular and often very rapid heart rhythm).Record review revealed the following physician's order:4/6/2026-Metoprolol tartrate 25 milligrams (mg) twice daily. The order contained instructions to hold for a heart rate below 55 beats per minute (bpm), and to notify the physician.A review of the Medication Administration Records (MAR) from April 7 through April 30, 2026, revealed the medication was held on the following dates and times with no notification of the physician:4/7/2026- 5:00 PM to 8:00 PM dose- held for a HR of 524/14/2026-7:00 AM to 11:00 AM dose- held for a HR of 574/14/2026-5:00 PM to 8:00 PM dose- held for a HR of 524/16/2026-5:00 PM to 8:00 PM dose- held no documented HR4/18/2026- 5:00 PM to 8:00 PM dose- held for a HR of 524/20/2026-7:00 AM to 11:00 AM dose- held for a HR of 504/21/2026-7:00 AM to 11:00 AM dose- held for a HR of 524/22/2026-7:00 AM to 11:00 AM dose- held for a HR of 584/23/2026-5:00 PM to 8:00 PM dose- held for a HR of 524/24/2026-5:00 PM to 8:00 PM dose- held for a HR of 494/25/2026-7:00 AM to 11:00 AM dose- held for a HR of 544/26/2026-7:00 AM to 11:00 AM dose- held for a HR of 514/27/2026-7:00 AM to 11:00 AM dose- held for a HR of 674/27/2026- 5:00 PM to 8:00 PM dose- held no documented HR4/28/2026-5:00 PM to 8:00 PM dose- held for a HR of 504/29/2026-5:00 PM to 8:00 PM dose- held for a HR of 50Review of the MAR from May 1 through May 7, 2026, revealed the medication was held on the following dates and times with no notification of the physician:5/1/2026- 5:00 PM to 8:00 PM dose- held for a HR of 535/2/2026- 5:00 PM to 8:00 PM dose-held for a HR of 545/3/2026-5:00 PM to 8:00 PM dose-held for a HR of 565/4/2026-5:00 PM to 8:00 PM dose- held no documented HR5/6/2026- 7:00 AM to 11:00AM dose-held for a HR of 52Record review of the progress notes failed to reveal that the physician was notified, per the physician's order, that the metoprolol was held on the above dates and times. The physician failed to be notified 16 out of the 19 times the medication was held in April, and 5 out of the 6 times the medication was held in May.During a surveyor interview on 5/8/2026 at approximately 12:20 PM with Licensed Practical Nurse, Staff B, she acknowledged that the order was to notify the physician if the medication was held. She was unable to find evidence in the resident's record that the physician was notified when the medication was held on the above dates and times.During a surveyor interview on 5/8/2026 at approximately 12:30 PM with the Director of Nursing services she was unable to provide evidence that the physician was notified that the metoprolol was held on the above dates and times.Cross Reference F 760

Based on clinical record review and staff interview, the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 1 resident reviewed for medication errors due to heart rate parameters, Resident ID #38. Findings are as follows:Record review revealed the resident was admitted to the facility in March of 2026 with diagnoses including, but not limited to, cardiomyopathy (a disease effecting the heart muscle which causes the heart to have a harder time pumping blood), and atrial fibrillation (an irregular and often very rapid heart rhythm).Record review revealed the following physician's order:4/6/2026-Metoprolol tartrate 25 milligrams (mg) twice daily. The order contained instructions to hold for a heart rate below 55 beats per minute (bpm), and to notify the physician.A review of the April and May 2026, Medication Administration Records (MAR) revealed the medication was held for a heart rate above 55 bpm on the following dates and times:4/14/2026- 7:00 AM to 11:00 AM dose- held for a heart rate of 574/22/2026- 7:00 AM to 11:00 AM dose- held for a heart rate of 584/27/2026- 7:00 AM to 11:00 AM dose- held for a heart rate of 675/3/2026- 5:00 PM to 8:00 PM dose- held for a heart rate of 565/7/2026 - 5:00 PM to 8:00 PM dose- held for a heart rate of 57Further review of the April and May 2026 MARs revealed the medication was held with no documented heart rate listed on the following dates and times:4/16/2026- 5:00 PM to 8:00 PM dose4/27/2026- 5:00 PM to 8:00 PM dose5/4/2026- 5:00 PM to 8:00 PM doseDuring a surveyor interview on 5/8/2026 at approximately 12:25 PM with Licensed Practical Nurse, Staff B, she acknowledged the above doses of metoprolol were given outside the heart rate parameters.During a surveyor interview on 5/8/2026 at approximately 12:30 PM with the Director of Nursing Services, she could not provide evidence that the resident's metoprolol was administered as ordered on the above dates.Cross Reference F 658

Based on clinical record review and staff interview, the facility failed to ensure that the resident's formulated advance directive would be followed due to inconsistency between the signed advanced directive and the electronic medical record (EMR) for 1 of 1 resident reviewed for a change in code status, Resident ID #86.Findings are as follows:Record review revealed a signed Advanced Directive dated 4/27/2026, indicating that the resident checked Full Code, .911 will be called. All resuscitative and aggressive measure are provided and I will be transferred to the hospital.Record review revealed a physician's order for Do Not Resuscitate (DNR) with a start date of 5/27/2025. This order was not discontinued until 5/8/2026, after the surveyor brought it to the facility's attention.Record review of the resident's chart revealed that DNR was also displayed on the banner at the top of his/her medical record.During a surveyor interview on 5/8/2026 at 9:47 AM with Licensed Practical Nurse (LPN), Staff D, after reviewing the resident's EMR banner and the physician's order, she stated that the resident's code status was DNR. This indicates that resuscitative measures would not be provided to the resident. During a surveyor interview on 5/8/2026 at 9:49 AM with LPN, Staff B, she revealed that she would look at the EMR to discover a resident's code status. She revealed that this resident is listed as DNR in the computer. She acknowledged after looking at the advance directive with the surveyor that the resident updated his/her code status to full code on 4/27/2026, however, it had not been updated in the EMR. During a surveyor interview on 5/8/2026 at 9:58 AM with the Director of Nursing Services, she revealed that she would expect the code status order to have been updated to match the resident's advance directive.

Based on clinical record review and staff interview, the facility failed to ensure that a resident receives care, consistent with professional standards of practice to prevent pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure) for 1 of 2 residents reviewed with pressure ulcers, Resident ID #3.Findings are as follows:Record review revealed the resident was readmitted to the facility in March of 2026 with a diagnosis including, but not limited to, dementia.Review of a care plan focus area initiated on 3/3/2026 revealed the resident was admitted to the facility with pressure injuries to his/her left ankle and foot. An intervention includes, but is not limited to, monitor and treat areas to left ankle and foot, as ordered.Record review revealed a document titled, Skin Ulcer Documentation, dated 5/5/2026 which revealed the resident has a stage III pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer) on his/her left lateral foot.Review of a document titled, Extended Wound Care Service Line Procedure / Progress Note, dated 5/5/2026 revealed the resident was seen by the wound provider, Nurse Practitioner, Staff F, with an order for the resident's left lateral foot wound, which states, paint with betadine [an antiseptic solution].Record review revealed a progress note dated 5/5/2026, authored by Registered Nurse (RN), Staff G, which states, Wound nurse in for treatment to left ankle/foot. New order per wound nurse to apply iodine to left lateral foot. Order reviewed and approved by MD [Medical Doctor].Record review revealed a physician's order, with a start date of 5/7/2026 which revealed to wash the left lateral foot wound with wound cleaner, pat dry, apply calcium alginate (wound treatment), followed by zetuvit bordered dressing (an adhesive bordered dressing).Review of the May 2026 Treatment Administration Record revealed the above order was signed off as completed on 5/7/2026.During a surveyor interview on 5/8/2026 at 11:45 AM, with Staff F, she revealed that her recommendation on 5/5/2026 for the resident's left lateral foot wound was to paint the wound with betadine and leave it open to air, indicating she changed the treatment to dry out the wound.During a surveyor interview on 5/8/2026 at 11:51 AM, with Staff G, she revealed that Staff F verbally told her about the new recommendation for the resident's left lateral foot. She revealed that she was provided the Extended Wound Care Service Line Procedure / Progress Note on 5/5/2026 but indicated that she did not confirm the verbal recommendation with the written recommendation on the form because it was hard to read the providers handwriting.During a surveyor interview on 5/8/2026 at 12:02 PM, with RN, Staff H, she revealed that she transcribed the incorrect order for the resident's left lateral foot and acknowledged the order should have been to paint the wound with betadine and leave it open to air, based on the recommendation provided by Staff F.During a surveyor interview on 5/8/2026 at 12:17 PM, with the Director of Nursing Services, she revealed that she would expect staff to repeat the order back to the provider or call the provider if the recommendation needed to be clarified.

Based on clinical record review and staff interview, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed. Resident ID #1 was inadvertently administered multiple medications prescribed for his/her roommate, Resident ID #2. The medications included two antihypertensives (a medication prescribed to treat high blood pressure), an antidiabetic (a medication prescribed to lower high blood sugar), an antiplatelet (a medication prescribed to prevent blood clots from forming), an antiparkinsonian agent (a medication prescribed to treat Parkinson's Disease), an antidepressant (a medication prescribed to treat depression), a multivitamin, and two additional vitamins. As a result of this error, Resident ID #1 required hospitalization for hypotension (low blood pressure). Review of a facility reported incident submitted to the Rhode Island Department of Health on 2/13/2026 alleges that Resident ID #1 was inadvertently administered medications intended for another resident and s/he was subsequently transferred to the hospital after a change in condition. Resident ID #1 was admitted to the hospital with hypotension. According to the facility policy titled, Medication Administration Safety Program (MASP) - Safety Guidelines, states in part, .2. The same person preparing the doses for administration must administer the medication.4. Prior to actually giving the resident the medication(s), the licensed staff member must confirm the resident's identity. Record review revealed Resident ID #1 was admitted to the facility in January of 2026 with diagnoses including, but not limited to, orthostatic hypotension (a rapid sudden drop in blood pressure when rising from a sitting or lying position), autonomic nervous system disorder (a condition where the nerves that regulate body functions such as blood pressure heart rate and temperature, fail to function properly), and thrombocytopenia (lower than normal level of platelets in the blood which can lead to bleeding). Record review revealed that Resident ID #2 was admitted to the facility in July of 2025 with diagnoses including, but not limited to, Parkinson's Disease (a progressive neurodegenerative disorder affecting the central nervous system), diabetes mellitus (high blood sugar from the body's inability to produce insulin), high blood pressure, major depressive disorder, and coronary artery disease (a condition of the heart where plaque buildup narrows the arteries). During a surveyor interview on 2/16/2026 at 11:26 AM with Registered Nurse (RN), Staff A, she revealed that on 2/12/2026 she was training a newly hired nurse, Licensed Practical Nurse (LPN), Staff B, to administer medications during the morning medication pass. Staff A further revealed that after preparing each of Resident ID #2's medications at the medication cart with Staff B, she instructed Staff B to administer the prepared medications to Resident ID #2. Staff B went into the resident's room and then came back to the medication cart where Staff A had prepared Resident ID #1's medications. Staff A and B went back into Resident ID #1 and ID #2's room to administer the medications prepared by Staff A, to Resident ID #1 and at that time Staff B revealed to Staff A that she had administered Resident ID #1 the medications that were intended for Resident ID #2. Additionally, Staff A revealed that she prepared the following medications that were administered to Resident ID #1 in error: -Lisinopril 10 milligram (mg) (antihypertensive)-Metoprolol Succinate extended release 50 mg (antihypertensive)-Plavix 75 mg (antiplatelet) -Sinemet 25-100 mg (antiparkinsonian agent)-Venlafaxine 37.5 mg (antidepressant) -Metformin 1,000 mg (antidiabetic) -Daily multivitamin 1 tablet -Folic acid 1 mg (vitamin)-Vitamin D3 1000 units (vitamin) During a surveyor interview on 2/16/2026 at 11:57 AM with LPN, Staff B, she revealed that on 2/12/2026 RN Staff A was training her to administer medications during the morning medication pass. Staff B further revealed that Staff A was reviewing each medication that she was preparing for Resident ID #2 with her, and that she was watching Staff A and also viewing the electronic medication record. Staff A then handed her the cup with the medications prepared for Resident ID #2 and instructed her to administer the medications to Resident ID #2. Staff B further revealed that she went into the residents' room and proceeded to identify both Resident ID #1 and Resident ID #2, and then administered the medications intended for Resident ID #2 to Resident ID #1. Staff B returned to the medication cart to meet Staff A, who had prepared Resident ID #1's medications for administration. Staff B re-entered the residents' room with Staff A to administer Resident ID #1 his/her medications and it was at that time that Staff B informed Staff A that she had administered Resident ID #1 the medications that were intended for Resident ID #2. Record review revealed the following: A nursing progress note dated 2/12/2026 at 12:44 PM, authored by Staff A revealed the resident's blood pressure was noted at 99/61 (normal blood pressure reading 120/80) immediately after the error was identified, the physician was notified and ordered Resident ID #1 to receive his/her medication, Midodrine (a medication prescribed to treat low blood pressure). A subsequent blood pressure was obtained after the Midodrine medication was administered, and the results were 104/60. A nursing progress note dated 2/12/2026 at 3:21 PM, authored by Staff A, revealed Resident ID #1 had a blood pressure of 78/40, the physician was notified and ordered for Resident ID #1 to receive Midodrine 10 mg, one time, STAT (immediately). A subsequent blood pressure was obtained approximately 1 hour later, and the results were 87/48. A nursing progress note dated 2/12/2026 at 5:10 PM, authored by Staff A, revealed Resident ID #1's blood pressure was 63/37 and s/he was now pale and weak. The physician was notified, and an order was obtained to transfer the resident to the hospital. A nursing progress note dated 2/12/2026 at 9:05 PM revealed Resident ID #1 was admitted to the hospital with a diagnosis of hypotension (an abnormally low blood pressure). Record review of the hospital continuity of care documentation revealed the Resident ID #1 arrived at the Emergency Department (ED) via EMS (emergency medical services) transport on 2/12/2026, where s/he presented with a blood pressure reading of 80/60, dizziness, and lightheadedness. The document indicated that s/he was administered an intravenous (IV) fluid bolus during EMS transport prior to his/her arrival to the ED. Additionally, the record indicated that his/her blood pressure was monitored, and that Resident ID #1 required additional IV fluids for systolic (the top number of a blood pressure reading that measures the pressure in the arteries when the heart muscle contracts) blood pressure readings in the 80's. During a surveyor interview on 2/16/2026 at 9:48 AM and 10:38 AM with the Director of Nursing Services, she acknowledged that Resident ID #1 inadvertently received Resident ID #2's medications on 2/12/2026, and that Resident ID #1 subsequently became hypotensive, and was transferred to the hospital where s/he was admitted with hypotension.As a result of this survey, it has been determined that Resident ID #1 was placed at risk for serious harm, injury, impairment or death due to Staff B's failure to identify the correct resident prior to administering medications. As a result of this failure, Resident ID #1 exhibited adverse effects from receiving the medications that were not prescribed to him/her. Resident ID #1 was transferred to an acute care hospital, required interventions and was subsequently admitted .

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling Foley catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #3. Findings are as follows: Review of a facility reported incident received by the Rhode Island Department of Health on 4/9/2025 revealed that Resident ID #3 had a Foley catheter replaced at the facility without a physician's order. Review of Lippincott Nursing Procedures Manual Ninth Edition, last revised in 2023, states in part, .Indwelling Catheter Care and Removal .Indwelling Urinary Catheter Insertion .verify the practitioner's order . Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, obstructive (a structural or functional hindrance of normal urine flow) and reflux (a condition where there is a backflow of urine into the kidney) uropathy and retention of urine. Review of the resident's care plan dated 3/26/2025, revealed a focus area for an indwelling urinary catheter related to his/her diagnosis of obstructive uropathy. Interventions include, but are not limited to, monitor, record, and report signs and symptoms of a urinary tract infection. Review of a physician's order dated 3/26/2025 indicated the use of an 18 French (Fr; refers to the measurement of the outer diameter of the catheter) Foley catheter with a 10 cubic centimeter (cc) (the amount of saline required to inflate the catheter's balloon for stability in the bladder). The order also revealed that the resident had a urology appointment scheduled for April 24, 2025, at 1:30 PM to have the Foley catheter replaced. Review of a progress note dated 4/9/2025, authored by Registered Nurse, Staff A, states in part, Resident observed to be pulling on Foley at times overnight and resistant to redirection to not pull on it. Foley noted to have less than 100 ml (milliliter) urine output at approximately 2am, nurse attempted to flush Foley but unable to get return. Foley removed and new foley 16 fr 5 cc balloon coude tip (a urinary catheter with a curved tip designed to navigate around obstacles in the urethra, such as an enlarged prostate) catheter inserted with immediate return of more than 100 ml urine . This progress note indicates that Staff A replaced the resident's Foley with a Foley that is larger in diameter, has a smaller balloon to anchor it in place, and is a different style Foley than the physician's order. Additionally, the order did not indicate that the resident required a coude catheter. Record review failed to reveal evidence of a physician's order to change the resident's Foley catheter prior to the 4/25/2025 scheduled appointment. Further review of the progress note dated 4/9/2025 revealed, .During foley insertion [genitalia] noted to be slightly enlarged. Nurse provided resident with rolled towel under [genitalia] while in bed. Upon nurse-to-nurse handover [genitalia] and hematuria [blood in the urine] reassessed. [Genitalia] noted to have increased significantly in size while elevated on rolled towel. Hematuria noted to foley bag. Blood noted to urethral opening. Transfer to emergency room for evaluation initiated. During a surveyor interview on 4/17/2025 at approximately 8:30 AM with the Director of Nursing Services, in the presence of the Administrator, she revealed that the resident's diagnosis upon hospital admission was pyelonephritis (inflammation of the kidney usually due to a bacterial infection). She indicated that Staff A should not have changed the resident's Foley catheter, because the resident had an order in place to have it changed at the urologist's office. Additionally, she revealed that she would have expected the nurse to call the physician with her concerns, for further recommendations and orders.

Based on record review and staff interview, it has been determined that the facility failed to ensure that resident records are complete and accurately documented, relative to narcotic medication administration, for 3 of 6 residents reviewed, Resident ID #s 2, 4, and 5. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/9/2025 indicated that two alert and oriented residents reported they did not receive their PRN (as needed) narcotic pain medication overnight after requesting it multiple times and that there appeared to be discrepancies between the narcotic log book and the resident's Medication Administration Records (MAR). According to the Lippincott Nursing Procedures Ninth Edition last revised in 2023 states in part, .Safe Administration Practices .Document all medications administered in the patient's MAR or EMAR [Electronic Medication Administration Record]. Include the medication strength, dose, route of administration, and date and time of administration . A. Record review revealed Resident ID #2 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, pain related to lumbar spinal stenosis (a condition in which the spaces in the spine narrow, compressing the spinal cord or nerves) and cognitive communication deficit. Record review revealed a physician's order dated 3/25/2025 for oxycodone (a narcotic medication prescribed to treat pain) 10 milligrams (mg), with instructions to administer 1 tablet every six hours, as needed. Review of the Narcotic Administration Log revealed documentation that the resident was administered one tablet of oxycodone, 10 mg , on 4/9/2025 at 12:30 AM, by Registered Nurse, Staff A. Review of Resident ID #2's April 2025 MAR failed to reveal evidence that the 4/9/2025 dose of oxycodone 10 mg, was documented as being administered to Resident ID #2. B. Record review revealed Resident ID #4 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, spondylolisthesis (a condition that develops when one of the bones in the spine slips out of alignment). Record review revealed the following physician's orders dated 4/6/2025: - oxycodone 5 mg, with instructions to administer one tablet every six hours, as needed for severe pain (for a pain score of 8-10) - oxycodone 5 mg, with instructions to administer 1/2 tablet (2.5mg) every six hours as needed (for a pain score of 4-7) Review of the Narcotic Administration Log revealed documentation that Staff A administered oxycodone twice on 4/9/2025. Once at 12:05 AM, and then again 6:15 AM. Review of Resident ID #4's April 2025 MAR failed to reveal documentation that the 4/9/2025 doses of oxycodone at 12:05 AM and 6:15 AM were administered to Resident ID #4. C. Record review revealed Resident ID #5 was admitted to the facility in April of 2025 with diagnoses including, but not limited to encephalopathy (a disorder and/or disease of the brain that affects its normal functioning) and multiple cancerous tumors throughout the resident's body. Record review revealed the following physician's orders dated 4/7/2025: - oxycodone 5 mg, with instruction to administer 1 tablet every six hours, as needed for pain (for a pain score of 5 - 8) - oxycodone 5 mg, with instructions to administer 2 tablets, every six hours, as needed for pain (for a pain score of 9 - 10). Review of the Narcotic Administration Log revealed documentation that Resident ID #5 was administered two tablets of oxycodone, 5 mg, on 4/8/2025 at 10:00 PM, by Staff A. Review of Resident ID #5's April 2025 MAR failed to reveal documentation that the 4/8/2025 dose of oxycodone, 10 mg, was administered to Resident ID #5. During a surveyor interview on 4/17/2025 at approximately 9:00 AM, with the Director of Nursing Services, she acknowledged that the documentation in the Narcotic Administration Logs for Resident ID #s 2, 4, and 5, were not documented on the residents' MARs.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms observed and 3 of 4 medication carts observed. Findings are as follows: Review of the facility policy dated 1/2021, titled, Medication Storage states in part, .POLICY: It is the policy of this facility that medications and biological's are stored properly, following manufacturers or provider pharmacy recommendations .14. Outdated, contaminated, discontinued or deteriorated medications .should be immediately removed from stock . 1a. During a surveyor observation on 2/11/2025 at 8:50 AM of the Pond View unit medication cart, in the presence of Registered Nurse (RN), Staff A, the following was revealed: -One Wixela inhaler, opened with a date of 12/12. Review of the manufacturer's instructions indicate to discard the inhaler one month after opening. -One Arnuity inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler one month after opening. -One Treligy Ellipta inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. During a surveyor interview with Staff A, she acknowledged that the Wixela inhaler had a date of 12/12, and that it was outdated. Staff A revealed that the other two inhalers should have been dated when opened. 1b. During a surveyor observation on 2/11/2025 at 9:15 AM of the Tradewinds unit medication cart, in the presence of Licensed Practical Nurse, Staff B the following was revealed: -One Treligy Ellipta inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. During a surveyor interview with Staff B, he acknowledged that the inhaler was opened without a date, and he revealed that the inhaler should have been dated when opened. 1c. During a surveyor observation on 2/11/2025 at approximately 9:30 AM of the Robin's Way unit medication cart, in the presence of RN, Staff C, the following was revealed: -One Anoro Ellipta inhaler, opened with a date of 12/16. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. -One Anoro Ellipta inhaler, opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. -Two Treligy Ellipta inhalers, both were opened without a date. Review of the manufacturer's instructions indicate to discard the inhaler 6 weeks after opening. -One Combivent Respimat inhaler, opened without a date. Review of the manufacturer instructions indicate that once the cartridge is inserted, discard in three months. During a surveyor interview with Staff C, she acknowledged that one of the Anoro inhalers had a date of 12/16. and that it was outdated. Staff C revealed the other inhalers should have been dated when opened. 2. During a surveyor observation on 2/11/2025 at approximately 9:45 AM of the Robin's Way medication room, in the presence of Staff C the following was revealed: -One bottle of Lorazepam intensol, opened without a date. Review of the manufacturer's instructions indicate to discard the Lorazepam 90 days after opening. During a surveyor interview with Staff C, she acknowledged that the Lorazepam intensol should have been dated when opened. During a surveyor interview on 2/11/2025 at 8:50 AM and 4:19 PM with the Director of Nursing Services, she revealed that she would expect that medications are dated when opened and that the outdated inhalers should have been discarded.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that they distribute and serve food in accordance with professional standards for food safety relative to 2 of 4 units observed during the lunch meal service. Findings are as follows: According to the, State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last updated in August of 2024, states in part, .'Food Service' means the processes involved in actively serving food to the resident. When actively serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance (i.e., down a hallway, to a different unit or floor) . A surveyor observation on 2/11/2025 at approximately 12:00 PM of the Pond View unit, revealed a sheet pan rack (a heavy-duty aluminum rack with uniformly spaced tray slides) being transported from the kitchen to the unit, approximately 300 feet, with desserts that were uncovered. Staff then distributed the desserts to the residents. During surveyor observations on 2/11/2025 at 12:15 PM and 2/12/2025 at 12:18 PM of the Tradewinds unit, revealed a sheet pan rack being transported from the kitchen to the unit, approximately 400 feet, with desserts that were uncovered. Staff then distributed the desserts to the residents. During a surveyor interview on 2/12/2025 at 12:20 PM with Nursing Assistant, Staff D, she acknowledged that the desserts were not covered while being transported from the kitchen. During a surveyor interview on 2/12/2025 at approximately 12:45 PM with the Food Service Director, she acknowledged that the desserts were not covered when being transported to the units. Additionally, she indicated that it has been the facility's practice to not cover desserts, for the last [AGE] years. 21613

Based on record review, staff, and resident interview, it has been determined that the facility failed to protect a resident's right to be free from abuse for 2 of 2 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: Record review of facility reported incident submitted to the Rhode Island Department of Health on 9/30/2024 indicates that Resident ID #2 was witnessed by staff slapping Resident ID #1 on the back of his/her head at which time, Resident ID #1 then slapped the hand of Resident ID #2. Record review revealed that Resident ID #1 was admitted to the facility in November of 2021 with diagnoses including, but not limited to, Alzheimer's disease, dementia with agitation, cognitive communication deficit, adjustment disorder, anxiety disorder and major depressive disorder. Record review for Resident ID #1 revealed a Minimum Data Set (MDS) assessment dated [DATE] that revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. A surveyor interview with Resident ID #1 was unable to be conducted due to the resident's cognition. Record review revealed that Resident ID #2 was admitted to the facility in December of 2023 with diagnoses including but not limited to vascular dementia with agitation, mechanical complication of a ventricular intracranial shunt, cerebrovascular disease, depression, muscle weakness, adjustment disorder, and convulsions. Record review for Resident ID #2 revealed an MDS assessment dated [DATE] that revealed a BIMS score of 99, indicating that s/he was unable to complete the assessment due to his/her cognition. Record review revealed that Resident ID #2 has a history of behaviors including physical and verbal abuse towards others. A surveyor interview with Resident ID #2 was unable to be conducted due to the resident's cognition. During a surveyor interview with Registered Nurse, Staff A, on 9/20/2024 at 12:57 PM, she revealed that on 7/30/2024 she witnessed Resident ID #2 slap Resident ID #1 on the back of the head followed by Resident ID #1 slapping the hand of Resident ID #2. During a surveyor interview with the Administrator and the Director of Nursing Services on 9/20/2024 at approximately 1:45 PM, the Administrator acknowledged that this incident did happen as it was witnessed by staff and Resident ID #2 did sustain an abrasion on the back of his/her hand as a result of this incident.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight for 1 of 2 residents reviewed for weight gain, Resident ID #11. Findings are as follows: Record review of an undated facility policy and procedure for Weight Loss/Gain Protocol and Heights, provided to the surveyor on 2/28/2024, states in part, .All residents are to be weighed upon admission and at least monthly; so as to monitor for weight loss or gain, to assess for underlying causes of weight loss or gain, to intervene accordingly and timely to allow for an optimal level for well-being .PROCEDURE: .For purpose of this policy, a significant weight discrepancy is defined as: .A loss/gain of 5% or greater within one month .When a significant weight loss/gain is noted (as defined above), the following interventions may be considered: 1. Reweigh all residents who are reported to have significant weight discrepancy in order to assess the accuracy of the weight. The reweigh shall be done within 2 days of the initial weight. 2. If the re-weigh is accurate and there has been a significant weight loss/gain, nursing must notify the; -physician -Dietician -DNS [Director of Nursing Services] .start the weekly weights, if not already on .Document all information in the medical record and update the care plan .If weight loss/gain is desirable, then simply document accordingly and assure plan is current . Record review of the resident revealed s/he was admitted to the facility in July of 2023, with diagnoses to include, but not limited to, cognitive deficit, hyponatremia (sodium levels in the blood are abnormally low), high blood pressure, chronic kidney disease, and atrial fibrillation (irregular and rapid heart rate). Further record review revealed the resident has a care plan for nutritional status dated 8/18/2023 that indicates, I am of nutritional concern r/t [related to] edema [swollen]/diuretic [medication to reduce fluid build up in the body], weight fluctuation . with an intervention including, but not limited to, monitor and record weight per schedule . Record review revealed the following documented weights: 11/8/2023 - 133 pounds (lbs) 1/5/2024 - 138 lbs 2/8/2024 - 146 lbs Further review of the above-mentioned weights revealed a total weight gain of 13 lbs. between 11/8/2023 and 2/8/2024, indicating a 9.77% significant weight gain over 3 months. Additionally, the resident experienced an 8 pound weight gain between 1/5/2024 and 2/8/2024 indicating a 5.8% significant weight gain over one month. Record review failed to reveal evidence that the resident was re-weighed per the facility's policy. Additionally, record review failed to reveal evidence that the physician was notified or that the dietitian was consulted when the resident experienced an unplanned significant weight gain. During a surveyor interview on 2/28/2024 at 10:50 AM, with Registered Nurse, Staff A, she revealed that she was unaware of the above-mentioned weight gain. She revealed that a reweigh should be obtained when a resident experiences a 5 pound weight gain/loss in one month, if the reweigh accurately reflects a significant unplanned weight loss/gain, they whould notify the physician and the dietitian. She further indicated that weekly weights would then be obtained. During a surveyor interview on 2/28/2024 at 11:10 AM, with the DNS, she revealed that she was unaware of the resident's weight gain. Additionally, she was unable to provide evidence that a reweigh had been obtained or that the resident's care plan was revised to reflect the significant weight gain. Additionally, the DNS was also unable to provide evidence that the resident's physician was notified, or that the dietitian was consulted as per the facility policy. During a surveyor interview on 2/28/2024 at 11:12 AM, with the Dietitian, Staff B, she revealed that she was unaware of the above-mentioned weight gain. She further revealed that she would expect staff to inform her when a resident experiences a significant unplanned weight gain and would expect that staff would obtain a reweigh to ensure accuracy.

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 designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident observed specific to finger stick blood glucose testing, Resident ID #194. Findings are as follows: Record review of a facility policy titled, Diabetes - Care of equipment SECTION: Infection Control, dated 3/11/2005 states in part, .It is the policy of this facility to develop and support Infection Control practices that are designed to prevent transmission of blood borne pathogens from diabetes-care procedures .4. Dispose of used lancets [used to obtain a blood sample from a finger] at the point of use in approved sharp containers . Record review of a document titled, Competency Validation for Blood Glucose Testing states in part, .discarding the used lancet after use in the sharps container . Record review revealed the resident was admitted to the facility in February of 2024, with a diagnosis including, but not limited to, diabetes (high blood sugar). During a surveyor observation on 2/28/2024 at 12:00 PM, Registered Nurse, Staff C, was observed checking the resident's blood glucose level, she was then observed to remove her used gloves and dispose of them in the resident's waste basket along with the used lancet. During a surveyor interview with Staff C immediately following the above observation, she acknowledged that she disposed of the used lancet in the resident's waste basket, and not in a sharps container per the facility's policy. During a surveyor interview on 2/28/2024 at approximately 12:15 PM, with the Director of Nursing Services, she acknowledged that Staff C should have disposed of the lancet in a sharps container per the facility policy. 43987

Based on record review and staff interview, it has been determined that the facility failed to revise a care plan after each assessment for 1 of 6 residents reviewed relative to safe patient handling (SPH), Resident ID #7. Findings are as follows: Review of a facility policy titled Safe Resident Handling last reviewed on 1/25/2022 states in part, .Conduct a resident handling hazard assessment to identify resident handling tasks .an assessment will be done in order to identify the resident's safest transfer status .Once determined, the resident's transfer status must be added to the care plan and record so that other direct care employees are aware of the resident transfer status . Record review revealed the resident was admitted to the facility in October of 2021 with diagnoses including, but not limited to, muscle weakness, muscle wasting and atrophy [loss or thinning of muscle]. Additional record review revealed the resident had impaired decision making and cognitive communication deficit. Record review revealed a Safe Patient Handling assessment dated [DATE] which states in part, .what is the Patients Weight Bearing Capability with the answer marked as None. Further review of the assessment revealed the resident cannot bear weight when transferring. Further record review revealed an annual Minimum Data Set (MDS) Assessment was completed on 10/20/2022. Record review revealed the resident's care plan was revised on 11/4/2022 and failed to specify that the resident cannot bear weight during transfers. During a surveyor interview with Licensed Practical Nurse, Staff A on 12/07/2022 at 9:54 AM, she revealed she was unaware of the 10/4/2022 SPH assessment that indicates the resident cannot bear weight during a transfer. During a surveyor interview with the MDS Coordinator, Staff B on 12/8/2022 at approximately 9:00 AM, she was unable to provide evidence that the resident's care plan was revised relative to the resident's non-weight bearing status as required. 46715

Based on record review and staff interview, it has been determined that the facility failed to ensure that the medical care of each resident is supervised by a physician, relative to radiology testing for 1 of 4 residents reviewed, Resident ID #7. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2021 with diagnoses including, but not limited to; muscle wasting and atrophy (loss or thinning of muscle). Record review of the resident's bone densitometry test (a test used to measure bone strength) dated 10/12/2022, revealed radiology results indicating s/he had osteopenia (low bone mass). Additional record review failed to reveal evidence that a provider was notified of the bone density results prior to the resident being transferred to the hospital on [DATE]. During a surveyor interview with the Director of Nursing Services on 12/7/2022 at 8:24 AM, she was unable to provide evidence that the provider was aware of the results of the bone density test. During a surveyor interview with the Physician Assistant on 12/7/2022 at 10:06 AM, she acknowledged that she was unaware of the results of the bone density test until 11/29/2022 following the resident's admission to the hospital with a diagnosis of a pathological fracture. During a surveyor interview on 12/7/2022 at 11:40 AM, with the Primary Physician he was unable to provide evidence that the facility notified him of the bone densitometry test results from 10/12/2022.

Based on record review and staff interview, it has been determined that the facility failed to ensure a physician reviewed the resident's total program of care, relative to radiology testing for 1 of 4 residents reviewed, Resident ID #7. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2021 with diagnoses including, but not limited to; muscle wasting and atrophy (loss or thinning of muscle). Record review of the resident's bone densitometry test (a test used to measure bone strength) dated 10/12/2022, revealed radiology results indicating s/he had osteopenia (low bone mass). Additional record review failed to reveal evidence that a provider reviewed the bone density results prior to the resident being transferred to the hospital on 11/29/2022. During a surveyor interview with the Director of Nursing Services on 12/7/2022 at 8:24 AM, she was unable to provide evidence that the provider was aware of the results of the bone density test. During a surveyor interview with the Physician Assistant on 12/7/2022 at 10:06 AM, she acknowledged that she was unaware of the results of the bone density test until 11/29/2022 following the resident's admission to the hospital with a diagnosis of a pathological fracture. During a surveyor interview on 12/7/2022 at 11:40 AM, with the Primary Physician he was unable to provide evidence that the facility notified him of the bone densitometry test results from 10/12/2022.

46715 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that staff utilize Personal Protective Equipment according to professional standards to prevent the potential development and transmission of COVID-19 for 1 staff member, Staff A, relative to 2 resident who tested positive for COVID-19, ID #s 6 and 52. Findings are as follows: During the entrance conference on 12/04/2022 with the Director of Nursing Services she indicated that the facility is experiencing a COVID-19 outbreak and there are 17 COVID-19 positive residents in the facility. Record review of a facility policy titled, Care of the Covid-19 Positive Resident last reviewed on 11/18/2022, states in part, .Full PPE [personal protective equipment] for Staff- N95, gowns, gloves, face shields/goggles will be worn during care of the COVID positive resident (on isolation) . 1. Record review revealed Resident ID #6 was admitted to the facility in December of 2021 and was diagnosed as COVID-19 positive on 11/26/2022. During several surveyor observations from 12/4/2022 until 12/6/2022 signage was posted outside of Resident ID #6's room that stated in part, Isolation, Droplet/Contact Precautions. In addition to Standard Precautions Staff and Providers MUST: .Eye protection (goggles or face shield) . During surveyor observations on 12/4/2022 at 9:06 AM, 12/5/2022 at 1:34 PM, and 12/6/2022 at 8:36 AM, LPN (licensed practical nurse) Staff A was observed entering Resident ID #6's room without a face shield or goggles. During a surveyor interview on 12/6/2022 at approximately 8:45 AM with Staff A, she acknowledged entering the residents room without wearing eye protection. 2. Record review revealed Resident ID #52 was admitted to the facility in February of 2022 and was diagnosed as COVID-19 positive on 12/1/2022. During several surveyor observations from 12/4/2022 until 12/8/2022 signage was posted outside of Resident ID #52's room that stated in part, Isolation, Droplet/Contact Precautions. In addition to Standard Precautions Staff and Providers MUST: .Eye protection (goggles or face shield) . During surveyor observations on 12/4/2022 at 11:01 AM and 12/6/2022 at 8:31 AM, Staff A was observed entering Resident ID #52's room without a face shield or goggles. During a surveyor interview with the Infection Control Nurse on 12/6/2022 at 12:47 PM, she revealed that she would expect the staff to follow the signage on the door and wear full PPE in a COVID-19 positive residents room including a face shield or goggles. During a surveyor interview on 12/6/2022 at 10:17 AM, with the Director of Nursing Services, she revealed that all staff entering a COVID-19 positive resident's room are expected to wear full PPE including a face shield or goggles per the facility policy.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 sample residents reviewed for medication administration, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to The Rhode Island Department of Health, received on 7/6/2022, revealed the resident reported to staff that s/he did not receive his/her intravenous (IV) antibiotics at 12:00 AM or 4:00 AM on 7/5/2022. Record review revealed the resident was admitted to the facility in June of 2022 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review further revealed a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Record review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's internal investigation revealed Staff A did not administer the resident his/her Penicillin on 7/5/2022 at 12:00 AM or 4:00 AM. Further review of the facility's internal investigation revealed in part there were two doses of the Penicillin that were left over that could not be accounted for. During a surveyor interview with the Administrator and the Director of Nursing Services (DNS) on 7/8/2022 at approximately 11:30 AM they acknowledged the resident did not receive his/her scheduled doses of Penicillin on 7/5/2022 at 12:00 AM and 4:00 AM.

Based on record review and staff interview, it has been determined that the facility failed to protect the resident's right to be free from abuse for 2 of 2 resident's reviewed, Resident ID#s 1 and 2. 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 .willful infliction of .sexual .abuse . Review of the facility reported incident of alleged abuse received by the Rhode Island Department of Health on 5/12/2022 at 4:05 PM, revealed in part: .Both residents were found engaged in an affectionate embrace kissing on the lips, in the room of victim [Resident ID #1] .During my immediate investigation, a potential similar interaction occurred yesterday with both residents .resident representatives have been notified of the incident .Witness (s) .[Activity Aide Staff A] Review of Resident ID# 1's record revealed that s/he was admitted to the facility in August of 2020 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 3/4/2022 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) [a structured evaluation aimed at evaluating aspects of cognition in elderly patients] was conducted on which s/he scored a 10/15, indicating that s/he had moderately impaired cognition. Review of Resident ID# 2's record revealed that s/he was admitted to the facility in June of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 3/3/2022 Quarterly MDS revealed a BIMS assessment was conducted on which s/he scored a 99, indicating s/he had severely impaired cognition. During a surveyor interview on 5/17/2022 at 9:30 AM with Staff A, it was indicated that she was notified of Resident ID# 2's inappropriate behaviors towards members of the opposite sex when she first began working at the facility in December of 2021. It was further stated that on 5/11/2022 she observed Resident ID# 2 in the room of Resident ID# 1 touching on the chest of Resident ID# 2, over his/her clothes, while s/he was standing in front of him/her. She reported this observation to the activity aide working on that unit, Activity Aide Staff B. During a surveyor interview on 5/17/2022 at 2:15 PM with Staff B, it was revealed that she reported the above-mentioned incident to the nurse working on the unit, Nurse Staff C. During a surveyor interview on 5/17/2022 at 2:25 PM with Staff C, she acknowledged that Staff B reported the above-mentioned incident to her and that she failed to document it in the resident's record. Additionally, she acknowledged not reporting the incident to the Director of Nursing, Administrator, either of the resident representatives, or the physician on 5/11/2022. Review of the progress notes from September 2021 through May 11th, 2022, for Resident ID# 2 revealed the following: - 9/30/2021: Behavioral Note: Pt [patient] .did grab a CNA's [Certified Nursing Assistant] bottom. [Resident ID #2] made several attempts to continue the behavior and needed a lot of redirection . - 12/20/2021: .noted with delusions .believes that they are all [his/her spouses]. Redirection .difficult, resident becomes angry and verbally abusive towards staff . Review of the facility behavioral health documentation for Residet ID# 2 titled, Med Management Note MediTelecare revealed in part: - 12/30/2021: .Discussed with nursing. Resident being too friendly to [opposite sex], has been trying to kiss them .Recommend adding [MEDICATION(S)], 25 mg [milligrams], PO [by mouth], one time a day to decrease libido .PLAN OF CARE: Document behaviors, interventions and outcomes . - 1/30/2022: .Discussed with nursing. Resident being too friendly to [opposite sex], has been trying to kiss them .PLAN OF CARE: Document behaviors, interventions and outcomes . - 2/18/2022: .Discussed with nursing. Resident continues to be inappropriate (trying to kiss [opposite sex]) .Will consider increase next assessment if behaviors continue .PLAN OF CARE: Document behaviors, interventions and outcomes . - 3/11/2022: .Discussed with nursing. In agreement with increasing [MEDICATION(S)] for inappropriate behaviors .PLAN OF CARE: Document behaviors, interventions and outcomes . - 3/25/2022: .Resident continues with inappropriate behaviors (kissing [opposite sex]) .As [MEDICATION(S)] was just increased, will hold on medication changes until next assessment .PLAN OF CARE: Document behaviors, interventions and outcomes . During a surveyor interview on 5/17/2022 at 8:50 AM with CNA's Staff D and E, it was revealed that Resident ID #2 frequent exhibits .loving behaviors . towards [members of the opposite sex], and that the behaviors have been ongoing .for a while . It was further stated these behaviors include wandering into other resident's rooms and touching and rubbing the backs of those residents, as well as hugging and kissing them. Additionally, it was stated that the more cognitively intact residents will notify the staff to assist with redirecting him/her away from them. Review of the Care Plan, with a problem start date of 5/12/2022, revealed in part, .Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by: [sic] kissing and embracing others . During a surveyor interview on 5/17/2022 at approximately 4:00 PM with the DNS, she was unable to provide evidence that all residents are free from abuse.

Based on record review, staff and resident interview, it has been determined that the facility has failed to ensure that each resident receives adequate supervision and assistance devices to prevent accident hazards relative to 1 of 2 residents with past transfers resulting in harm (ID #49). Findings are as follows: The facility policy, titled, Mechanical lifts, states, in part, .Procedure: .Every resident is to be assessed, as part of the Safe Patient Handling Program, for their transfer needs .The assessment recommendations are to be followed unless it is apparent that the resident's condition has changed since the assessment was last performed, at which point the Charge Nurse is to perform an assessment and document whether changes I the transfer are necessary . 1. Record review revealed that Resident ID #49 has a physician's orders [REDACTED]. Further record review revealed a current physician's orders [REDACTED]. Review of the resident's Post Fall Huddle documentation dated 7/28/2018 revealed the following: cna did not plant feet in easy stand and strap legs. res. (resident) legs became tangled when started to lift legs gave out and res. lowered to floor. Hoyer used to get res off floor. Review of the Physical Therapy Evaluation dated 7/29/2018 revealed the following, resident presents to therapy due to a fall on 7/28/18 as a result of error with EZ stand lift resulting in LLE (left lower extremity) pain. Review of the progress notes revealed a note dated 7/29/2018 which states, in part, received x-ray results .Recent distal tibia left lower leg fracture. During a surveyor interview with the alert and oriented resident on 10/1/2018 at 11 AM, s/he revealed that s/he fell from the EZ stand while being transferred by two nursing assistants. The resident indicated that one of the nursing assistants did not place his/her foot appropriately or strap legs in and s/he ended up with a fractured ankle. During a surveyor interview with Nursing Assistant, Staff C, who was involved with the transfer, he indicated that the resident's legs were not strapped in properly. During a surveyor interview with the DNS, she acknowledged that the nursing assistant, Staff D, had not strapped the resident's legs in the EZ stand properly, resulting in a fall with fracture. Since the above incident, the facility has implemented the following interventions: 1.) All nursing assistants were educated on both the proper use of the EZ stand lift and Hoyer lift. 2.) Staff A and Staff B were evaluated for competency of Using Mechanical Lift. 3.) Staff A and Staff B received verbal counseling for substandard work. 4.) Staff C was re-educated on the use of the EZ stand and signed the Staff Education Acknowledgement documentation. Staff D was an agency staff and chose not to return to work at the facility. 5.) The care plan for resident ID #49 were updated regarding falls. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities they are deficiencies under State Regulations and grounds for licensure sanctions.